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Tuesday, January 10, 2017

Another Medical Conundrum

"The degree of variability did surprise me."
"Distance to transplant centre didn't have an impact."
"If we can find out why these disparities exist, then we can help make the kidney transplant system more equitable for all patients."
Dr. Greg Knoll, senior scientist, head, division of nephrology, The Ottawa Hospital

A patient undergoing kidney dialysis

In the Province of Ontario, eleven thousand people with kidney failure are on chronic dialysis; much of their life is taken up with having to be hooked up to a dialysis machine to cleanse their blood of waste products and filter out excess water. A normal, uncompromised kidney filters 1,500 liters of blood daily. Waste products must be removed from blood, otherwise waste products built up in kidneys that produce a buildup of blood waste, results in a condition that can lead eventually to coma and finally, death.

People with diabetes are particularly sensitive to kidney failure. As they are to heart, and to neurological problems, along with eyesight deterioration. With an increasingly overweight and obese population the incidence of diabetes, heart problems, and kidney failure steadily grows.  Over one thousand people in the province are currently on waiting lists hoping for a kidney transplant, some of whom have been waiting for up to seven years.

Jim Ward with Dr. Greg Knoll.
Dr. Greg Knoll . CTV News

There is a five percent mortality rate annually, among people on kidney waiting lists. A record six hundred kidney transplants from deceased donors took place last year in the province. Increasingly live donor transplants are taking place, with the medical community hoping that a continued increase in living kidney donations should serve to relax waiting times and help in the improved equality of access.

Kidney transplant rates are known to vary among the provinces in Canada, a condition verified by research findings. A new, first-time study in the province has now pointed out that variability in access and transplants occur within the provinces themselves. Research led by Dr. Knoll, chair in clinical transplantation at the University of Ottawa, discovered that rates of transplant ranged from a low of 7.4 percent of patients in one regional kidney care program, to the opposite, a high of 31.4 percent in another.

The study, published in the American Journal of Transplantation, was based on data collected between the years 2003 to 2013. While the research took pains not to reveal which regions of the province have the lowest or the highest rates of transplant, there are some health authorities who are pushing for that data to be made public. The medical director of Ontario Rental Network, Dr. Peter Blake, characterized the research conclusions as a "call to arms", increasing the urgency of access equally province-wide.

Since 2013, it is likely that the regional disparity has been reduced somewhat, due to changes that were undertaken, including the manner in which patients are evaluated and referred for kidney transplant, and sharing some deceased donor kidneys across the province instead of retaining them locally for transplantation, in an effort to fill the gaps. That, and the fact that deceased donors are on the increase alongside persuasive efforts to inspire living donors.

A kidney dialysis machine
A dialysis machine

There are 27 regional renal programs in Ontario. Researchers studied transplant rates for patients within those programs. One conclusion reached was that ready access to a transplant centre did not necessarily present as a major factor in the number of kidney patients receiving transplants in specific regions. Adult kidney transplant centres exist in Ottawa, Kingston, London, Hamilton, and two located in Toronto.

Among patients most eligible for transplants those between 18 and 50 years of age who had no history of cancer, diabetes or heart disease, reflected similar results of variability. The transplant rate for those patients went from 32.5 percent to 82.7 percent across the province. Followed for as long as 11 years, the study tracked over 23,000 chronic dialysis patients of whom 46.1 percent died, while 11.8 percent received a transplant.

Kidney transplants increase survival, improve quality of life and result in lower health care costs, compared to regular dialysis treatments, however the demand for deceased donor kidneys outstrips their available numbers. The analysis pointed out that 15 of the 27 regional kidney-care programs performed kidney transplants at the average Ontario rate, while six programs reflected rates higher, and six produced lower than expected rates.

A study in the United States discovered similar wide variations in transplant rates occurring there, despite that the American and Canadian health care systems are very dissimilar. In the United Kingdom, which also has a universal health care system, similar variability to the Canadian study resulted as well; again potentially different referral rates across regions, amount of education received by potential recipients rated among the reasons for variation.

Access to kidney transplants varies across Ontario

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