1 in 10 adults globally suffer from chronic renal failure; the burden worldwide is increasing and is calculated to become the 5th most common cause of ‘years of life lost’ by 2040. This pathology currently costs 3% of the healthcare budget of most 1st world countries and is increasing. The main treatment modalities of progressive renal disease are renal dialysis and/or renal transplant.
To be eligible to be considered for kidney transplant, the patient must have chronic irreversible kidney disease with poor response to medical or surgical treatments. Most patients will already be on dialysis or may require dialysis in the near future. The patient must be fit to tolerate an invasive operation, the necessary general anaesthetic and the
postoperative immunosuppressive medication (to prevent organ rejection). Therefore, only a minority of patients with chronic renal failure are eligible for such surgery. Of course, the other main issue is availability of matching organ doners. Ideally a matching live doner (usually a relative) is available, otherwise a cadaveric matching doner. Currently in the UK 1 in 3 kidney donations are from live doners.
Recently, Daoud Chaudhry et al published (in the BMJ) the largest review of the literature evaluating mortality in all studies comparing patients who had primary renal transplantation with those on dialysis who were awaiting transplant. The overall result overwhelmingly supported renal transplantation conferring reduced mortality compared to those on renal dialysis. Although this was the consensus in the vast majority of studies, there were a few studies that did not support this. Therefore, although renal transplant is the gold standard treatment of choice, each individual patient needs to be carefully evaluated for risks vs benefits of transplant and management must be tailored according to their individual needs.
There is a massive shortage of renal physicians and dedicated multi-disciplinary transplant units in many regions of the world, including Western developed countries. There is also a gross lack of nephrology nurses and technicians. The two biggest causes of renal failure are hypertension and diabetes which are often sub-optimally managed resulting in worsening renal disease. As a result, many patients with low grade renal failure worsen due to lack of education and medical care and go on to end stage renal failure.
This study suggests that more patients with chronic end-stage renal disease across the world would benefit with renal transplant. However, given the lack of access to renal physicians and surgeons, effective local transplant programmes and a lack of matching live or cadaveric doners, many patients may only have dialysis available to them and not even be aware that transplant could be more beneficial.
