Dialysis, Transplantation, and Work
Downloaded from http://journals.lww.com/cjasn by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A
Honoring Original Intent
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/28/2023
Stephen Z. Fadem
CJASN 17: 1431–1432, 2022. doi: https://doi.org/10.2215/CJN.09840822
The invention of hemodialysis in 1943 was, at its
implementation, immediately recognized as a bridge
for patients with kidney failure (1). In 1947, dialysis
was brought to America and immediately envisioned
by John Merrill, a pioneer in dialysis, as a stopgap
measure for patients awaiting a kidney transplant (2).
The first kidney transplant was performed by Joseph
Murray in 1954, but it would not be until 1960 that
Belding Scribner first used dialysis as a means of sus-
taining chronic patients (2).
Dialysis and transplantation have both been envi-
sioned as ways to rehabilitate patients with ESKD to
return to an optimal lifestyle, including gainful part-
time or full-time employment where appropriate and
consistent with their aspirations. This was the shared
understanding among the elected leaders and patient
advocates involved, including the patient founders of
the American Association of Kidney Patients (AAKP),
when Medicare coverage was passed into law by the
US Congress in 1972 and signed by President Richard
Nixon in 1973 (3). AAKP has consistently viewed kid-
ney disease as both a health care and workforce issue
and understands that there are distinct barriers affect-
ing the well-being of the patient that prevent those
with a chronic illness from returning to work. I under-
stand and share this perspective more fully after hav-
ing endured an illness in the past (4).
General observation and the medical literature both
demonstrate that the majority of patients worldwide
undergoing dialysis are not employed. In a systemic
review and meta-analysis of 31 studies, the employ-
ment rate for patients on dialysis was 26% (range,
11%–60%) (5). This varies from country to country
and between modalities. Patients on peritoneal dialy-
sis are more likely to work than those receiving hemo-
dialysis (5). The ability to work is understandably
worse in those with diabetes and in those with the
comorbidities associated with it, namely peripheral
vascular disease, heart failure, and cognitive decline.
Patients who are not limited by these comorbidities
still experience the shortfall in expectations, which is
not related so much to the person as it is to the chal-
lenge of navigating the constraints of hemodialysis.
Transplantation helps to remove the barriers that pre-
vent one from working—and working effectively.
This is why AAKP works diligently to make certain
www.cjasn.org Vol 17 October, 2022
Baylor College of
that patients with kidney disease are informed of their Medicine, Department
care choices, including preemptive transplants. of Medicine, Section of
The paper “Employment Status and Work Function- Nephrology, Houston,
ing among Kidney Transplant Recipients,” published in Texas
this issue of CJASN, analyzes the characteristics of
Correspondence:
employed patients with kidney transplants (6). The study
Dr. Stephen Z. Fadem,
contrasts 688 patients with kidney transplants of working Kidney Associates,
age (51611 years) with a control of 553 community- 6560 Fannin, Suite
dwelling adults and 246 kidney donors. Transplanted 1730, Houston,
patients had an employment rate of 56%. Work function- TX 77030. Email:
fadem@bcm.edu
ing was evaluated in transplanted patients. A higher
education level, preemptive transplantation, and receiv-
ing a living donor transplant were factors associated
with work functioning. Data were obtained through the
responses to a validated Work Role Functioning Ques-
tionnaire (WRFQ; version 2.0) that measured how emo-
tional and physical issues affected the ability to perform
a work role.
WRFQ scores improved with transplantation. The
strongest negative association with work functioning
was fatigue, followed by concentration and memory
problems, restlessness and anxiety, muscle weakness,
and depression. Transplanted patients worked shorter
hours and were more likely to have jobs that are men-
tally rather than physically demanding when com-
pared with the community-dwelling employed adults.
The need and general desire for patients on hemodi-
alysis not in retirement to continue a working and inde-
pendent lifestyle are often thwarted by the dialysis
procedure, medications, and complications associated
with underlying diseases. Cognitive decline or severe
physical conditions preclude employment, but for
many, the ability to continue working is in the planning
and strategy that begins long before the commence-
ment of KRT. For some, employers are unconsciously
biased against hiring a patient with an underlying dis-
ability, regardless of whether it will play a role in one’s
performance.
The real takeaway message is that patients with trans-
plants do well during employment despite challenges
and obstacles. Early education about KRT can help
patients and employers work as a team, design a retrain-
ing option, and allow for the transition to a less physi-
cally demanding job. The paper by Knobbe et al. (6) also
identifies fatigue as a major factor interfering with work
function. Identifying therapeutic maneuvers that reduce
Copyright © 2022 by the American Society of Nephrology 1431
 1432 CJASN
fatigue and improve the health of the patient serves as a chal-
lenge to clinicians. Patients with CKD who undergo a preemp-
tive kidney transplant or undergo home dialysis have better
outcomes. This winning strategy will enable patient indepen-
dence, gainful employment, and the preservation of the qual-
ity of life—while honoring the original intent of the law.
Downloaded from http://journals.lww.com/cjasn by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A
Disclosures
S.Z. Fadem is the chairperson of the Medical Advisory Board
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/28/2023
for the American Association of Kidney Patients.
Funding
None.
Acknowledgments
The author thanks all patients and advocates, especially those
with AAKP and their medical allies. The hard work over several
decades has better aligned kidney treatments and innovations to the
aspirations of patients.
The content of this article reflects the personal experience and
views of the author(s) and should not be considered medical advice
or recommendation. The content does not reflect the views or opin-
ions of the American Society of Nephrology (ASN) or CJASN.
Responsibility for the information and views expressed herein lies
entirely with the author(s).
Author Contributions
S.Z. Fadem conceptualized the study, was responsible for for-
mal analysis, was responsible for resources, wrote the original
draft, and reviewed and edited the manuscript.
References
1. Kolff WJ: The artificial kidney. J Mt Sinai Hosp N Y 14: 71–79,
1947
2. Fadem SZ: Milestones in dialysis. In: Issues in Kidney Disease–
Dialysis, edited by Fadem SZ, Moura-Neto JA, New York, Nova
Science Publishers, 2021, pp 1–31
3. Himmelfarb J, Ikizler TA: Hemodialysis. N Engl J Med 363:
1833–1845, 2010 10.1056/NEJMra0902710
4. Fadem SZ: One year later. Perit Dial Int 19: 509–511, 1999
5. Kirkeskov L, Carlsen RK, Lund T, Buus NH: Employment of
patients with kidney failure treated with dialysis or kidney
transplantation: A systematic review and meta-analysis.
BMC Nephrol 22: 348, 2021 10.1186/s12882-021-02552-2
6. Knobbe TJ, Kremer D, Abma FI, Annema C, Berger SP, Navis GJ,
van der Mei SF, Bu €ltmann U, Visser A, Bakker SJL; the Trans-
plantLines Investigators: Employment status and work function-
ing among kidney transplant recipients. Clin J Am Soc Nephrol
17: 1506–1514, 2022
Published online ahead of print. Publication date available at
www.cjasn.org.
See related article, “Employment Status and Work Functioning
among Kidney Transplant Recipients,” on pages 1506–1514.