By Peter Laird, MD
Renal transplant is considered the gold standard renal replacement treatment for American ESRD patients. The longest living survivors of renal transplant such as Nancy Spaeth and Dr. Robin Eady defy the odds stacked against any person in with severe renal failure. The median survival once on dialysis is only 36-38 months depending on whether patients choose conventional in-center hemodialysis or peritoneal dialysis. (here) For those such as Nancy Spaeth and Dr. Eady, their survival since the original days of Dr. Scribner's Seattle program through today came about by a combination of hemodialysis, PD and renal transplantation. For long term survivors, multiple modalities and often successive transplants is common.
Renal transplantation is complicated in patients with high levels of antibodies most often accumulated from multiple blood transfusions. The USRDS notes troubling trends in blood transfusions even in candidates for renal transplant where the transfusions can delay the hoped for transplant.
Surprisingly, there are no data regarding transfusion frequency, factors associated with transfusion administration in patients on the kidney transplant waiting list, or transfusion impact on graft and recipient outcomes. We used United States Renal Data System data to identify 43,025 patients added to the waiting list in 1999-2004 and followed through 2006 to assess the relative risk of post-listing transfusions. In 69,991 patients who underwent transplants during the same time period, we assessed the association between pre-transplant transfusions and level of panel-reactive antibody (PRA) at the time of transplant, and associations between PRA and patient outcomes. The three-yr cumulative incidence of transfusions was 26% for patients added to the waiting list in 1999, rising to 30% in 2004. Post-listing transfusions were associated with a 28% decreased likelihood of undergoing transplant, and a more than fourfold increased risk of death. There was a graded association between percent PRA at the time of transplant and adjusted risk of death-censored graft failure, death with function, and the combined event of graft failure and death. These data demonstrate that transfusions remain common and confirm the adverse association between transfusions and PRA, and high PRA and inferior graft and patient outcomes.
Delays while on the renal transplant list can be deadly, especially for those on conventional in-center hemodialysis or PD and not on daily home hemodialysis or nocturnal home hemodialysis which offers survival rivalling cadaveric transplant. (here and here) The issues of blood transfusions in dialysis patients is likely to become more prominent now that Hb parameters of dialysis patients has no minimum level. While the debate over the level of Hb needed for optimal quality of life remains unsettled except of course by patients themselves who know how they feel at each level, those with lower levels subject themselves to increased risks of transfusion under emergency blood loss. Dialysis patients have a high risk of bleeding from the stomach and intestines. The troubling trends that USRDS documents will continue.
Patients as in most matters medical must become their own best advocates. Dr. Scribner believed that dialysis patients should know more about their disease than their doctors. The risks and benefits of EPO are well documented. Cardiovascular events and increased risk of cancer top the list. However, for someone contemplating renal transplant, the added burden of blood transfusions pushes the risk benefit analysis back into the direction of continued EPO use for those that need this support. I would hope that nephrologist would take these issues into consideration not only for those that have expressed interest in renal transplant, but also for those that may be a candidate in the future.