New Hope On Organ Donation? Or False Hope for Americans with CKD

[okarol]

September 25, 2008
New Hope On Organ Donation? Or False Hope for Americans with Chronic Kidney Disease.

By Peter Laird, MD

Senator Specter (R-PA) has entered the arena of the payment for organ donation controversy with the Organ Donation Clarification Act of 2008 that if passed will eliminate some of the prohibitions against financial incentives for organ donation established in the The National Organ Transplant Act of 1984.

The call to action voiced by all that support financial incentives for renal donation is America’s exceedingly high renal related mortality. This is even more tragic for those that will die while waiting on the renal transplant list to receive the “gift of life."  However, I am continually troubled by the rightful outrage shown for our 25% average annual mortality of American CKD-5 patients that is wrongfully diverted into the false hope that an organ procurement system will significantly reduce this unacceptable death rate.

Those that support financial incentives for organ procurement are growing in strength in America and I concede that it is likely only a matter of time before this experiment begins in earnest:

    In a letters to all 100 U. S. Senators, AAKP President Roberta Wager, RN, MSN, states, “As the waiting list for organs grows ever longer, it is time to allow government controlled trials of financial incentives to help increase the number of organ donors. A financial incentive is not necessarily a cash payment: for example, a donor could receive something as simple as lifelong health insurance, or families could receive funeral benefits for the deceased donors.”

    A kidney specialist at Beth Israel Medical Center in Manhattan, Richard Amerling, agrees. "Transplantation provides the best quality of life and survival. Arguments against compensation such as exploitation of the poor, 'commoditization' of the body, and the loss of altruism, are all extremely weak, especially in the face of high mortality on the waiting list."

Nevertheless, I have not once seen data showing expected renal donation rates once these financial incentives are enacted.  For the sake of argument, should the renal donation rate expand by an unrealistic estimated 500 percent (approximately 15,000 transplants to 75,000 transplants/year), what impact would this have on annual American chronic renal disease mortality rates?  Looking at hypothetical estimates using a widely touted 5% annual mortality post renal transplant is instructive:

A)  Current American CKD-5 Death Rate:

350,000 CKD-5 patients with 25% mortality = 87,500 deaths/year

B)  Estimated Death Rate Reduction with 500% Increased Donation from financial incentives:

75,000 CKD-T with 5% mortality = 3,750 deaths/year
275,000 CKD-5 with 25% mortality = 68,750 deaths/year
Total: 72,500 deaths/year

This would be a significant reduction in annual mortality of 15,000 American CKD-5 patients each year and would entirely eliminate the renal transplant wait list.  Yet, even with a hypothetical 500% increased renal donation rate from an incentivized financial system that completely eliminates the renal transplant list, American CKD death rates  would still be substantially higher than that which Japan has achieved for decades with it's consistent and successful approach:

    Differences in Dialysis Practice Are the Main Reasons for the High Mortality Rate in the United States Compared to Japan (Carl M. Kjellstrand, Christopher R. Blagg)

    The cumulative survival of Japanese hemodialysis patients is more than 2.5 times better than that of dialysis patients in the United States (U.S.). The difference is particularly pronounced in older patients, being 4 times better in patients over the age of 50 years. The mortality in U.S. patients has increased from 10 to 25% over the last three decades, but has remained stable at around 10% in Japan.

    There is no obvious difference in patient selection. The Japanese accept almost as high a proportion of diabetic patients as does the United States, and the mean age of incident patients is higher in Japan.

    Renal transplantation, virtually absent in Japan, should increase mortality in U.S. dialysis patients by removing patients with the highest probability of survival, but even if one adds surviving transplant patients and studies prevalent populations, the survival rate is much better in Japan. Genetic factors are unlikely to explain differences in mortality, as older Americans live much longer than older Japanese.

    We speculate that the difference lies in the practice of dialysis. Patients in the United States are generally treated by much faster and shorter dialysis than in Japan. This puts a severe burden on the cardiovascular system of older patients, leading to the poorer survival rate. Japanese physicians also appear to be better trained in dialysis and to spend more time with their patients. The nursing shortage in the United States may also contribute to the increased mortality. Whatever the explanations, the U.S. dialysis community must work to equal and, hopefully, surpass the now superior survival of Japanese dialysis patients.

C) Estimated American CKD-5 Death Rate with 10% annual mortality:

350,000 CKD-5 with 10% mortality = 35,000 deaths/year
     

The American CKD-5 death rate with a complete elimination of our current transplant list with no change in usual dialysis practices for the remaining CKD-5 patients would still be twice the death rate that could be achieved if America adopted the same optimal dialysis practices of Japan for all patients, not just the selected few.

My personal opinion is that American dialysis patients are given false hope when politicians, ethics professors, medical doctors and "resident scholars" place the well being of my fellow renal patients in the hands of those that proclaim a “New Hope”  in unethical renal donation financial incentives when the old hope of a humble Japanese people tolls the truth of our shame.  I feel betrayed by my own colleagues who have ignored the simple truths of optimal dialysis for the unachievable holy grail found in payment for organ donation ethics.  It is a false hope that shall leave many dead in its wake with much pain, suffering and torment that could have been avoided by universal adoption of the same sound optimal dialysis methods that we have already known about for years.

http://www.billpeckham.com/from_the_sharp_end_of_the/2008/09/new-hope-on-org.html

[okarol]

October 10, 2008
Financial Incentives for Renal Transplantation: False Hope for Americans with CKD

By Peter Laird, MD

In my post last week on the false hope of financial incentives for renal donation, I used 75,000 (500% of current levels) as an arbitrarily high level of renal transplantation to demonstrate that even such an unreachable goal would still fall short of Japanese mortality levels achieved without the benefit of renal transplantation.  Zoran Lazarevic responded and compared successive annual survival rates over the course of seven years with 75,000 transplants/ year vs 15,000 transplants/year arriving at the conclusion that this level of transplantation would exceed the Japanese survival rates after 7 years.

Zoran’s point is interesting but not reflective of the actuality that 105,000 new CKD patients/year are added here in America which needs to be included in this actuarial analysis.   

    In the last five years the USRDS has noted a continued growth in the number of treated patients, but a slowing of the incident rates. More than 106,000 new patients began therapy for ESRD in 2005 (2.0 percent more than in 2004), while the prevalent dialysis population reached 341,000 (3.3 percent more), and the prevalent transplant population grew to more than 143,693 (5.6 percent more). Both prevalent populations have more than tripled since 1988, while the number of incident patients has grown 159 percent. Since 1999, however, incident rates have been relatively stable, ranging from 333.1 per million population that year to 347.1 in 2005.

I cranked out by hand 15 years of data with a 2% increase in new CKD patients/year, 75,000 transplants per year with 5% mortality/year, and 25% mortality/year for those remaining on dialysis and starting with a cohort of 350,000 patients as Zoran did.  Contrary to Zoran’s conclusion that survival in America would exceed survival in Japan at seven years, we instead find that it would take 7 years to equal Japan’s mortality rate of 10%.  After 15 years, the total CKD-5 mortality rate with 75,000 transplants/year would still be 9.2% which is within Japan’s average published mortality rates of 8.5-10%.

The significance of this number is that we have established 75,000 as the minimum number of annual renal transplant surgeries that America would have to perform to equal the total survival benefit of optimal dialysis already practiced in Japan for decades. At best, America is only able to muster approximately 15,000 renal transplants each year now and the expected benefit of financial incentives is to increase this number by 10-20%, not 500% as I have done in my hypothetical analysis.  Certainly, there is no medical capacity in America to perform anywhere near 75,000 renal transplants at this time even if that number of donors were somehow available.

The current emphasis on financial incentives for renal transplantation lends a false sense of hope to American dialysis patients because there shall only be a small number of patients that benefit from renal transplantation even with financial incentives, while the vast majority of patients will suffer an unduly high level of mortality who are treated with usual, incenter, three days a week dialysis.  It is unfortunate that the advocates for renal donation financial incentives have not taken to heart that optimal renal care for all CKD-5 patients in America is complementary and not competitive to their goals.  Optimal renal care for all patients, not just the selected few, will reduce costs, improve patient outcomes, and reintroduce quality renal care back to America that we now shamefully lack.

http://www.billpeckham.com/from_the_sharp_end_of_the/2008/10/financial-incen.html