The recently published paper in the NEJM entitled “Survival Benefit with Kidney Transplants from HLA-Incompatible LiveDonors” caused a huge impact on Brazil’s media. Our main broadcast TV
devoted few minutes explaining it, suggesting as a real breakthrough. Patients
and many members of our multidisciplinary team were questioning if
compatibility could be forgotten as a barrier to transplantation.
Moved by this
repercussion, on our weekly meeting we debated the article. Three questions
were posed:
1. Does transplanting HLAi
patients really improve quality of life (life expectancy was shown to be
expanded), compared to waiting on the list for a deceased donor?
2. Why 5-year life
expectancy for live donor kidney recipients in the US is 86% (USRDS data),
while in the UK, Australia and at our own service it is around 97%. Does anyone
has any suggestion of why such a huge difference?
3. What about the high costs
of desensitization?
The former question is far from our reality. In our center, we do not
perform HLAi transplants despite our high volume of over 900 kidney transplants per year. Due to low reimbursement, complications that may arise from HLAi
transplants such as re-hospitalizations, requirement for additional
plasmapheresis and IVIG as well as biopsies may significantly affect the cost
of post-transplant care and prevent appropriate treatment of complications.
This cautious approach to cost is immensely influenced by our political
and economical scenario. After chaotic administration and corruption, our GPD
is falling ~3%. State health insurance is paying less than the actual cost
for a dialysis session. In some centers, this is forcing doctors do reduce
the dialysis session by 30 minutes (from 240 minutes to 210 minutes/session).
In this context, proposing a new and costly treatment (like desensitization)
that should be reimbursed by our Public Health System would sound as an
outrage to the state health managers. Clearly, it seems the media has been over
optimistic with the article conclusions. Many centers in the USA are actually favoring
kidney paired exchange to minimize the complications and costs of desensitization.
Thiago Reis, MD
Hospital do Rim, UNIFESP, São Paulo, Brazil
5 comments:
This is a very valid question and concern. Few centers in United States do perform ABO and HLAi kidney transplant. But I do believe that paired exchange is where majority transplant programs are heading and a nationwide program may be created eventually.
This is indeed an interesting article! Working in transplantation research, one professor said something that I think is very valid to your query - we do not, and probably never will, fully understand the way the immune system works, so if you can avoid challenging it, then you should do so. For this reason, I feel paired exchange is a much more sensible option than an expensive HLAi transplant. Unless there is no realistic option (i.e. 100% sensitisation) then my opinion (which seems to be backed by the evidence) is that paired exchange is a much more viable and sensible option, particularly in a nationalised healthcare system where you are not relying on two insurance companies agreeing to a paired operation. If you have a country-wide healthcare system then make use of it!
Thanks for the post Thiago. Its interesting!
Regarding your question about the discrepancy in life expectancy for live donor kidney recipients in the US compared to UK and Australia, I will tell you my own opinion but unfortunately I cannot back it up with evidence. I think the difference in the structure of the healthcare system could explain this discrepancy. Healthcare is almost completely free in the UK and patients don't pay for insurance to access services. In contrast, the healthcare system in USA requires insurance to access these services. Uninsured patients will definitely have less visits to nephrologists & primary care physicians, therefore the management of risk factors like hypertension, dyslipidaemia, albuminuria ..etc is compromised and hence they end up with a llarger burden of the disease. The cost of medications is another contributory factor; it leads to non-compliance and its unwanted consequences. As i said this is a personal perspective. Checkout this link:
http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror
This is a huge fight.
A fight between Time and Money: a kidney paired exchange is hard to realize and time-consuming; HLAi transplants are expensive.
A fight between Reason and Medicalism (does this word exist?). From a rational point of view, a kidney paired exchange is always the better choice. From a medical point of view (I mean a very narrow point of view), It's always easy to fix something giving more drugs.
I guess in addition to the financial issue (which is huge in itself) we also need to consider long term issues with 'additional' immunosuppression including malignancies.. Also, given the recent changes in allocation system in US( with higher priority to high pRA patients) as well as the recent trends twoards paired exchanges not sure how these results will influence what we do.. Lastly, is it really worth the risk lets say for a patient who is doing otherwise well on PD or home HD or even conventional HD for that matter
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