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Altruistic, non-directed and paired living kidney donation Rachel Johnson

Altruistic, non-directed and paired living kidney donation Rachel Johnson. Living kidney donation. Kidney transplantation from living donors increasing In 2007 number of living donors exceeded number of deceased donors Now represents over one third of all kidney transplants performed.

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Altruistic, non-directed and paired living kidney donation Rachel Johnson

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  1. Altruistic, non-directed and paired living kidney donation Rachel Johnson

  2. Living kidney donation • Kidney transplantation from living donors increasing • In 2007 number of living donors exceeded number of deceased donors • Now represents over one third of all kidney transplants performed But, blood group or HLA incompatibility still prevent many transplants

  3. Arrangements for paired living kidney donation • Donor and patient assessments • Registration with Organ Donation & Transplantation (ODT) • Quarterly ‘matching runs' to identify possible transplants • Crossmatch tests for suitability of transplants • Independent Assessor & HTA panel approvals • Operations arranged and carried out simultaneously

  4. Donor 1 Donor 2 Donor 3 Donor 4 Donor 5 Recip 1 Recip 2 Recip 3 Recip 4 Recip 5 Matching runs • 2-way matching runs quarterly since April 2007 • 3-way exchanges also considered since April 2008 2-way exchange 3-way exchange (paired exchange) (pooled exchange)

  5. Matching run summary 36 transplants to date – all 2-way exchanges

  6. Activity to date • Approximately 300 patients have been registered • 35% patients identified for transplant • Over 50% of identified transplants do not proceed • Positive crossmatch tests, alternative transplants, donor issues • 30% of patients removed from scheme • 80% due to other transplant (deceased donor, alternative live donor) • 15% registered patients actually transplanted through paired donation scheme • 1.8% of live donor transplants in 08/09

  7. Altruistic donation • The process is as follows: • Donor assessments and work-up • Approval by HTA • Notification to ODT • Identify most appropriate recipient - through Kidney Allocation Scheme for deceased donor kidneys • Crossmatch tests for suitability • Centres liaise to organise transplant • Final crossmatch and transplant

  8. Identifying a recipient for an altruistic donor kidney Deceased donor ‘matching run’ identifies most suitable recipient: Tiers A,B – Well matched paediatric patients (000 mismatch) Tiers C,D – Well matched adult patients + other priority paediatric patients Tier E – All other eligible patients Within Tiers, patients prioritised by point score for 6 factors Waiting time HLA match & age combined Age difference Location of donor relative to recipient HLA homozygosity Blood group match

  9. Altruistic non-directed donors • 26 altruistic donor transplants, July 2007 – Oct 2009 • Mean donor age 54 years (range 27-68); 12 F, 14 M • Average time between notification and donation – 56 days (range 2-224 days) • Mean recipient age 49 years (range 24-67 years) • Average recipient waiting time 4 years • Median CIT 6 hrs (range 1-20 hrs) • 1.7% of live donor transplants in 08/09

  10. Important to make best use of this additional donor pool Altruistic donor chains (domino paired donation) increase number of transplants achievable US have introduced non-simultaneous, extended altruistic donor (NEAD) chains Future developments

  11. N Engl J Med 2009, 360;11

  12. NEAD Chain

  13. Altruistic donor chains (domino paired donation) agreed in principle Likely to operate outside of quarterly matching runs Simultaneous transplants and short chains in first instance Prioritise paired donation patients who have had most unsuccessful matching runs UK developments

  14. Domino (chain) paired donation Instead of allocating an altruistic donor’s kidney to a patient on the deceased donor (DD) list, Altruistic donor Patient on DD list

  15. Domino (chain) paired donation Instead of allocating an altruistic donor’s kidney to a patient on the deceased donor (DD) list, it could be allocated to a paired donation patient, whose incompatible donor then donates to the DD list – two transplants instead of one Altruistic donor Patient on DD list incompatible Paired donor Paired recipient Alternative patient on DD list

  16. Domino (chain) paired donation

  17. Domino (chain) paired donation

  18. Domino (chain) paired donation

  19. www.organdonation.nhs.uk rachel.johnson@nhsbt.nhs.uk

  20. Thank you

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