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Strategies to increase transplantation

This review outlines strategies to enhance living donation and transplantation processes, including trends in living donor transplants, paired/pooled donation, altruistic donor chains, and organ utilization. It also discusses the impact of these strategies on transplant outcomes and the importance of optimizing organ offerings.

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Strategies to increase transplantation

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  1. Strategies to increase transplantation Professor John Forsythe

  2. Outline • Living donation and transplantation • Length of donation–transplantation process • Organ utilisation

  3. Living donors in the UK Up to 40 liver donors per year

  4. International data - living donor (LD) kidney transplant rates 2010

  5. Adult living donor transplants Increasing complexity of living donor kidney transplantation

  6. Adult living donor transplants Steady fall in both ABOi and HLAi adult living donor kidney transplants since 2012/13

  7. Adult living donor transplants Rise in both paired and altruistic adult living donor kidney transplants

  8. Include: Paired/pooled donation (PPD) Altruistic Donor Chains (ADC) Non-directed altruistic donation (NDAD) UK Living Kidney Sharing Schemes (UKLKSS)

  9. Non-Directed Altruistic Donation Direct to Waiting List Short AD Chain (ADC) Long ADC 2007 2012 2015 AD AD KEP pairs AD R1 D1 R1 D1 WL R2 D2 WL WL

  10. Altruistic donor and kidney exchange transplants No. of transplants Transplants according to exchange type

  11. Types of incompatibility between registered pairs to 31 Dec 2016 Since 20th October 2011

  12. HLA MM and Age difference of registered compatible pairs Median age of recipients: 44 (33 – 51) Min = 2, Max = 66

  13. Minimum match grade and maximum donor age specified for recipients in compatible pairs HLA Level 4

  14. Outcomes for 66 registered compatible pairs 74% of compatible pairs only enter 1 matching run

  15. Transplants enabled by compatible pairs • 29 compatible pairs enabled: • 3 short altruistic donor chains • 2 long altruistic donor chains • 7* two-way exchanges • 17 three-way exchanges • 75 transplants • 10 HSP *One two-way exchange was between two compatible pairs

  16. Predicted 15 year graft survival by HLA level based on a recipient with “baseline” values HLA Level 1: 78% HLA Level 2: 75% HLA Level 3: 71% HLA Level 4: 69% 78% “Baseline” values 14.8yrs 13.3yrs Donor age = 46 Recipient age = 36 Transplant year = 2007 PRD = Glomerulonephritis 11.3yrs 10.1yrs

  17. Types of incompatibility between registered pairs to 31 Dec 2016 by centre 11 centres registered compatible pairs

  18. Length of donation-transplantation process

  19. DBD donation process 10.5 hours longer

  20. DCD donation process 8.5 hours longer

  21. Offering and retrieval planning DCD DBD

  22. Why does it matter?

  23. Time of family approach DBD DCD

  24. DBD retrieval operation start times Shift in time of day from 2-5 am to 6-12 am

  25. DBD process Cardiothoracic organs retrieved Cardiothoracic organs not retrieved

  26. DCD withdrawal of treatment times Shift in time of day from 10pm-3 am to 4-12 am

  27. Reasons for family not giving consent/authorisation for donation 4% 17 families 15% 124 families 2015/16 data: 405 DBD families, 829 DCD families

  28. Organ utilisation

  29. Kidney offers, retrievals and transplants

  30. Offers, retrievals and transplants liver kidney pancreas heart lung

  31. Discard rates for kidneys from deceased donors, 2014 No. kidneys retrieved N= 2986 14754 2432 700 % adult deceased donor kidney transplants from DCD ~ 11% in Spain ~ 15% in US ~ 37% in UK ~ 26% in Australia 24% overall 19% overall % of retrieved kidneys not transplanted 10% overall Source: ONT – Spain data, OPTN - US data ANZ - Australia data, NHSBT - UK data ¹ 2012 data

  32. Summary • Living donation • UK Living Kidney Sharing Schemes a big success • Organ offering taking longer • Impacting on time of day of retrieval and transplantation surgery • NHSBT initiative to streamline the process • Need to address organ utilisation • UK Strategy for Organ Utilisation

  33. Acknowledgements Transplant unit, H&I laboratory and other hospital staff and Specialist Nurses for Organ Donation for provision of data to the UK Transplant Registry www.odt.nhs.uk RTSM, February 2017

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