Statistical support for or against transplantation

Survival on integrated therapies--what assumptions shall we make?

The problems inherent in using actuarial survival calculations in order to compare different methods for treating end-stage renal failure (ESRF) are emphasized. Assumptions must be made concerning the date for commencement of follow-up observation, the method for handling patients who change therapy, and the impact of antecedent therapies on the one under consideration. It is stressed that patients involved in different treatment methods do not comprise comparable groups since they are not randomly assigned but are selected by the availability and applicability of treatment modes as well as physician and patient preferences. We have proposed that interval mortality and treatment change rates are descriptions of clinical events that have happened to any defined group of patients and may be easily understood by the physician who must advise and make decisions.

Prognostically controlled comparison of dialysis and renal transplantation

Because the comparison of survival in patients with renal failure treated by dialysis and transplantation may be biased by pretreatment prognostic differences in the patients who receive these two therapies, we quantified the pretreatment prognosis of all 430 dialysis and transplant patients who began therapy for end-stage renal disease at two hospitals from 1970 to 1980. Five pretreatment factors had a statistically significant adverse effect on survival: age, duration of diabetes, left ventricular failure, myocardial infarction, and other serious comorbid illness. Dialysis patients had a worse pretreatment prognosis than transplant patients did. When we controlled for these pretreatment differences, the actuarial 5-year patient survivals were 80% for dialysis (D), 79% for cadaver transplantation (CT), and 91% for living donor transplantation (LDT), (P = 0.9 for CT vs. D, and P = 0.05 for LDT vs. D). This similarity in survival with dialysis and cadaver transplantation was quite different from the results obtained when pretreatment prognosis was not controlled; the uncontrolled 5-year patient survivals were 43% for D, 77% for CT, and 89% for LDT (P less than 0.001 for CT vs. D, and P less than 0.001 for LDT vs. D). Our data suggest that the major factor determining differences in survival with dialysis and renal transplantation is not the relative efficacy of the two treatments but the pretreatment prognostic status of the patients chosen to receive them.

A comparison of psychosocial disability in males undergoing maintenance hemodialysis or following cadaver transplantation

Sixteen males undergoing maintenance hemodialysis were evaluated for social disability through the use of the Ruesch Social Disability Rating Scale and were compared with a group of 16 cadaver renal transplant recipients, matched for age and marital status. All 16 had excellent functioning of their transplanted kidney. In both groups most patients experienced a major degree of social disability, indicating significant interference with life-style. Patients who were married had lower social disability scores (DS) than those who were divorced or single (P less than 0.01). Contrary to expectation, no differences were noted between these two groups with regard to the overall degree of social disability. The DS data are corroborated by other clinical indices, such as employment status, financial stability, degree of depression and sexual functioning, which indicated similar degrees of impairment in both groups. New approaches, aimed at the preservation and enhancement of social and avocational skills, are mandatory of a comprehensive effort seriously geared towards rehabilitation is to be implemented in the overall treatment of these patients. The expertise of the mental health professional, especially the liaison psychiatrist, is critical for this task.