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Transplanting Too Soon

Kidney transplants can extend lives by 10 years or more

| Monday, Sept. 28, 2009, 11:02 a.m.

Ten years.

That's the projected time a person with kidney disease can gain by getting a transplant instead of lingering on dialysis treatments, according to a 1999 study in the New England Journal of Medicine.

"The standard of care should be to immediately refer patients on dialysis for a transplant," said Dr. Didier Mandelbrot, a nephrologist at Harvard University's Beth Israel Deaconness Medical Center in Boston. "That evaluation should take place even before they start dialysis. After four months on dialysis, there's no excuse to not refer them for evaluation."

The study, which many kidney doctors cite as the basis for medical decisions, showed clear benefits to kidney transplantation over dialysis. People ages 20 to 39 received the largest benefit from kidney transplants, gaining 17 years of projected lifespan over those who remained on dialysis while waiting for a transplant. Indeed, every age group benefited from the surgery.

The amount of time a patient spends on dialysis is linked to the survival rates of the patient's new organ after transplant surgery, according to a study published in the journal Transplantation in 2002.

Five years after receiving kidneys, three-quarters of people who spent fewer than six months on dialysis had functioning organs, compared with 58 percent of those who received treatments for longer than two years.

Ten years after surgery, the disparity was even greater. Nearly two-thirds of people with fewer than six months of dialysis had working kidneys, versus 29 percent of long-term dialysis recipients.

Dr. Richard Marcus, a nephrologist at Allegheny General Hospital, said he encourages all patients with significant chronic kidney disease to consider transplantation and undergo an evaluation.

"The referral for transplantation should definitely be done before someone starts on dialysis," Marcus said. "We ask people to err on the side of referring."

Most patients referred for transplantation are on dialysis, and Marcus said it is unfortunate they are not informed about a transplant option beforehand.

"Clearly, patients deserve to be informed," he said.

A transplant is not an option for every dialysis patient, doctors said, and many times patients realize they have kidney failure when it's too late for them to register on the kidney waiting list before starting dialysis treatments.

For example, it might be too risky to perform such complex surgery on a patient with severe coronary artery disease, said Dr. Paul Palevsky, a nephrologist at the VA Pittsburgh Healthcare System. Patients with cancer or lung disease or those who are morbidly obese might not qualify for transplants.

Still, about 80,000 people on dialysis would benefit from receiving kidneys but are not registered on the waiting list, according to a paper last year in the American Journal of Transplantation.

"Certainly, every transplant center is really battling with the nephrologists to get the patients referred as early as possible," said Dr. Herwig-Ulf Meier-Kriesche, a co-author on the study. "You really have to put a lot of energy into trying to inform everybody and to make that one of their priorities."

It's possible that some kidney doctors do not know about medical advantages of providing kidney transplant surgeries for patients before they start dialysis, Meier-Kreische said. And other factors, such as rules by Medicare and private insurers on when patients can be treated, affect patient referrals.

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