Transplantation


Figure 1: Number of Deceased and Living Donor Kidney Transplantations in WHO Member States in 2010, Correlated with Human Development Index and Grouped by WHO Regions


0.0 10.0 20.0 30.0 40.0 50.0 60.0


Croatia Portugal Spain Australia Turkey Iran C. Rica Syria Mauritius India 0.5 South Africa 0.6 Thailand Algeria 0.7 0.8 Human development index AFR AMR EMR EUR SEAR WPR


AFR = Africa; AMR = Americas; EMR = eastern Mediterranean; EUR = Europe; pmp = per million population; SEAR = south-eastern Asia; WPR = western Pacific. Source: WHO.18


0.9 1.0 Singapore Japan Rep of Korea Norway


global epidemic of type 2 diabetes and other causes of chronic kidney disease (CKD). Dialysis is expensive even for developed countries, but its cost is prohibitive for many emerging economies. The majority of patients commencing dialysis for ESRD in low-income countries die or stop treatment within the first three months due to cost restraints.13 The cost of maintenance haemodialysis varies considerably according to country and healthcare system. In Pakistan, for example, maintenance haemodialysis is reported to cost US$1,680 per year, which is beyond the reach of most of people without humanitarian financial aid.14


Despite exemplars, both the provision of haemodialysis facilities and the uptake of peritoneal dialysis remain very limited in middle- and low-income countries. While the cost of transplantation exceeds that of maintenance dialysis in the first year following transplantation (in Pakistan, US$5,245 versus US$1,680, respectively), the cost of transplantation is much reduced, compared with dialysis, in subsequent years, especially with the advent of inexpensive generic immunosuppression.15


Transplantation thus expands access and reduces overall costs for successful treatment of ESRD. low titre ABO antibodies.3 Even for patients with high titres of


donor-specific human leukocyte antigen (HLA) antibodies, who were previously ‘untransplantable’, better desensitisation protocols4 paired kidney exchange programmes5 successful transplantation.


and now afford real opportunities for


Ethnic minorities and disadvantaged populations continue to suffer worse outcomes; Aboriginal Canadians, for example, have lower 10-year patient (50 % versus 75 %) and graft (26 % versus 47 %) survival compared with white Canadians.6


African-American kidney transplant


recipients have shorter graft survival compared with Asian, Hispanic and white populations in the US.7


In New Zealand, Maori and Pacific Islander


recipients of deceased donor transplants have a 50 % eight-year graft survival, compared with 14 years for non-indigenous recipients, in part due to differences in mortality.8


By contrast, despite a resource-poor


environment, Rizvi et al. report one- and five-year survival rates of 92 % and 85 %, respectively, among 2,249 living related kidney transplants in Pakistan,9


while, in Mexico, 90 % and 80 % one-year survival rates for living and deceased donor kidney transplants were reported among 1,356 transplants performed at a single centre.10


However, while it is


possible to achieve such excellent long-term results, most patients and their families in resource-poor environments are not able to afford the high cost of immunosuppressants and antiviral medications needed to reduce the risk of graft loss and mortality.11


The Place of Kidney Transplantation in the Treatment of End-stage Renal Disease Kidney transplantation improves long-term survival compared with maintenance dialysis. In 46,164 patients on the transplant waiting list in the US between 1991 and 1997, mortality was 68 % lower for transplant recipients than for those remaining on the transplant waiting list after more than three years’ follow-up.12


The transplanted


patients of both sexes, aged 20–39 years, were predicted to live 17 years longer than those remaining on the transplant waiting list, an effect that was even more marked in diabetics.


The number of people known to have ESRD worldwide is growing rapidly, as a result of improved diagnostic capabilities and also the


70


There are also within-country disparities in transplant rates among minorities and other disadvantaged populations. In Canada, all minority groups have significantly lower transplant rates; compared with whites, rates in Aboriginal and African-Canadians, Indo-Asians and East Asians were 46 %, 34 % and 31 % lower, respectively.19 In the US, transplantation rates are significantly lower among African-Americans, women and the poor, compared with Caucasians, men and the more affluent populations.20


The situation is similar


in Australia, where Aboriginal Australians fare worse than non-indigenous Australians (12 % versus 45 %), and in New Zealand, where Maori/Pacific Islanders are disadvantaged (14 % versus 53 %).21 In Mexico, the transplant rate among uninsured patients is 7 pmp, compared with 72 pmp among those who have health insurance.22


Multiple immunological and non-immunological factors contribute to social, cultural and economic disparities in transplant outcomes, including biological, immune, genetic, metabolic and pharmacological factors, as well as associated co-morbidities, time on dialysis, donor


EUROPEAN NEPHROLOGY


Transplantation of the kidney, when properly applied, is thus the treatment of choice for patients with ESRD because of lower costs and better outcomes.


Global Disparities in Access to Kidney Transplantation


Substantial disparities in the access to transplantation worldwide are shown in Figure 1 (derived from the WHO Global Observatory on Donation and Transplantation),18


which demonstrates the relationship


between transplant rates and human development index (HDI) in 2010 in WHO member states. There are reduced transplant rates in low and middle HDI countries, and a large spread of transplant rates among the richer nations. Transplant rates of more than 30 per million population (pmp) are restricted to Western Europe, the US and Australia, with a slightly broader spread of countries achieving between 20 and 30 pmp.


Pre-emptive transplantation, boasting reduced cost and improved graft survival, is an attractive option for both patients and payers.16 Pre-emptive transplantation is associated with a 25 % reduction in transplant failure and 16 % reduction in mortality compared with recipients receiving a transplant after having started dialysis.17


Kidney transplants (pmp)


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