While tremendous progress has been made in the field of kidney transplantation since the first successful transplant in 1954, long-term outcomes remain suboptimal. Only half of kidney transplant recipients still have their transplanted kidney after 10 years. Improving medication adherence among kidney transplant recipients might help improve long-term outcomes.
I always enjoy the holiday season. I enjoy the festive mood, and the chance to see friends and family. Plus the time off does not hurt either. For me, there is another reason why I like this time of the year. On Dec. 23, 1954, the first successful kidney transplant was completed. It is an amazing story.
It was right around this time, 61 years ago, that Richard Herrick lay dying in his hospital bed at Peter Bent Brigham Hospital in Boston, MA. In another room, his identical twin brother, Ronald, was planning to donate his kidney to Richard. Although Richard tried to talk Ronald out of his selfless act, Ronald courageously went forward and donated his kidney. It would become the world’s first successful organ transplant that resulted in long-term survival.
On Dec. 23, 1954, Dr. Joseph Murray removed a kidney from Ronald and implanted it in Richard. Years later, Murray shared a Nobel Prize for his groundbreaking work. For the Herrick brothers, then 23, the results were more immediate and personal. Ronald gave Richard eight more years of life. Previous transplant recipients had lived for only a few months at best.
The courage displayed by the Herrick twins, and the transplant team ushered in transplant medicine. In the past six decades, thousands of lives have been saved, and countless patients have restored their health. Innovations in surgical procedures, medications, organ preservation solutions, etc. have expanded the number of people of transplanted and improved treatment outcomes.
Long-term outcomes for kidney transplant recipients
While tremendous progress has been made in the field of kidney transplantation, long-term outcomes for U.S. patients remain suboptimal. At a decade, only a half of kidney transplant recipients still have their transplanted kidney. This figure has remained fixed for some time without any improvement.
In August 2015, I celebrated the 11-year anniversary of my kidney transplant. I am also happy to report that my renal function has remained stable for the entire time. I recognize that I have benefited from an exceptional set of circumstances. For example, I had a pre-emptive kidney transplant that enabled me to avoid dialysis completely. In addition, through my personal experience, I have gained some valuable lessons that can be applied to the broader kidney transplant community.
It was because of my personal and professional interest in transplantation that this September I attended the “FDA Workshop: Surrogate Endpoints for Clinical Trials in Kidney Transplantation.” The meeting started with the acknowledgement that long-term outcomes are lagging. After several presentations on the possibility of new treatment pathways and potentially new treatments, it was exciting to learn that help may be on the way. However, that potential help is several years away.
At the meeting, I felt like there was an elephant in the room that no one wanted to acknowledge. The elephant was medication non-adherence to immunosuppressant medications.
Early at the meeting, there was an excellent presentation on medication non-adherence. Research estimates conservatively that significant non-adherence occurs in 22% of patients and contributes to graft loss 36% of time. In adolescent transplant recipients, it is estimated that non-adherence occurs 30-50% of the time.
As the meeting progressed, the role of non-adherence was linked to the development of medical conditions resulting in the loss of transplanted kidneys. I left the meeting thinking why are research dollars allocated to finding new pathways when patients are not taking their medications now? This is an issue that can be addressed now and has the potential to improve long-term outcomes.
The issue of addressing non-adherence becomes compelling by examining the economic consequences of non-adherence in kidney transplant recipients.
According to the 2014 Milliman Research Report, the average annual cost of a kidney transplant is $334,300. If a patient loses their transplanted kidney, they do have the option of dialysis. Including hospitalization costs, the annual cost of dialysis ranges from $70,000-100,000. The break-even point where a kidney transplant becomes more cost effective than dialysis is around 2–4 years after surgery, and some research shows the timeframe is getting shorter.
Beyond the economic argument is the quality of life experience. Kidney transplantation offers a superior quality of life compared to dialysis. Because of the diminished quality of life on dialysis, 20% of dialysis patients annually elect to stop their dialysis treatment and opt for palliative care.
Addressing medication non-adherence in kidney transplant recipients
In the midst of this darkness, there is light to be found. As a member of the transplant community, I have provided my recommendations to address non-adherence:
- Consensus conference on medication non-adherence in kidney transplantation: I would like to see a Consensus Conference conducted with a broad range of stakeholders: payers, nephrologists, transplant coordinators, academic experts on non-adherence, patient organizations, etc. The meeting could be sponsored by the FDA or by one of the professional societies such as the American Society of Transplantation. The objective of the meeting would be to provide a set of recommendations to improve medication non-adherence. I would like to see this meeting occur within the next 12 months.
- Patient reported outcome trials in kidney transplantation: To my knowledge very little research has been allocated to patient reported outcome trials in kidney transplantation. To me, this seems like a missed opportunity to gain insights into the causes of non-adherence and advance the knowledge in this field. Possible routes to conduct this research exist within the Patient Centered Outcomes Research Institute and the Kidney Health Initiative. The research dollars are there, but proposals have to be generated.
- Lessons from other disease states: As Kerri Cavanaugh, MD MHS Associate Professor, Vanderbilt has pointed out, health literacy remains poor in Chronic Kidney Disease patients. She has looked at other diseases such as diabetes with higher literacy rates. The higher literacy rates may be attributable to the role of Diabetic Educators. The HIV community is a field with high adherence rates as well. I am sure there are lessons to be gained here as well.