Some of the factors that detract from the choice of transplantation in my mind include the fact that cardiovascular disease is the number one cause of death among transplant patients, even greater than infection. True, cardiovascular disease is also the number one cause of death among dialysis patients, but I have avoided CV disease on dialysis by limiting fluid gain. I may be vulnerable to transplant-induced CV through a different mechanism. Added to this would be the fact that five-year graft survival is considered a good result. Another concern is that I have observed several transplant patients who have had significant psychological and emotional problems associated with the immunosuppressive drugs.
Cancer is another major concern.
Peter Morris, MD, speaking at the American Society of Nephrology meeting in San Diego last fall, warned transplant physicians that they must be careful that they do not start a cancer epidemic in the transplant population. Although not a medical concern, losing Medicare coverage three years after a transplant is no small financial concern for prospective transplant patients. Certainly the palatability of one's diet is an important lifestyle consideration when considering a treatment modality. It seems to me that the low sodium, low fat, and low sugar diet of transplant patients is nearly as restrictive as the dialysis diet, especially since home hemo patients can enjoy an almost normal meal immediately before dialysis. Based on these problems and ongoing observations of transplant patients whom I have known over a considerable period of time, I have reached the conclusion that really good home hemodialysis may be medically equivalent to transplantation, if lifestyle factors are not considered.