Organ Utilisation Strategy Professor John Forsythe

UK Strategy – Taking Organ Transplantation to 2020 Targets for deceased donors and transplants Target figures to 2020

Age of UK deceased donors % of donors

Age of deceased donors – UK vs Spain (2015)

Discard rates for kidneys from deceased donors, 2014 % of retrieved kidneys not transplanted N= 2986 14754 2432 700 No. kidneys retrieved ¹ 2012 data Source: ONT – Spain data, OPTN - US data ANZ - Australia data, NHSBT - UK data 24% overall 10% overall 19% overall

Adult DBD kidney offer decline rates EXTENDED CRITERIA Offer decline rates vary from 36% at Leeds to 77% at Leicester STANDARD CRITERIA Offer decline rates vary from 24% at Leeds to 69% at Leicester

Offer decline rates vary from 17% at Birmingham to 70% at Newcastle Adult elective liver offer decline rates DCD liver Offer decline rates vary from 23% at King’s college to 78% at Newcastle DBD liver Offer decline rates vary from 17% at Birmingham to 70% at Newcastle

Offer decline rates vary from 19% at Guy’s to 94% at Newcastle Pancreas offer decline rates DCD pancreas Offer decline rates vary from 19% at Guy’s to 94% at Newcastle DBD pancreas Offer decline rates vary from 39% at Guy’s to 71% at Edinburgh and Newcastle

Adult heart offer decline rates Offer decline rates vary from 67% at Papworth to 90% at Newcastle and Harefield

Median waiting time to transplant Lower 95% confidence limit Upper 95% confidence limit 30 months UK average 14 months 43 months

Strategy Length of donation-transplantation process Support to use of higher risk donor organs Local MDT process and challenge Better information DCD donor assessment Use of Fast Track/Simultaneous offering www.odt.nhs.uk/odt

DBD donation process 10.5 hours longer

DCD donation process 8.5 hours longer

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

Offering and retrieval planning DBD DCD

Post meeting Stick to referral times Delay once only Delay for specified time as maximum Night-time retrieval? Streamline donor characterization…..

Better Information

Reasons for retrieved organs not being transplanted (2015/16) KIDNEY N=276

Reasons for retrieved organs not being transplanted (2015/16) LIVER N=168

Support for Higher Risk Donors

Donors with cod as drug overdose Drug overdose as COD includes deaths from polypharmacy, paracetamol overdose, and alcohol poisoning Slide courtesy of Sarah White, Sydney. Data from NHSBT, ANZOD and OPTN

Support SaBTO advice Aide memoire Incidents and events Consent

Introduction to TRANSPLANT APP

Options of diseases to select

Example A Hepatitis C Patient with a UKELD score of 55 What will happen to 100 people like me post-registration

Reasons for decline We send monthly reports to all transplant centres detailing each offer they have received and whether they accepted or declined, with the reason for decline. We indicate whether the organ was transplanted elsewhere. These reports are used in transplant centre MDT meetings and lead to changes in practice.

Challenge Advisory groups Named patient allocation Patient involvement/Consent

DCD donor assessment

DCD donor assessment Actual donors of those referred: DBD 47% DCD 9%   Referred to SNOD SNOD attended Family approached Actual donors Organs Transplanted 2014/15 DBD 1679 1563 1291 783 2604 DCD 5718 3579 2131 496 1132 Actual donors of those referred: DBD 47% DCD 9%

DCD donor assessment Review of evidence suggested: Inconsistent practice by SNODs in handling of DCD referrals Clinical donor criteria that never resulted in transplantation of donor organs New DCD assessment process agreed with clinical support to improve efficiency in the DCD pathway

DCD donor assessment Potential DCD donors excluded on basis of past non-donation/tx: Regular review and dialogue with clinical community to ensure viable potential donors not missed (as novel technologies come into use)

DCD donor assessment 12 months data (Dec 2015-Nov 2016) DCD referrals 6182 Absolute contraindication? No 5019 81% Yes 1163 19% DCD exclusion? No 3469 56% Yes 1550 25% SNOD overrides 131 3600 - 58% of our referrals

DCD donor assessment 12 months data (Dec 2015-Nov 2016) DCD referrals 6182 Absolute contraindication? No 5019 81% Screening call made to transplant centres Yes 1163 19% Yes 1340 22% DCD exclusion? No 2260 37% No 3469 56% Yes 1550 25% Screening centre decision SNOD overrides 131 Not acceptable 936 – 70% Acceptable 404 - 30% 3600 - 58% of our referrals

Use of Fast Track offering

Fast Track Offering Schemes Fast track schemes are designed to maximise the utilisation of organs available for transplantation Simultaneous offering to speed up allocation Offers are sent to all eligible centres via SMS, pager or fax Centres have 45 minutes to respond to the offer via telephone No response is assumed to be a declined offer More than one centre accepts - organ allocated to centre highest on list or rota This is done by simultaneous offering of an organ, by the ODT duty office, to speed up the allocation process

Trigger points for fast track offering Kidney deemed unsuitable Kidney 5 centres declined donor/organ reasons (3 DCD) Accrued 6hrs CIT (3hrs DCD, 12hrs multi-organ) Pancreas deemed unsuitable Pancreas 4 centres declined donor/organ reasons (3 DCD) Pancreas removed Proposed: after 6 hrs of offering or 3 centres declined for same donor reason At or after cross-clamp the liver is declined/ not yet accepted Liver At removal or already removed Heart and lungs To be removed within 90mins First organ offered Organs retrieved Organs transplanted Further details can be found in the organ allocation policies available at www.odt.nhs.uk/transplantation/guidance-policies/

% fast tracked (of those donated)

Activity- transplanted of those fast tracked N fast tracked: 458 428 21 8 77 182 13 31 0% 0% 3% 15% 34% 37% 55% 63%

Introduction of Pancreas Fast Track Scheme Number of pancreases offered 6 times or more has reduced from 23% to 13% Number of offers

Simultaneous Offering Higher risk donors eg viral risk Scheme and response requires agreement Organ specific

Reasons why donation did not proceed following consent/authorisation 6% 34 families 7% 7 families 15% families who withdraw because process too long 2015/16 data: 104 DBD families, 546 DCD families

Enhanced Retrieval response?

Resource

DBD kidney offer decline rates

Summary www.odt.nhs.uk/odt Donors becoming more complex and offering taking longer Many more organs offered than are ever accepted High offer decline rate with wide centre variation Reasons for decline reported to centres monthly for review Much that can be done www.odt.nhs.uk/odt

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