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?
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