Competing or Complimentary? Transplant or Daily Dialysis

by Peter Laird, MD

Dr. Jeremy Chapman and Dr. Benjamin Hippin have been kind enough to respond to emails sent to them on the recent payment for renal donation articles that were featured in the BMJ (pro and con). Bill and I as well as Dr. Hippin and Dr. Chapman in the end agree on several issues.

First, the standard three days a week dialysis session incenter is not meeting the needs of CKD-5 patients; second, renal transplant and daily dialysis proponents do not need to be in opposition to each other.  In fact, Dr. Chapman reported that he has 20% of his patients on home hemodialysis and 35% on home peritoneal dialysis in his practice in Australia where interestingly, he considers himself primarily a transplant advocate.  If America had across the board numbers such as Dr. Chapman's practice, Bill could fold up his blog and we would simply need only Home Dialysis Central for a resource of information and not need any advocacy for daily dialysis home programs at all, we would have arrived already.

However, one interesting aspect of my initial correspondence with Dr. Chapman is the dichotomy of competing resources leading to a fractured approach to improving access to either transplantation or home hemodialysis especially, when applied to the developing world. When responding to the relative values of dialysis and transplantation Dr. Chapman wrote:

I would agree with you that for a well dialysed patient the quality of life can be equivalent to transplantation. I have a number of patients who have been on dialysis more than 25 years. The difficulty that I have in advising this, as a global solution, is that the relative costs are vey different and for the emerging economies of the world we could not advise spending money on dialysis treatment to the neglect of renal transplantation. Dialysis performed well is a viable alternative that individuals in the developed world have available to them.

Yes, for the underdeveloped "third world nations," the tragic truth is that there are competing economies of scale. 

Looking at this competition for resources Dr. Hippen thus promotes payment for kidney donation because harvesting cadaveric kidneys is a labor intensive and expensive enterprise. Few nations outside of the developed world have the resources to initiate and maintain organ donation networks.  The dilemma of funding a dialysis program, cadaveric transplant networks and ultimately even payment systems for renal donations in third world nations is that these nations do not have the resources for any of these programs.  Nor do the majority of their patients have access to the expensive post transplant immunosuppressive medications. Rightly, the priorities in the third world focus on routine health care.  The poor in these nations will still be at risk no matter what ethical or economic package the debaters in England settle on.

Yet for the developed world, Dr. Hippen likewise promotes and is involved in home dialysis programs in his transplant nephrology practice and he actively promotes it as an alternative to patients not able to undergo renal transplant.  Indeed, he commented to me that if he was not eligible for a preemptive or quick transplant should he develop CKD-5, his next choice would likewise be daily home hemodialysis.  Yes, here in America and in the other developed nations, renal transplant and home dialysis should be complimentary and not competing programs implemented and managed side by side saving lives. 

Nevertheless, the debate in England, America and other affluent nations on payment for renal donation is led by the discussion on the "global" solution to renal disease which many believe is renal transplant by either altruistic donation (Dr. Chapman) or paid donation (Dr. Hippen).  Yet, here in America where we do have the resources for transplant and optimal dialysis, why does the discussion of underdeveloped nations apply?  Why is the same all or none approach to renal transplant OR optimal dialysis the leading argument in this debate even here in America, England, Australia and other affluent nations? 

The truth is that in America, we can maximize home hemodialysis, home peritoneal dialysis and renal transplant all at the same time to reach the largest numbers of people, saving lives and at the very same time, saving billions of dollars with all of these programs over the current suboptimal, three days a week hemodialysis treatments.

Yes, if America had the same practice profile as Dr. Chapman, Bill, Anna, Mel and I could spend more time with our families and less time on an infernal typing machine.  We thus need to deliberately so note that there are two discussions on the "global" solution.  One for developed economies where renal transplant and optimal dialysis programs are complimentary and not competing strategies, and in the economically challenged nations where the funding of these programs is sadly lacking for all modalities.

Comments

[Jeff]

"here in America and in the other developed nations, renal transplant and home dialysis should be complimentary and not competing programs implemented and managed side by side saving lives."

While I am (obviously) pro-transplant, I wholeheartedly agree with this statement. Transplant has worked well (so far) for me, yet I am fully aware that daily home hemo or PD is either a more desireable or a more practical option for others. One size does NOT fit all; having options is the most ideal solution.

[Somerville]

Laird's suggestion ignores three important problems. First, there are presently no dialysis filters capable of removing all the molecules removed by healthy renal function, and no amount of additional time on dialysis will correct that deficiency. Second, 15% of hemodialysis patients die ultimately from lack of venous access, and his suggestion of daily hemodialysis would only worsen that problem, which transplantion would of course entirely avoid. Finally, dialysis in any form represents such a massive intrusion on the patient's time and freedom that it has to be regarded as a major dimunition in the patient's quality of life. For all these reasons, renal transplantation is now and will remain for the foreseeable future an infinitely superior form of renal replacement therapy to dialysis, even daily home hemodialysis.

[Bill Peckham]

Actually Agar has shown that time dependent molecules are controlled by more time on the machine. There are a studies that looked a fistula health for people dialyzing at home more frequently. The buttonhole technique allows frequent canulation without damaging the fistula and fistula health generally is improved by the switch to home hemodialysis, even if that switch is accompanied by greater frequency.

Is a good transplant more logistically convenient then frequent dialysis? Yes. But that isn't the basis for the arguments in favor of paying for kidneys.

The idea of paying for kidneys is fraught with problems and no mention is made by the pay for kidney advocates about the possible impact their pay for kidney scheme might have on the altruistic donation of postmortem livers and hearts. The fact is there are good alternatives to kidney transplantation, there are not good alternatives to liver or heart transplantation.

Those advocates for new kidney procurement schemes should first be sure to do no harm to those waiting for other organs.

[Somerville]

Since it is not damage to the fistula, but collapse of the vasculature, which accounts for the 15% death rate among dialysis patients because of lack of access, any improvement in fistula lifespan would not solve the problem. Also, even buttonhole fistulas have their problems, including a disposition to infection, which can in turn damage the fistula and threaten the patient with septicemia.

All dialysis causes toxic cytokine release in the patient, and more frequent dialysis does not remove this problem.

Further, it minimizes the burden of dialysis greatly to characterize it merely as an 'inconvenience,' when in fact it represents such a profound interference with the quality of life that it can destroy the capacity of the patient for coherent life planning, travel, and work. The fact that 20% of dialysis patients voluntarily stop dialysis and prefer certain death instead, and that independently of this, the suicide rate among dialysis patients is many times higher than in the general population, demonstrates that dialysis cannot be regarded as a mere logistical disturbance rather than a life-changing problem.

To argue that the fact that some people are being paid to donate an organ would somehow destroy the willingness of other people motivated by entirely different reasons to donate altruistically is like saying that the fact that prostitutes sell sex means that no one will ever have sex with anyone again out of love. If someone is motivated altruistically to donate an organ, they are obviously not the sort to be motivated by money instead. But if it is worthwhile to increse the death rate among dialysis patients by forbidding paid organ donation in order to preserve altruistic donation, then it logically follows that we should also make it illegal for surgeons to operate for money, since this too will diminish their morally-superior motivation to perform surgeries pro bono.

[Bill Peckham]

People on the verge of vascular collapse are not candidates for renal transplant either. Obviously people on dialysis are not a homogeneous group, rather they are on a continuum of health.

There is no perfect renal replacement therapy but it is misleading to compare an idealized transplant result with the dialysis experience of people using dialysis for palliative care. Clearly this website stands as testimony that high dose hemodialysis is compatible with work, travel and volunteerism.

Alastair V. Campbell has a good piece that restates the ethical basis for the prohibition on an organ market. Organ transplant is a serious business, we should resist all temptations to over sell the benefits and minimize the problems.

[Somerville]

No, transplantation is often used as a rescue therapy for patients with lack of dialysis access, since the renal graft is connected deep within the circulatory system at points not available for dialysis access.

Since leaving patients on dialysis exposes them to the inflammatory stress of cytokine release as well as an increased cancer risk, and more intensive scheduling of hemodialysis does nothing to correct these problems, but in fact worsens them, escape from dialysis remains the preferred option over frequent home hemodialysis.

In general, since any limitation on transplant options means an increased rate of death for renal patients, all the ethical presumptions in any debate about paid organ donation have to be in favor of permitting it rather than promoting policies which will certainly have the effect of killing yet more members of an extremely vulnerable minority.

[Bill Peckham]

CKD kills people, not medical policies. The data on long term consequences of living renal donation are as unknown as the long term consequences of high dose dialysis.

Biocompatibility can be a feature of dialysis machines - the Aksys PHD had a biocompatible blood tubing set to go with its biocompatible dialysate. I used the Aksys for five years I know that it was the best dialysis per minute that I have yet experienced - but the biocompatibility did not manifest in a significant mortality advantage. In theory improved biocompatibility would prevent or diminish long term consequences.

The ethics of renal replacement therapy do not require a transplant at all costs approach, a transplant is not a cure. Living donation is not a risk free procedure and should not be undertaken lightly. Our society is not ready to embrace living donation by those with dubious motives.

[Somerville]

There have been several large-scale studies of the epidemiology of kidney donors, and not only have these demonstrated that they suffer no significant medical problems from their donation, but it has even been established that they have a longer life expectancy than the general population. See I. Fehrman-Eckholm, et al, "Kidney Donors Live Longer" Transplantation, vol. 64, no. 7 (1997) 976-978.

A renal transplant is not regarded as a cure for endstage renal failure, but transplant recipients enjoy a much higher quality of life, suffer fewer co-morbidities, and have a significantly extended life expectancy. For example (see Gabriel Danovitch, 'Handbook of Kidney Transplantation' (Philadelphia: Lippencott, 2001), a diabetic dialysis patient in his forties has an 8 year life expectancy, but that same patient with a transplant can expect to live another 24 years. Since all men are mortal, murder always amounts only to shortening the life expectancy, and any policy that unnecessarily traps patients on dialysis has to be regarded as killing them. In this sense it is undeniably true that it is medical policies which kill people who suffer renal failure, even though renal failure makes these patients vulnerable to cruel medical policies in the first place. These unnecessarily lethal policies include forbidding altruistic donation in some jurisdictions, forbidding paired organ sharing in other jurisdictions, supplying too few hospitals with life support machines for organ harvesting, refusing to enact laws enforcing presumptive organ donation from all deceased persons who have not registered a contrary wish, and refusing adequately to inspect for-profit dialysis centers to ensure patient safety in the US, which has almost double the death rate among dialysis patients as the rest of the developed world. This pattern of discrimination by the healthy majority against the vulnerable minority of dialysis patients reaches its pinnacle in the ban on organ purchasing, which traps patients in a non-optimal dialysis and replacement organ procurement system with lethal results, just as if governments had barred the door of a burning building, preventing the escape of people facing death inside.

[Bill Peckham]

The question is: should there be markets for organs? The answer is no. To make a case for it requires exaggeration of the need and overstating the consequences of inaction. Calling the status quo murder illustrates your emotional commitment to your position but it does not advance your case.

People waiting for hearts, lungs and livers deserve more consideration than those waiting for kidneys. Coming at this from a kidney-centric viewpoint comes up short. As a thoughtful proponents of paying for organs concede (Hippen, et al) most people on dialysis are under dialyzed, we don't know the full consequence of routinely offering higher doses. High frequency dialysis is relitively new and little utilize but it's impact on health undercuts the need for aggressive transplant policies.

We don't know what the long term consequence of transplant will be; we won't know for another ten or more years. Loosing half your renal mass at 30 may not be a problem but what about when the donor turns 70, forty years later? Having half your renal mass will become increasingly problematic as age diminishes renal function.

I'm all for increasing altruistic organ donation but there is no need to oversell the program. Overselling the program is myopic. Our donation programs should resist the calls to puffery and remain on a sober, conservative foundation.

[Peter Laird, MD]

Somerville, you have migrated widely from the basic topic of my post. Renal transplantation is an excellent renal replacement therapy for the right person but it is not a universal solution for all CKD-5 patients. Furthermore, the survival benefit of quotidian dialysis has been demonstrated in several observational studies to be equal to that of cadaveric renal transplantation in a recent study.

The main point of my post is that we need to consider quotidian dialysis as a complementary and not competing renal replacement therapy when discussing renal transplantation. Those involved in the debate on payment for renal donation noted in the BMJ have agreed with that premise. In fact, just to repeat what Dr. Jeremy Chapman stated, that his own practice has over half on home therapies with 20% on home hemo programs, yet he describes himself as a transplant advocate.

Certainly the practice profile of Dr. Chapman illustrates what I would consider an ideal practice profile for the United States. Yes, as I strongly protested in my post, it is time to look at optimal dialysis strategies as a complementary part of the renal transplant disucssion.

I will defer comment on the many off topic issues that you have brought to this discussion but to so note Bill's comments to you already.