Health: Second Opinion

AMONG the many negative aspects of the Government's NHS reforms is a decline in the chances of kidney patients getting transplant operations. More than 4,000 patients are on the waiting list of the United Kingdom Transplant Support Service Authority, and the number has been rising by around 10 per cent a year.

This long queue for a kidney transplant gets little publicity. No such queue exists for people waiting for hearts, livers or lungs - for a grim and simple reason: sick patients whose heart, liver or lungs are failing need a transplant within a few weeks or they will die. Kidney patients have an alternative: for 40 years now they have had the lifeline of regular dialysis on an artificial kidney (still the only successful man-made substitute for a complex internal organ) or similar treatment by peritoneal dialysis. Having chemical impurities and wastes removed from the blood by one of these techniques three times a week does keep people alive, but they do not feel really well. People on regular dialysis have to follow strict controls on what they eat and drink, spend many hours each week on treatment, and even so they lack energy and vitality.

A successful kidney transplant, by contrast, frees the patient from the need for dialysis, allows them to eat and drink what they like, and restores verve and enthusiasm. After transplantation patients go on to have children, climb mountains and hold down demanding jobs. And in economic terms a successful transplant is a good buy for the NHS and society.

In 1981 there were 814 kidney transplant operations in Britain using kidneys removed after death. By the end of the 1980s this figure had doubled to 1,728, but since then it has slipped back to 1,640 in 1992, the last year for which figures are available. As the number of operations has fallen the numbers waiting have risen from 3,666 in 1990 to 4,361 in 1992. Most of the kidneys used for transplants came from patients dying in hospital intensive care units. (The best results have been shown to come from operations in which the kidneys are removed from patients certified as brain dead but whose hearts are beating). The decline in kidney operations seems to be linked with the growing pressure on hospital beds. It all takes time to keep the patient breathing and his heart beating to prepare for organ donation, to contact the relatives and to carry out the necessary tests. That time is often not easily available. In the words of the British Medical Journal: 'A shortage of intensive care beds undoubtedly influences decisions on whether to ventilate patients who are comatose after cerebrovascular accidents'.

Furthermore, in one third of cases the family does not give consent, being unable to agree whether or not the patient would have wanted to act as a kidney donor. Fewer than one third of people in Britain carry a kidney donor card. In far too many cases the medical staff make no enquiries about the possibility of organ donation. Transplant surgeons are being forced to use kidneys taken after the heart has stopped in patients who die in wards other than intensive care units. The results obtained with these kidneys are not as good as those with kidneys taken from patients on ventilators.

The failure of the transplant programme to keep up with demand is a problem that needs action. I should like to see a change in the law so that people would have to register an objection if they did not want to donate their organs after death, together with an auditing system to check that all patients dying in hospital are assessed as potential organ donors. It cannot be right to have hundreds of people added each year to the thousands, many of them young, waiting for a chance to return to normal life.