Can we improve deceased donor kidney utilisation? Chris Callaghan National Clinical Lead for Abdominal Organ Utilisation, NHSBT Consultant Transplant Surgeon, Guy’s Hospital Renal Transplant Services Meeting, March 2016

Introduction How has UK deceased donor kidney transplantation changed? Can we improve kidney utilisation? If so, how?

How has deceased donor kidney transplantation changed?

Variation in appetite for risk High risk Standard risk

Can we improve kidney utilisation?

Transplantation pathway Organs suitable? Organs accepted? Organs retrieved? DBD donors DCD donors Organs consented? Organs transplanted? SNODTransplant centres NORS teams/ tx centres Transplant centres SNOD/ Tx centre SNODTransplant centres NORS teams/ tx centres Transplant centres SNOD/ Tx centre Death in timeframe? Organs consented? Organs suitable? Organs accepted? Organs retrieved? Organs transplanted?

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Discard rate of retrieved kidneys from deceased donors, Apr 2009 – 31 Mar 2014

Deceased donor kidneys retrieved but not transplanted – reasons for non-use

NHSBT service evaluation: discarded donor kidneys Shruti Mittal, Chris Callaghan On behalf of NHSBT

Methods 30 consecutive discarded kidneys; April 2015 Assessed at Guy’s Hospital – EOS core donor data form (CIT ignored) – Macroscopic appearance – Histology: Remuzzi/Karpinski score (0-12) – Usable / probably usable / not usable

Characteristics of discarded kidneys n= 31 Donor type24 DCD, 7 DBD Median CIT, mins (range)9h 32 (16m – 15h 20) Median age, years (range)67 years ( ) UKKDRI (range)1.60 (0.85 – 2.14) KDPI (range)93% ( ) Reason for discardDonor issues +/- K-score (n=12) Anatomy (n=4) Mass / malignant histology (n=5) Poor perfusion (n=7) Retrieval injury (n=3)

Kidney 5 & 6 (113734) 72F DCD, intracranial haemorrhage, weight 71kg PMH: Hypertension UO 8105 ml/24 hours, creatinine 55 K-score 5 and 6

Kidney 11 (113929) 67M DCD, intracranial haemorrhage, weight 104kg PMH: haematuria, atrial flutter UO 1520 ml/24 hours, creatinine 100 K-score 3 +

Kidney 10 (113900) 72M DBD, hypoxic brain injury (anaphylaxis), weight 90kg PMH: hypertension, renal calculi, UO 3790 ml/24 hours, creatinine 97 K-score 4

Analysis of discarded kidneys 10 (32%) were considered usable Equates to 75 discarded kidneys in 2014/15 Are discarded kidneys really usable?

Quality Assessment of Discarded Human Kidneys - Recruitment DCD: DBD Age (y) Reason for DeclinedOutcome 1DCD35 Poor perfusionTransplanted 2DCD35 Poor perfusionTransplanted 3DCD75 Poor perfusionNot Transplanted 4DCD36 Poor perfusionNot Transplanted 5DCD53 Stripped ureter and poor perfusionTransplanted QAS 01QAS 02QAS 03QAS 04QAS 05 Mean RBF (ml/min/100g) Total Urine output (ml) EVNP Score12333

Quality Assessment of Discarded Human Kidneys - Outcome QAS 01QAS 02QAS 05 WIT (min)13 12 CIT 1 st (h.min) EVNP (min)60 CIT 2 nd (min) Anastomosis (min)33 39 Total ischaemic time (h.min) QAS 01QAS 02QAS 05 Age (y) GenderMaleFemaleMale DialysisHDPDHD Initial Graft FunctionYes DGF

How do we improve kidney utilisation?

Improving organ utilisation General – Engagement with colleagues to identify barriers to utilisation Recent survey to surgeons

Improving organ utilisation General – Engagement with colleagues to identify barriers to utilisation – Raise awareness of utilisation issues

Improving organ utilisation General – Engagement with colleagues to identify barriers to utilisation – Raise awareness of utilisation issues – Provide an evidence-base to enable better decision-making

Improving organ utilisation General – Engagement with colleagues to identify barriers to utilisation – Raise awareness of utilisation issues – Provide an evidence-base to enable better decision-making – Improve data on utilisation practices to centres

Improving organ utilisation Kidney – Analyses of discarded kidneys – Better data on reasons for organ decline / discard – More efficient organ offering / allocation policies for marginal kidneys – Minimising cold time before kidney inspection – Provision of organ images with fast-track offers – Use of warm perfusion technology to enable viability assessment

Conclusions Rapid changes in donor type and demographics Transplant outcomes are stable Variation in clinical decision-making Likely that usable organs are being discarded Multiple approaches needed to improve organ utilisation and support clinicians to make difficult decisions

Acknowledgements Lisa Bradbury Rachel Johnson Sarah Hosgood Mike Nicholson Shruti Mittal Sally Rushton James Neuberger