Kidney transplantation as primary therapy for end-stage renal disease: a National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (NKF/KDOQITM) conference

Abstract

Background and objectives: Kidney transplantation is the most desired and cost-effective modality of renal replacement therapy for patients with irreversible chronic kidney failure (end-stage renal disease, stage 5 chronic kidney disease). Despite emerging evidence that the best outcomes accrue to patients who receive a transplant early in the course of renal replacement therapy, only 2.5% of incident patients with end-stage renal disease undergo transplantation as their initial modality of treatment, a figure largely unchanged for at least a decade.

Design, setting, participants, & measurements: The National Kidney Foundation convened a Kidney Disease Outcomes Quality Initiative (KDOQI) conference in Washington, DC, March 19 through 20, 2007, to examine the issue. Fifty-two participants representing transplant centers, dialysis providers, and payers were divided into three work groups to address the impact of early transplantation on the chronic kidney disease paradigm, educational needs of patients and professionals, and finances of renal replacement therapy.

Results: Participants explored the benefits of early transplantation on costs and outcomes, identified current barriers (at multiple levels) that impede access to early transplantation, and recommended specific interventions to overcome those barriers.

Conclusions: With implementation of early education, referral to a transplant center coincident with creation of vascular access, timely transplant evaluation, and identification of potential living donors, early transplantation can be an option for substantially more patients with chronic kidney disease.

Figure 1.

Expenditures associated with institution of long-term dialysis for patients transitioning from chronic kidney disease (CKD) care to renal replacement therapy (RRT) in 2003, by age. Per-person per-month expenditures for the transition to ESRD Medicare, incident patients with Medicare as primary provider; Medstat/employee group health plan [EGHP], patients enrolled for full year in both 2003 and 2004 (5).

Figure 2.

Decline in functional status associated with institution of dialysis, recovery, then a secondary decline associated with transplantation. Preemptive transplantation, by reducing transitions from two to one, has the potential to decrease substantially the adverse impact of RRT on quality-of-life measures (Rebecca Hays, NKF/KDOQI Conference on Early Kidney Transplantation, Washington, DC, 2007).

Figure 3.

By estimating per-month expenditures for patients aged 45 to 64 as 85% of those documented in a 67-yr-old, it is possible to approximate the financial impact of preemptive transplantation versus transplantation that occurs after 12 mo of hemodialysis. At 2 yr after onset of RRT, expenditures for the patient who undergoes preemptive transplantation are 34% less than in a comparable patient who undergoes 12 mo of hemodialysis before transplantation. In general, the longer a patient spends on dialysis before transplantation, the greater the cost savings that might accrue with preemptive transplantation (Eugene Schweitzer, NKF/KDOQI Conference on Early Kidney Transplantation, Washington, DC, 2007).

Figure 4.

Impact of duration of time undergoing dialysis on allograft survival at 10 yr after transplantation for recipients of kidneys from living (LD) and deceased (DD) donors (7).

Figure 5.

Comparison of Medicare reimbursement to a nephrology practice on an annual per-patient basis for care of a patient on dialysis (at two different frequencies of visits) versus posttransplantation office visits (assuming one visit per month) at three different levels of care. In most practices, transplant recipients are seen much less often than on a monthly basis (Andrew Howard, NKF/KDOQI Conference on Early Kidney Transplantation, Washington, DC, 2007).