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Opinion: We need less dialysis, more kidney transplants

Transplants provide longer life expectation, better quality of life and save money. Yet the system isn't producing them

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According to the Ontario Renal Network, 700,000 Ontario adults are living with early chronic kidney disease. That’s roughly equivalent to the population of Hamilton, Ont. Even worse, a University of Toronto study sponsored by the Ontario Hospital Association forecasts that kidney disease and related kidney failure will be the fastest growing chronic illness in Ontario between now and 2040.

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Kidney disease and kidney failure are serious, even devastating conditions, so the forecast that they will increase rapidly is real cause for alarm.

Opinion: We need less dialysis, more kidney transplants Back to video

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Over 25,000 Ontarians are already receiving dialysis and/or care in specialized clinics for end-stage kidney disease. Last century’s development of dialysis was a major milestone: it keeps people alive. But it’s a burdensome therapy, requiring either home-based administration, which can be challenging, or frequent, regular trips to a clinic.

Kidney transplants are a much better alternative. They deliver better patient outcomes, longer life expectation and a far superior quality of life for people with end-stage kidney disease. Dialysis is life support; a kidney transplant restores life.

But the renal network’s most recent report finds that only 5.6 per cent of people treated for end-stage kidney disease received a transplant in 2023, while fewer than two per cent of these transplants took place before dialysis had become essential. Because half of Ontarians on dialysis are likely eligible for kidney transplants, these numbers reveal a system that is drastically failing kidney patients.

Not only do transplants deliver better outcomes, they save health-care dollars. Dialysis is one of the most expensive publicly-funded treatments, costing $100,000 per patient per year. A kidney transplant carries a one-time cost of about $60,000 but then just $24,000 per year after that for followup and anti-rejection medications. Over five years, dialysis will cost $500,000 per patient, a kidney transplant just $146,000. The transplant therefore saves roughly $350,000 of system costs.

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Dialysis also has indirect costs. With 80 per cent of dialysis patients too ill to work, it’s estimated the national financial burden in terms of disability insurance and lost productivity exceeds $300 million a year. Yet in Ontario in 2018, $660 million was spent on dialysis, only $20 million on kidney transplants.

Over the past five years, about 1,200 Ontarians on average were waiting for a deceased-donor kidney transplant and the average wait time was approximately four years, resulting in some patients becoming too ill for a transplant or dying before receiving one. Even so, we’ve been told by nephrologists that some transplant hospitals, which already have surgical staff and operating-room time available, are working at only 50 per cent capacity.

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So what’s standing in the way of more kidney transplants instead of dialysis?

Getting living donors to come forward and persuading more people to register to become donors after death is not easy. But we also need our health-care system to prioritize transplants over dialysis. Dialysis has long been the default solution: it’s an easy referral for specialists to make, the machines are there, and the system is set up to fund the treatment — including funding the clinicians and support staff who make it happen.

By contrast, transplant-eligible patients and willing kidney donors face unnecessary barriers and delays that prevent timely access to transplantation. It’s usually a complex process that’s difficult to navigate. For living donors, there are no incentives (beyond their tremendous goodwill). What reimbursement programs there are to help with travel and other expenses often don’t cover full costs.

Another problem is that in many provinces, kidney transplants from living donors are officially designated as “elective surgery,” which is crazy: no one simply “decides” to get a kidney transplant or donate an organ. It’s a life-saving procedure, not a lifestyle indulgence.

The provinces, including Ontario, need to set standards of care that make kidney transplants easier. Health-care dollars should be reallocated to give greater priority to transplants, including with early education and support for recipient and donor “work-up” testing to ensure a successful match. Money spent this way will actually save health-care dollars while delivering better outcomes and quality of life.

These problems are not new. In 2019, Ontario’s auditor general made 14 recommendations to improve care for kidney patients and to increase health-care savings. Only four dealt specifically with transplant and there has been only limited progress toward their implementation.

A kidney disease storm is coming. Solutions exist. What’s needed is action.

Susan Q. McKenzie, a kidney transplant recipient, is founder and president of the Kidney Patient & Donor Alliance Canada and co-founder and chair of the Transplant Ambassador Program. Lynn van der Linde, a kidney donor, is board director of the Kidney Alliance and Renal Patient Foundation of Canada.

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