The truth about paying for kidneys

by Peter Laird, MD

On Friday both RenalWEB and NephrOnline ran the story from Britain where doctors are debating payment for organ donation.  One article gives a more balanced report on this issue and the other is actively promoting this practice.

It is sad to note the prognostication of the need for such a system based on the  false premise that without a transplant, people will die and they have no alternative to this which is not true. The overwhelming evidence is that short daily dialysis is as good as cadaveric transplant for long term survival and nocturnal, quotidian dialysis rivals living related donor transplants.

The time has come for a discussion on the real risks, benefits and alternatives of renal transplant. Unfortunately,  I have yet to see any article calling for promoting the ethically corrupt donor payment system coupled with the truth of daily dialysis.  Before we once again head down one more slippery slope, perhaps some truth in advertising should be applied to the entire renal donor debate, especially since there is a real alternative to renal transplant with similar survival and quality of life.

Comments

[Somerville]

There are a number of reasons why short daily dialysis can never be as good as renal transplant. The most stunningly obvious one is the fact that 15% of dialysis patients ultimately die from lack of dialysis access, and short daily dialysis offers no answer to that tragic problem. Second, the many morbidities associated with continued dialysis treatment, from toxic cytokine release to rhabomyelosis, from osteoporosis to neuropathy, continue with short daily dialysis, even if more slowly. Finally, dialysis represents such a massive intrusion into the patient's life that only 30% of dialysis patients in the working age group actually do work, and having to set up, run, and conclude a dialysis process every day of the week except one, when the dialysis machine has to be cleaned, vastly diminishes the quality of life of a dialysis patient compared to the relative freedom of a transplant patient.

[Peter Laird, MD]

Despite the comments on the lack of efficacy by Somerville for daily dialysis, the comment is not in keeping with the topic of discussion that the mortality rates of daily dialysis and cadaveric renal transplant are in fact equal.

This is the main point of my first post on this subject and the follow up posts after discussions with Ben Hippen and Jeremy Chapman. In contradistinction to Somerville's negative comments, both Dr. Hippen and Dr. Chapman acknowledge that there is an underutilization of this modality and not all patients are transplant candidates. The relative impact of daily dialysis on quality of life has likewise been reported on in several well done studies which are likewise in contradistinction with Somerville's negative global comments on daily dialysis.

Nevertheless, just as renal transplantation is not for all patients, so likewise, daily dialysis is not for all patients as well. The many patients such as Bill Peckham and Anna Bennett that have done exceptionally well with daily dialysis modalities would, I am sure, disagree with such a negative assessment. For those that find the daily regimen prohibitive, I in no manner disagree with renal transplantation as an alternative renal replacement therapy that should be utilized in all eligible patients who choose to proceed with this option.

[Bill Peckham]

You have to wonder if someone with vascular disease would be a viable transplant candidate. But the question isn't transplant per se but paying for transplant.

Someone waiting for a transplant should be on daily dialysis because as the NxStage data base is showing graft survival is much higher for those who used the System One vs. conventional dialysis.

[Somerville]

Death from lack of vascular access among dialysis patients arises from lack of superficial vein patency, not from lack of patiency in the deep vasculature where a renal graft is connected. In any case, the point is that early transplant can nip all problems with lack of dialysis access in advance so that huge cause of death among dialysis patients never has a chance to come into operation. However, the recommendation of perpetual short daily hemodialysis does nothing to address the problem of eventual lack of dialysis access, which kills 15% of dialysis patients.