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Dialysis patients have a lower life expectancy than patients living with HIV, breast cancer and prostate cancer.

Consultant Nephrologist at the Queen Elizabeth Hospital, Dr. Lisa Belle, made this startling revelation recently during the hospital’s conference on Live and Cadaveric Organ Transplantations – Truths and Myths, at the Lloyd Erskine Sandiford Conference Centre, Two Mile Hill, St. Michael.

Citing 2006 statistics from the United States Renal Data System, Dr. Belle explained that for every year patients were on dialysis, there was a marked decline in the survival rates. In fact, by the fifth year on dialysis, a patient’s survival rate was said to be that of just 25 per cent.

"To make it worse, they compared it to patients with other chronic illnesses – breast cancer, HIV, [and] prostate cancer and concluded that these patients actually had a better survival rate. For example, the prostate cancer patients at five years… the survival was just under 75 per cent compared to the survival rate for a dialysis patient," Dr. Belle pointed out.

She noted that the mortality rates looked even grimmer when you factored in the ages of those on dialysis. According to the doctor, those between the ages of 40-44, had a life expectancy of about 10 years after commencing dialysis, while patients in the 60-64 age bracket had a 50 per cent mortality rate at five years. When these figures are compared to a patient who has had a living donor transplant, there is a stark difference,

Dr. Belle observed. "Approximately 91 per cent of people who had living donor kidney transplants were alive after five years. And, even if a patient received a cadaver kidney,

the mortality at five years – 84 per cent – was still better than that of a patient on dialysis," she pointed out.

The options for therapy for individuals with Chronic Kidney Disease are: haemodialysis, peritoneal (home) dialysis and renal transplantation. Presently, there are 194 patients at the QEH receiving haemodialysis; 15 on peritoneal dialysis and seven transplantations – those seven are actually not all locally done transplants but take into account the overall number of transplant patients that the hospital manages.

According to Dr. Belle, the statistics at the QEH show that there are more women being treated for kidney disease than men. Women represent 54 per cent of dialysis patients. In addition, kidney disease has proven to be no respecter of age with the hospital treating patients ranging from age eight to 82.

The number of patients on dialysis at the QEH has been increasing exponentially, the renal expert explained. In its infancy, in 1979, there were initially three patients on dialysis, increasing to 150 in 2005 and, most recently, to 209 patients.

"[Dialysis] is life sustaining. For patients who have progressed to end-stage disease, dialysis offers life. It may be the only option for a large proportion of patients. It may be offered acutely for patients – acute renal patients who haven’t developed Chronic Kidney Disease and probably will recover renal function, but dialysis is offered

as support for them during their illness," Dr. Belle outlined. However, the benefits of kidney transplants far outweighed those of dialysis, she said.

??"If you ask a patient who has been transplanted they will probably tell you the biggest thing for them was a better quality of life – they feel better; they have more time; they can travel. Their options to travel have increased because some places don’t offer dialysis and it is a very costly therapy. They also have a wider scope as far as their diet restrictions are concerned. So, being off dialysis is the biggest boost for them. And, while that is also important for us as caretakers, our most important reason for wanting a patient to have a kidney transplant are improved costs. The cost of transplantation is lower," the doctor explained.

It costs the hospital approximately $48,000 to $50,000 annually to treat one dialysis patient. This figure does not include the cost of medication or hospitalisations as a result of complications.

???Comparatively, with renal transplant patients most of the cost is incurred in the first year of transplant.?? This includes the cost of the operation, medication, all the investigations, CAT scans, X-rays, ultrasounds etc., making it more expensive – about $90,000 to $100,000 – than the dialysis patient for that year. However, by the third year, that cost drops significantly to between $20,000 and $25,000 a year. In addition, hospitalisations are fewer and medications are tapered over time so there is less expense,’ Dr. Belle informed the audience.

But, she also warned that transplantation was not for everyone. Patients who access the services of the Artificial Kidney Unit at the hospital are evaluated based on a number of factors. These include: age, since there are more risks associated with surgery, – the age of the patient; whether patients are diabetic, hypertensive or have severe vascular disease or heart disease.

While Dr. Belle said these individuals were not ruled out, she added that if the burden of disease was "heavy enough", it impacted the decision on whether or not they would be transplant candidates. Another important factor was compliance – whether the patient would continue to take the medication once they had the transplant. Social and financial issues are also taken into account, so only about 20 to 25 per cent of patients are actually eligible for transplant based on the criteria.

The consultant nephrologist noted that most patients were not able to find a living donor out of a lack of information on both the part of the potential donor and the patient. This was one of the reasons why living donor transplants could not be the final solution, she said.

She also warned that it was not all smooth sailing after a kidney transplant. There were some early and late risks, as well as complications that could develop with prolonged treatment. The doctor gave a brief history of the transplant programme at the QEH, in addition to its successes and failures.

"Our first transplant patient was in 1987. He had a good functioning graft for about 10 years, after which he developed late rejection and returned to dialysis. He is currently still alive on dialysis. Between 1987 and 1995, nine transplants were

performed on patients. Three are still alive with functioning grafts; two are alive and back on dialysis because of late rejection; two had late rejections and subsequent deaths and there were two early deaths," Dr. Belle disclosed.

There was a hiatus and the QEH returned to doing transplants in 2009. So far, they have done three kidney transplants – two are alive with functioning grafts and there was one early death. One triumph, Dr. Belle shared, was that the longest surviving patient had a renal graft for 20 years and "she seems to be doing quite well".

melissa.rollock@barbados.gov.bb

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