KIDNEY TRANSPLANTATION in the CARIBBEAN -2019 Lesley Roberts January 19th 2019

CONTENTS Introduction Status Challenges Next Steps

Including Guyana Caribbean Islands, a massive archipelago of islands that are divided into 4 groups. For the purpose today , English Dpeaking Islands, lie in Caribbean Sea, including Guyana and members of CARICOM

First transplant done in Barbados in 1987 First successful transplant performed by Prof Lawson Douglas 13th Sept 1970 123 TRANSPLANTS DONE 14 Transplants done

TRANSPLANT ACTIVITY in the CARIBBEAN LIVING DONOR DECEASED DONOR HD. FACILITIES PDFACILITIES ANTIGUA YES NO N0 BARBADOS BAHAMAS DOMINICA GRENADA GUYANA SKNF ST. LUCIA ST. VINCENT TRINIDAD & TOBAGO JAMAICA

Transplants 2006 - 2018

ACTIVE TRANSPLANT ACTIVITY -2017-2018 ANTIGUA BARBADOS GUYANA JAMAICA TRINIDAD AND TOBAGO TRANSPLANTS PERFORMED 6 1case from the Philippines in 2018 5 (1,4) 14 (7,7) 9 19 (8,11) SURGEON Surgical Team from University of Toledo Combined Surgical Team TLC and Local Surgeon Local Team with oversight from University of Calgary TLC and Local Surgeons Local Team PHYSICIAN Local Nephrologist caring for 11pts Local Nephrologist caring for 13pts Transplant Surgeon caring for 14 pts. Local Nephrologist DONOR STATUS Only Living Donor A paired Exchange-7/18 Living and Deceased Donors (8D)

2017 -2018 TRANSPLANT ACTIVITY cont’d ANTIGUA BARBADOS GUYANA JAMAICA TRINIDAD AND TOBAGO CROSS MATCHING Off Island /Miami Off Island/UK Off Island/Miami Locally FINANCIAL INPUT Government and Renal Society of Antigua and Barbuda Government Facility Administration and External Agencies POSITIVE ASPECT Improvement of Care for the ESRD patient Public more aware of the benefits of transplant. Public trust gained ; no mortalities Sustainability achieved. Corporate Sponsorship-Repsol Foundation

OUTCOMES 1yr 5yr NIGERIA Patient 90.2% 73.4% Graft 83.2% 58.7% TRINIDAD and TOBAGO 98% 75% 93% 73% Guyana 100%

GREATEST CHALLENGES CHALLENGES PROPOSED SOLUTIONS Lack of resources for support services for follow up post op. Establish Regional Centres of Excellence; Involvement of NGO’s and CBO’s Not performing enough Transplants Employ Strategies for increasing LDKT Unwillingness of Donors to come forward Education and Research Not increasing the nos. of transplants performed An analysis of where the gaps occur. Reintroduce incentives for Transplantation Absence of “on island” Tissue Typing and Drug Level testing Establish Regional Centres of Excellence

CHALLENGES Number of Cases Performed Donor Pool needs to be increased Deceased Donation Public Awareness and Education Healthier Nations Recipient Care Early detection of Progressive CKD; Need for Registries and Data Bases Encouraging Pre Emptive Transplants and Dialysis Centre Education

Challenges Cont’d Lack of Service Support with an increasing programme size Establish transparent, documented policies for the conduct of Transplant Services Match services with your intentions! Allocation of Beds, theatres and slots for investigations On going reviews of the necessary infrastructure required for programmes. Build Capacity within the region for adequate follow up services. Specialized services follow up such as Transplant biopsy interpretations, Immunology follow up. Video conferences with discussions. Protocols re follow up care, return to Dialysis, second transplants, care for the Donor

CHALLENGES (cont’d) Financial Support Additional non governmental sources of funding required to ensure sustainability of service. Role of NGOs , CBOs Insurance providers Corporate Partners WHO/PAHO – Resource Personnel, Bulk buying of pharmaceuticals Proper Financial Planning Assessment of Donor and Recipient Finances “Ring Fencing” Budget for Transplant Services . Appropriate accountability!

THE WAY FORWARD An increased Donor Pool Implementing Strategies to increase Living Donor Kidney Transplantation Paired Exchanges Sophisticated Cross Matching Public Education/ Awareness Drive/ More involvement of NGO’s/ CBO’s and Foundations Deceased Donation Legislation Training

THE WAY FORWARD (cont’d) TRANSPLANT RESOURCES must be made available Pharmaceuticals – Bulk Buying for the Region PAHO/WHO Involvement Ability to do Therapeutic Drug levels Involvement with the Region’s thrust for Non Communicable Disease ACKNOWLEDGEMENT and COMMITTMENT that RENAL TRANSPLANT is the OPTIMAL WAY to treat ESRD Incentives for Transplantation Targeted out reach programmes, professionals, dialysis centres Succession Planning

Future Research to define effective strategies to improve access to LDKT. Education and Outreach Removal of disincentives Evaluation efficiency Patients with kidney failure Potential living donors Social Networks Dialysis Units General public Research needed to optimize Frequency Content Delivery modalities Uncompensated costs for donors Travel Medications Lost time from work Dependent Care Complex donor evaluation process Delays may discourage donors and necessitate recipients starting dialysis Adherence to standard guidelines for assessment allowing for transparency and completion of complete risk assessment Research needed to: Define donor evaluation efficiency Scope and precision of long term risk CJASN12, Sept.17

THE END.