The AJT Report: Surgical Reimbursement Cut, Increased Risk of ESRD in Donors

[Clark]

http://onlinelibrary.wiley.com/doi/10.1111/ajt.12728/full

The AJT Report
Sue Pondrom
DOI: 10.1111/ajt.12728
American Journal of Transplantation
Volume 14, Issue 4, pages 741–742, April 2014

Reimbursement Realities
Kidney surgery RVUs cut by 10%, other organ transplants by 3% to 5%

...

KEY POINTS
Kidney transplant surgeons will take a pay cut of 10% in RVUs in 2014.
The 10% cut is related to post-op visits, malpractice insurance and practice expenses.
RVUs for other organ transplants were reduced by 3% to 5%.

...

Studies Confirm Increased Risk of ESRD in Kidney Donors
Two recent independent studies have shown an increased risk of end-stage renal disease (ESRD) in kidney donors compared with healthy, nondonor controls. At the same time, that risk is still lower than in the general population.

Krista L. Lentine, MD, PhD, associate professor of medicine in the division of nephrology at the Saint Louis University Center for Outcomes Research and a member of the United Network for Organ Sharing Living Donor Committee and the Kidney Disease: Improving Global Outcomes work group on live donor evaluation and care, says that a new study by Muzaale and colleagues, along with other emerging evidence, is changing how the specialty views kidney donation.[1] “I believe a paradigm shift is occurring in our understanding of the long-term consequences of living kidney donation,” she says. “The evidence is sufficiently compelling to warrant another look at current informed consent practices.”

Donors Versus Healthy Nondonors
In the Muzaale study, published in February in JAMA, the authors compared the incidence of ESRD in 96,217 donors (between 1994 and 2011) and 20,024 healthy nondonors who were linked to data from the Centers for Medicare and Medicaid Services (CMS) to ascertain development of ESRD. The estimated cumulative incidence of ESRD at 15 years after donation was 30.8 per 10,000 in donors and 3.9 per 10,000 in healthy nondonors. By age 80 years, the estimated lifetime risk of ESRD was 90 per 10,000 in donors and 14 per 10,000 in healthy nondonors. Compared with the general population, live donors had a much lower estimated lifetime risk of ESRD, which was 326 per 10,000.

“Muzaale et al offer critical new insights by ascertaining ESRD events among a sample of controls with baseline good health, thereby for the first time allowing estimation of the risk of ESRD attributable to donation itself in a large, demographically diverse sample of U.S. donors,” says Dr. Lentine.

Hassan N. Ibrahim, MD, medical director of the kidney transplant program at the University of Minnesota Medical Center in Fairview, says that the study affirms the current belief and previously published data[2] that the risk of ESRD in donors is less than in the general population, but slightly higher than someone who is healthy but does not donate a kidney. The donors in this study had a higher systolic blood pressure and a high body mass index and were twice as likely to be smokers, he added. “I personally believe this residual confounding explains this reported increased risk. I think we should think twice about potential donors who smoke.”

Furthermore, he notes that, in the study, 83% of all ESRD cases occurred in those who donated to a relative, but living related donors only accounted for 65% of donors, suggesting the “huge impact” of genetics on the risk of kidney disease.

In an accompanying editorial, John S. Gill, MD, and Marcello Tonelli, MD, said “it would be easy to misinterpret the findings of Muzaale et al as suggesting that kidney donation is a risky procedure. In reality, the authors have shown that the absolute risk of ESRD among living donors is extremely low; this is their key finding and does not imply the need to alter existing clinical practice.”[3]

Similar Study Finds Increased Risk
Drs. Gill and Tonelli further stated in their editorial that the relative increase as reported in the Muzaale study is qualitatively similar to that described in a recent Norwegian study. That study, which was published in November, suggests that kidney donors are at increased long-term risk for ESRD, as well as cardiovascular and all-cause mortality, compared with a control group of nondonors who would have been eligible for donation.[4]

For the period from 1963 to 2007, the Norwegian authors identified 1,901 donors who could be followed for a median time of 15.1 years. The 32,621 controls who would have been eligible for donation, but didn't donate, came from the Norwegian Health Study of Nord-Trøndelag (HUNT) and were followed for a median time of 24.9 years.

The authors said the hazard ratio for all-cause death was significantly increased to 1.30 for donors compared with controls. There was also an increase in cardiovascular death to 1.40, while the overall incidence of ESRD among donors was 302 cases per million. The overall incidence in Norway was reported to be about 100 per million.

Benefits of Living Donation
“The bottom line of these studies is that we may always have to accept some level of uncertainty regarding the risk of living kidney donation,” says Gabriel Danovitch, MD, medical director of the kidney and pancreas transplant program at the University of California, Los Angeles. “We deal with this by seeing donors as patients, and as with patients, we need to consider the risk/benefit ratio of any invasive intervention. Yes, there are risks to live donation, but there are also clear benefits. Donors feel good about themselves. They have increased psychological well-being, self-esteem and improved relationships. For the great majority of living donors, the balance will be a favorable one, even with a degree of uncertainty regarding their risk.”


References
1
Muzaale AD, Massie AB, Wang MC, Montgomery RA, McBride MA, Wainright JL, et al. Risk of end-stage renal disease following live kidney donation. JAMA 2014; 311: 579–586.
CrossRef,Web of Science® Times Cited: 1
2
Ibrahim HN, Foley R, Tan L, Rogers T, Bailey RF, Guo H, et al. Long-term consequences of kidney donation. N Engl J Med 2009; 360: 459–469.
CrossRef,PubMed,Web of Science® Times Cited: 261
3
Gill JS, Tonelli M. Understanding rare adverse outcomes following living kidney donation. JAMA 2014; 311: 577–578.
CrossRef
4
Mjøen G, Hallan S, Hartmann A, Foss A, Midtvedt K, Oyen O, et al. Long-term risks for kidney donors [published online ahead of print November 27, 201. Kidney Int. doi: 10.1038/ki.2013.460.