Dialysis or transplant? During kidney failure, know your options

Dialysis and kidney transplantation are treatments for severe kidney failure.

When kidneys are no longer working effectively, waste products and fluid build up in the blood. When they fail – often because of diabetes, high blood pressure or hereditary conditions – the damage can spread to other parts of the body.

There is a shortage of organs available for donation. Many people who are candidates for kidney transplantation are put on a waiting list and require dialysis until an organ is available.

A kidney can come from a living relative, a living unrelated person, or from a person who has died. Only one kidney is required to survive. Organs from living donors generally function better and longer than those from deceased donors.

Dialysis takes over a portion of the function of the failing kidneys to remove the fluid and waste products. Kidney transplantation is a more complete solution.

About 60 years ago, the first living kidney transplant was performed in Boston between identical twins. More than 50,000 have received kidneys from living donors, most of them blood relatives. In 2006, nearly 4 out of 10 kidney transplants were living donor kidneys. Two out of 3 nations reported a 50 percent increase from the previous decade.

However, it is difficult to find willing relatives or friends who also match blood type and antibody levels. The need will grow as baby boomers age into retirement. Nearly half of all new kidney-failure patients are older than age 65.

According to the Living Kidney Donor Network, the advantages of living donations are numerous:

• Living donation eliminates the recipient’s need for placement on the national waiting list. The average waiting time for a deceased donor kidney is more than two years.
• Short- and long-term survival rates are significantly better for transplants from living donors than transplants from deceased donors. On average, living donor recipients live five years longer than those who received an organ from a deceased donor.
• The recipients usually know the donors, their lifestyle choices and medical histories.
• Living donor kidneys usually start functioning immediately, compared with deceased donor kidneys that can take as long as a few weeks to start functioning.
• Health deteriorates the longer someone remains on dialysis, and a living donor recipient may be able to avoid dialysis altogether.
• The surgery can be scheduled at a mutually agreed upon time rather than performed on an emergency basis.

Donors should be age 18–65 with two normal kidneys and have a compatible blood type with the recipient. The donor’s medical expenses typically are covered by the recipient’s medical benefits.

Steven Hays, MD, medical director of hemodialysis and renal replacement therapy and living donor kidney program at Baylor University Medical Center at Dallas, says about 1 out of 3 transplanted kidneys at Baylor Dallas are from live donors.

Dr. Hays advises patients to think in terms of “pre-emptive transplantation,” meaning that patients should seek getting a transplant before having to go on dialysis. He says patients who have been on dialysis for longer than six months have a higher likelihood of the kidney transplant not lasting as long, not working immediately, or having the body reject the new organ. These risks rise with the length of time on dialysis.

“Patients need to be planning ahead of time when the kidney function gets worse. Once it is down to one-third, I tell them to start rounding up their donors,” he said.

A multidisciplinary team evaluates potential kidney donors on Mondays and Tuesdays. Of those, only half are fit enough to make a donation.

“We only take the cream of the crop,” Dr. Hays noted.

A committee makes a decision on each potential donor’s fitness on Fridays. A transplant can happen as soon as two weeks later, compared with the prospect of years on a waiting list and likely dialysis.

Because of the aggressive screening, donors with one kidney on average are healthier than a random sample of American adults, according to a 2014 study in the Journal of the American Medical Association. The same researchers reported in 2010 that there was no significant increase in death following kidney donation.

Dr. Hays says healthy adults in their early 30s on average could expect to live another 45 years. He says those who go on dialysis at that age could expect to live only another 12 years, compared with 34 years for those who receive a kidney transplant. For all ages, he says only 54 percent of dialysis patients are alive after three years.

“A kidney transplant truly is a gift of life,” said Dr. Hays.

Learn more about living kidney transplants.