Management of end-stage renal disease : Transplant Vs Dialysis
In this episode, we focus on managing end-stage renal disease, comparing transplant versus dialysis. This educational session aims to update physicians on kidney disease management. End-stage renal disease (ESRD) affects over 2.6 million globally, with rising incidence, notably in Asia and the Americas. India's ESRD prevalence is 1,800 per million population, with a significant portion opting for long-term renal replacement therapy. Kidney transplants remain scarce, with only around 10,000 living donor transplants annually, contrasting with millions needing treatment. ESRD's primary causes include diabetes, hypertension, and glomerulonephritis. Treatment options include dialysis modalities—hemodialysis (HD) and peritoneal dialysis (PD)—and kidney transplants. Despite socioeconomic challenges, PD utilization is rising. Late referrals and financial constraints limit access to treatments, underscoring healthcare disparities. Family dynamics influence treatment choices, with kidney transplants offering better survival and quality of life compared to dialysis. Cost-effectiveness favors transplants, with over 1 trillion dollars spent annually on ESRD care worldwide. Efforts focus on prevention, early detection, and equitable access to quality care, with kidney transplants offering the most positive outcomes amid resource disparities.
Dr. Manish Singla
Hello everyone, I am Dr. Manish Singh-Lauret, CIDD, Kydney Specialist from Chandigarh area. Today's topic of discussion is management of end-stage renal disease comparison of treatment modalities, transplant versus dialysis. The discussion is meant for physicians to discuss updates and management of kidney diseases and comparing transplant versus dialysis. This topic is meant for educational flexibility. It is possible that some information on specific drugs is out of the approved label and cell OPHE is not responsible for off-label usage of their burnouts. Because each and the requested to refer to the full describing information before describing any products. Many objectives for today's module and discussion are to get an overview of end-stage renal disease and its different treatment modalities. To understand the factors influencing the choice of different treatment that is why some patients choose dialysis versus why some patients choose transplant. And to understand the outcomes related to transplant and dialysis as treatment modalities. We will discuss today's topic in three sections. First section is overview of end-stage renal disease and its various treatment modalities. Global scenario is that over 2.6 million people are affected worldwide by end-stage immunology. We all know that out of 8 million population 2.6 million are affected. Global health burden is rapidly increasing. And incidence rates are notably high in Asian countries and America. 1.4 million patients receive RRT globally and 8% annual incidence rate of RRT. In Indian scenario, prevalence of ER-ESRD is 1,800 per million population. 10 to 20% of these patients continue with long-term renal disease infection. Next due to ESRD. In 1990, we're around 40%. But this proportion increased to 66% by 20 million. Disease donor kidney transplants rocks 1,500. This is 2022 data by local and approximately 10,000 living kidney transplants. So compared to the huge number of end-stage renal patients, number of transplants is very big. We can clearly see that out of millions of patients, only 10,000 patients undergo kidney transplant. Why such a high number of kidney disease and what are the treatment options available? We all know that diabetes is the leading cause of kidney disease and is the most important cause for end-stage renal disease as well, followed by hypertension and global immunophysics. Then there are some rare causes like cystic kidney disease, urologic causes and other unknown causes. ESRD due to pulmonary arthritis and cystic kidney disease, but commonly initiated with PD or preemptive kidney loss. That is another interesting data point. As per global scenario, if we talk about RRT modalities like diences or transnomis, two modalities, PD and HLE. In America, 83% of these populations are actually 12.7% on PD. Only 3% receive a kidney transplant. In Europe, similar figures can be seen, 85% on HLE, 11% on PD and only 4% to significant kidney transplant. By day 91 of commencing RRT, 82% patients were receiving HLE, 13% PD and 5% had a kidney transplant. In the Indian scenario, comparing the three options of HLE versus PD versus transplant, HLE is the most common modality followed by transnomination. Department of Health and Family Welfare annual report of 2012, 2012 showed that Belsi services around 1.17 million and sessions were around 1 million. This is the number as per department of health and family welfare. And about peritoneal analysis, despite the barriers such as lack of health insurance coverage, probability expensive, PD utilization is still increasing. A total of 8,000 patients on PD by year is recorded. Number of transplants, the disease donor kidney transplant was started. The numbers were 15 and that as we discussed, 10,000 for living. The practices of transplant living versus disease depend a lot on state about how the welfare funding is done, brain death, declaration, practices, personal and religious beliefs, availability of technical expertise and then immunospheric medication costs. So this was a brief about what leads to end-state renal disease, what is the prevalence, what are the treatment modalities. Starting on to section 2, factors affecting choice of treatment. So this is a pathway. CKD risk factors progress to CKD and state renal disease and finally they are treated. Prevention is always better. If CKD has already developed, we shall try to slow the progression. And once the patient has reached end stage disease, a comprehensive care involving not just dialysis modality, but various other factors which needs to be taken care of like bone health, anemia correction, infection prevention, vaccination, maintaining cardio vascular risk. So all these include a comprehensive and innovative care. Challenges in the medical management about maintenance sciences, it is life-sustaining but purely accessible in lower and middle income contracts. Functional dialysis centers, not enough functional centers in the public sector and in the private sector. Again dialysis is costly and prohibitively expensive for lower income companies especially. Rushing these results in the need for the rationing of public sector dialysis beds or catastrophic out of focal explanation. Lower socioeconomic backgrounds, death occurs in majority of patients with an extended analysis due to lack of dialysis facilities and the costs involved. Challenges in medical management of care nutrition. Medical management of KTRs can be challenging and primary care physicians may be unfamiliar with the medical nuances of tearing per these patients including drug toxicity, rejection and graft injury. Infections and malignancies related to long-term immunospression may pose agnostic and treatment challenges. Healthcare professional related factors and the choice of treatment modality. Late reference with an interval of less than one to six months between the first consultation and dialysis initiation. This is usually associated with a very high prevalence of during the complications and socioeconomic costs. On the contrary, early reference to an ephrologist that is more than a year before our RTP gains is associated with improved survey, better quality of life, lower total costs. Early choice depends on factors like age, race, socioeconomic status rather than just the timing of the referral. However, late referral may limit access to PDE. If there is inappropriate evaluation, early referral to an ephrologist is highly neglected. Late referral is a substantial problem associated with management of these patients. Different reported factors influencing the choice of treatment modality. And this depends on availability of treatment modalities, different health care systems, private versus public treatment data and varying patient preferences, whether to do dialysis that are all in hospital is more of a personal choice. Majority of decisions were made involving more patient and neurologist. And reported subjective quality of life and fears and patient reported objective reasons like cost, availability of treatment etc. Several time to dialysis center. Patient had good experiences with all modalities, but experiences were better for more than actually and kidney nose. What is the role of significant others, that is family members, in making this choice about the modality? Many a times there are multiple stakeholders of family members and sometimes they have negative experiences about dialysis or one or the other modality. Family members described a broad range of unexpected negative experiences with these modalities. Needs to disrupted routines, induced negative emotions and imposed challenges and inconveniences. Following efforts are needed to prepare families for end stage disease treatments. More family centered care early and tailored education interventions targeting care partner preparedness. Health care provider family member communication. Relationship dynamics in family member patient in. Homorability of contemporary transplants. Blood groups are other than type O and non diabetic end stage. For significantly associated with higher disease donor transplantation. New comorbidities patients who develop the new onset cardiovascular disease during the waiting time showed a low transplant rate. The risk of cardiovascular event. Most studies also found that the risk of cardiovascular event was significantly reduced among transpondered symptoms. And despite increasing age and comorbidities of contemporary recipient, the relative benefits of transplant still seems to be progressively increasing. Multiple estimates of accessibility to transplantation. It is estimated that over 1 trillion dollars are spent on ESRN. RRT for these patients. In only the heavy financial burden on the health care. Kidney transplant is most positive among the three. Kidney transplant availability in low income to high income moves from 23% to 89%. The industries for kidney transplants. Again, very low in low income and almost universal in high income countries. Number of centers per million population is again from 0.04 to 0.60. Professional variations are seen in kidney transplant availability, accessibility, quality across these different income companies. So we always need to keep this in mind while evaluating data from different countries. What are the ongoing efforts and future solutions for management of such a mammoth problem? Prevention and early detection. Facilities and expertise available in different parts of the country are unequally distributed. Prevention and early detection mandates the involvement of physicians at all levels. These competence, Indian Society of Mythology and educational modules for community physicians with helpful algorithms regarding kidney disease management and timely technology. Welcome initiatives. Governmental provisions of affordable and easily accessible, randomly placed. Clinical reduction in machine transplantation, increasing catabriic donor transplants, these are all helping in improving the care of these patients. Optimal treatment. Kidney transplantation is the optimal treatment for kidney failure in future due to much better quality of life and better sub-iongates. This is how we discussed about modality choices and the effect of socioeconomic status. Moving on to third session. Outcome related to kidney transplant and dialysis. That is how are the short term and long term outcomes compared to these two modalities. So increasing the survival rate, reducing complication and mortality and improving the quality of life. Overall survival rate, cardiac event free survival and rehabilitation. And mortality discretion and in the quality of life, residents, higher socioeconomic status, higher education, positive effectiveness and employment rate. Survival outcomes of kidney transplant versus dialysis, global studies. That respective study on kidney transplant prolongs the survival time and with kidney failure across all candidate age and waiting times. Forward study patients with any KPS attain better survival outcomes and lower risk of death from receiving high KDPI, KDPs, and dialysis without a transplant. Systemically 92% of studies reported a long term survival benefit. So from all this it's very clear that kidney transplant with high KDPI gives better survival compared to dialysis. And we can see in these Kaplan Meyer curves that the treatment term which is kidney transplant has a much better survival compared to the control zone. Either overall survival or cardiac event free survival will hazard ratios. Very much in favor of kidney transplant. In the first year patients are able to better study kidney transplant versus PD. So in the first year patients are able to better study kidney transplant but after adjustment for BMI and L-Bibbin both short term and long term survival in elderly kidney transplant group was better than. Survival rates of kidney transplant versus dialysis. We can see the similar figures that transplant patients are much better. Similarly if we sub-categorize them by age across the age groups transplanted much better than survival compared to dialysis even after 75 years or so. Mortality discussion of the two modalities. Metalligration line for the year of study publication and mortality discussion associated with transplant versus dialysis. The era of study publication was significantly associated with the risk of mortality associated with transplantation indicating that relative magnitude of benefit increased over time. Then quality of life. So transplant experience survival benefits in all age groups better health related quality of life and is cost effective. QOL was significantly and substantially better on transplant recipients. Death sensor graft failure in kidney transplant has improved significantly over the last few decades. Clinical characteristics with higher QOL scores in transplant recipients than in dialysis patients. Contracepiums, urban residents, higher socioeconomic status, better education and dieptic status. These were the significantly associated factors with better QOL. Comparing employment rates in pre and post transplant versus dialysis. Kidney failure patients treated with dialysis or transplant experience difficulties in maintaining their employment due to various health related issues. So it was seen that in dialysis pre-transplant or post-transplant period the patients who had transplant had the best chance of employee compared to pre-transplant or analysis. Coming to the cost analysis and economic assessment. Compared with dialysis therapy, transplant was found to be cost effective. Dialsis cost was estimated to be $7,200,000 for over 10 years per quality and actually competitive and well-matched kidney transplant provided the most positive effective form of replacement therapy. With predicted almost half the cost, we can see the cost analysis of dialysis then various kidney transplants better matched, abu in from bativa, german mismanaged. We can clearly see that dialysis is a cost cumulative. So key messages found today's discussion are that over 2.6 million people are affected by end stage renal disease. For over prevalence in India is 1870 per million and 10 to 20% patients in India continue with long term renal incursable therapy rather than on class. ESRD is characterized by permanently benefited. RRT such as dialysis or transplanting mandatory. Two dialysis modalities are PD and H. Transplant remains the optimal treatment among the three because it gives the best lifespan and quality of life. As of 2017, RRT predominantly our private health care driven initiated and there are over 1,30,000 patients receiving dialysis and the number is increasing by about 2,3,000 per million population reflecting increasing non-v because due to various sectors like funding by government. Kidney transplant is the optimal treatment for these patients associated with the best quality of life.
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