Nov. 14, 2024
Patients who are referred for kidney transplantation early have the best opportunity for a successful transplant. However, many people face long wait times.
In the state of Arizona, the overall wait time for a deceased donor kidney can range from 2 to 6 years, depending on blood type. In more populated areas, the wait time for deceased donor kidneys can extend up to 10 years. Mayo Clinic in Arizona has one of the shortest times to transplant for waitlisted candidates in the nation. On average, patients wait 8 months for a kidney transplant, compared with a wait of 30 months nationally.
There is a critical need for better education and earlier referrals to decrease these numbers.
Pooja Budhiraja, M.B.B.S., a transplant nephrologist at Mayo Clinic in Arizona, explains that doctors should consider early referral for a kidney transplant for the following reasons.
1. Dialysis can cause complications
Dialysis is associated with a significant decline in quality of life and an increased risk of complications, including infections, anemia and cardiovascular events such as stroke, heart failure and myocardial infarction.
United States Renal Data System reports that mortality rates for patients receiving dialysis are approximately 15% to 20% a year, and patients on dialysis typically have a life expectancy of 5 to 10 years. The highest risk of death occurs within the first 90 days, and prolonged time on dialysis increases the chance of becoming too frail for transplant.
In contrast, kidney transplantation significantly improves survival rates. The one-year survival rate for recipients of deceased-donor transplants is approximately 90% to 95%. For recipients of living-donor transplants, the one-year survival rate is even higher at 95% to 98%.
"Receiving a kidney transplant before the need for dialysis, known as preemptive transplantation, offers the best results," says Dr. Budhiraja. "People who have this type of transplant tend to live longer and often have lower rates of rejection than those who get transplants after starting dialysis. Preemptive transplant also allows patients to avoid many of the health complications that dialysis can cause."
While preemptive transplants are effective, they're relatively rare. Recent data published in the American Journal of Transplantation reported that 33% of adult living-donor kidney transplant recipients underwent transplant without dialysis, compared with 12% of deceased-donor kidney transplant recipients.
2. GFR of 25
Glomerular filtration rate (GFR) is a test to measure kidney function. Physicians should refer patients when their GFR reaches 25. While patients with GFRs in the range of 15 to 30 may not have severe symptoms, waiting for problems to appear can mean missing transplant opportunities.
Once kidney disease progresses to a GFR of 10 or below, patients often require dialysis and their overall health may deteriorate, potentially making them too ill to undergo transplantation. Early referral ensures that patients are evaluated and listed for transplant before their condition worsens, helping to avoid the complications of dialysis that may affect transplant eligibility.
3. Education helps patients prepare
Early education is essential for patients with chronic kidney disease (CKD). Teaching patients about the progression of kidney disease and the benefits of early transplant evaluation can better prepare them for timely listing, as well as improve outcomes.
Dr. Budhiraja says that although referring patients with GFRs of 25 is recommended, discussions about kidney transplantation should begin even earlier. CKD can progress rapidly, and the medical and psychological evaluations required for transplant candidacy take time. By initiating these conversations early, patients can explore all of their transplant options, including living donation.
4. Living-donor opportunities take time to cultivate
Living-donor kidney transplants provide the best outcomes. Living-donor kidneys often last significantly longer than deceased-donor kidneys, even among those from donors with the lowest kidney donor profile index (< 20%). While the average lifespan of a living-donor kidney transplant was previously estimated at 12.5 years, recent data suggest that the average functional lifespan is approximately 19 years.
Early discussions about living donation are critical, but many patients with kidney disease find it difficult to ask potential donors. Educating patients can empower them to explore their options and talk with family members or friends who may be willing to donate or assist in the search for donors.
In addition to social media, several resources are now available to empower patients to reach out to their communities and workplace organizations for support. When potential donors are identified, they can register with advanced donation programs that allow living donors to donate when they are in good health and provide a voucher for the recipient to use when needed. This proactive approach helps patients avoid dialysis and be better prepared for transplant when the time comes.
Mayo Clinic in Arizona offers a remote evaluation process for living kidney donors designed to make the process easier and more efficient.
5. Some people need pretransplant prehabilitation
Many patients with advanced kidney disease can become suitable candidates for transplant if underlying medical conditions are addressed beforehand. For example, patients with cardiac conditions may need to take blood thinners for a year before surgery, while those with obesity may benefit from medications or bariatric surgery to help them reach a suitable weight for transplant surgery.
"Early referral leaves time for prehabilitation interventions that are designed to improve a patient's fitness for surgery and address concerns such as cardiovascular health, weight management or frailty," says Dr. Budhiraja. "Treating these conditions early increases the likelihood of a successful transplant outcome."
For more information
United States Renal Data System. 2022 Annual Data Report: Epidemiology of kidney disease in the United States. National Institute of Diabetes and Digestive and Kidney Diseases.
Lentine KL., et al. OPTN/SRTR 2022 annual data report: Kidney. American Journal of Transplantation. 2022;24:S19.
Refer a patient to Mayo Clinic.