Management of End-stage renal disease: Transplant Vs. Dialysis
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Worldwide, around 26 lakh individuals are affected by end-stage renal disease (ESRD), and in India, the incidence rate is 187 cases per lakh people. This adds to the escalating global health burden associated with the disease. Over 20% of ESRD patients remain receiving renal replacement treatment over the long term. In the Indian context, the selection of treatment modalities for ESRD commonly involves hemodialysis as the primary choice, followed by transplantation. Despite obstacles like insufficient health insurance coverage and the considerably high recurring costs, there is a growing trend in the utilization of peritoneal dialysis (PD).
For individuals with ESRD, renal replacement therapy, such as kidney transplantation, is imperative. The procedures involved are shaped by a range of factors, encompassing state welfare funding, protocols for declaring brain death, personal religious beliefs, the availability of technical expertise, and the affordability of immunosuppressive medications.
In this episode of TRANSFORuM, Dr. Sudeep Singh Sachdev discusses the topic of "Management of End-Stage Renal Disease: Transplant vs. Dialysis." The speaker goes over the factors that influence the decision to choose between transplant and dialysis as treatment modalities, gives a general overview of end stage renal disease and its various treatment options, and discusses the results of each option.
Dr Sudeep Singh Sachdev Video_Ver_01
A very good evening to everyone. I am Dr. Sudeep Singh Sachidev and I am currently the Director and Senior Consultant of Nephrology and Renal Transplant at Narayana Super Speciality Hospital Guru Ground. So today I'll be taking up a very important topic that is the management of end-stage renal disease, transplant versus dialysis. So I'll be talking about what are the various options of end-stage renal disease which are available to us. And what is it, the therapy that we can provide, whether it should go for kidney transplant, whether to go for dialysis, and what are the other various options that are available to the patient, and what option should a patient opt for. So it not only depends upon the characteristics of the patient, but it also depends on the availability of the nephrologist, the various facilities, the healthcare facilities, and the near vicinity available to the patient. And then we'll discuss about the different scenarios in developing countries and developed countries and how we can deal with these scenarios and how we can improve the patient outcome as well as a graft outcome with the patient undergoes kidney transplant. So I'll be starting with the learning objectives. So first we have to get an overview of the end-stage renal disease and the various treatment modalities available to us to understand the factors influencing the choice of different treatment modalities for end-stage renal disease. And to understand the outcomes related to transplant and dialysis, both has treatment modalities available to an end-stage renal disease patient. So first section I'll be talking about the overview of PSRD and the different treatment modalities which are available to us as a nephrologist which we can offer to the patient. So firstly coming to the epidemiology of end-stage renal disease over 2.6 million people are affected by ESRD worldwide. The global health burden of ESRD is rapidly increasing and why is that? Because the most common causes of end-stage renal disease would be diabetes and hypertension and these two comorbidities are extending over the entire world like an epidemic even though they are non communicable diseases because of the sedentary lifestyle, because of the food that we eat has fatty fried items, the less physical activity that one is doing and increasing diagnosis of such diseases at an earlier stage. It is because of this that the disease is rising at a rapid pace and year on year we'll see that the incidence and the prevalence of end-stage renal disease is rising. So if we talk about various continents, you'll see that the incidence rates were notably higher both in Asia as well as the United States of America. Here you can see in the US it ranges from 300 to 400 per million population while in India it would be slightly lower 100 to 100 per million population. So around 1.4 million people or patients actually receive renal replacement therapy globally and 8% is the annual global incidenc rate of renal replacement therapy. So as you can see these numbers are pretty high and kidney disease end-stage renal failure is becoming one of the major cause of comorbidities and modalities and this is causing a huge huge debt on the healthcare system of every country. So one has to find ways of diagnosing it early preventing it if possible and once you reach that stage you should have a protocol in your mind that what are the various modalities available to a patient and seeing that particular patient in which direction one should proceed. So continuing the epidemiology of ESR in India the prevalence of ESRD is 1870 per million population the debts due to ESRD are 40.4% in 1990 and this went up to a higher percentage of 66.7% in 2020. So you can see even after the diagnosis the mortality rate is extremely high so it's an extremely dangerous disease patients are getting affected early and if you don't diagnose this disease and don't take the proper treatment then mortality is a pretty common outcome which happens with these patients. Only 10 to 20% of ESRD patients in India will actually continue long term renal replacement therapy. So you can see those patients who don't receive transplant most of them would require long term dialysis whether it is hemodialysis or peritoneal dialysis and because of the severe constraints which are there in our country financial social and so on only 10 to 20% of these ESRD patients actually receive long term renal replacement therapy. If we go according to the data of notto of 2022 the disease donor kidney transplant in our country was 1589 and the life donor kidney transplant was 9,834. This is still you know a small number if we compare it to the prevalence of the disease in our country. So there is a lot more scope to improve the transplant program in our country. So what are the primary causes of ESRD and the treatment modalities? The most common causes are diabetes which accounts for 20 to 40% cases of ESRD hypertension which accounts for 11 to 30% cases and from there on we have various other causes like glomello nephritis, 11 to 24% cases genetic diseases for example cystic diseases, urological causes including obstruction, stones, prostate problems and so on and there are certain other unknown problems which can for example like chronic developed interstitial disorders which can also lead to kidney failure where the causes are unknown. So the outcomes which are available for the patients are either you go for hemodialysis which could be an incentive hemodialysis or home hemodialysis, peritoneal dialysis or go ahead with a preemptive kidney transplant. So it has been seen that individuals who suffer from ESRD due to either glomello nephritis or cystic kidney disease were more commonly initiated on either peritoneal dialysis or undergo a preemptive kidney transplant rather than hemodialysis. So the choice of treatment modality for ESRD what is the global scenario? So let's compare the US data with the European data so according to the US RDS data greener replacement therapy such as dialysis or kidney transplant patient is mandatory for ESRD and the two dialysis modalities which are available are both peritoneal dialysis and hemodialysis. So according to the US RDS data of 2020 ESRD patients were 83.9% were initiated on hemodialysis and 12.7% of these patients were initiated on peritoneal dialysis while only 3.1% of the individuals received a kidney transplant as the initial mode of ESRD treatment where as we compare this to the European data of 2017 the treatment modality at the start of renal replacement therapy was hemodialysis for 85% of the patients peritoneal dialysis for 11% of the patients and a kidney transplant of around 4%. So you can see that the percentage of kidney transplant is the lowest in both the countries as the first form of treatment for ESRD and the majority of the patients actually undergo hemodialysis at first being diagnosed that they have ESRD. When we continue this data by day 91 the commencing RRD patients were 82% out of the 85% which started treatment with hemodialysis at the time of ESRD 13% of the patients were on peritoneal dialysis and 5% had a kidney transplant so as you can see as the longevity on ESRD increases patients tend to undergo kidney transplantation. So what is the choice of the treatment modality for ESRD especially in the Indian scenario should we go over hemodialysis, peritoneal dialysis or transplantation. So HD is the most common modality followed by transplantation according to the data published by the health and family welfare in 2021-22 the number of dialysis services were given to 1.178 million people and the number of hemodialysis sessions were 12.037 million. When we talk about peritoneal dialysis despite all the barriers for example the lack of health insurance as PD is a pretty expensive therapy along with that expensive recurring cost PD utilization is still increasing in our country year on year if we see the data the number of people actually being initiated on peritoneal dialysis for end-stage renal disease is rising a total of 8500 patients on PD per year has been recorded and now coming to transplantation which according to in my opinion is the most curable and the best form of treatment for a end-stage renal disease patient. So according to the data of not only in 2022 the number of disease donor kidney transplants was 1589 the number of live donor kidney transplants was 9834 the transplantation practices actually dependent upon a large number of factors for example the state welfare funding the brain death declaration practices the personal religious beliefs of the people and availability of technical expertise and expensive immunosuppressive medication so you can see there are a host of factors and some of them are dependent on the patient and his religious beliefs while other independent upon the expertise or the financial issues like one can afford the expensive immunosuppressive medication here on lifelong so you have to take a congregation of all these factors to actually decide whether a person should undergo which modality because doing a transplant at that moment of time would be fine but if the person doesn't have finances to sustain himself and even buy the medications which are important to continue kidney transplantation post the transplant by taking immunosuppressive medication then there is no point in actually undergoing the transplant so one has to see the economic status of the person as well so now in the section two we'll be talking about the various factors affecting the choice of treatment as a modality for end-stage renal disease patients so the ESRD pathway for choice of modality chronic kidney disease risk factors if we see all those risk factors and we treat them early we would prevent chronic kidney disease altogether and this this would prevent occurrence of end-stage renal disease thus making our task a lot more easier less number of patients requiring dialysis of kidney transplantation once the patient has already entered the stage of chronic kidney disease our focus should be delaying or preventing end organ damage that is end-stage renal disease and preventing the complications related to that once the patient has reached ESRD stage then he requires a comprehensive conservative care which includes diet management which includes various medications in order to control his metabolic parameters and undergoing treatment of end-stage renal disease would be would be either in the form of a hemodialysis where he would have to undergo maintenance hemodialysis either twice or twice a week or peritoneal dialysis which is a continuous modality the number of sessions varying from 3 to 4 in 24 hours where fluid is kept in the abdomen and it helps to clear urea creatinine other toxins depending on the peritoneal membrane filtration parameters or the most definitive form of treatment which would be kidney transplantation so what are the challenges in the medical management of dialysis maintenance dialysis is life sustaining but it is poorly accessible in low and middle-income countries then functional dialysis centers they are not enough functional dialysis centers in the public sector and in the private sector and dialysis is prohibitively expensive rationing this results in the need for need factor rationing of public sector dialysis beds or catastrophic out-of-pocket expenditure so the number of patients are so many who require dialysis or have opted for hemodialysis that the number of machines are less it is an extremely expensive therapy and is mainly concentrated on the private sector so economics or finances also become an issue and now the government has started coming up with various charitable institutes or sustainable form of dialysis programs which are cheaper but again you have to then rush and out and decide which patients would be the first to be taken on the list how many times in a week we can actually do dialysis often the duration of dialysis also seems to be compromised and these problems are more in the lower socio-economic backgrounds because of all these problems that occurs in the majority of the patients of lower socio-economic backgrounds because either dialysis cannot be initiated or maintenance hemodialysis cannot be continued in the frequency where it has been advocated so what are the challenges in the medical management in kidney transplantation it is not true that kidney transplant is doesn't have its own share of problems or challenges because once the patient undergoes transplantation then the the game or the ball game as they say has just started so you have to make sure that the kidney sustains its function for a long period of time as long as possible you detect even the slightest bit of kidney damage which can be in the form of either protein leakage or rise of creatine which could be asymptomatic and most importantly the person has to continue immunosuppressive treatment post transplant so that he or she doesn't undergo rejection so the medical management of kidney transplant recipients can be challenging the primary care physicians most of them in our country are unfamiliar with the medical nuances of taking care of post kidney transplant patients excuse me which include drug toxicities rejections and graft injuries and another facet of immunosuppressive medication is the increased risk of infections especially the rare ones and the severe ones as well as developing various malignancies as the immunosuppressive medications they have an increased risk of causing malignancies in patients who are on this treatment for a long period of time so let's talk about the healthcare professional related factors about the choice of treatment modalities so it not only depends on the patient it also depends on the finances it depends upon your environmental exposure to various centers and doctors who can you can undertake a dialysis or a kidney transplant and then it also depends on your healthcare professionals who are treating you so a late referral with an interval of less than 1 to 6 months between the first consultation and a renal replacement therapy initiation is associated with the high prevalence of uremic complications and socioeconomic cost so in other words if one is referred late to a nephrologist then the prognosis is poor and there is a substantial problem associated with ESR ASRD management and the improvements are relatively less on the contrary if a patient is referred only to a nephrologist that is more than a year before the RRT begins then this is associated with an increased survival improve quality of life and a lower medical cost so when you find a patient as a physician that has kidney problems the patient has renal failure or the creatine is rising rapidly or even if it is deranged and the patient is of a young age then it is best to refer the patient to a super specialist nephrologist who can evaluate find the cause and delay the progression of the disease however if there is an inappropriate evaluation and delayed treatment occurs early referred to a nephrologist is highly recommended so the modality choice depends on factors such as age, race, socioeconomic status and rather than on the timing of the nephrologist referral however late referral also may limit the access of patient to peritoneal dialysis so the congregation of factors exists which decide what to do with the patient when he or she first gets diagnosed with kidney failure or end stage renal disease so the patient reported factors influencing the choice of treatment modality the choice of treatment depends upon the availability of the treatment modalities the different healthcare systems and the varying patient preferences the majority of modality decisions are taken by involving both the patient and the treating doctor which is a nephrologist now the patients reported subjective quality of life factors and fears in taking up the modality of choice and there are objective reasons also for example the cost of the availability treatments which are there for ESRD so patient had good experience with all modalities but experiences are best with either home modalities or kidney transplantation then we talk about the role of the family members in the choice of treatment modalities so family members have an extremely important role to play for the treatment of an ESRD patient the patient requires huge amount of social mental physical and emotional support and negative experiences can significantly outcome change the of ESRD patient treatment especially even from the family members point of view so family members describe a broad range of unexpected negative experiences with ESRD treatments this could be the form of disrupted accustomed routines induce negative emotions and impose practical challenges and inconveniences so lots of efforts have been taken to prepare the families of ESRD patients more family centered care early education which is tailored towards the cause of the disease and the treatment of the disease and the future prognosis intervention targeting care partner preparedness healthcare provider family member communication and relationship dynamics in the family member and the patient so one not only has to work upon the patient but the family members also have to be confident in detail that how they have to take this forward how they have to help the patient because the patient requires huge amount of social mental physical support so the comorbidity of contemporary transplant recipients so those patients who develop new onset cardiovascular disease during the waiting time have showed a lower transplant rate compared with those who don't develop these new comorbidities so patients of kidney failure are likely to have let's say coronary syndromes or unstable enzymes to the tune of 20 times as compared to a similar normal healthy person of the same age group so if you are diagnosed with that during your waiting time of a kidney transplant then you are likely in all possibility not to undergo the transplant if the damage is severe to the heart and this will significantly and adversely affect your future outcome so despite all factors ages four morbidities the temporarily transplant recipients have been having relatively more benefits of kidney transplantation over a period of time and it has been seen and the data has suggested according to this publication which was in the transplant journal but you are not at all that blood groups other than type O and non-diabetic ESRD was significantly associated with a higher likelihood of disease tone of kidney transplantation so it depends not only on the other blood group but also the kind of disease you have that leads to ESRD so non-diabetics are more likely to undergo successful kidney transplantation and most studies have also found that the risk of cardiovascular events was significantly reduced after transplant recipients so all parameters are actually favoring kidney transplantation as the best modality of choice for end-stage needle disease patients so now we talk about the global estimates of accessibility to kidney transplantation it is estimated that this causes huge burden on the economy and over one trillion dollars are actually spent on ESRD globally renal replacement therapy work patients with ESRD impose a heavy financial burden on the healthcare systems in many countries kidney transplantation still remains the most post effective RIT modality so if we can see the kidney transplant availability goes on increasing as we go from a lower income to a higher income this thing group in a developing or a developed country so from 23% to 89% in wages from and the registries for kidney transplantation also in countries born increasing as the socio-economic strata improves and the number of centers which perform transplant significantly improves with their access to sub centers especially the private centers which are hugely costly so substantial variations are seen in the kidney transplant availability accessibility and quality worldwide and the lowest rates are actually evident in low and lower middle income countries so what are the ongoing efforts in the future solutions for ESRD first is prevention and early detection there should be various facilities and expertise available in different parts of the country and they should be equally distributed prevention and early detection mandate the involvement of physicians at all levels so it is one of the most important things to educate all primary care physicians about the various kinds of kidney symptoms that are there that are what are the early warning signs and symptoms of kidney disease so that they can diagnose the disease early then they refer the patient early to a nephrologist in case they find a kidney disease which is hard to handle and then treating it properly and the patient being provided with all the social support the financial support in order to continue therapy so there has to be an increasing competence whether Indian society of nephrology has made educational modules for the community positions with helpful algorithms regarding kidney disease treatment and a timely nephrology reference these modules should increase competence and need to uniformity of delivery care so the society is also playing its role in its way the best it can they should be welcome initiatives governmental provision of a affordable and easily accessible RRT a drastic reduction in commercial transplantation and an increase in a disease donor transplants are improving the care of patients with ESRD so having a better or improved disease donor kidney transplant program is one of the most important goals that this country has to aim for and we have to try and mimic what is happening in the West and in more developed countries where the program is really robust and is helping and saving the lives of millions of ESRD patients optimal treatment in the form of kidney transplantation should be provided to a patient of kidney failure in the future and it will be really helpful in living a good quality of life and better survival when we compare this to either form of dialysis the section three we'll be talking about the outcomes related to kidney transplants and dialysis so the various outcomes which are related to kidney transplants so kidney transplantation increases the survival rate the overall survival rate the cardiac events free survival the survival even in elderly patients whether they are above the age of 65 or 75 reducing complications and mortality which is significantly the mortality risk ratio is better in patients who I've undergone kidney transplantation as compared to patients who are on dialysis and peritonial dialysis or hemodialysis the amount of mortality risk is much higher on dialysis patients as compared to kidney transplant patients and improving the quality of life whether it means living in a better residence having a higher socioeconomic strata and going ahead with higher education pursuing employment or an education in a higher institute and even cost effectiveness so you'll be surprised to know that kidney transplantation is actually cheaper than undergoing hemodialysis long term or peritonial dialysis long term coming to the survival outcomes of kidney transplantation versus dialysis what do the global studies have to say if we take retrospective studies kidney transplantation prolongs the survival time of persons with kidney failure across all candidate ages and waiting times so definitely it is the best form of therapy according to the retrospective analysis cohort studies show that patients who have had any karnoskey performance scores attain better survival outcome and lower risk of death from receiving high kidney donor patient kidney transplant than dialysis without a transplant so again cohort studies also favoring kidney transplant and the systematic review 92% of the studies have shown long term survival benefits of the patient with transplantation rather than dialysis so all three of data is actually favored transplantation over any other form of dialysis so here we can clearly see that this graph shows that the patient survival was significantly better in the kidney transplant group as compared to the matched group so this is the kidney transplant group this is the survival probability this is the matched control group and as we can say that as time rolls on in terms of months or years the transplantation still holds to be the most significant and best form of treatment therapy in terms of the survival rate even if we talk about the cardiac event free survival rate here we can see that a patient undergoing transplant has a significantly better cardiac survival rate as compared to a patient who's undergoing any other form of treatment in the dialysis group so kidney transplantation has better clinical socioeconomic benefits than maintenance dialysis when we compare the survival outcome in an elderly Indian ESRD patients receiving a kidney transplant or a peritoneal dialysis so here you can see that in the first year a body in this study which was published by call at all in in general of nephrology the first year outcome of peritoneal dialysis was better as compared to kidney transplants as you can see however as time rolled on and one adjusted for the BMI and albumin both the short term and long term survival in elderly kidney transplant patients was better in transplant group significantly as compared to the peritoneal dialysis group where you can see at 10 years the technique survival of peritoneal dialysis is almost negligible and when we compare the graft survival versus the technique survival here you can see even an elderly ESRD patients kidney transplantation was significantly better as compared to peritoneal dialysis so we should not with kidney transplantation according to even patients who are more than 65 years o pair or elderly age group so elderly age groups also should undergo kidney transplantation because it is significantly better form of therapy when compared to either hemodialysis or peritoneal dialysis now comparing survival outcomes in elderly Indian ESRD patients receiving kidney transplant versus dialysis so when we compare with hemodialysis a superior survival rate was observed in kidney transplant to dialysis at the same time interval so whenever we compare even in short term or long term or to 70 years here we can see clearly that kidney transplantation patients do much better as compared to dialysis patients and when we compare in terms of age group you will find that people who are greater than age of 65 years have a superior survival rate as compared to people who are greater than 75 years of age at the same time interval the first third and fifth year so as you can see the survival rate is actually better for people aged above 65 but even the survival benefit does exist even if you are over the age of 75 and undergoing kidney transplantation when we compare that with dialysis whether it is hemodialysis or peritoneal dialysis so when we talk about the mortality risk ratio of kidney transplantation versus dialysis here we can see that the meta regression line for the year of study publication which is 2011 the mortality risk ratio associated with transplantation and dialysis patient you can compare the two and as time goes on the difference between the two graphs is actually widening the in thus showing that as years have progressed the outcome is much better with kidney transplantation as compared to dialysis patients or in other words the mortality ratio or the mortality risk is much higher with dialysis as compared to transplant patient so now we talk about the health related quality of life with kidney transplantation and versus dialysis so when we compare kidney transplant recipients with dialysis patients in terms of the various parameters of quality of life the survival benefits amongst all age groups are better for kidney transplantation they have a better health related quality of life kidney transplantation is most more cost effective as compared to dialysis quality of life was significantly and substantially better for transplant recipients the deaths censored graph failure in kidney transplantation has improved significantly over the last 25 to 40 years so transplantation and the research or transplantation is is just evolving at such a rapid pace that now ab you incompatible highly sensitized transplantation all can be done successfully with almost the same rate of success so it is extremely important that transplantation if a donor is available or disease donor kidney transplantation if you have a robust program one should go ahead with transplantation rather than dialysis then when we talk about the clinical characteristics higher quality of life scores were seen in transplant recipients than in hemodialysis patients transplant recipients tend to be living more in urban residents have a higher socioeconomic status a higher education diabetic status all these are significantly better in transplant recipients as compared to patients undergoing dialysis even if we compare the employment rate in pre and post kidney transplantation versus dialysis you can clearly see that the employment rate post transplant is the highest then second comes the pre transplant and thirdly amongst patients who are on hemodialysis or peritoneal dialysis so dialysis patients have the least rate of employment of kidney disease patients as compared to pre transplant or post transplant patients so it was really hard in under the words for people to maintain employment while undergoing dialysis alongside thus adding to the constraints of the economy so when we just talk about purely about economically that what is costly whether a transplantation and dialysis dialysis and this is a study you just published in the American Journal of Transplantation by Axelrod DA at all in 2018 you can see that compared with dialysis therapy transplantation was found to be more cost effective resulting in substantially lower cost for quality of life here so here you can see on this graph now the yellow dot is dialysis which is extremely costly and they were talking about 10 years now here and an ABO compatible transplant was the best form of therapy which was available as compared to an incompatible transplant which was more costlier as you can see here or even an ABO incompatible so an incompatible transplant which was highly sensitized transplants is costlier as compared to an ABO incompatible versus a patient who is a well-matched kidney transplant so the maintenance dialysis cost if we estimate over 10 years comes out to be 72,476 dollars while an actually compatible well-matched live donor kidney transplant is the most cost effective form of real replacement therapy and it is 45% less expensive than dialysis so you can see undergoing kidney transplantation with a well-matched donor is actually the best form of treatment when we talk about its burden on healthcare costs so last but not the least I will just be now conveying the key messages of this entire presentation so around 2.6 million people are affected by ESRD worldwide the prevalence of ESRD in India is 1870 people per million 10 to 20% of ESRD patients in India continue with long-term renal replacement therapy which is a very low figure and our objective should be to provide facilities and to help these patients in some way so that they can continue their life-saving form of therapy for a longer time and increase the mortality ratio which is actually increasing with time ESRD is characterized by permanent kidney failure at this stage RRT such as dialysis of kidney transplantation is mandatory the two dialysis modalities which are available to these patients are either peritoneal dialysis or hemodialysis kidney transplantation remains the optimal treatment of choice for management of ESRD it provides a longer lifespan a better quality of life and lower healthcare costs as of 2017 RRT is predominantly a private healthcare driven initiative there are over one lack 30,000 patients receiving dialysis and the number is increasing by about 232 per million population a reflection of increasing longevity in general kidney transplantation is the optimal treatment for kidney failure in the future due to the association with the better quality of life and a survival as compared to dialysis thank you
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