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    Case History: Medical And Ethical Quandary
    By Becky Jungbauer | May 13th 2010 11:27 PM | 2 comments | Print | E-mail | Track Comments
    About Becky

    A scientist and journalist by training, I enjoy all things science, especially science-related humor. My column title is a throwback to Jane

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    In medicine, physicians often present case histories or case reports of an interesting situation/patient, along with the outcome (typically a diagnosis) and discussion.1 On controversial cases, medical ethics can be invoked (although not quite to the expertise or depth of Dr. Pigliucci). Here's one I recently came across - whether to perform a kidney transplant for a middle-aged male with multiple co-morbidities - and I thought the implications were really interesting. I'll give you basic relevant facts and context and would like to know what you'd do.

    Patient: A 50-year-old Caucasian male with Cystic Fibrosis (CF) and Type 1 Diabetes.

    Patient background: Married with two children. Recovering alcoholic. Recurrent pneumonia, as is typical with CF, and a regular inpatient at the local hospital. About 6 months ago, started on dialysis, which markedly improved his health. Dialysis is burdensome - it is difficult to get to dialysis and financially it is a stretch, so he wants a kidney transplant. He would not qualify for a transplant from UNOS given his age and disease, so his family was tested and his 45-year-old sister (married with three children) is a match. She is willing to donate a kidney.

    Disease background: Cystic Fibrosis is a multi-system disease characterized by chronic respiratory infections, pancreatic enzyme insufficiency and other gastrointestinal issues. Thick sticky mucus builds up in the lungs and GI tract, causing chronic infection and difficulty breathing and digesting. Although this was considered a pediatric disease even just 50 years ago due to the lack of therapy (patients often died as children), recent advancement in therapy has lead to improvement in survival. Currently, the predicted median survival age for a patient with CF is 37, although some patients can live to their 40s and older. Cystic fibrosis patients are considered immunosuppressed.

    Kidney transplant background: Kidney transplants are typically performed on patients with end-stage renal disease (usually due to diabetes) or chronic renal failure. Physicians may recommend against a kidney transplant in patients with heart, lung or liver disease. For patients with a very close match, 90%  of relatively "healthy" patients may still be alive after one year, and 70% may still be alive after five years. A transplanted kidney can extend the life of an otherwise healthy patient by 10-15 years more than would be if the patient stayed on dialysis. (The average lifetime of a transplanted kidney is about 10-15 years, so a patient may require a second transplant or more dialysis if the kidney fails.) The recipient will usually stay in the hospital for 3-7 days and will have constant checkups and blood tests for 1-2 months post-transplant. The recovery time for a "typical" patient is about 6 months, but the patient will need x-rays and blood tests regularly for years. The patient will also be placed on immunosuppressants for the remainder of his/her life to try and prevent the body from rejecting the new organ, although immunosuppressants put patients at higher risk for infection and cancer. Immunosuppressants alone can cost over $1,500 per month. Acute rejection occurs in 10-25% of patients within the first 60 days post-transplant. Other risks of kidney transplant include bleeding and infection during and after the surgery, blood clots, heart attack or stroke, osteoporosis, GI inflammation, type 2 diabetes. The donor often experiences more pain than the recipient; the hospital stay is about 2-7 days. The remaining kidney may take a few days to recover but the outcome is usually good. Risks include blood clots, infection, heart attack or stroke, and hernia. A possible long-term complication is if the remaining kidney were to fail, the patient would need dialysis and transplant.

    So, given the benefits and risks to all involved (medical and otherwise), considering the above patient's background, and assume the patient will accept whatever recommendation you give him, would you recommend for or against a kidney transplant in this case?

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    1The nice part about case histories is that they're de-identified so you have a vague picture of the patient but not who the patient is, which can make a difference in your decision. For example, would your recommendation change if the patient described above was (a) a generous, highly valued member of the community beloved by all, or (b) a violent criminal? For example, see the widely circulated, two question "ethics test" here (although, to be fair, these questions may not be entirely valid).

    Comments

    Amateur Astronomer
    When faced with a medical decision, I always remember the biography of Oliver Goldsmith the English writer. He died from prescribing the wrong medicine for himself.

    The financing doesn’t look too good. With dialysis being financially challenging, and transportation being a problem, it doesn’t look like insurance or federal programs are available to pay for the surgery either. So they are probably looking at a large medical bill that largely wipes out the savings from dialysis.

    This decision should be between the doctor and the patient, maybe in consultation with the family. It sounds like he decision has already been made with the family members being tested.
    Becky Jungbauer
    A story about aging CF patients popped up on Scientific Codex.