Computers

and Kidneys:A Need

That MustBe Filled

LARRY SCANLAN

Mr. Scanlan, a former assistant. editorof CANADIAN FAMILY PHYSICIAN, is now a re-porter with the Nelson Daily News, Nel-son, BC. Reprint Requests to: 370 BakerStreet, Apt. 2, Nelson, BC. VI L 4H5

M ORE, as the saying goes, isn'talways better. But for Canadian

kidney patients eligible for transplantsurgery, MORE is best.MORE stands for Metro Organ Re-

trieval and Exchange, a Toronto-basedservice designed to match kidneydonors with patients needing new kid-neys. Dr. Michael Robinette, a urolo-gist and transplant surgeon at TorontoGeneral Hospital, directs the two yearold MORE program, the only one ofits kind in Canada. He told CANADIANFAMILY PHYSICIAN that the programencourages both physicians and thepublic to participate in the kidneydonor plan.

In Ontario there are about 850 pa-tients currently on some form of renaldialysis, including 500 eligible fortransplantation. Across Canada, 1500of 2000 kidney patients are waiting fordonor kidneys.

The MORE program, said Dr. Ro-binette, was organized to stem thegrowing backlog of dialysis patientswaiting for kidney transplants. Each

year in Canada 800 new patients go ondialysis, while as recently as 1975only 350 kidney transplants were per-formed. But in two years MORE hasdoubled the number of kidney trans-plants in Ontario.

Transporting the KidneyA typical scenario for the program

would be as follows: a patient whosedriving license identifies him as a kid-ney donor has died. The physician,after seeking the permission of the pa-tient's relatives as a courtesy, calls the24-hour MORE telephone number inToronto. A team of two surgeons,either from the donor hospital or theMORE program, removes the donorkidneys, which are then packed in iceand immediately transported to theMORE office where they are hookedup to a portable perfusion unit until arecipient can be found, if not in On-tario, then another province or theUnited States.MORE kidney perfusionist Vince

Mulder said they have 72 hours to lo-cate a recipient before the kidney startsto deteriorate. "We work against theclock and the airline schedule", hesaid. When the most suitable recipientis found, the perfusionist-either inthe MORE truck or when necessary an

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airplane-accompanies the kidney andmonitors it all the way to its destina-tion. The unit travels at half fare; pas-sengers occupying the next seatusually react when they discover thebox beside them contains a perfusingkidney.

Dr. Robinette said that most dialysispatients are eager to undergo trans-plant surgery: "The social factors arereally dramatic. The patient's life iscompletely turned around. They'reborn again. This is what keeps ourspirits up when occasional transplantsfail through rejection-still a centralproblem." While dialysis will flushout the body's poisons, it cannot, forexample, maintain hemoglobin level,so that dialyzed patients feel weak andtired. They are also prone to bonecomplications and must adhere to rigiddietary restrictions. Successful kidneysurgery eliminates those problems andgives the patient new freedom. Al-though he will be on immunosuppres-sive drugs for life, his twice weeklysix to ten hour sessions on tde dialysismachine are over. About two thirds ofthe transplanted kidneys are still func-tioning after two years; after five yearsabout half are still functioning. Thesurvival of the graft is much higher ifthe kidney is donated by a close rela-tive, Dr. Robinette added.

In the U.S.'some patients have triedup to five kidney transplants."They've had a taste of what it's liketo be off dialysis", said Dr. Robinette."That keeps them going".

Where Does the MoneyCome From?

Patient motivation then is not aproblem; government motivation is.Dr. Robinette cited figures showingthat the average annual cost of keepinga patient on dialysis is $20,000. Multi-ply that by 2,000 patients and the Ca-nadian dialysis bill comes to $40 mil-lion. Kidney transplants cost $5,000,most of which pays for the three weekpost-operative in-hospital costs, whilesurgeons removing donor kidneys arepaid $200. The MORE program-per-fusion units, transportation system andadministrative costs-is currentlyfunded from the global budget of theToronto General Hospital and the Kid-ney Foundation of Canada. "The pro-vincial government really has to cometo grips with the economics of the situ-ation. There's a feeling of restraint ingovernment now, and rightly so, butthe point is if a program is expandingand saving money, why not jump at

it?" asked Dr. Robinette. He lamentedthat "we just came on the scene at abad time". He also argues that sinceMORE is increasingly serving otherprovinces, the federal governmentshould get involved, preferably byproviding a computerized matchingservice for donors and recipients.

The FP's RoleWhere does the family doctor fit

into the kidney donor program? Dr.Robinette described a major role forthe family physician in educating andencouraging patients to be aware of theneed for donor kidneys. Driving li-cense donor cards are only one way,he said. Not everyone drives and hefeels family physicians should havedonor cards in their offices. "Anyfamily doctor who has a patient ondialysis receive a donor kidney appre-ciates the value of this", said Dr. Ro-binette. Secondly, the family doctorhas a,role after a patient's death inidentifying potential donors and ap-proaching relatives for permission. insmaller hospitals without neurosurgi-cal units, family physicians on call inemergency departments can identifypotential donors in patients who havesuffered cardiac arrest or drowning,been resuscitated, and then suffered ir-reversible brain damage. Most donors,however, come from the neurosurgicalor trauma units in larger hospitals.

Neurosurgical DeathCrucial to the successful removal

and transplant of a donor kidney, saidDr. Robinette, is the concept of neuro-logical death. "We're missing somepotential donors because the patientdeteriorates to the point where he isneurologically dead and then continuesto deteriorate until the heart stops beat-ing". He wishes physicians in particu-lar would remember that once the pa-tient's heart has stopped for tenminutes, his kidney is no longer usefulin transplant surgery. Criteria forneurological death include unrespon-sivity, lack of central reflex, fixed di-lated pupils and no spontaneousbreathing (all donors are on a respira-tor). This is a clinical determination,said Dr. Robinette, made by any twodoctors not associated with the trans-plant program-usually a neurologistor neurosurgeon. An EEG can also beused, he added. "We try to time remo-val of the kidney with the time of de-terioration of heart function". Notingthat both the U.S. and Europe havecomputers to link donor kidneys with

recipients, Dr. Robinette listed manyadvantages to computerizing theMORE program. "At present we haveto make a lot of phone calls to find asuitable recipient. A computer wouldmean quicker and better matching anddrawing from a Canada-wide and notjust Ontario pool of recipients, proba-bly with better graft survival results".He added that a computer would saveMORE sending six to eight kidney tis-sue samples 'helter skelter' across thecountry; instead three samples wouldbe sent to the transplant centres of thethree best recipients. The computerwould also keep accurate, comprehen-sive records for research purposes. Dr.Robinette called the idea for a Canada-wide, computerized donor system''our contribution to Canadianunity".

Funding for the MORE programprovided by the Toronto General Hos-pital is guaranteed until 1980. MOREalso occasionally sells donor kidneysto the U.S. when recipients can't befound in Canada. Dr. Robinette saidselling to the U.S. enables MORE inturn to buy U.S. kidneys, since On-tario's Medicare plan does not pay forkidneys procured outside Canada.When kidneys are sent to other parts ofCanada, MORE charges a perfusionfee plus air fare.Looking ahead, Dr. Robinette is

hopeful. He said that in the past twoyears, MORE has handled over 350donor kidneys, half of them obtainedthrough donor cards attached todrivers' licenses. The donor cardmethod is relatively new, and Dr. Ro-binette is confident time will bring bet-ter results. At the moment, only Mani-toba, Saskatchewan, Ontario andQuebec have the donor card system;other provinces are in the process of

783CAN. FAM. PHYSICIAN Vol. 24: AUGUST 1978

formulating legislation. He said thepublic and especially young peoplesupport the notion of donating organsafter death. "The donor program willget better. What we're trying to do ispublicize this fact to people and makeit as natural as giving blood to the RedCross", said Dr. Robinette. He com-mented that relatives of a dying patientnow will approach physicians saying'we realize the situation is hopeless.What about using the kidneys or eyesfor transplantation?' He also felt that aprogram of automatic organ removalafter death, as some countries haveproposed, would not succeed in Can-ada, nor is it necessary.

Dr. Robinette, who spends a greatdeal of time talking to both physiciansand the public about MORE, admitsthe program is expensive. MORE'stwo portable perfusion units cost$7,000 each (one was donated by theManulife Insurance Company and theother by the Owen Sound RotaryClub), while the non-reusable cas-settes used to transport kidneys are$300 each. However, he feels the re-turns are worth more than money.Two years ago in Toronto about five

kidney transplants a month were beingdone. That number has since doubledand in some months as many as 25extra transplants are performed acrossCanada as a result of kidneys suppliedby the MORE program. Of 120 trans-plants performed in Toronto in 1976,60 percent were successful. Five yearfollow up usually trims that successrate to 50 percent. These figures, said

Dr. Robinette, are comparable to thoseof other kidney transplant centres inNorth America.

The European SituationIn Europe, seven countries partici-

pate in the Eurotransplant program,based in Holland. A computer in Lei-den holds tissue data on about 1,000possible recipients. When a donor kid-ney becomes available, all data on itstissue group are fed into this computerwhich then selects the most suitablecandidate. West Germany, Belgium,The Netherlands, Britain, Denmark,Norway. and Sweden cooperate in theEurotransplant program, which hasbeen in existence for ten years.

Dr. Eric Guthy, a surgeon at theMedizinische Hochschule in Hanover,West Germany, says that about 1,200donor kidneys were required in thatcountry last year. Proposed legislationwhich would permit automatic organremoval following death, unless thepatient has forbidden it beforehand inwriting, has so far met stiff resistancein the West German parliament.

Other solutions to the donor prob-lem are the 'Spenderpasse'-a cardwhich the donor carries bequeathinghis organs-and relatives' consent. Inthe absence of a Spenderpasse, WestGerman law requires the family's con-sent before organ removal, a time losswhich can hurt the donor organ's qual-ity.

There is no doubt, said Dr. Guthy inan interview, that the number of kid-ney transplants must increase due to

the sky-rocketing costs of renal dia-lysis. By 1980 the cost of dialysis inWest Germany could hit 1.2 billionmarks ($516 million). Dr. Guthy putthe current cost of a kidney transplantin West Germany at under 50,000marks, including three year follow up,while dialysis care over the same threeyear period costs six to ten times asmuch.The Medizinische Hochschule's

own study comparing surgery and dia-lysis in renal disease projected thatover a five year period, averaging 100operations per year and counting on a50 percent success rate, surgery wascheaper per year by 24 million marks.

Dr. Guthy, looks forward to aworldwide donor program. His hospi-tal has already received kidneys fromChicago, Poland and East Germany.But he admits there are obstacles-theSoviet Union, for example, does notaccept the concept of neurologicaldeath.

Although there are 145 renal pa-tients on the recipient waiting list innorthern West Germany, including 25in the urgent category, there is no pro-motional plan to increase the numberof potential donors. "We'll do it pa-tiently", commented Dr. Guthy."We'll just work harder on promotingthe Spenderpasse and try to convincefamilies that organs should be do-nated."To obtain the organs, surgical teams

from the university may go out to ruralhospitals or rural teams may undertakethe organ transfer themselves. Dr.Guthy suggested that although not allhospitals had been cooperative in thepast, this is changing. The Dutch, hesaid, have had considerable successpaying rural hospitals to remove donororgans. Following a decision to payhospitals about 1,200 guilders ($500)per organ, the Dutch doubled theirprocurement rate in two years and nowdo twice as many kidney transplants asthe West Germans, despite a smallerpopulation.

In Hanover 49 kidney transplantswere performed in 1971. Better bloodtyping and research could well im-prove success rates and Dr. Guthy ishopeful that within ten years legisla-tion making organ donation after deatha matter of course will be on the WestGerman lawbooks.

Family physicians interested inMORE should write 101 College St.,Suite 143, G.W.3, Toronto, ON.M5G 1L7 or telephone (416) 595-3155.

CAN. FAM. PHYSICIAN Vol. 24: AUGUST 1978784