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
