Creating and managing wait list for kidney transplantation at Viet Duc University Hospital in 2019

ABTRACT:

The kidney has many important functions, such as, excretory and blood pressure regulation. If both kidneys lose their functions, it is called end-stage renal disease (ERSD). The patient then must survive by one of the three renal replacement methods: hemodialysis, peritoneal dialysis or kidney transplant. In whiich, kidney transplant is the most optimal solution. Organ transplantation is a medical procedure in which an organ is removed from one body and placed in the body of a recipient, to replace a damaged or missing organ. This process is complicated, requiring a synchronous coordination of specialties in the field of medicine - pharmacy. Kidney transplantation has become routine in the Viet Duc Univesity hospital, with an average of two cases per week. Creating a waiting list is very important to select and prepare patients quickly when there is an available donor, deceased or living. From this situation, this study assesses the creation and the management of the wait list for kidney transplantation at Viet Duc University Hospital.

Keywords: hemodialysis, kidneytransplant, wait list for kidney transplantation.

1. Introduction

The kidney has many important functions, such as, excretory, blood pressure regulation, acid-base and electrolyte balancing, erythrocyte formation, calcium-phosphate metabolism regulation… If a patient has irreversible kidney diseases, causing both kidneys to lose their functions, it is called end-stage renal disease (ERSD). The patient then must survive by one of the three renal replacement methods: hemodialysis, peritoneal dialysis or kidney transplant, among these, hemodialysis is the most common method.

Transplantation wait list is a list of patients with ERSD with transplant indication who wish to receive a transplantation.

The first kidney transplantation was between a homozygous pair of twins on December 23^rd, 1954 in Peter Bent Birmingham Hospital, Boston, USA.

In Vietnam, the first kidney transplantation from living donor was performed on June 4^th, 1992 at 103 Military Hospital. The first kidney transplantation from deceased donor was performed in 2008 at Cho Ray hospital. In order to have a successful transplant operation, four steps should be prepared well: (1) Donor (living or deceased); (2) Recipient; (3) Equipment, technique and personnel; (4) Postoperative care and follow-up. Preparing a waiting list helps finding the most suitable recipient in the shortest time.

According to the latest research by National Center for Human Organ Transplantation in December 2016 on the demand for kidney transplantation at 14 medical centers in Hanoi, there were 2,200 patients who wished to become a recipient. Nation-wide, there are 18 centers capable of kidney transplantation and there are 24 years of experience since the first transplantation in 1992. There is no particular wait list for the patients.

Viet Duc University Hospital is a specialist center, with 1,507 beds specialized for surgical patients, 40 operating rooms serving more than 67,000 operations every year. Kidney transplantation has become routine in the hospital, with an average of 2 cases per week. A unit of dialysis was established in 2005 with 41 medical staffs serving 30 outpatient beds, on an area of 400 m2. With 32 dialysis machines serving 180 patients regularly. At the moment, National Center for Human Organ Transplantation, along with Viet Duc University Hospital have managed patients with indication for kidney transplantation, however the records were sparse and incomplete, unsuitable for the increasing number of patients. Thus, recording and managing patient wait list are very important to select and prepare patients quickly when there is an available donor, deceased or living. From this situation, we conducted the study “Creating and managing wait list for kidney transplantation at Viet Duc University Hospital in 2019” with 2 purposes.

1. Describing the current status of the wait list for kidney transplantation at Viet Duc University Hospital in 2019

2. Describing the current management of the wait list for kidneytransplantation at Viet Duc University Hospital in 2019.

2. Subjects and method

2.1. Location and study duration

- Location: Viet Duc University Hospital

- Duration: August 2019 to March 2020

2.2. Subjects

Patients with indication for hemodialysis in the study period, fulfilling these criteria:

Selection criteria: Patients with ESRD on hemodialysis

Exclusion criteria

+ Patients with ESRD on peritoneal dialysis

+ Patients on emergency dialysis

+ Patients with chronic kidney disease stage 3B with the indication for transplantation but not on dialysis

2.3. Study design: Cross-section descriptive study

2.4. Sample size and selection

- Sample size: Whole sample size

- Sample selection: All patients fulfilling the selection criteria will be chosen for data collection. In August, medical records will be obtained. In December, patients with indication for transplantation will be interviewed and put on wait list. The patients are managed and monitored for 3 months (January 2020 to March 2020). Currently, there are 3 dialysis shifts per day at our hospital, and there are 30 patients for each shift.

Sample size selected: 172 patients.

2.5. Data collection and processing

2.5.1. Data collection

Study record, including demographic and personal identifier of the patients were approved by Scientific Board, including indication, medical and surgical history, history of kidney diseases, dialysis history, laboratory results, spending capability…

2.5.2. Data collecting technique

In this study, we collected data in medical record, after that we approached the patients, explained the reason for the study and performed the interview.

Study procedure

- Step 1: Select patients with indication for hemodialysis to be in the study.

- Step 2: Collect data on demography, history and wishes by interviewing. Para-clinical data was obtained from the medical records.

- Step 3: Put patients on waiting list

- Step 4: Follow-up, interview patients through phone and medical record to determine if the patients are suitable for the wait list

- Step 5: Data processing and manuscript writing.

2.5.3. Data processing

Data is processed using the software Epi Data.

3. Results and discussion

3.1. General characteristics

3.1.1. Demographics

Table 3.1. Demographics

Characteristics (N=172)	Number (n)	Percentage (%)
*Age group*
< 18	4	2,3
18-40	53	30,8
40-60	65	37,8
>60	50	29,1
Average age (N±SD)	50,05 ± 1,65
*Gender*
Male	94	54.7
Female	78	45,3
*Geographic location*
Rural area	69	40,1
City	103	59,9
*Occupation*
Farmer	27	15,7
Worker	10	5,8
Artist	3	1,7
Engineer/Doctor/Pharmacologist	12	7,0
Businessman/woman	48	27,9
Other	72	41,9
*Highest education level*
Primary education	2	1,2
Secondary education	16	9,3
High school education	66	38,4
College and vocational school	40	23,3
University and post-graduate school	48	27,9

Average age is 50,05±1,65. In a study by Olyuombo et al (Nigeria, 2014), the average age is 44,87±17,21 (N=176) [1]. The age groups in Viet Duc University Hospital is younger than other countries, especially those under 60. 30% of our patients are younger than 30, in comparison to Duong Minh Cuong et al, in a dialysis center in Ho Chi Minh City, at 41% (N=142), and much lower than studies by Xhulia et al (Greek, 2015) and Polokandrioti et al (Greek, 2017) at 46,1% (N=141) and 54,6% (N=650), respectively. In contrary, more patients are in the age group under 40 (33,1%) than those in the studies of Xhulia and Polokandrioti, at 9,9% and 12,9% [2], [3], [4]. This is the basic disease pattern in developing countries, because of late diagnosis and the unawareness of the patients, thus causing delays in seeking medical care for younger people [1], [5], [6]. Meanwhile, 80% of the dialysis patients are middle-aged and senior citizens in developed countries, where there is better access to medical services [7]. Thus, more intervention on the awareness of the public is needed to screen for risk factors and to diagnose early those with kidney diseases [1] , [2].

Occupation is an important factor in compliance and spending capability during treatment. Most patients have high school education or higher, with jobs and most are in working age [8].

Nearly 60% of the patients live in Hanoi, which is the capital of the country and most of the patients live in the vicinity of the city. Only a small number of the patients come from rural area. Study by Duong Minh Cuong et al shows similar result, with the percentage of patients who live in suburban area is 30% [16].

3.1.2. Clinical and para-clinical features

Table 3.2: Clinical and para-clinical features

Characteristics	N=172	Percentage (%)
*Previous surgery*
Yes	68	39.5
No	104	60.5
*Medical history*
Diabetes	3	1.7
Hypertension	20	11.6
Cardiac/coronary artery disease	7	4.1
Other	47	27.3
No	95	55.2
*Kidney disease*
Chronic glomerulitis	120	69.8
Urolithiasis	14	8.1
Trauma	0	0.0
Hypertension	10	5.8
Cystic kidney disease	10	5.8
Gout	0	0.0
Lupus	9	5.2
Other	9	5.2
*Time of dialysis*
< 5 year	72	41.9
5-10 year	61	35.5
>10 year	39	22.7
*Blood types (n=154)*
A	37	24.0
B	50	32.5
O	59	38.3
AB	8	5.2
*HBV (n=164)*
Yes	22	13,4
No	142	86,6
*HCV (n=163)*
Yes	36	22.1
No	127	77,9
*HIV (n=72)*
Yes	0	0
No	71	100

Most patients on dialysis had a history of chronic glomerulitis, accounts for 70% of the cases. Chronic glomerulitis occurs early in those from 16 to 44 years of age, at 88,32% [9]. This explains the younger age of the patients in this study [10]. This result is similar to Duong Minh Cuong with 80% of the patients on dialysis had chronic kidney failure [2]. A study by Oluyombo et al (2013) on 176 patients at a rural university hospital in Nigeria shows that the rate of chronic glomerulitis is 45,3%, while the rate of hypertension (23,3%) and diabetes (12,1%) is higher than in this study [1]. 60% of the patients had been on dialysis for more than 5 years. Those with chronic glomerulitis were on dialysis for longer than those with diabetes. 70% of the patients had a history of chronic glomerulitis.

3.2. Transplantation waiting list at Viet Duc University Hospital in 2019

3.2.1. The rate of patients on dialysis with indication for transplantation

89% of the patients on hemodialysis have the indication for transplantation (N=172).

3.2.2. Rate of patients on hemodialysis who wish to be a transplant recipient.

89% of the patients on hemodialysis have the indication for transplantation (N=172). However, only 42% among those wish to receive a transplantation (n = 153), or 63 patients in the study.

3.2.3. Characteristics of the patients on waiting list

Table 3.4. Characteristics of the patients on waiting list

Characteristics	Number (n)	Percentage (%)
*Age group (n=63)*
< 18	1	1,5
18-40	20	32
40-60	39	61,5
>60	3	5
*Time on dialysis*
< 5 years	37	59
5-10 years	16	25
>10 years	10	16
**Blood type (n=54)***
A	16	29,6
B	16	29,6
O	20	37
AB	2	3,8
*HBV (n=60)*
Yes	8	13,4
No	52	86,6
*HCV (n=60)*
Yes	13	21,6
No	47	78,4
*HIV (n=36)*
Yes	0	0
No	36	100

Although the percentage of patients on dialysis with indication for transplant is high, at 90%, only 41% wish to receive a transplantation.

There is a major difference in age groups. Only 3 patients older than 60 wishes to receive a transplantation, while 50 patients younger than 60 wishes to receive a transplantation. However, limitation in the number of donors and waiting recipients creates a challenging problem in equal distribution for all age groups. Because of the long wait time, many older patients with chronic diseases do not wish for a transplantation. [11].

Other reasons for contraindication of transplantation are active hepatitis and HIV infection. Monitoring HIV, HBV and HCV markers before putting patients on wait list may help managing them better.

3.2.4. Spending capability of patients with transplant indication who wish for a transplantation.

Factors related to finance, spending capability affect the decision for transplantation. Among those in demand for transplantation, nearly 50% can pay for the operation. While both pre-operative and post-operative treatment are covered by insurance, the operation itself is not, thus some patients were unable to fulfill their demand.

In the USA, the average cost for a kidney transplant operation is 334.300 USD (7 billion 550 million VNĐ) including 30 days of preoperative treatment (525 million); intraoperative cost and hospital stay (3 billion 200 million VNĐ); 6 months of post-operative treatment (1 billion 510 million VNĐ); cost for allocating and transporting the organ (1 billion 900 million VNĐ); cost for anti-rejection drugs and other medication (447 million VNĐ) [12]. In the UK, the cost for dialysis for 1 patients per year is 30.800 pound, or 40.000 USD (≈ 900 million VNĐ), while the cost for a transplantation is only 17.000 pound (≈ 500 million VNĐ) and the cost for anti-rejection drugs for 1 year is 5.000 pound (≈ 150 million VNĐ [13]. In Taiwan, the cost for a transplantation is about 9500-10.000 USD (200-220 million VNĐ) [14]. The cost in Malaysia is 10.485 USD for deceased donor and 14.985 USD for living donor [15].

In Vietnam, there is no fixed price set by the Ministry of Health at transplantation centers. To our knowledge, the cost for an operation at Viet Duc University Hospital is 300 million VND for living donor, and 500 million VND for deceased donor. At Cho Ray Hospital, an operation alone costs 100 million VND, and further postoperative treatment costs about 250-300 million VND. The cost for a transplant operation in Vietnam is relatively low, in comparison to other countries, however, this cost is still a substantial amount for many Vietnamese. Post-operatively, the patients have to use anti-rejection drugs for the rest of their lives. This is covered by insurance; the cost is about 8-10 million VND per month but it may reduce year-by-year depending on the patients’ condition.

3.2.5. The percentage of patients with insurance in those with the demand for transplantation

100% patients with demand for transplantation had health insurance.

3.3. Management of the wait list

3.3.1. Constant laboratory monitoring

100% of the patients had their vital laboratory figures monitored regularly.

3.3.2. Patient withdrew from wait list

In 3 months, only 1 patient withdrew from the wait list

3.3.3. Patients passed away during wait time

In 3 months, 2 patients passed away, account for 3,2% of the patients who wish to become a recipient.

3.3.4. Patients removed from wait list because of contraindication

Table 3.5. Patients removed from wait list because of contraindication

Reason (N=)		Number	Percentage (%)
Cancer	Yes	0	0
Cancer	No	63	100
Cirrhosis or active hepatitis	Yes	0	0
Cirrhosis or active hepatitis	No	63	100
HIV infection, tuberculosis, syphilis, systemic lupus erythematosus	Yes	0	0
	No	63	100
Other diseases: Uncontrolled acute infection, proliferative glomerulitis, Berger disease, uncontrolled psychiatric diseases	Yes	0	0
	No	63	100

No patient was removed from wait list because of contraindication

3.3.5. Patients became recipients

Table 3.6. Patients became recipients

Patients became recipients	Number	Percentage (%)
Yes	13	21
No	63	79

13 patients were removed from the wait list because they became recipients, accounts for 21%.

3.3.6. Updating patients on the waiting list

In 3 months, there are 9 patients added to the wait list, bringing the total number to 56 patients.

Managing patients includes not only putting them on wait list, but also monitoring their health regularly, ready for an available organ. Most of the patients on dialysis were followed at the hospital to check for vital laboratory figures.

In fact, not all patients followed guideline during dialysis period. In the study of Duong Minh Cuong et al (2015) in Ho Chi Minh city, some patients skipped one or two day, or shortened their dialysis time. Some even were exposed from HBV or HCV. 8% of the patients were infected with HCV in the study [16]. Thus, the fact that there was no acquired comorbidity at Viet Duc University Hospital shows that the managing and monitoring of patients at this hospital is good and should be maintain for the benefit of the patients.

In 3 months, no patients acquired serious comorbidity, 13 patients became recipients and 2 patients passed away. No other study in Vietnam focused on this issue. In the USA, in 2014 there were 34296 patients removed from the wait list, including 11586 patients received from deceased donors, 5817 patients received from living donor, 4578 patients passed away, 3668 patients deteriorated, and 3278 patients removed for other reasons. The number of patients removed for adverse reasons doubled from 2007 to 2014, and surpassed the number of deceased waiting patients [17], [18].

Updating wait list in a timely matter allows the patients to receive transplantation as soon as possible. However, in Vietnam, the process is still passive. There is no guideline for patients to sign up on wait list. This needs to improve further in organ allocation in Vietnam.

3. Conclusion

- The rate of dialysis in the age group of more than 40 is the highest, at 67%. 90% of the patients had high school education or higher.

- Chronic glomerulitis is the most common reason for ESRD, at 70%, nearly 60% of the patients had dialysis for more than 5 years.

- Among 153 patients with transplant indication, 63 patients wish to be a transplant recipient (41%).

- 100% patients have health insurance, but more than 50% are not able to pay for the operation.

- In 3 months (January 2020 to March 2020), 1 patient withdrew from the wait list, 2 patients passed away, 13 patients became recipients and 9 patients were put on the wait list of Viet Duc University Hospital.

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TÓM TẮT:

Thận đảm nhiệm nhiều chức năng quan trọng như: bài tiết các chất độc hại sau khi cơ thể đã chuyển hóa thông qua sự bài tiết nước tiểu, điều hòa huyết áp,… Khi cả hai thận không còn thực hiện được chức năng và không có khả năng hồi phục thì được gọi là suy thận mạn giai đoạn cuối. Khi đó, người bệnh sống được nhờ một trong ba biện pháp điều trị thay thế thận: chạy thận nhân tạo hoặc thẩm phân phúc hoặc giải pháp tối ưu là ghép thận. Ghép tạng là hình thức phẫu thuật cho phép thay thế một cơ quan hoặc một bộ phận của cơ thể bị bệnh, không đảm bảo được chức năng, bằng một tạng khác khỏe mạnh. Quá trình này diễn ra phức tạp, đòi hỏi sự phối hợp đồng bộ của các chuyên ngành trong lĩnh vực y - dược. Tại Bệnh viện Hữu nghị Việt Đức, ghép thận đã trở thành phẫu thuật thường quy với bình quân 2 cặp/1 tuần. Việc xây dựng danh sách người bệnh chờ ghép thận tại bệnh viện là rất quan trọng, tạo điều kiện thuận lợi, giúp lựa chọn được người bệnh ghép thận nhanh chóng, phù hợp khi có người cho chết não hoặc sống. Vì vậy, nghiên cứu này được thực hiện để ghi nhận và quản lý danh sách người bệnh chờ ghép thận tại Bệnh viện Hữu nghị Việt Đức.

Từ khóa: chạy thận, ghép thận, danh sách chờ ghép thận.