Epidemiology

Odds of getting new kidney uneven

Last Updated: 2010-09-03 15:55:06 -0400 (Reuters Health)

By Frederik Joelving

NEW YORK (Reuters Health) - Patients with kidney disease tend to get onto the transplant waiting list earlier in the course of their disease if they've already had some other solid organ transplant, a new study shows.

Most patients don't get listed for a kidney transplant until they've been on dialysis. But more than one in three patients with prior organ transplants get listed preemptively, before they needed dialysis, according to researchers who examined a U.S. registry of transplant recipients.

Such preemptive listing is known to improve survival chances, but happened only in about one in five kidney disease patients who hadn't received a transplant previously.

Getting a kidney transplant depends mainly on how long a patient has been on the list, whereas for hearts, lungs and livers, the sickest patients get top priority, said Dr. Titte Srinivas of the Cleveland Clinic in Ohio, who led the new study.

"People can wait for years before they get a kidney," said Dr. Srinivas. Of those older than 60 years, he added, "about half of them won't live to be offered a kidney."

The new study, published online September 2nd in the Clinical Journal of the American Society of Nephrology, followed more than 330,000 people placed on the kidney waiting list between 1995 and 2008.

The number of candidates who'd had previous heart, lung or liver transplants more than tripled during that period, reaching almost 5,000 in total.

Women had better odds of being added to the list, as did patients who were white, had private insurance or had received a previous organ transplant.

One possible explanation, the researchers write, is that patients who've already had one transplant are in close contact with their transplant centers, where the doctors might recognize the need for a new kidney before a primary care doctor would.

The disparity "certainly may not have been intentional in any way but raises a serious ethical concern related to justice," said Kerry Bowman, a clinical ethicist at Mount Sinai Hospital in Toronto, Canada, who was not involved in the research.

"Physician advocacy is a positive aspect of medicine but cannot trump the elements of justice built into waiting lists," Bowman told Reuters Health in an e-mail. "Justice is the foundation and goal of transplant waiting lists and transplant ethics in general. Policy and procedures in this domain need attention on ethical grounds."

Dr. Gail Van Norman, an anesthesiologist and bioethicist at the University of Washington Medical Center in Seattle, pointed out that the uneven odds of making the waiting list could also reflect the type of patients who've had an earlier transplant.

"They are generally savvy, mainstream healthcare consumers, probably even before they received a transplant," Dr. Van Norman, who was not part of the new study, said in an e-mail to Reuters Health.

Dr. Srinivas said doctors might speed up things, wittingly or unwittingly, because patients with previous organ transplants tend to do poorly on the kidney waiting list. On average, his results show, these people tend to deteriorate faster once they're listed, usually surviving less than four years -- or about half as long as those on the waiting list who hadn't received a previous transplant.

"I don't think anybody is doing something really unfair," he said.

Patients with a transplant history "are frequently listed preemptively but have rapid decline once placed on the waiting list," the research team concludes. "Targeted use of expanded-criteria donor and living-donor transplants in (this) population may be particularly important given their high mortality on the waiting list."

SOURCE: http://link.reuters.com/cew98n

Clin J Am Soc Neph 2010.