Home Hemodialysis vs. Transplant: The Elephant in the Room

This blog post was made by Dori Schatell, MS, Executive Director, Medical Education Institute on September 25th, 2014.
Home Hemodialysis vs. Transplant: The Elephant in the Room

If you’ve ever watched Jon Stewart or John Oliver, you may have seen one of those tape reels where they show how the same messages are given out over and over again by different sources. This is a lot like what I see happening in nephrology re: transplant survival:

  • Kidney transplantation is the treatment of choice for end-stage renal disease, with improved mortality and quality of life compared with dialysis.” i
  • Kidney transplant improves quality of life and survival compared with dialysis.” ii
  • “…great advantage in survival and considerable socioeconomic advantages of transplantation vs. dialysis...” iii
  • Renal transplant is the best form of treatment for most patients with end-stage renal disease (ESRD), because that therapy improves quality of life, prolongs survival, and is cost-effective.” iv
  • Renal transplantation has been established as a first line treatment for diabetic nephropathy unless there are major contraindications and provides not only a better quality of life, but also a significant survival advantage over dialysis.” v

Interestingly, though, when I did a PubMed search for transplant vs. dialysis survival, I found 810 articles. When I limited my search to randomized controlled trials (RCTs), 51 results came up—but not one of these was a survival trial of transplant vs. dialysis. (They were looking at things like cardiorenal endpoints, machine perfusion vs. cold storage of kidneys, intensive diabetes control, etc.). Not too surprisingly, there were no meta-analyses either.

Actually, when you think about it, there is no way to do an RCT of transplant vs. dialysis. How can you allocate donor kidneys randomly? And even if you could, who would sign up to be randomized? Carl Kjellstrand has pointed out on numerous occasions that there are no RCTs of what happens when someone jumps out of an airplane without a parachute—common sense makes that outcome pretty clear. There are also no RCTs of survival in smokers vs. non-smokers—and there never will be (again, some serious randomization challenges for that one). Yet, as a society, we now agree that smoking causes cancer.

So, basically, we have a nephrology community that seems united in its lauding of transplant as the “treatment of choice” for kidney failure, on the basis of…nothing? Hmm. Well, common-sense, then? Because, getting a kidney means 50% kidney function—vs. the 10% or so provided by standard in-center hemodialysis (HD). So, it makes sense that people would live longer.

For the sake of argument, let’s assume that common-sense tells us people live longer because they have a transplant than if they do “dialysis” (if you read my last blog, you know there is an issue with just lumping all dialysis together without knowing how many hours or days it is). And, let’s unpack “common-sense.”

People who do dialysis and those who get transplants are the same group, right?

Wrong.

Folks who get transplanted are the most medically scrutinized group in nephrology. They are screened literally up one side and down the other—from dental exams to colonoscopies and everything in between. So, is it fair to say that because of a kidney transplant, they live longer? No, it’s not. This group is highly selected. And, patient selection is the elephant in the room.

Since this is a blog post for Home Dialysis Central, you can probably see where I’m going with this. We accept, as a community, that transplant causes longer survival (in a highly selected group), yet far too many still don’t admit that more HD does the same—and for the same common-sense reason: more kidney replacement therapy.

More HD even has a dose-response, which suggests that the amount of kidney replacement really does offer a survival advantage:

  • “Short daily” HD (hours not reported, but possibly in the range of ~15-18 hours of dialysis/week) boosts survival by 13% over standard in-center HD vi
  • In-center nocturnal HD done three nights per week (~24 hours of dialysis/week) boosts survival by 25% over standard in-center HD vii
  • With home nocturnal HD done 5 or 6 nights per week (~30-45 hours of dialysis/week), survival was about three times better than standard in-center HD, and equivalent to deceased donor transplant

A good transplant is a miracle of modern medicine. It’s portable, convenient, and allows a more normal quality of life. I wish everyone whose kidneys failed could have one, and down the road, if we can grow kidneys in a lab or 3D print them, perhaps that will happen. But, for now, while there are not enough kidneys to go around, and some folks are not medically eligible, let’s acknowledge the elephant. Rather than focus on transplant alone as “ the treatment of choice,” why not focus on getting as many people as possible more kidney replacement therapy? Then, if they are eligible, they will be far more likely to live long enough to get a transplant. And, if they are not eligible, they will still feel better and live longer than with standard in-center HD.

i Santos C, Costa R, Malheiro J, Pedroso S, Almeida M, Martins LS, Tafulo S, Henriques AC, Cabrita A. Kidney transplantation across a positive crossmatch: a single-center experience. Transplant Proc. 2014 Jul-Aug;46(6):1705-9

ii Barnieh L, Yilmaz S, McLaughlin K, Hemmelgarn BR, Klarenbach S, Manns BJ, For the Alberta Kidney Disease Network. The cost of kidney transplant over time. Prog Transplant. 2014 Sep;24(3):257-62

iii Spasovski G, Vanholder R. Kidney transplantation in emerging countries: do we know all issues? Minerva Urol Nefrol. 2012. Sep;64(3):183-9

iv Cantekin I, Ferah H, Gulcan E. Investigation of features of patients in renal transplantation waiting list: Who wants much more of what for renal transplantation? Pak J Med Sci. 2013 Jul;29(4):962-5

v Fourtounas C. Transplant options for patients with type 2 diabetes and chronic kidney disease. World J Transplant. 2014 Jun 24;4(2):102-10

vi Weinhandl ED, Liu J, Gilbertson DT, Arneson TJ, Collins AJ. Survival in daily home hemodialysis and matched thrice weekly in-center hemodialysis patients. J Am Soc Nephrol. 2012 May;23(5):895-904

vii Lacson E, Xu J, Suri RS, Nesrallah G, Lindsay R, Garg AX, Lester K, Ofsthun N, Lazarus M, Hakim RM. Survival with three-times weekly in-center nocturnal versus conventional hemodialysis. J Am Soc Nephrol. 2012 23:687-95

Comments

  • sharonrays

    Jun 1, 3:31 AM

    Great work! Keep on.

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  • David R

    Sep 27, 9:38 AM

    No doubt more dialysis is better. I changed long-time center/provider to have access to extended dialysis. Though I am on the transplant list (almost 6 years), high PRA levels make it unlikely that I will get a kidney soon. Because of the low probability of transplant, I decided I needed the best possible treatment available.

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  • Henning Sondergaard

    Sep 27, 8:02 AM

    I think one of the underlying problems here that adds to the fact that transplantation is being touted as the treatment of choice (compounded with the selection problem which I think is of great importance) is the fact that dialysis is not sexy.

    There is no prestige in working with dialysis patients for nephrologists. Dialysis patients are looked upon as the ‘walking dead.’ The End Stage Renal Disease patients who are now waiting to keel over when they or their treatment fail, one way or another.

    Virtually all research funds in nephrology go to research into transplants in some capacity or another. Transplants are the new black despite it being more than half a century old. There are preciously few nephrologists who are seriously interested in dialysis as their special field of study despite the many interesting questions that it brings up regarding treatment length, frequency, choice of modality and/or machine as well as a plethora of other things that still needs to be explored in a reasonable fashion.

    This lack of interest seems rather hypocritical considering that virtually all people with stage 5 CKD (I refuse to use the acronym ESRD) will undergo this treatment form. Even those who eventually are selected for a transplant have done some – and a lot of them even years of –dialysis.

    Unfortunately, this is just another sign of the double standards that seem to be a prerequisite for those who choose nephrology as their medical specialty. There are many others, like the fact that 90% nephrologists would choose some kind of home treatment for themselves while they only recommend it for about 10% of their patients – again one of those things where the RCT method falls short, what patient in their right mind would let themselves be selected to the in-center option?

    Nephrology is busy narrowly treating the bodily aspects of CKD while completely neglecting the psycho-social problems that come with CKD, many of them caused by treatments that are so invasive that they are nothing short of abuse to the individual. One can only wonder how professionals would react to this question if they knew what it truly felt like to be treated in this way day in and day out.

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    • Dori

      Sep 28, 6:38 AM

      Henning, I just had a conversation with a nephrologist yesterday in which I called dialysis the "Rodney Dangerfield of nephrology"--it gets no respect. When it was new, in the 1960s and 1970s, it was a huge deal, very prestigious, and garnered lots of national attention. But as soon as the bugs were (seemingly) worked out and the process became more routine, it was turned over to nurses (and, later, techs) and nephrologists who worked with it were called the "salt and water boys." Nephs distanced themselves from it to the extent that fellowship training programs deemphasized dialysis in favor of bench science that might bring in NIH research dollars and nephs have told me that they were taught in training "Don't worry about dialysis; the nurses will handle it. Your job is to do research." Of the 140 or so US nephrology fellowship training programs, I'm told that only about 10 require a chronic dialysis rotation--most only ever see dialysis in folks who are in ICUs and don't even have an in-depth, down to the ground understanding of IN-CENTER HD. So, I view this as a huge challenge for home therapies...

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      • David Rosenbloom

        Sep 28, 10:05 PM

        This is so ironic, Dori. Particularly in this day and age when we are adding dialysis patients in alarming numbers year after year. No, dialysis is not going away any time in the near future. It's very real and medical schools need to update their curriculum. It's also highly unprofessional and unethical for any doctor to leave his/her patients totally in the care of a nurse or tech. It's an abdication of duty.

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        • Dori

          Oct 1, 7:53 AM

          Absolutely! To me, this is akin to having an oncologist who only knows chemotherapy--not surgery or radiation. It's unfair to the people they see. Another problem was that the American Board of Internal Medicine's nephrology certification exam has 240 items--and just 12 (5%) directly covered ANY kind of dialysis. That will hopefully be changing soon. ASN has a committee on neph training, and the ABIM has a new Executive Director who is committed to making sure that the exams prepare MDs to practice.

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  • David R

    Sep 25, 9:04 PM

    I read a paper a years ago ago that showed a comparison between nocturnal dialysis, cadaver donor and living donor transplant. The numbers in the study showed that nocturnal dialysis survival is statistically equivalent to cadaver donor transplantation. I think this is the study:

    http://ndt.oxfordjournals.org/content/24/9/2915.abstract

    I might argue the same underlying cause exists in this comparison... for home nocturnal dialysis, there is a substantial bias for selection of patient. In-center nocturnal might not have the same extent of bias, but my guess is that there is still a bias. Patients willing to learn how to manage nocturnal home hemo or willing to submit to extra hours in the clinic are also the most likely to be compliant in diet, medication, and other relevant treatment issues. They are probably more educated on their condition and treatment and as a result, pay more attention to their care and maintaining their health. My guess is that all those factors make dialysis more survivable for them compared to the person that goes to sit in a chair 4 hours, three times a week then pays no more attention to their treatment or their health.

    There is other evidence that even 3-times weekly extended, nocturnal, dialysis is more beneficial than shorter treatments. Here's an abstract from a paper written in 2012:

    http://jasn.asnjournals.org/content/early/2012/02/22/ASN.2011070674.abstract

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    • Dori

      Sep 26, 8:33 PM

      Exactly, David! Is selection a factor? Sure! But so is more kidney replacement therapy. :-)

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      • John Agar

        Sep 30, 4:22 AM

        Henning, David,

        While I hear your frustration, there are some out there trying on your behalf ... seriously, there are.

        And, in my country, where national data shows about a third of all patients are at home on dialysis - and more than that in my own service - we do 'get' the 'home is best' message.

        But you are right, dialysis isn't 'sexy'. I am lucky to be old enough to have grown up in that long past time that Dori describes when .. "it was new. In the 1960s and 1970s, it was a huge deal, very prestigious, and garnered lots of (inter) national attention".

        It is also (largely) true that much more research goes into cytokines and immunology, than goes into dialysis and it's modalities - though the Titanic HAS managed a slight right turn in the last few years.

        A major problem is - and this is a real 'turn-off' - that dialysis research is hugely, dauntingly complex and difficult. It really is. It is almost impossible to get 'clean' and rightly comparable data. Dori will have seen the paper I was requested to write for the most recent edition of the ASN monthly newsletter: Kidney News, September 8th. I was asked to write a 'no' response to the question: "Do we need more RCTs in home hemodialysis" ... a paper from Dori was immediately adjacent to my own ... and it was a response I was happy to make. I wrote a similarly flavoured article for NNI back in 2007.

        I am also in the middle of penning the introduction to a special edition on Home HD for HDI in which I try to put aside the 'idiocy argument' of selection bias. Transplant patients are one of the most highly selected groups of patients anywhere - yet we don't cry foul over 'selection bias' and dismiss the transplant outcome data. We extoll it. Yet, while it is clear that home dialysis patients are 'selected' too, somehow 'selection bias' is turned back against home patients and home therapies to somehow 'diminish' their achievement, and their clear outcome advantages.

        Odd, that. We offer the best (in transplantation) to the best, but when some of us try to do the same in dialysis, we get howled down as 'selectors', as 'cherry pickers'.

        I have always felt that where the best is on offer, that it should be offered ... and, where it is achievable, that achievement should be encouraged, facilitated, and supported. But, maybe I am odd, or just plain old-fashioned.

        I hear your pain and frustration. It is shared.

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        • Dori

          Oct 1, 7:59 AM

          Just today, yet another paper came out about awareness of transplant, and the transplant surgeons were practically hopping up and down (figuratively).

          "Nobody is doing fine on dialysis to the point where a transplant wouldn't be better for them,” senior author Dr. Dorry Segev told Reuters Health. “Transplantation is the better form of renal replacement.” A kidney transplant doubles a recipient's life expectancy, said Segev, a transplant surgeon at the Johns Hopkins Hospital in Baltimore, Maryland."

          It's clear to me that these docs are A). Diminishing the impact of a less-than-stellar transplant outcome. If ALL transplants were universal successes, and Chimerism could be easily and reliably induced, this really would be a no-brainer. But, neither of those things is yet true. I've seen some tragic transplant outcomes. And, B). They are conflating all types of dialysis together--and don't even have their stats straight! A deceased donor transplant that succeeds can TRIPLE (not double) life expectancy compared to standard in-center HD, and a living donor kidney can do even better than that. But, nocturnal HD can ALSO triple life expectancy vs. standard in-center HD--so why aren't we pushing that as hard as transplant? Why isn't CMS, since it keeps people out of the hospital? Why doesn't the FDA kick out an approval of the NxStage machine for nocturnal treatment?

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