Chain of goodwill saves livesA radical approach to kidney transplants is set to slash millions from the national health bill, writes Amanda O'Brien
April 04, 2009
Article from: The Australian
SCORES of sick Australians could potentially be freed sooner from their dependence on dialysis machines during the next few years, as a groundbreaking Perth transplant trial prepares to go national.
A trio of kidney recipients recently plucked from the misery of the five-year transplant queue in Western Australia is living proof of what is possible.
The men, aged 49, 50, and 65, are the first kidney recipients in Australia to benefit from a "domino chain" of three linked transplants from three living donors.
It was made possible by WA's revolutionary Paired Kidney Exchange, which proceeds from a situation in which people waiting for a transplant find they are not compatible with a friend or relative prepared to donate a kidney. Instead of sending the friend away, the exchange swaps them with a donor from another incompatible couple, to allow cross-donation between the two couples.
The WA trial has already gone further by achieving an Australian-first three-way domino chain of transplants.
It started with an altruistic stranger who offered to donate a kidney to someone in need. A 65-year-old man was the recipient. His wife then donated one of her kidneys to another man on the paired exchange, and his wife did the same for another man.
The chain ended there only because the third recipient did not have a partner able to donate a kidney, but potentially it could go much further.
Program director Paolo Ferrari says the possibilities are considerable. "We're only limited by the number of couples in the exchange and when we go national that will expand," he says.
Matthew and Julie Clements have nothing but praise for Ferrari, whom they call "St Paolo". Matthew Clements, 50, spent almost a year on dialysis. For five hours a day, three days a week, he was chained to a machine. His engineering consultancy business suffered; his social life crashed; he was tired, grumpy and always thirsty because of the brutal fluid intake restrictions associated with dialysis. Julie Clements offered to give him a kidney and was devastated to learn she was not a match.
But now Matthew Clements is fighting fit and even talking about taking a holiday, something unimaginable under his regimented life on dialysis.
Julie Clements, a successful artist under her maiden name, Julie Podstolski, can't stop smiling. She says her confidence has soared.
"I used to be angry, resentful. I felt I had no control. Now I just think: 'Wow, I did that!"' she says.
She was the third donor in the Perth domino chain, her husband the second recipient. The transplants were carried out in November but revealed only recently when it was decided enough time had passed to ensure everything had gone well. Ferrari says the benefits go far beyond Matthew Clements and the other men who received kidneys from the domino chain.
Everyone on the waiting list won because the use of living donors meant fewer people were left in the queue for scarce organs from deceased donors.
Ferrari admits the exchange system is not perfect. Not everyone who wants to donate a kidney is suitable and there are risks.
"The first thing that we tell any potential living donor is they have a three out of 10,000 chance of dying," he says. "Surgery is always a risk." There is also the prospect of pain, possibly persisting for weeks, surgery-related wound infections and localised haematomas.
"One in 20 may have a small degree of wound infection, although that can usually be treated with antibiotics as an outpatient," Ferrari says.
Most important, donors need to be healthy. Serious illnesses such as heart disease or cancers, even when in remission, will usually rule people out. Diabetes -- a main cause of kidney disease -- means a would-be donor is automatically barred.
Even when a match is confirmed, Ferrari says, recipients face a 5 per cent chance of rejecting their new kidney in the first year and ending up back on dialysis. There is also an increased risk of developing cancer due to the immuno-suppressant drugs they must take for the rest of their lives, although those cancers are usually non-fatal skin cancers.
Ferrari predicts kidney transplants will increase by up to 10 per cent, or an extra 50 to 60 people, as more live donors are used when the paired program goes national.
"It doesn't sound much but it's actually a lot," he says. "By taking 7 to 10 per cent of patients off the deceased donor list, those (who) remain will reduce their waiting time at least six months. We know that the longer you wait for a kidney, the higher is the chance of not surviving."
The savings also will be substantial. In-hospital dialysis costs more than $80,000 a year a patient. This compares with transplant costs of about $50,000 in the first year and less than $20,000 in subsequent years.
He estimates that if 100 pairs enrolled nationally and 30 transplants were done annually, the savings from avoiding dialysis would be about $3.5million.
Ferrari says people with end-stage kidney disease have contacted him from across Australia offering to move to Perth to participate in his program. But he hopes it won't be necessary after Kevin Rudd's recently created Australian Organ and Tissue Donation and Transplantation Authority confirmed the start date for national expansion was likely to be July 1.
"We have to go national because the chance of finding a match in a paired exchange program increases as more couples take part," Ferrari says.
"We only have 14 pairs in the West Australian exchange program and with that number the chance of finding a match is about 10 per cent. If we have 50 pairs the chance is about 50 per cent."
The new organ donation authority's chief executive Karen Murphy says it is hoped some paired exchanges can happen quickly in other states once the number of pairs build up.
"Paired kidney exchange is a complex process that requires robust and ethical management, but the aim is for a commencement date of July 1 or earlier if possible, pending key staff appointments," she says.
Since the WA trial began in late 2007, nine patients have had successfully transplants through the paired exchange. Six were through two-way exchanges, while the others were in the three-way chain.
All are doing well.
Australian Kidney Health says more than 1500 Australians are waiting for kidney transplants at any one time and, although Australia has one of the world's best transplant success rates, it also has one of the lowest organ and tissue donation rates.
One in three Australian adults has an elevated risk of developing chronic kidney disease and one in seven already has at least one clinical sign of it.
http://www.theaustralian.news.com.au/story/0,25197,25280848-23289,00.html
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