(1) Donor and Transplant Activity There has been an increase in the number of liver donors since 2007/08, with a concurrent mean 12% increase in the liver transplant rate with respect to 2007/08. However, over the same time period the number of patients on the active transplant list has doubled following the introduction of revised liver patient selection criteria in 2007.

Donors: adults who died in the allocation zone for each centre. Transplants: elective and super urgent transplants that occurred at each transplant centre. The donated liver could have come from within the centre’s allocation zone or not. The donated livers would have been offered to a tx centre according to the sequence in the supplementary slide. Waiting list: elective and super-urgent registrations. Living donor transplants include 4 and 5 living liver lobe transplants, and 2 and 0 domino transplants in NHS Group 1 and Group 2 recipients, respectively NHS Groups 1 and 2. Slide shows percentage from national (+ Dublin) total for each donor type, ie. from the total adult DBD liver donated in the time period, 20% came from Birmingham’s zone, 13% from Cambridge, etc. From the total DBD livers transplanted into adult recipients, 20% were transplanted at Birmingham, 12% at Cambridge, etc. Data source: Adult, 1 April 2012 - 31 March 2013 Deceased donors Deceased transplants DBD DCD Total DBD DCD Total Living donor transplants Active transplant list N N N N N N N N Birmingham 139 53 192 124 49 173 2 76 Cambridge 87 24 111 72 13 85 0 46 Dublin 56 0 56 42 0 42 0 21 Edinburgh 79 15 94 79 9 88 0 47 King's College 150 44 194 124 25 149 6 108 Leeds 79 27 106 73 22 95 1 88 Newcastle 45 5 50 40 1 41 0 22 Royal Free 45 13 58 61 13 74 2 75 Total 680 181 861 615 132 747 11 483

Donors: adults who died in the allocation zone for each centre. Transplants: elective and super urgent transplants that occurred at each transplant centre. The donated liver could have come from within the centre’s allocation zone or not. The donated livers would have been offered to a tx centre according to the sequence in the supplementary slide. Waiting list: elective and super-urgent registrations. Living donor transplants include 12 and 9 living liver lobe transplants, and 1 and 0 altruistic donor transplants in NHS Group 1 and Group 2 recipients, respectively. NHS Groups 1 and 2. Note that numbers are very small, eg. 50% DCD paed donors were from Birmingham’s allocation zone but this just means that 2 DCD paed donors in the time period were from Birmingham’s zone whereas only 1 was from King’s and Leeds. Slide shows percentage from national (+ Dublin) total for each donor type, ie of the total paediatric DBD livers donated, 35% came from Birmingham’s donation zone, 18% from King’s College, etc The blue bars in DBD do not add up to 100% because there were some DBD donors in other capture zones, eg. 12% of DBD paed donors came from Cambridge’s zone (not a paed centre). There were not DCD donors from non-paediatric liver allocation areas, ie neither of Cambridge, Dublin, Edinburgh, New Castrle or the Royal Free allocation areas had DCD paed donors. The percentages in waiting list do not add up to 100% because there was 1 paed patient (3%) registered at the Royal Free – presumably a 15 or 16 year old. Paediatric, 1 April 2012 - 31 March 2013 Deceased donors Deceased transplants Living donor transplants Active transplant list DBD DCD Total DBD DCD Total N N N N N N N N Birmingham 6 2 8 28 1 29 2 8 Cambridge 2 0 2 0 0 0 0 0 Dublin 1 0 1 0 0 0 0 0 Edinburgh 2 0 2 0 0 0 0 0 King's College 3 1 4 35 3 38 14 19 Leeds 1 1 2 12 0 12 6 4 Newcastle 1 0 1 0 0 0 0 0 Royal Free 1 0 1 0 0 0 0 1 Total 17 4 21 75 4 79 22 32 Total for only paed centres 10 4 14 75 4 79 22 31

NHS Group 1, adult, liver-only transplants NHS Group 1, adult, liver-only transplants. Both elective and super-urgent registrations are shown. Donors from any where – not only from the UK. There were 747 txs from deceased donor in UK+Dublin in 2012/13. The total of txs from deceased donors in this slide differs from that reported in slides 5 and 6 because NHS Group 2 and multi-organ transplants have not been considered in this figure. More info on Group 2 recipients in the Group 2 LAG paper at: http://www.odt.nhs.uk/transplantation/advisory-groups/liver/papers/

Exclusion: Dublin, small bowel txs ie liver tx because of IFALD, paediatrics stha pop (m) North East 2.6 South Central 4.18 South East Coast 4.48 East Midlands 4.54 Yorkshire and The Humber 5.29 South West 5.3 West Midlands 5.61 East of England 5.86 North West 7.06 London 8.2 England 53.11 Isle of Man 0.08 Channel Islands 0.16 Wales 3.06 Scotland 5.25 Northern Ireland 1.81 Total (England, Isle of Man, Channel Islands, Wales, Scotland and N Ireland) 63.47

Factors used for the risk adjustment: Year of transplant Recipient age Recipient sex Recipient creatinine Recipient sodium Organ appearance Type of graft (whole, segment) Previous abdominal surgery Liver disease (Primary biliary cirrhosis, Primary sclerosing cholangitis, Alcoholic liver disease, Autoimmune and cryptogenic disease, Hep C, Hep B, Cancer, Metabolic, Other) Cold ischaemic time Recipient albumin

Elective, liver-only txs Event is defined as graft failure or patient death Estimates obtained using the Kaplan-Meier method Example interpretation of outcome: Newcastle - 7 patients that underwent DBD split tx at risk on day 0, only 2 of them died or graft failure within 3 years. General interpretation: For these centres, there isn’t enough evidence to reject the hypothesis that survival DBD whole = survival DBD split = survival DCD.

Example interpretation of outcome: King’s College - DBD split Example interpretation of outcome: King’s College - DBD split. Either something fails very soon after tx or later on, at >= 3 years, ie. events (graft failure or patient death) cluster either early on or late. General interpretation: For these centres, there is enough evidence to reject the hypothesis that survival DBD whole = survival DBD split = survival DCD. One, or more, of the following must be true: survival DBD whole != survival DBD split survival DBD whole != survival DCD survival DBD split != survival DCD where ‘!=‘ means ‘not equal to’.

Factors used for risk adjustment: Age, gender, ethnicity, blood group, serum creatinine, serum bilirubin, serum sodium, INR, primary disease

Paediatric tx centres: Birmingham, Kings College & Leeds

Current liver allocation scheme is centre based Super-urgent cases: very high risk of mortality without transplantation. Hepatoblastoma. A cancer of the liver that tends to occur in children. Decesased donor livers for adult and paediatric patients registered for an elective liver tx are currently allocated by tx teams in each centre. Donated livers are distributed to the seven liver tx centres based on the percentage share of new adult elective registrants at each centre, and any liver retrieved in a particular allocation zone can automatically be used in a patient chosen by the centre. Most centres prioritise cancer patients and those with a higher UKELD score.