By Peter Laird, MD
Until the time that we are able to regrow our kidneys in a petri dish, the debate will continue over allocation of a limited supply of donated living and deceased kidneys. Some castigate unfairly, in my opinion, those that have altruistically given their very flesh to family and stranger alike in an effort to stem the dance of death renal patients abide in. The gift of life of a living renal donation makes headline news on a regular basis. Complete strangers have stepped forward to give this gift of life to those in need. Yes, despite the many detractors of altruistic living donation, it does exist. The fact that we have even one stranger willing to give selflessly to another should always be applauded, especially by those that have so received.
Many continue to strive for a commercial system of financial reward in exchange for these extreme acts of altruism. Yet, in my mind, the debate on renal donations and various methods of increasing altruistic donations, financial compensation for vendor donations and deceased organ donations procured by opt out systems of presumed consent miss the central issue at hand, is kidney transplantation the primary treatment for CKD-5 or is it the secondary treatment option?
In the case of a patient that has a living related donor that gives this gift before the start of dialysis, many would argue reasonably that preemptive renal transplantation is the primary treatment option. Nevertheless, not all renal patients are transplant eligible. Issues of cardiovascular risk, cancer risk, obesity and co-morbid disease states eliminate thousands from the transplant list every year. Many choose not to place family or friends at jeopardy by asking for their healthy organs. I for one have a combination of relative medical risk and refusal to place my two willing donors at risk, my wife and my daughter who both came forward willing and eager to give me one of their healthy kidneys.
While I was exploring my own personal options, I had a great unease at accepting their gift if there was another viable option available to me. Certainly the diagnosis of malignant melanoma one month after I started dialysis settled the issue once and for all for me. The advent of cancer spreading out of control by aggressive immunosuppression augmented by my own willingness to bear my own disease without endangering my loved ones won out in my decision to pursue home, daily dialysis as my primary treatment option.
In the end, the issue of whether dialysis is the primary treatment option or renal transplant is turns out to be an individual decision based on many factors. Yet today, even though the overwhelming majority of patients will either choose to forgo transplant or not be eligible for transplant, the only consideration given publicity is that of renal transplant. We have about 1% of the hemodialysis census dialyzing in the comfort of their own home when other nations have up to one third taking advantage of this option.
For the majority of people with CKD-5 dialysis is their primary treatment option whether, home hemodialysis, home PD or incenter and they should be hopeful when reading the information that optimal dialysis has survival rates that rival living related transplant. These two CKD5 realities should place the primary treatment option of dialysis at the forefront of the discussion.
We continue to hear of those that die on the transplant waiting list. Yet, I have not seen one advocate of the various transplant procurement options come forth publicly in support of optimal dialysis even for those on the transplant list. Australia and other nations have a high transition rate from home hemodialysis to transplant with improved outcomes in their optimally dialysis patients awaiting their secondary treatment option of transplant.
Why are these very vocal advocates of renal transplantation so silent on the issue of optimal dialysis? I have my own private theories on why they remain silent publicly, but for those that understand that optimal dialysis is medically available but not socially promoted here in America, the tragedy that Belding Scribner sought to prevent overwhelms the benefit of all of our directed efforts for increasing renal transplantation when we consider those that could have survived if they had only had access to optimal dialysis.
Our short sighted efforts to focus all of our primary treatments in the renal transplantation option alone when the supply shall likely never meet the total demand from all who would wish a kidney, leads me to ask again, is renal transplantation a primary or secondary treatment option for the majority of American CKD-5 patients? If it is a secondary treatment option for the majority of our renal patients, then Dr. Scribner’s work was left unfinished. Perhaps answering this simple question first about dialysis and renal transplant will better focus our future efforts against this deadly condition.
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