Survival rates up for kidney recipients

By Diane Chun

Sun staff writer

November 25, 2006

Shands at the University of Florida's kidney transplant patients had been dying at higher-than-expected rates for several years, according to records reported to the United Network for Organ Sharing in January 2002.

Dr. Richard Howard, a professor of surgery in the College of Medicine and director of the transplantation program at Shands at UF, says the transplant picture at Shands at UF is considerably brighter today.

"Our results are now as good as anyone's," Howard said. "Currently, our data are at or above the national average."

Of the 210 adult patients undergoing kidney transplants at Shands at UF between July 1, 2000 and Dec. 31, 2002, 86.67 percent survived after three years; 28 patients died. Based on national experience, the expected rate of survival was 89.89 percent. That's roughly nine out of every 10 patients, compared to more than eight of 10 at Shands.

The data were reported to the United Network for Organ Sharing, charged with ensuring safety and fairness in the nation's organ transplant system. Currently, UNOS regulates 259 transplant centers and 58 regional groups that procure and distribute organs.

The competition for scarce organs is growing. And the stakes are high - life, death, prestige and millions of dollars for hospitals with a busy transplant program such as Shands at UF.

The first kidney transplant was performed at Brigham and Women's Hospital in Boston in 1954; Shands began in 1966. The program will do between 110 and 120 surgeries this year.

Howard said that in the late 1990s, the prevailing philosophy in the transplant community was to try to make transplantation available to as many patients as possible. In the case of the Shands at UF center, that included patients who were older, were diabetic or had other chronic illnesses in addition to kidney disease.

"They were patients we might not have transplanted otherwise because they were too sick," he said. "The 2000-2002 data reflects those cases. The patients did not do as well as we had hoped."

The data also reflect the fact that survival rates were slightly worse for transplant candidates who received an organ from a deceased donor rather than a living donor.

In both 1998 and 1999, there were more than 90 transplants from deceased donors.

"The numbers I have for 2000 are 121 transplants, 85 from a deceased donor and in 2001, 112 transplants, 70 from a deceased donor.

In 2002, the Shands program "pulled back a bit," Howard reports.

That year, the center did just 86 kidney transplants, with 61 patients receiving kidneys from deceased donors.

Howard said transplant surgeons at Shands are now more conservative in their choice of patients to add to their waiting list for an organ or to perform transplants on, and as a result, survival numbers are improving.

According to the U.S. Transplant Web site, which collects data for the Scientific Registry of Transplant Recipients, 94.67 percent of adult patients who had a kidney transplant at Shands at UF between Jan. 1, 2003, and June 30, 2005, were alive one year after the transplant, compared to 95.70 percent that would be expected based on the characteristics of these patients - a difference that is statistically insignificant, according to the registry.

"Every center screens potential candidates, and (whom you select for transplant) becomes as much a philosophical as a scientific issue," Howard said.

The figures reflect national averages and are based on statistical models that are incomplete, Howard said.

"We know for virtually any disease, an important determinant of success is the social class of the recipient, yet that is not a part of any model," he said.

Shands at UF now has 388 people on the waiting list for a kidney transplant. Seventy-seven patients have received transplants this year. Howard said he doesn't believe any of them should worry about the status of UF's program, which will transplant between 120 and 130 patients in 2006.

The numbers to look at, in Howard's view, are the more than 300,000 people in this country now on dialysis, when U.S. transplant centers do about 16,000 kidney transplants each year.

The surgeon notes that the results of transplantation are better than staying on dialysis for any given patient, but transplant programs such as UF's face forces that pull them in different directions.

"The federal government through its transplantation collaborative wants us to transplant as many patients as possible, and we want to do as many as possible," Howard said. "But another arm of the federal government is making our results available so they appear on the front page of newspapers. These different forces are at odds, even with each other."

Some people ask why a center should be transplanting marginal organs, rather than waiting for a better organ, the surgeon said.

"But for all recipients, the choice is not between getting a kidney that is perfect or one that is not quite so perfect," he added. "The choice is between getting an organ that isn't quite perfect or dying."

The single biggest problem for transplant programs is the lack of available donor organs, Howard said. And the issue at the heart of the debate over transplant success rates, in his view, is that no usable organ go to waste.

"We transplant virtually all organs that are suitable, but who are you going to transplant? We could make our results look excellent if we chose to transplant only the lowest-risk patients. But I don't think that is the right thing to do," he said.

Transplant centers across the country are asking the same questions: Should an organ go only to someone young, who will get the most use out of it? How do you determine benefit? Should anyone over the age of 50 not be considered for transplant?

Every new question requires a more precise crunching of the numbers, Howard said.

"This is not a decision to be made by the medical community alone, because these organs are a national resource and these issues will persist as long as there is a limited supply," he said.

Diane Chun can be reached at 374-5041 or chund@gvillesun. com.

Copyright © 2006 The Gainesville Sun.

This article posted December 6, 2006.