Oleh: harui | Mei 24, 2008

Another “Gift of Life?”

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New study on more frequent dialysis compares survival to transplant

  1. At the height of their success, the late John Lennon blurted out to the news media that the Beatles were “more popular than God.” Lennon later clarified the statement, but the shock value sent a message about the popularity of the group.This week, a new study in Nephrology Dialysis Transplantation also reached for its own shock value, suggesting that short dialysis has survival outcomes similar to deceased donor transplants.It’s a hard comparison to swallow. For years, a kidney transplant has been the “holy grail” of treating kidney disease, particularly among the younger age group. If a preemptive transplant with a living related or unrelated donor was not possible, then early placement on the waiting list for a deceased donor transplant becomes a high priority for individuals with advancing kidney disease. Go on dialysis? If I must, but let’s try and avoid it.As some have argued about the merits of erythropoietin (“It’s not the drug, it’s how you use it”), dialysis therapy may fall into the same category. In the article, “Short daily hemodialysis: survival in 415 patients treated for 1006 patient-years,” by Kjellstrand et al. and other home hemodialysis advocates and published May 5 online in NDT, the quality of life and survival benefits of short daily hemodialysis stacked up well against the transplant option.A detailed look at the survival benefit of more frequent dialysis was needed, the authors acknowledged. “Survival statistics for daily hemodialysis are lacking, as most centres providing this have treated only a small number of patients for short observation times.”The retrospective study reviewed 23 years of data from five dialysis centers in the United States and Europe, totaling 1,006 patient years. Altogether, the lives of 415 patients treated by short daily hemodialysis––150 treated in-center and 265 at home or at a self-care unit––were examined. Patients were on daily hemodialysis for 29 months (± 31 months). Treatment time was 136 minutes daily (± 35 min.), frequency 5.8 (± 0.5 times/week) and weekly stdKt/V was 2.7 (± 0.55).

    Of this group, 85 patients (20%) died; 5-year cumulative survival was 68 ± 4.1% and 10-year survival was 42 ± 9%. Age, secondary renal failure, and in-center dialysis were associated
    with mortality, while gender, frequency of dialysis (5, 6 or 7 per week), continent, country, and blood access were not.

    Survival data in this group was compared to two others

  • Matched in-center hemodialysis patients from the U.S. Renal Data System 2005 Data Report using the standardized mortality ratio and cumulative survival curves. The comparison showed that the “survival of the daily hemodialysis patients was two to three times higher and the predicted 50% survival time 2.3 to 10.9 years longer” than that of the matched in-center HD patients.
  • Age-matched recipients of deceased donor renal transplants. In this comparison, survival of patients dialyzing daily at home was similar to this group, reflecting an approximate 50% survival rate at 10 years. The mean age of U.S. patients receiving a transplant was similar to that of the daily home dialysis patients, 50 vs. 49 years (P = 0.280).

Patients who take on the rigors of daily dialysis should have a payoff: a longer, healthier life than those patients treated in-center. This study confirms that theory. But to likewise show similar life expectations among daily dialysis patients and transplant patients takes dialysis––perhaps in its optimal form as a daily therapy––into “the big league,” which has had, up until now, only one team: transplant.

Lead author Kjellstrand told NN&I that the age match between the in-center, conventional HD patients, the short daily dialysis patients, and the deceased donor transplant patients was an important measuring stick when comparing data. “This takes the air out of the argument ‘selection explains all survival advantages of short daily HD,’ as the patients who wait for and receive a cadaver transplants are the most selected of all dialysis patients.” If he had to go on dialysis, the Swedish-born nephrologist wrote, “I would advice long night dialysis as the first choice, short daily as the second and a transplant as the third and only if the dialysis did not go well.”

Both short daily treatments and a transplant have their drawbacks, and are not for everyone. Self-care, in general, can be a time-consuming task; patients required to set up and take down a dialysis machine each day may suffer burnout, and may start skipping treatments. A kidney transplant may help an individual break free of needle sticks and limitations on fluid intake, but the immunosuppressant treatments can have side effects, and are expensive. So there are trade-offs.

The good news? If this study proves acceptable to the renal community, we now have evidence that there are alternatives to extending life with renal disease. In this case, the “shock value” may hold water: Daily dialysis is a viable alternative to transplant.


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