PKD Kidney Transplant: 2-Staged Procedure Offers Better Outcome, VICTOR Act for Transplants

Kidney Transplant

From Journal of American College of Surgeons 

Kidney Transplant With and Without Native Nephrectomy for Polycystic Kidney Disease: Results of the National Inpatient Sample and the Rationale for a 2-Staged Procedure

Abstract

Background

Polycystic kidney disease (PKD) is one of the most common causes of end-stage renal disease requiring hemodialysis or transplantation. In patients requiring transplant, there are several indications for native nephrectomy, including recurrent cyst infection, bleeding, or to provide room for the graft. There is disagreement about whether it is advisable to perform kidney transplant alone (KT), or to perform kidney transplant with simultaneous native nephrectomy (KTN). We compared postoperative outcomes of KTN and KT in a large national cohort.

Study Design

The Nationwide Inpatient Sample (NIS) between 2000 and 2014 was examined for a diagnosis of PKD with evidence for KT or KTN. Logistic regression, adjusting for age, sex, comorbidity, and hospital region, was used to compare groups for the need for blood transfusion, the need for critical care interventions, and the development of postoperative complications.

Results

A total of 4,003 hospitalizations were identified, which was representative of 19,302 weighted discharges nationally. In adjusted logistic regression models, KTN demonstrated significantly higher risk for blood transfusion (OR 2.06, 95%CI [1.44, 2.96], p<0.0001), postoperative complications (OR 1.44, 95%CI [1.05, 1.96], p=0.02) and critical care interventions (OR 1.44, 95%CI [1.07, 1.95], p=0.02). Other significant predictors for blood transfusion included female sex (OR 1.76, 95%CI [1.45, 2.13], p<0.0001), age over 61 years (OR 1.60, 95%CI [1.21, 2.10], p=0.001) and Charlson comorbidity score ≥2 (OR 1.52, 95%CI [1.10, 2.09], p=0.01).

Conclusions

Among patients with PKD, in comparison to KTN, KT-alone represents a decreased risk for negative postoperative outcomes. A 2-staged procedure should be considered, when feasible, to minimize adverse patient outcomes.

From Knox News, Knoxville, TN, by Terrence Jay O’Neil, Guest column

VICTOR Act would greatly improve lives of veterans with kidney failure

Imagine it’s 5:30 in the morning and you have to be at the clinic by 6:30. You had a pretty good day yesterday. Not too much achiness or shortness of breath, and you slept fairly well last night. You bolt down a light breakfast, get in your car and drive the 20 miles to the dialysis clinic you go to three times a week.

You check in, and after a few minutes you are sitting in a recliner surrounded by other people like yourself with kidney failure. You have two one-eighth-inch-wide needles stuck in your left arm. Those needles are pulling a soft-drink can full of blood out of your body every minute, cleaning it and returning it. You know that you will probably be going home with two bandages over the needle sites to prevent bleeding, feeling tired, nauseated, with muscle cramps and a headache, and you will have to lie down for a good part of the rest of the day to recuperate.

On treadmill for rest of life

Imagine doing that over and over. For the rest of your life. With no hope of getting off the treadmill. Worse, imagine you are an East Tennessee veteran of limited means who served his country faithfully and trusted what you thought were lifelong military health care promises and so you never got commercial health insurance or signed up for full Medicare.

You cannot get off dialysis because you lack means to travel over 300 miles to a VA transplant center in Nashville, Lexington, Ky, or Birmingham, Ala., for transplant evaluation and if you are lucky, the surgery. Because the VA is currently forbidden by law to use money under the CHOICE program for kidney transplants at non-VA facilities, you can’t afford a transplant at the excellent University of Tennessee Medical Center transplant program at Knoxville.


This effectively condemns you and many other East Tennessee veterans with only VA coverage who are potential kidney transplant recipients to dialysis forever.

Transplants a possibility

In May U.S. Rep. Neal Dunn, R-Fla., proposed the Veterans Increased Choice for Transplanted Organs and Recovery Act of 2017, otherwise known as HR 2601, or the "VICTOR Act of 2017”. If approved, this bill would allow many East Tennessee veterans to be evaluated and get on the list to receive kidney transplants at Knoxville. The quality of their and their families’ lives would be dramatically improved. Many could return to work at least half time to help support themselves and their families. Very few of those on dialysis can work to help support themselves because dialysis takes up so much time and dialysis patients just don’t feel well enough to work.

If the VICTOR Act is made law, the government would save money because transplant maintenance is cheaper than dialysis. Each year of hemodialysis costs $85,000. Peritoneal dialysis (another form of kidney failure treatment) costs $60,000. Transplants have a one-time cost of about $120,000 but every year after that maintaining the transplant drops to $30,000. So, after three years, money is saved. Using today’s advanced medications, half of kidney transplants continue to work for 10 years, and a quarter are still working at 20 years. So, the savings can go on for a long time.

If you put yourself in the place of that veteran, you can see why the VICTOR Act is the right thing to do. It improves the quality of the lives of those who have helped defend us. It saves money in the long run. I urge community support through our local legislators the VICTOR Act.

Terrence Jay O’Neil is a retired colonel of the U.S. Air Force Medical Corps