Early Referral for Kidney Transplantation
A patient in his 50s with stage 4 chronic kidney disease (CKD) was referred to the kidney transplant program at Duke in the summer of 2013. His CKD was a complication of type 1 diabetes, which he had been living with for most of his life. He had several other diabetes-related complications but was still physically active and employed and had not begun dialysis yet.
Transplant nephrologist Matthew Ellis, MD, evaluated the patient. “At the time he came to Duke, his estimated GFR [glomerular filtration rate] was a little below 20 mL/minute,” Ellis said. “But he was feeling fine—he wasn’t having any symptoms associated with his kidney dysfunction.”
Do you think this patient would benefit from early kidney transplantation?
Answer: This patient’s outcomes, including life expectancy, can be optimized if he receives a transplant before being exposed to dialysis.
Kidney transplantation is the treatment of choice for renal replacement in patients with end-stage renal disease (ESRD) and, in certain situations, can double a person’s life expectancy when compared with dialysis. Furthermore, transplantation outcomes are optimized when performed before a patient is exposed to dialysis. Unfortunately, most patients are referred for kidney transplantation only after they have begun dialysis; the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) reports that just 2.5% of patients with ESRD undergo transplantation as their initial modality of treatment.
“Patients can go on the kidney transplant waiting list before they need renal replacement, so if they are referred to us when their GFR is around 20 mL/min, we can get them listed early,” Ellis explained. “They can accumulate at least some of their time—or perhaps all of their time—on the waiting list and can avoid dialysis.”
This patient’s estimated GFR of less than 20 mL/minute qualified him to be registered with the United Network for Organ Sharing and placed on the kidney transplant waiting list. An initial evaluation confirmed that he would be an appropriate candidate for transplantation because he was healthy enough to undergo the procedure and tolerate immunosuppressive therapy.
In the United States, there are nearly 100,000 patients on the kidney transplant waiting list and about 20,000 patients receive transplants every year. This means that wait times can be as long as 4 to 5 years for a deceased donor kidney.
Ellis also began the process of evaluating potential living kidney donors for this patient. “In addition to being on the deceased donor list, identifying a viable and compatible living donor before transplantation allows for greater control of the transplantation process,” Ellis explained.
“During the 3 to 5 years that the patient is on the deceased donor list, kidney function usually continues to decline,” Ellis said. “So you just pray that about the time they need renal replacement therapy they get it in the form of a transplant, instead of dialysis. You don’t have control over that with a deceased donor kidney, but you do with a living kidney donor.”
Fortunately, the patient had several compatible living donors—biologically related and unrelated. Ellis pointed out that living donors do not have to be genetically related to the patient for a match to be successful. “Many people have that misconception,” he said. “In some instances, non-related donors may be a better choice, depending on blood typing and immunologic matching.” Other important criteria for finding a suitable match include age, body size, and sex.
“With this patient, we actually started working up a few possible donors at the same time,” Ellis said. Parallel processing of donors, rather than serial processing, is a good strategy if the patient’s insurance allows it.
The patient’s son was ultimately chosen as the most appropriate donor, but the transplant did not proceed immediately because the patient’s kidneys were functioning well enough to support him.
Ellis saw the patient again about 9 months after the patient's son was chosen as the most suitable donor. “His kidney function had declined to the low teens and he just wasn’t feeling well,” Ellis said. Because there was an identified living donor, the kidney transplant team was able to perform the kidney transplant immediately, allowing the patient to avoid dialysis completely.
“That was about 2 months ago. His kidney is working, his energy level is better, he’s exercising, and he feels great,” Ellis said. “I can’t tell you what his long-term outcome will be, but statistics tell us that his kidney will do much better, and he’s likely going to live longer because he avoided long periods on dialysis”.
Ellis said the Duke kidney transplant program receives close to 900 referrals annually but that only 10% to 15% are early referrals for preemptive kidney transplant. He noted, “This is where we could really make a big difference in terms of patient outcomes—if we saw more patients earlier before they are on dialysis.”