Updated: Jun 16, 2020
Written by: Dr. John Swinnen, Sydney, Australia
The effectiveness and inter-related complexity of RRT (Renal Replacement Therapy) has been progressing over the last few decades. Keeping patients without native renal function alive, in good health and without complications in the long term is now possible.
However, this goal is not being achieved in most countries, not even in some of the world’s most developed societies. Although the modalities to achieve the above aims exist, they are often implemented in an adhoc, inefficient and poorly coordinated way making the system both more morbid and more expensive than it needs to be.
RRT has four arms: Transplantation, HD, PD and Medical Care. The last is important in the management of all patients who need RRT but can only act as a standalone modality in those embracing “palliative care”.
There is no doubt that Transplantation is usually both the cheapest and most effective way of treating ESRF. However, for reasons of patient unsuitability or lack of available organs, transplantation remains the minority player in RRT worldwide, in developed countries and even more so in developing countries.
Worldwide, about 1,5 million people are alive without adequate native renal function; roughly, 1/5 are transplanted, 1/5 are on PD and 3/5 are on HD. The fraction receiving palliative care or no care is hard to determine. However, the funding, systems, and interest in Transplant programs is far greater than in the other 2 modalities, making for an overall ineffective RRT program.
It is our belief that the best outcomes in RRT, both at patient and societal level, will be achieved when all four arms of RRT are available, are properly funded, are efficiently run, are appropriately allocated and are properly integrated with each other.
The imbalance between funding and interest between Transplant and the other two active RRT modalities has two consequences that affect both individual patient outcomes, as well as the cost of treatment to society.
First, HD and PD programs generally do not compare in efficiency and effectiveness with transplant, though there are exceptions: (Hong Kong with 73% PD, and Japan with >90% HD.
Second, the different modalities of treatment, which many patients will use at various stages in their lifetime, are not integrated, to the detriment of RRT programs overall. Patients experience many preventable complications and death as a result. These include central vein occlusions with all their consequence, infected dialysis catheters, fistulas and grafts, ischemic limbs and congestive heart failure to name a few.
Patients requiring lifelong RRT are uncommon (1: 100.000), highly complex with a huge financial burden to society.
We believe RRT should be seen and managed as a single entity, with the patient’s lifetime need of management planned early and in a holistic way considering the four modalities they may end up using.
Interested in learning more about this topic?
Although Kidney Academy has many CMEs that are ready to be accessed online anytime. This mini-editorial by John Swinnen of Sydney, Australia is a sample of what will be covered in Module 1: Renal Replacement Therapies Integrated: The Global Perspective. Module 1 is still being finalized with a slated completion date of Fall 2020.
About the Author:
Dr. John Swinnen (FRACS General & FRACS Vascular) is a Vascular Surgeon / Dialysis Access Specialist at Westmead Hospital in Sydney, Australia. He is a qualified Sonographer (DDU Vascular) and runs the Westmead Vascular Ultrasound Lab. For the last 10 years, Dr. John also works 2 months every year as a War Surgeon with MSF (Doctors Without Borders) in zones of conflict, including Gaza, Afghanistan, Pakistan, Eastern Congo, Yemen and Central Africa. John is a Professor of Surgery at Sydney University and has an interest in clinical research.
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Comments to Dr John Swinnen's Mini-Editoreal by I. Davidson, MD, PhD, Dallas Texas.
The powerful image below from the USRDS 2018 Annual Data Report, Vol 2 ESRD, Chapter 11, describes the Renal Replacement Therapy (RRT) distribution from many of the worlds countries. It supports Dr. Swinnen's statement and is a reminder of the dramatic diverse approach to RRT around the globe. The overarching question to the readers becomes - where does my country and my program fit into this picture and what can or should I do, if anything, to improve.
So, is one country better or more "right" than others? The quote of Aristotle comes to mind: "We are what we repeatedly do. Excellence then, is not an act, but a habit". This image below and many similar others from the USRDS data base is an excellent source for information and increased understanding of global issues facing ESRD and dialysis access. As a stark reminder, only 10 % of the world's population has access to life-saving RRT including renal transplantation.
These and related issues will be covered at kidneyacademy.com in Module 1: Renal Replacement Therapies Integrated: The Global Perspective. This module is in progress with a slated completion in the fall of 2020.
Text below copied from USRDS 2018 Annual Data Report, Vol 2 ESRD, Chapter 11; figure 11.12. Percentage distribution of type of renal replacement therapy modality used by ESRD patients, by country, in 2016:
USRDS 2018 Annual Data Report, Vol 2 ESRD, Chapter 11; figure 11.12. Percentage distribution of type of renal replacement therapy modality used by ESRD patients, by country, in 2016.
Data source: Special analyses, USRDS ESRD Database. Data presented only for countries from which relevant information was available. Denominator is calculated as the sum of patients receiving HD, PD, Home HD, or treated with a functioning transplant; does not include patients with other/unknown modality. Data for Belarus from 43 of 51 RRT centers. Data for Canada exclude Quebec. Data for France exclude Martinique. Data for Indonesia represent the West Java region. Data for Italy representative of 35% (7 out of 19 regions) of ESRD patient population. Data from Latvia representative of 80% of ESRD patient population. Prevalent functioning graft data for Slovakia only available for prevalent transplant patients. United Kingdom: England, Wales, Northern Ireland (Scotland data reported separately). Abbreviations: CAPD, continuous ambulatory peritoneal dialysis; APD, automated peritoneal dialysis; IPD, intermittent peritoneal dialysis; ESRD, end-stage renal disease; HD, hemodialysis; PD, peritoneal dialysis; sp., speaking. NOTE: Data collection methods vary across countries, suggesting caution in making direct comparisons