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Oxford and Thames Valley Region KQuIP day 2018 LKD

Dr Phil Mason presents Living Kidney Donor Transplantation to the region

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KQuiP Transplant first- Living kidney
donor transplantation
Presented by Dr Phil Mason
NHSBT data slides provided by Lisa Mumford and Caroline Wroe
KQuiP 2018
Background
Living donor kidney transplants,
2002-2017
28.5
19.8
18.2 17.9
16.9 16.6
14.6
8.1
5.1 4.8 4.5 4.4 4.2
3 2.4 2
1.3 1.3 0.9
0
5
10
15
20
25
30
The
N
etherla
nds
U
SA
D
enm
ark
S
w
eden
N
orw
ay
U
KS
w
itzerlandG
erm
any
S
pain
P
ortugal
C
roatia
France
H
ungary
Italy
G
reece
Fin
land
P
ola
nd
S
lo
vakia
Latvia
Country
transplantspmp
2010
International Comparison
Benefits of living donor transplant
Median waiting time to deceased
donor kidney transplant for adult
patients, 1 April 2011 – 31 March 2014
829 days
2.3 years
Ad

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Oxford and Thames Valley Region KQuIP day 2018 LKD

  • 1. KQuiP Transplant first- Living kidney donor transplantation Presented by Dr Phil Mason NHSBT data slides provided by Lisa Mumford and Caroline Wroe KQuiP 2018
  • 3. Living donor kidney transplants, 2002-2017
  • 4. 28.5 19.8 18.2 17.9 16.9 16.6 14.6 8.1 5.1 4.8 4.5 4.4 4.2 3 2.4 2 1.3 1.3 0.9 0 5 10 15 20 25 30 The N etherla nds U SA D enm ark S w eden N orw ay U KS w itzerlandG erm any S pain P ortugal C roatia France H ungary Italy G reece Fin land P ola nd S lo vakia Latvia Country transplantspmp 2010 International Comparison
  • 5. Benefits of living donor transplant
  • 6. Median waiting time to deceased donor kidney transplant for adult patients, 1 April 2011 – 31 March 2014 829 days 2.3 years
  • 7. Source: Annual Report Kidney Transplantation 2014/15, NHS Blood and TransplantSource: Annual Report on Kidney Transplantation 2016/17, NHS Blood and Transplant
  • 8. Pre-emptive transplants, 1 April 2016 – 31 March 2017
  • 9. Cold ischaemia time for kidney transplants, 1 April 2016 – 31 March 2017
  • 10. HLA mismatch levels of transplants, 1 April 2015 – 31 March 2017 Level 1 = 000, Level 2 = [0 DR and 0/1 B], Level 3 = [0 DR and 2 B] or [1 DR and 0/1 B], Level 4 = [1 DR and 2 B] or [2 DR]
  • 12. Living ~ 48% (42-53%) DBD ~ 40% (38-42%) 30 year estimates Graft survival estimates following kidney transplant Period analysis, 01Apr12 – 31Mar16 Median survival estimates: Living donor ~ 27 years DBD donor ~ 23 years
  • 13. UK Variation in access to living donor transplantation
  • 14. ATTOM study Access To Transplantation Outcome Measures 2055 patients transplanted 2011-2013: 40% received LKDT & 60% deceased donor kidneys
  • 15. What do we know from the ATTOM study?
  • 16. Referral centre Dialysis unit Transplant centre Source: Annual Report Kidney Transplantation 2014/15, NHS Blood and TransplantSource: Annual Report on Kidney Transplantation 2016/17, NHS Blood and Transplant Transplants (living) kidney living donor transplant rates Low rate (8.8-<12.7 pmp) Low-Medium rate (12.7-<15.5 pmp) Medium-High rate (15.5-<16.5 pmp) High rate (16.5-41.6 pmp) 21.4 15.8 16.5 15.5 41.6 12.1 8.8 13.9 14.1 15.9 12.7 17.6 11.5 Figure 2.7 Living donor kidney transplant rates (pmp) by recipient country/Strategic Health Authority of residence Source: Annual Report Kidney Transplantation 2014/15, NHS Blood and TransplantSource: Annual Report on Kidney Transplantation 2016/17, NHS Blood and Transplant Transplants (living) kidney living donor transplant rates Low rate (8.8-<12.7 pmp) Low-Medium rate (12.7-<15.5 pmp) Medium-High rate (15.5-<16.5 pmp) High rate (16.5-41.6 pmp) 21.4 15.8 16.5 15.5 41.6 12.1 8.8 13.9 14.1 15.9 12.7 17.6 11.5 Figure 2.7 Living donor kidney transplant rates (pmp) by recipient country/Strategic Health Authority of residence
  • 17. rce: Annual Report Kidney Transplantation 2014/15, NHS Blood and Transplantce: Annual Report on Kidney Transplantation 2016/17, NHS Blood and Transplant 21.4 15.8 16.5 41.6 12.1 8.8 13.9 14.1 15.9 12.7 17.6 11.5 Oxford units Transplant centre Referral centre LKDT referred from Oxford Reading Gloucester Northampton
  • 18. Population/ millions Number of living donors/year Mean LKDT rate pmp 2014/15 2015/16 2016/17 Estimated Oxford transplant centre catchment area 3.41 47 46 52 15.5 Oxford data Extracted from UK transplant registry data 2014-2017 Renal Unit Population covered/millions Oxford 1.69 Reading 0.91 Gloucester (assumption half population ref to Bristol) 0.30 Northampton (assumption Northampton population ref to Oxford) 0.22
  • 19. How can we offer every opportunity for living kidney donation?
  • 20. • How do we assess the quality of our living donor pathway? • What are the problems we encounter on a regular basis? • What barriers to living kidney donation should we expect to see in the community we serve? • What steps can we take to reduce these problems and barriers? Where could we start?

Editor's Notes

  1. The purpose of this slide set is to: Update Renal communities on the latest NHSBT data showing the benefit of living kidney donor transplantation (LKDT). Understand the variation in access to LKDT within the UK Look at local data by referral centre and highlight the impact of referral centre activity on overall transplant centre and UK performance Create an opportunity for review of current practice within individual centres who want to take up KQuIP transplant first or evaluate their LKDT service
  2. This slide shows numbers of LKDT by type over the last 10 financial years. The data shows that LKDT numbers have fallen slightly over the last 4 years after a peak in 2013/14. Along with this we also see An increase in Altruistic and Paired exchange A fall in ABOi and HLAi pairs This shows the success of the sharing scheme and the impact of altruistic donors in improving transplant outcomes for others who receive LKDT by reducing the numbers of ABOi and HLAi
  3. This slide compares the UK performance in LKDT with international data. The UK has moved from 6th to 4th place between 2010 and 2016 second to the US, Denmark and the Netherlands The UK Transplant 2020 strategy (joint BTS, NHSBT and RA) has called for world class performance in LKDT by 2020 (ie we want to be up there with the Netherlands!)
  4. This slide is a reminder that the average waiting time for a deceased donor kidney is 2.3 years, LKDT can occur at a time convenient to the donor and recipient (ideally pre-emptively with the associated benefits of pre-emptive transplantation) International data suggest patient and graft survival worsen after 12mo on dialysis cf pre-emptive although UK data suggest only >2yr on dialysis
  5. This highlights the increase chance of being transplanted pre-emptively if the recipient has a living donor with all the associated benefits of pre-emptive transplantation
  6. Cold ischaemic time is associated with delayed graft function, which is in turn related to poorer creatinine at 1 year post transplant. LKDT have the lowest cold ischaemic time of all types of kidney transplantation.
  7. This slide shows HLA mismatches by type of donation. 20% of Living related have a 000 mismatch (45% of all LKDT in 2016/17) Living unrelated have the 70% level 4-worst matching, however if the sharing scheme is used this drops to 40% This slide is easy to trip up on so decide what you want to say about it first or remove it if you want!
  8. This slide highlights the excellent outcomes for both LKDT and DBD, but confirms that LKDT on average last longer than DBD kidneys (DCD kidneys are not included in this data)
  9. The ATTOM study collected data prospectively on 2055 transplant patients who were transplanted between 2011-2013 in the UK. Of those transplanted 40% received LKDT 60% deceased donor kidneys. Data showed widespread inequality in access to LKDT in the UK with the following highlighted- You were more likely to get a LKDT transplant if you were young, white, married, living in Northern Ireland, owned a car and house and had tertiary education. i.e. the barriers to LKDT are ethnicity, poverty, social isolation (or lack of a close potential donor) and health illiteracy. While these facts do not perhaps surprise us they should as a community make us uncomfortable and question ‘how can we do all that we can to remove these barriers for our patients?’ Full ref: NDT 2017, May 1;32(5):890-900 Wu et al. Barriers to living donor kidney transplantation in the United Kingdom: a national observational study.
  10. The left had map shows the dialysis, renal and transplant units across the UK. 50% of the population is cared for in a renal unit not a transplant centre so the whole renal community plays a critical role in preparing people for LKDT The Right hand map shows LKDT per SHA in 2016/17. With the previous slide in mind do we expect to see this range in LKDT rates pmp?
  11. Oxford transplant unit works across 2 strategic health authorities with variable LKDT rates. Patients are from diverse ethnic minorities and covers areas of affluence and poverty
  12. This slide attempts to estimate the LKDT if all the geographical areas represented by referral centres are included-it does come with a warning that this is an ‘estimate’ If the population is roughly correct then to achieve 20pmp Oxford would be doing 68 LKDT per year