Strategies to increase transplantation Professor John Forsythe

Outline Living donation and transplantation Length of donation–transplantation process Organ utilisation

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

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

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

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

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

UK Living Kidney Sharing Schemes (UKLKSS) Include: Paired/pooled donation (PPD) Altruistic Donor Chains (ADC) Non-directed altruistic donation (NDAD) ODT, NHSBT November 2011 8

Non-Directed Altruistic Donation Direct to Waiting List Short AD Chain (ADC) Long ADC 2007 2012 2015 AD AD KEP pairs AD D1 R1 D1 R1 WL D2 R2 WL WL ODT, NHSBT November 2011 9

Transplants according to exchange type Altruistic donor and kidney exchange transplants No. of transplants Transplants according to exchange type ODT, NHSBT November 2011 10

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

HLA MM and Age difference of registered compatible pairs HLA Level HLA MM N 2 110 1 3 n=7 111 4 211 220 n=58 021 022 112 121 122 14 212 6 221 10 222 17 Age diff N ±20 yrs 54 ±30 yrs 7 ±40 yrs 4 ±60 yrs 1 Median age of recipients: 44 (33 – 51) Min = 2, Max = 66

Minimum match grade and maximum donor age specified for recipients in compatible pairs Match grade N ***=3 1 **0=2 5 **1=2 **1=3 19 011 110 3 111 21 211 7 220 2 112 221 222 HLA Level 4

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

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

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

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

Length of donation-transplantation process

DBD donation process 10.5 hours longer

DCD donation process 8.5 hours longer

Offering and retrieval planning DBD DCD

Why does it matter?

Time of family approach DBD DCD

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

DBD process Cardiothoracic organs retrieved Cardiothoracic organs not retrieved

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

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

Organ utilisation

Kidney offers, retrievals and transplants

Offers, retrievals and transplants liver kidney pancreas heart lung

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

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

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