The shortage of kidneys for transplantation in Australia

The treatment alternatives available to Australians with endstage kidney failure are dialysis, transplantation or no active treatment. The last of these options allows kidney failure to progress spontaneously to uraemia and death. Over the past decade the number of Australians on dialysis has grown by 6% per annum, adding an additional $25 million yearly to healthcare expenditure. The availability of kidneys in Australia remains low and, if anything, is worsening, with only 6.8% of those on dialysis receiving transplants in 2002, compared with 11.7% a decade earlier.

204 MJA • Volume 182 Number 5• 7 March 2005
ED I T O R I A L S
The Medical Journal of Australia ISSN: 0025-
729X 7 March 2005 182 5 204-206
©The Medical Journal of Australia 2005
www.mja.com.au
Editorials
he treatment alternatives available to Australians with
endstage kidney failure are dialysis, transplantation or no
active treatment. The last of these options allows kidney
failure to progress spontaneously to uraemia and death. Over
the past decade the number of Australians on dialysis has grown
by 6% per annum, adding an additional $25 million yearly to
healthcare expenditure.1 This growth is caused by both increas-
ing numbers of people entering dialysis programs and a low rate
of transplantation because of a shortage of donor kidneys.
Kidney availability in Australia remains low and, if anything, is
worsening,with only 6.8% of those on dialysis receiving
transplants in 2002, compared with 11.7% a decade earlier.1
Dialysis is the only initial treatment option for most patients
with endstagekidney failure.Transplantation withoutprior
dialysis is increasingly popular, but
requires a live donor available at the right
time; currently, only 3% of patients under-
going transplantation have not been on
dialysis beforehand. Of those on dialysis,
only 23% overall and 39% of those aged
under 65 years are on the waiting list for a
deceased-donor transplant.2 Those not on
the list are either not interested in undergoing transplantation,
have medical barriers to safe transplantation, or are deemed
too frail to tolerate the procedure and subsequent immuno-
suppression.
Both patients and healthcare professionals believe that trans-
plantation, when feasible, is the preferred therapeutic option.
The scientific justification for this belief appears well founded.
In particular, there is strong evidence that patients who receive
transplants have a significant survival advantage. The annual
mortality rate of an age-matched population maintained by
transplantation is reduced about 80% beyond the first year
compared with those remaining on dialysis on the waiting list.3
The major difference is an up to 30-fold increase in relative risk
of cardiovascular events and death experienced by those on
long-term dialysis.4
In most Australian states, the average wait for a kidney from a
deceased donor is about 4 years, and some patients wait much
longer. The prospect of an extended wait on dialysis, as well as
the possibility that a suitable kidney may never become availa-
ble, drives some patients to consider more drastic options. One
pathway that is illegal in Australia, but open to those able to
afford it, is to travel overseas to purchase a kidney transplant. It
is not known how often Australians are choosing this option.
The report by Kennedyet al in this issue of the Journal
(page 224) describes the outcomes for 16 Sydney-based patients
who travelled overseas for kidney transplantation over the past
14 years. The risk of going down this path is evident, with an
increased risk of serious infection being a major hazard.
The annual rate of deceased-donor kidney transplants in
Australia for 2004 was a low 11 donors per million population.5
In 2003, the rate in Australia was 9.0 per million population,
compared with 33.8 in Spain, 23.9 in Austria, 24.8 in Belgium
18.3 in France and 22.1 in the United States.6 Thus, the rate of
organ donation in this country is low compared with oth
developedcountries,and remainsso despitethe publicity
campaign promoting organ donation following the untime
death following a brain injury of Australian cricket icon David
Hookes. One response to the shortage in deceased-donor org
has been an increase in live kidney donation, and the propor
of live donations in 2003 was 40% of total transplants.
source of live kidney donors, previously restricted to close bl
relatives, has broadened in recent years to allow unrelated a
poorly matched emotionally connected donors. In the past 12
months, there have been several kidney transplants from altr
tic strangers donating to the pool of waiting
dialysis patients(so-callednon-directed
donations). We can now add overseas com-
mercial sources as another contributor to
live kidney donation for Australian resi-
dents.
The real reasons for Australia’s poor per-
formancein deceased-donororgan pro-
curement have not been fully established. Clearly, there
lack of public support, which has exceeded 80% in repe
surveys over many years.7 One outstanding observation that has
received little prominence and no systematic study is the hig
and internationally competitive organ donor rate achieve
South Australia.Over thelast decade,South Australiahas
consistently doubled the rate in all other Australian state5 A
similar variation in performance is seen in the teaching hospi
in capital cities, with some having double the rate of others.
marked variation in the donation ratesbetween states and
hospitals points to the probability that the barriers to increas
organ donation are within the hospital system.
The situation in Australia appears ripe for a collaborat
approach, such as one reported from the United States
sought to “identify, learn, adapt, replicate and celebrate ‘bre
through’ practices associated with higher donation rates”.8 It is
remarkable that Australia has been so slow to fully examine a
take up systemsthat appearto work in some regionsor
hospitals.
Positive moves are being made. A special working grou
the Australian Health Ministers’ Council has recently made 11
recommendations for change in the arrangements and proc
for organ donation. The most fundamental recommendation
for intensive care staff to routinely interrogate the Austr
Organ Donor Registry to ascertain the recorded intent o
suitable patients with severe brain injury after the first
brain death tests. Relatives will then be informed of the inten
recorded on the Registry and be asked only if they are aware
any change. Importantly, in this approach, the family will
need to be asked for consent.
The shortage of kidneys for transplantation in Australia
T
Desperate people seek desperate remedies
It is remarkable that Australia
has been so slow to fully
examine and take up systems
that appear to work

MJA • Volume 182 Number 5• 7 March 2005 205
ED I T O R I A L S
If Australia’s organ donation rate could match that of its best-
performinghospitalsand states,the embarrassingsituation
driving dialysis patients to take the risks involved with travelling
overseasfor kidney transplantationwould not exist. Much
remains to be accomplished, but there are grounds for optimism
in believingAustralia’sdeceased-donororgan donationrate
could double if the barriers existing in the hospital system could
be removed.
Timothy Mathew
Medical Director
Kidney Health Australia, Adelaide, SA.
[e-mail]
Randall Faull
President
Transplantation Society of Australia and New Zealand, Sydney, NSW
Paul Snelling
President
Australia and New Zealand Society of Nephrology, Sydney, NSW
1 Australia and New Zealand Dialysis and Transplant Registry. Available at:
www.anzdata.org.au (accessed Dec 2004).
2 Chadban S. Transplant waiting list. ANZDATA Registry Report 2003.
Adelaide: Australia and New Zealand Dialysis and Transplant Registr
2003: 62-63.
3 McDonald SP, Russ GR. Survival of recipients of cadaveric kidney trans-
plants compared with those receiving dialysis treatment in Australia and
New Zealand 1991–2001. Nephrol Dial Transplant 2002; 17: 2212-2219.
4 Levey AS, Beto JA, Coronado BE, et al. Controlling the epidemic of
cardiovascular disease in chronic renal disease. National Kidney Founda-
tion Taskforce on Cardiovascular Disease. Am J Kidney Dis 1998; 32: 853-
906.
5 Australia and New Zealand Organ Donation Registry (ANZOD). Available
at: www.anzdata.org.au/anzod/anzodwelcome.htm (accessed Jan 2005).
6 Council of Europe. International figures on organ donation and trans
plantation — 2003. Newsletter Transplant 2004; 9(1): 18-20. Available at:
www.coe.int/T/E/Social_Cohesion/Health/TRANSPLANT%20NEWS-
LETTER%202004.pdf(accessedJan 2004).www.anzdata.org.au/anzod/
anzodwelcome.htm (accessed Jan 2005).
7 Pfizer Australia Health Report August 2004. www.pfizer.com.au/Media
Transplants.aspx (accessed Jan 2005).
8 US Dept of Health and Human Services – Division of Transplantation. The
organ donation breakthrough collaborative: best practices final report.
September 2003. Available at: www.organdonor.gov/bestpractice.htm
(accessed Jan 2005). ❏