Improving the access of the patients to renal trasplantation
Luis M. Pallardó MD, PhD Hospital Universitario Dr Peset
University of Valencia Valencia, Spain
Incident ESRD rates per million population by country, unadjusted. EDTA Report 2014
RRT Incidence rates (pmp) by country in 2013 Data from USRDS in 2013
Stability in the RRT incidence in some countries Data from USRDS in 2013
Canada Denmark Sweden Scotland Finland
RRT incidence rates between 1980 and 2013. The 18th Annual Report UK Renal Registry
The RRT incidence in Spain 2007-13 The Spanish Renal Registry 2013
Martín-Escobar E et al. Nefrologia 2016;36:97-120
Increasing the RRT incidence in some countries Data from USRDS in 2013
México Singapore USA Rpb Korea, Malasia Thailand Chile Croatia Phylippinas Russia Bangladesh
Incident percentages ERA-EDTA Report 2014
Incident percentages ERA-EDTA Report 2014
Prevalence rates of ESRD pmp by country, unadjusted. ERA-EDTA Report 2014
Prevalent percentages ERA-EDTA Report 2014
Modality changes in prevalent RRT patients, 1999–2014. 18th Annual Report UK Renal Registry
Age profile of prevalent RRT patients by modality on 2014
18th Annual Report UK Renal Registry
Modality changes in prevalent RRT patients, 2007-13 The Spanish Renal Registry 2013
Prevalent percentages ERA-EDTA Report 2014
Prevalent percentages ERA-EDTA Report 2014
Trends in the number of ESRD prevalent cases (in thousands) by modality, in the U.S. population, 1996-2013
2015 Annual Data Report, USRDS
17
30%
Why to do more renal transplants?
Why to do more renal transplants?
• Increase of patient survival – Wolfe RA et al. N Engl J Med 1999;341:1725-1730.
– Macrae J, et al. Int Urol Nephrol 2005; 37: 641.
– Lloveras J, et al. Transplanation 2015; 99: 991–996.
• Increase of quality of life – Laupacis A, et al. Kidney Int 1996; 50:235–242. – Tonelli M, et al. Amer J Transplant 2011; 11: 2093-2109.
– Dukes JL, et al. Clin Transplant 2013.
• Is more cost-effective than dialysis – Whiting JF, et al. Transplant Proc. 1999;31:1320–1321. – Arrieta J, et al. Nefrologia 2011;31:505-13.
Adjusted survival (after the day 91) in incident dialysis
patients and patients receiving a first transplant (between 2005 and 2009).ERA-EDTA Report 2014
Wolfe RA, et al. N Engl J Med 1999;341:1725-1730.
Adjusted Relative Risk of Death among 23,275 Recipients of a First Cadaveric Transplant
Wolfe RA, et al. N Engl J Med 1999;341:1725-1730.
Outcome among Recipients of First Cadaveric Transplants, According to Characteristics at the Time of Initial Placement on the Waiting List, 1991–1997.
ERA-EDTA Report 2014
Main determinants of renal Tx
• Organ shortage
• Medical and non-medical conditions
Deceased Donor Age in Spain 1992-2015 ONT Annual Report 2015
NHBD Renal Tx in Spain 1995-2014 ONT Annual Report 2014
Living donor renal Tx Activity ONT Annual Report 2014
Renal Transplantation in Spain 1993-2014 ONT Annual Report 2014
???Waiting list for renal transplatation ONT Annual Report 2014
Medical ad nonmedical conditions The way to ESRD
CRD ESRD RRT (TX/ PD-HD)
• Comprehensive nephrological care
• Educational and Sociological circumstancies of the patients, including understanding of the disease and their different treatments
• Programmed vs non-programmed initiation of RRT
• For profit vs non for profit dialysis Units
• Local or regional facilities for Tx
• Comorbidities
• Age
Medical ad nonmedical conditions The way to ESRD
CRD ESRD RRT (PD-HD / TX)
• Nephrological care
• Programmed vs non-programmed initiation of RRT
• For profit vs non for profit dialysis Units
• Local or regional facilities for Tx
• Educational and sociological circumstancies of the patients, including comprehension of the disease
• Comorbidities
• Age
……
• Patients older than 65 are the ones that more intensively increase
in the RRT population
• This group is underepresented in the transplanted population
• Age ‘per se’ cannot be a restrictive criteria to access to renal
transplantation, and there should be no upper limit for excluding
patients
• Older patients must be evaluated as the standard ESRD patients to
be included in the waiting list for renal transplantation, with
particular attention to the cardiovascular and malignancy riscs, and
a proper management after transplantation
‘Old for old’ renal transplantation Influence of age-matching on actual graft survival (using a cut-off age of 55 years).
Wolfgang Arns et al. Nephrol. Dial. Transplant. 2007;22:336-341
‘Old for old’ renal Tx The Eurotransplant Senior Programme
Frei et al. American Journal Transplantation 2005; 5:50-57
Patient survival in recipients of kidneys from donors >65 years old versus patients remaining on dialysis in a paired analysis
Catalan Renal Registry 1990-2010
Lloveras J, et al. Transplanation 2015; 99: 991–996
Survival Benefit From Kidney Transplantation Using Kidneys From Deceased Donors Aged ≥75 Years: A Time‐Dependent Analysis
Catalan Renal Registry 1990-2010
Pérez MJ et al. American Journal of Transplantation 2016; 16:2724-2733.
Mortality (HR) according to transplant status and CCI
Sørensen VR et al. Transplantation 2015. doi: 10.1097/TP.0000000000001002
KM patient survival of WL vs Tx patients >70 years of age
Period 1990-99 Period 2000-05
Heldal K, etal. Nephrol Dial Transplant (2010) 25: 1680–1687
Patient survival depending on the transplant era
Heldal K, etal. Nephrol Dial Transplant (2010) 25: 1680–1687
Death censored graft survival (A)
and Patient Survival in octagenarians (B)
(A) (B)
Lønning K, etal. Transplantation DOI: 10.1097/TP.0000000000001363
In conclusion:
• Conditioning circumstancies to renal Tx can vary
between different regions and countries.
• Medical and nonmedical factors can determine access
to renal Tx, and they must be evaluated in order to
find the proper solution.
• Aged population with ESRD is increasingly prevalent,
and their expectation to be transplanted depends on
taking advantage of older deceased, as well as, living
donors.
Thanks!!