With the number of kidney failure patients expected to continue to rise in the years to come, healthcare providers are seeking new ways to expand treatment options, improve outcomes, and reduce the chronic health conditions that contribute to the potentially deadly disease.
Among the national leaders in the field is the kidney transplant program at Saint Barnabas Medical Center, in Livingston, which has performed more than 6,300 surgeries in its nearly four decades and is the busiest renal replacement practice on the East Coast.
But transplants — which can be performed using a kidney from a deceased donor or an organ from a living donor, if certain biological factors can be matched — are only part of the picture. Efforts to find desperately needed donors, both living and dead, can only go so far, and the use of dialysis as a stopgap measure is far from optimal, experts said. As a result, doctors are now looking to stop kidney disease before it starts.
According a June factsheet from the federal Centers for Disease Control and Prevention, some 30 million people — or one in seven Americans — are estimated to have some form of the disease and nearly half of those with a serious condition aren’t aware of their situation.
The kidneys filter hundreds of poisons from the blood and metabolic system; kidney failure can lead to weakness, blood and bone problems and, if the disease progresses, heart and lung problems and a breakdown of other organs.
“Kidney disease has exploded in the last decade,” explained Dr. Shamkant P. Mulgaonkar, who heads the transplant division at Saint Barnabas. “And the expectation in this country is that the numbers are going to literally grow at an enormous rate” in the years to come, he continued. “That’s a challenge for our community.”
Despite significant improvements in the surgery and new techniques that allow far more options for matching living donors, there is a significant shortage of available kidneys; more than 100,000 people nationwide await healthy organs — including 4,500 in New Jersey — and at least a dozen Americans die daily because they couldn’t be matched in time, Mulgaonkar said.
Too few kidneys
“We are facing this dilemma: We have more people who need kidneys than there are kidneys available,” Mulgaonkar said. When he started, nearly 30 years ago, patients would usually wait six months for an organ from a deceased donor; now the average wait in New Jersey is five years, he said.
“That’s a lot of time to be strapped to a dialysis machine,” Mulgaonkar noted. Dialysis, which mechanically flushes the system, is far less effective than the human body, taxing on patients who sometimes need daily treatment, and extremely costly, he said. It is also the only real option for those awaiting or unable to receive a transplant.
(The New Jersey Department of Health oversees an assistance program to help patients with limited incomes cover the cost of medicines and dialysis, and provides other information on kidney failure through one of its chronic disease programs. Resources are also available for diabetes and heart disease, among other conditions.)
The scarcity of healthy kidneys has prompted growing interest in prevention, specifically efforts to reduce rates of diabetes and heart disease; together these conditions are considered a cause in three out of four cases of chronic renal failure, the CDC found. Between 1994 and 2014, diabetes rates jumped from 4.4 percent to 9.1 percent nationwide; in New Jersey, they went from 4.1 to 8.6 percent, before dropping to 7.9 percent in 2015, according to federal data.
Prevention and population health
For RWJ/Barnabas, the state’s largest healthcare network, efforts to prevent or reduce the incidence of renal failure fits well with its larger mission to invest in prevention and population health. The system, which has more than a dozen hospitals and serves 3 million patients annually, was formed in the spring of 2016 when Barnabas Health joined with Robert Wood Johnson Health System; it is one of a number of larger, combined systems that has focused on a proactive approach to public health.
“RWJ/Barnabas Health is directing significant resources toward promoting the health and wellness of the communities we serve to help avert illness,” said Barry H. Ostrowsky, president and CEO of the organization.
“Encouraging healthy lifestyle choices — such as food selection and exercise — reduces obesity, a major cause of diabetes, which contributes to kidney and cardiovascular diseases and many other conditions,” he added. “The emphasis on prevention will enhance quality of life and avoid or delay the need for dialysis or transplant.”
The Barnabas program, the Renal and Pancreas Transplant Division, which dates back to 1968, is among the 10 busiest in the nation and performed more than 300 transplants in 2015, including 135 that involved living donors, according to its website.
The group is also actively involved in research efforts, developing and testing new medications — including the immunosuppressants that are critical in transplant surgery — and conducting epidemiological studies to try and expand the options for living donors, Mulgaonkar said.
Living Donor Institute
In 2006, Barnabas added the Living Donor Institute, which has pioneered new techniques for these procedures, including developing systems that enable donors who might previously have been found incompatible to a specific patient to still give a life-saving gift.
Kidneys from a living donor last longer than an organ from a deceased person; surgeries are easier to schedule (organs must be harvested quickly after a healthy individual passes, making it nearly impossible to know when a transplant will occur); and recipients recover more quickly, Mulgaonkar explained.
Through the institute, Mulgaonkar and his team have developed protocols that involve matching for blood types, genetics, and even age ranges that enable them to perform various kinds of “donation chains,” in which altruistic donors are matched with recipients they may not know, and multiple patients end up receiving healthy organs. In the past decade, Barnabas has performed 150 of these chain surgeries.
“Our job is to promote living donation the best way that we can,” Mulgaonkar explained, calling those who do give “angels on this planet.”
Equally important is encouraging people to share their organs after death, he said. In New Jersey, organ donation has been on the rise in recent years, with more than 600 transplants performed last year. More than half a dozen organs are eligible for donation, if healthy, some of which — like tissues — can help multiple people.
“Those are organs that save so many lives,” Mulgaonkar said.