Published May 9, 2017 at 8:00 am (Updated May 9, 2017 at 7:01 am)
Bermuda has reverted to receiving mainly deceased donor organs for kidney transplant patients despite a rise in living donors between 2003 and 2009.
According to transplant co-ordinator Marianne Herbert, this could potentially be attributed to the high rate of contraindicated diseases in the local population.
“Living donors are selected very carefully and have to meet strict psychological and physiological criteria before being accepted as donors,” Ms Herbert, of Bermuda Home Dialysis Services, said.
“For a healthy individual, donating a kidney is safe and recovery is rapid.
“Having one kidney should not affect the donor’s health in any adverse way and the physical examination and testing involved in the preoperative work up will probably be the most comprehensive health evaluation that the person has ever undergone.”
But she said it was not always possible for transplant recipients to have a living donor “because of the very high incidence of contraindicated diseases such as diabetes and hypertension in the community”.
“Obesity, as we know, is a huge contributing cause of many diseases and this automatically rules out many potential donors.”
According to Ms Herbert, 106 people have received kidney transplants through programmes in Bermuda since 1972 and 32 of these were from living donors.
“Although recently we have had mainly cadaver donors for our clients, there was a period between 2003 and 2009 when we had as many living donors as cadaver donors.”
She said this mirrored a worldwide trend at the time, which could partly be attributed to the advent of laparoscopic or keyhole surgery to remove the donated kidney.
“It is a far less invasive surgery than the old traditional surgery where a rib was removed and the donor was exposed to major, painful, open surgery, which required a lengthy hospital stay and recovery period.”
She added that living donations were also opened up to friends and spouses, having at one time been reserved for blood relatives alone.
Other strategies to increase living transplants include “paired exchange programmes, ‘relay’ kidney transplantation programmes and other beneficial strategies such as moving a potential recipient to the top of the list if a donor who is unable to donate to that person is able to donate to someone else”, she added.
“Good Samaritan” donor programmes have even been set up for anonymous donations, she said, with one Bermudian the recipient of such a donated kidney and one altruistic donation by a Bermudian.
Kidney transplant funding for HIP and FutureCare patients is to increase by 50 per cent to up to $150,000 under new legislation.
A health Bill has been tabled to expand coverage from June 1 so that more patients can come off dialysis, a government spokeswoman said.
According to Irena Ashton, owner of Bermuda Home Dialysis Services, this is a move in the right direction but travel expenses, which can be significant, remain to be addressed.
She also stressed that more focus should be placed on living donors because this can lead to better patient outcomes, shorter wait times and therefore less time spent on dialysis.
“Money is everything when it comes to transplants,” the dialysis nurse told The Royal Gazette. “I would like things to be moving a little faster but this is a good start.
“HIP is really trying, they are moving it forward in a much faster way. Now we just have to wait and see — hopefully it is going to get passed.”
While Ms Ashton pointed out that “HIP actually covers a lot of things”, she added that “travel is sort of an outstanding thing”.
She said patients often had to spend up to six weeks abroad and also had to travel back to the transplant centre for follow-up appointments.
Extra help is available for those receiving financial assistance and others can apply to the Lady Cubitt Compassionate Association for loans, but she said travel costs can still make transplants “prohibitive”.
“Most dialysis patients in Bermuda, I’d say 60 per cent, have HIP — they cannot afford it,” Ms Ashton said, adding that they “are forced to remain on the much more expensive dialysis treatment”.
She added that performing the procedure locally, if this were a possibility, could be a positive development [see separate story].
Ms Ashton also stressed that more focus on living donors, which she said are not currently financially reimbursed for HIP and FutureCare patients, would be a “big step”.
“If there is another progression, it would really be to explore living donors,” she said, adding that this would “speed things up more”.
There are about 170 people in Bermuda who are on dialysis and Ms Ashton also emphasised the need for patients to start the transplant process sooner, ideally before starting dialysis.
“A lot of them are walking around with chronic kidney disease and don’t even know it. Ideally we would like to get these folks to get the proper education and part of that education is transplants.”
She added that “they don’t get transplanted overnight,” noting that patients on dialysis have to wait between three and seven years — depending on their blood type — for a suitable match.
According to the health ministry spokeswoman, the Mutual Reinsurance Fund covers $30,000 towards a kidney transplant, with HIP and FutureCare providing an additional $70,000.
“The ministry has tabled legislation seeking to increase the MRF coverage to $100,000 from June 1, 2017,” she said.
“HIP and FutureCare benefits are also being updated accordingly to cover up to $150,000 altogether, including the MRF portion, in order to ensure their policyholders can have access to transplants.
“The intent of the change is precisely to pay for transplants so that more persons can come off dialysis, which will be more cost-effective in the long run.”
The spokeswoman added that coverage of pre-transplant costs was dependent on the case rates at the different facilities, which vary in what they include.
“Pre-surgical evaluations can extend from several years to immediately before the surgery. HIP is currently in negotiations to improve the coverage.”
She also said that some overseas facilities had offered case rates that cover some of the costs of the live donor.
“When costs are not covered in the case rates for the transplant recipient, the facilities charge the live donors’ insurance separately.”
The legislation was tabled on March 20 as part of the Health (Miscellaneous) Amendment Act 2017.