sory Committee for the National Kidney Foundation for the past 3

years.

In addition, I am currently writing a textbook on transplantation. In the interest of brevity, I will highlight some of the statements from my prepared statement, which I would like to submit for the record.

I think it is a known fact there are approximately 8 million people in the United States afflicted with kidney disease. Of these, 50,000 individuals die each year from kidney disease. This is primarily kidney disease.

The unfortunate thing, Mr. Chairman, is that about 70 percent of these young people are under the age of 35. These patients are dying simply because the kidneys no longer function.

As a member of the Gottschalk committee, in 1966 and 1967, we determined that approximately 7,000 to 10,000 of these patients could be successfully treated each year with either dialysis or transplantation. At that time the criteria we established for entry into the program included young patients, patients between the ages of 15 and 45, patients without other conditions afflicting their kidneys. And since that time, in the past 2 years kidney transplantation has evolved in the sense that at the present time we now transplant patients from generally 6 months of age to as old as 65.

We have extended the age criteria and also transplantation patients with diabetes and other diseases afflicting the kidneys, so our conservative estimate at the time of the Gottschalk report was 7,000 patients can be successfully treated with known treatment at that time. And it can now be extended to closer to 20,000 or 25,000 patients a year.

This means, Mr. Chairman, that 20-to-25,000 patients are dying needlessly in the United States simply because we cannot implement the program set out in the Gottschalk report or a program as envisioned by this addition to the regional medical programs, the program for kidney disease.

Now, it is interesting that what has happened in the past three years since the Gottschalk report was submitted, we have had to run in a patchwork quilt of financing, as was indicated, and we turned to thirdparty payments of insurance. And we turned to Title XIX and various private donations, even use of research dollars, to support activities in transplantations.

Despite this, as these programs have grown, in 1967, there were approximately 300 kidney transplants in the United States. Last year, in 1969, there were approximately 500 to 550 kidney transplants in the United States, an increase of only 250. And this means that there are 20-to-25,000 patients that are dying simply because there is no method of treatment available to them at the present time.

To my knowledge, this unconscionable situation has never presented itself to medicine before, when a treatment modality has been available and not been given to the people because of lack of funds to implement the programs envisioned by those who have studied the kidney disease.

Now, it is interesting to note from a pragmatic sense that kidney fits nicely in a regional medical program. Kidney disease affects heart disease. And, as Dr. Merrill pointed out, it has been a tremendous spin off in the area of investigation of cancer, affects strokes by hyper

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tension. And, in addition, it is the ideal disease to add categorically to the end of the diseases in the "RMP program."

The other thing important, as far as the RMP program is concerned, is at the present time we have regional programs, regional programs within our own five-State area of Minnesota, the Dakotas, Wisconsin, and Iowa, which allow us to keep approximately 100 to 125 patients on the artificial kidney at any time, all waiting as recipients for transplants when organs become available.

It is implemented by a system of helicopters, airplanes, ambulances, and cooperative satellite units.

This program extends even beyond the microscopic regions to the region of the whole United States. A classic example may thus be brought forth based upon a series of events that occurred just last week.

A young man died in Salt Lake City, Utah. And the survivors felt the patient wanted his kidney used for transplantation. And he was typed. And this was done through a computer in Los Angeles. The computer readout of the other 1,000 patients awaiting transplantation throughout the United States indicated the two closest patients to this patient were two patients located in Minnesota, one on dialysis at Mayo and the other in the veterans' dialysis unit in Minneapolis.

These kidneys were flown from Salt Lake City to Minneapolis, both transplanted successfully to these two patients. This shows the kind of regional and superregional representation that can occur with kidney disease.

To extend this even one step further, in Los Angeles recently a kidney was removed from a dog, placed in a container, and airshipped to Israel and placed in another dog and successfully transplanted. It is keeping the dog alive, which indicates the kind of progress being made in preservation and utilization of these organs for transplantation.

Now, kidney disease today and kidney transplantation is no longer experimental. It is therapeutic and is the best treatment for patients dying because their kidneys no longer function. This differs from other pilot programs in transplantation of heart and lung and pancreas and bone marrow, and so forth.

If this is true, what are the results? At the present time, if you receive a kidney from a blood relative donor, the chance of you being alive and well with a functioning kidney 5 years later is between 90 to 95 percent in the institution. If you receive a kidney from somebody recently dying, a cadaver, unrelated, the chance of being alive and well are 50 to 60 percent at 5 years in our own statistics.

What this means is a 100 percent fatal condition has been now reversed to a completely treatable condition as far as the kidney is concerned.

I think, as far as I am concerned, that there is to me a tremendous urgency needed for implementing this program.

What about cost analysis? Kidney disease and urological disease is the primary cause of loss of work for women, work hours, and the fourth leading cause of loss of work for men. So it does cause an economic loss as well as 25,000 patients dying needlessly because of lack of treatment.

What happened economically is the following:

Kidney work used to cost $25,000 because of research and other

developmental projects associated with it. At the present time kidney transplantation costs approximately $10,000.

It is my hope and aim in the not too distant future that kidney transplantation will not be any more expensive than that of any other major surgery. And these cost reductions have been made in a situation where we have rising costs in all other areas of health care.

How can we implement these programs? I think it is important that somehow or other the development of the kidney center concept as outlined by the Gottschalk report should be followed, and the training as exemplified by the two previous speakers, the training of personnel, can be implemented in these centers.

In addition, the centers can relate to large regional areas in keeping with the regional concept in this program.

In closing, Mr. Chairman, I would like to say I think the need is extremely urgent to recognize we are only treating one out of 20, or 5 percent, of the individuals that could be effectively treated for or are dying from kidney disease, because of lack of funds and facilities and personnel. There is no question that dialysis and transportation are most convenient methods of treatment that do save lives.

The tragedy of some 20,000 to 25,000 productive Americans who die needlessly each year continues to add fuel to public allegations against our health care delivery system of the most affluent nation in the history of man. I therefore strongly urge this committee to enact H.R. 17570.

I thank you, Mr. Chairman, Representative Nelsen, the Representative from Minnesota, for your courtesy.

(Dr. Najarian's prepared statement follows:)

STATEMENT OF DR. JOHN S. NAJARIAN, PROFESSOR AND CHAIRMAN, DEPARTMENT OF SURGERY AND DIRECTOR OF THE TRANSPLANTATION AND DIALYSES PROGRAM, UNIVERSITY OF MINNESOTA HEALTH SCIENCES CENTER, MINNEAPOLIS

Mr. Chairman: Thank you for giving me the opportunity to appear before your committee in support of HR-17570 and other companion bills to extend the Regional Medical Program and amend its title to read "Heart, Cancer, Stroke, Kidney and other Related Diseases" as well as earmarking other funds and adding Regional Representatives to the National RMP Council.

I am Dr. John S. Najarian, Professor and Chairman of the Department of Surgery and Director of the Transplantation and Dialyses Program at the University of Minnesota Health Sciences Center, Minneapolis, Minn. I have been concerned and active in the field of organ transplantation since 1954, when the first successful kidney transplant, using identical twins, was performed at the Peter Bent Brigham Hospital in Boston. At that time I felt that transplantation represented one of the brightest of all medical-surgical horizons and that it would be as vital a development as were the development of anesthesia and subsequently antisepsis.

The successful transplantation of a kidney between identical twins produced evidence that successful transplantation could be accomplished if the immunological barriers presented by the host during rejection of foreign tissues could be controlled. Therefore, I devoted the next eight years of my training to include not only surgery but basic science training in the rapidly advancing field of immunology. My primary research endeavors are documented in 130 publications concerned with control of the immunological response to allow successful transplantation. In addition, I am currently completing a standard textbook in transplantation. I was privileged to be a member of the Committee on Chronic Kidney Disease (serving under the Chairmanship of Dr. Carl Gottschalk) advising the Bureau of the Budget in the area of chronic kidney disease. I have been a member of the Scientific Advisory Council of the National Kidney Foundation for the past three years. I have been involved in finding methods to implement the tremendous potential of treatment available by dialyses and/or transplantation

and to improve the delivery of these measures of health care. At the University of Minnesota we are transplanting between 60 and 100 kidneys each year as well as 10-12 pancreases. Our pilot programs in heart, lung, intestine and bone marrow transplantation are progressing rapidly.

Mr. Chairman, I will direct my discussion to the field of transplantation while my colleagues and friends, Drs. Schreiner, Merrill, and Perry will elaborate on the subjects of renal dialyses, prevention of renal diseases and urological aspects for the proposed legislation.

It is an established fact that more than 8 million Americans are afflicted by diseases of the urinary tract. Approximately 50,000 of these individuals die of primary kidney disease each year. Between 1965 and 1967 the Gottschalk Committee concluded that at least 10,000 of these 50,000 individuals who would be ideal candidates for life-saving treatment from either the artificial kidney (dialyses) or transplantation. The ideal patient criteria established by our Committee was very limiting; it included only patients between the ages of 15 and 45 with primary kidney disease and no other systemic conditions. Since that time, in only two years, kidney transplantation has evolved to the point that we no longer set age limitations as were suggested in 1967. We now transplant children from the age of 6 months, as well as adults, 60 years and older. In addition, our transplant program accepts patients with diabetes, lupus, and a variety of other systemic diseases that cause chronic kidney failure. Even the extended criteria has produced most gratifying results. I would estimate that the number of terminally ill individuals who could benefit from either dialyses or transplantation today is about 25,000 per year if programs were available. Last year only 500 patients received kidney transplants and only 300 patients were placed on dialyses. To my knowledge, the unconscionable situation has never before presented itself in the history of medicine. A treatment modality is available and 25,000 lives could be saved each year but less than 5 percent of those who need this life-saving treatment are getting it. I sometimes wonder what the impact of these factors would be on our current socially active generation that desires and demands our extraction from South Viet Nam where, in fact, at the cost of $35-$40 billion a year we are deliberately taking the lives of thousands of Vietnamese soldiers and civilians, our own soldiers included. Yet, in the same context the most affluent country in the world has, in fact, overlooked the recommendations proposed in the Gottschalk Report that could potentially save 10 to 25 thousand lives a year for an extremely modest investment..

When the recommendations of the Gottschalk Report were presented there were misinterpretations of the figures. A total fiscal commitment of care was envisioned by some individuals. However, since the cost of dialysis and transplantation have not been implemented, a variety of institutions including the University of Minnesota, have gone forward with active programs in dialysis and transplantation, seeking funds from third-party insurance carriers, private donations, Title IXX beneficiaries, and utilizing the limited research monies to cover a small portion of clinical transplantation costs. These clinical-research transplantation programs have developed techniques of improved organ graft survival and at the same time have given the very distinct and tangible service of saving lives. Thus, transplantation and dialyses programs have had to evolve with a patchwork-quilt type of financing. Despite efforts by many centers to expand their capabilities, the increase in the number of kidney transplants performed is minute. In 1966, 300 transplants were performed-in 1969, 550 were performed, an increase of only 250.

Mr. Chairman: Another staggering fact is that approximately 70 percent of all individuals afflicted with primary kidney disease are youngsters or patients under the age of 35 years. These are individuals who's life is cut short in their prime only because their kidneys no longer function.

Kidney transplantation today is no longer experimental but is, in fact, treatment; the best treatment for terminal kidney failure. The established transplant centers schedule kidney transplants in the operating room as they would schedule appendectomies, removal of gall bladder, stomach or other elective procedures.

The success of kidney transplants are such that of the 3,700 patients who have received a kidney transplant since 1954, 62 percent of these patients are still alive and well today. If any of us in this room was to receive a kidney transplant from a blood relative, the chances of being alive and well with a functioning kidney 5 years later is close to 90-95 percent. At the University of Minnesota, our patients who receive a kidney from someone who has re

cently died (cadaver) have a 50-60 percent chance of being alive and well with a functioning kidney in five years. Five years has been used as a biological measure because a patient who survives five years will usually follow normal life tables thereafter. To deny these lifesaving procedures to dying patients simply because there is a lack of funds, facilities, or personnel would be a modern American tragedy. We espouse the importance of health delivery systems and make platitudes such as "health care is the right of every American Citizen," and to quote Secretary Finch "As long as there are people in this Country who are denied essential health care services because of poverty, race or lack of access for any reason, we have fallen short of our promises as a Nation." Clearly, by not acting towards development of a kidney health care delivery system we have definitely fallen opprobriously short of our promise to one of the obvious and frustrating problems presented to physicians interested in patient care related to kidney disease.

I have a very pragmatic sense, the addition of kidney disease to the RMP Programs is a very obvious utilization and extension of the extremely important program. Certainly kidney disease does effect heart disease, cancer and, through hypertension, the development of strokes. Thus, kidney disease is most intimately related to the other three categorical diseases defined for the RMP Programs. The Regional aspect of this program in kidney disease is already being implemented in crude, poorly supported, yet enthusiastic programs. A classic example exists at the University of Minnesota Hospitals: In order to maintain adequate numbers of patients for transplantation it is necessary to keep a large number of patients on the artificial kidney, patients who will eventual recipients of cadaver kidney transplants. In recent years we have found it possible to match cadaver kidneys with the very best recipients and the results are markedly improved when such conditions are met. Thus, at the University of Minnesota we have developed a Center for "tissue typing." For patients who do not have a blood relative donors and must await a kidney from someone who has recently died. We have a method to find the very best kidney for a patient by tissue typing the recipients and matching a subsequent donor kidney to the closest matched recipient. To obtain the very best kidney transplant, it is necessary to have a large pool of potential recipients. We must maintain at least 25 patients on dialysis at the University of Minnesota Hospitals. At our County Hospitals and in peripheral hospitals throughout the five state area there are another 100 patients on dialyses who are potential candidates for transplantation.

A classic example of what happens when a cadaver donor kidney becomes available may be exemplified by an event that occurred last week: A man died in Salt Lake City, Utah; tissue typing on this individual was fed to a computer in Los Angeles which contained tissue typing on more than 1000 patients awaiting a kidney transplant. Two patients matched almost identical the individual who had just died. These two patients were available on dialyses at the Mayo Clinic and at our Veterans Administration Hospital in Minneapolis. The donor kidneys were shipped by air and transplanted successfully. We have received kidneys from as far away as Boston. In one instance a dog kidney was sent from Los Angeles to Israel and subsequently transplanted into another dog. The kidney survived, indicating that it is possible to ship kidneys or other organs over wide distances for purposes of transplantation.

This same program is used regionally in our own five state area; not only for obtaining kidneys from patients who die in that area but in addition we maintain patients on dialyses in so-called "satellite dialysis units" in small hospitals scattered throughout Minnesota, North Dakota, Wisconsin, and South Dakota. If a patient comes to us in kidney failure and has no immediate related donor, he is placed on dialysis first in our own institution and subsequently in the satellite unit closest to home. His life is maintained on dialyses twice or three-times weekly. When a kidney is available the patient is flown to our Hospital for transplantation. The current Regional Program underway in kidney therapy is working basically on shoestring financing and unfortunately lacks the concept of the kidney center approach as outlined in the Gottschalk Report. A Kidney Center should have a nephrology, dialysis, and transplantation unit as well as research and development endeavors based at a central hospital associated with peripheral subsidiary dialyses units.

With the increased experience in dialysis and transplantation during the past ten years, the cost of transplantation which initially was $30,000 per transplant has been reduced in our own experience to about $10,000 per transplant, despite rising hospital costs. It is our hope and our aim that in the not-too-distant future