Review of DCD allocation scheme: the first 6 months Lisa Bradbury Statistics and Clinical Studies Renal Transplant Services Meeting 2015

Introduction Organs donated for transplantation are a national resource Kidneys should be allocated in an open, objective and transparent way DCD donor kidneys are the ‘norm’ rather than the ‘exception’ Deceased kidney donorsDeceased kidney-only transplants

DBD kidneysFormalised national allocation scheme for both kidneys DCD kidneys Non-standardised local arrangements Some centres were ‘pairing-up’ to share DCD kidneys For example: North Thames area, Edinburgh and Glasgow Local sharing arrangements may reflect difficulty in performing two same centre concurrent kidney transplants? Allocation prior to implementation of the scheme

One kidney retained locally, second kidney shared regionally within four pre-defined regions Both kidneys to be prioritised according to the 2006 DBD donor kidney allocation scheme principles To avoid significant changes to centre activity, donor age criteria will apply to manage the ‘phasing-in’ process New DCD kidney sharing scheme

Region Patients listed at any one time North 1911 (30%) Midlands 1642 (25%) London 1704 (27%) South West 1100 (17%) GlaEdi Bel New Lee Liv Man Shef Not LeiCam Bir Cov NT ST Car Ply Por Bri Oxf DCD donor kidney sharing regions

Donor age criteria YearMinimum age (years) Maximum age (years) % of kidneys shared One550 19% Two555 25% Three560 30% Four565 37% Five570 43% In the first year one kidney from donors aged 5 to 49 will be shared regionally (5 to 64 in London) Donors aged under 5 years Automatically offered for en bloc transplantation – local first Upper age limit reviewed regularly - guide increments: Phasing-in DCD kidney sharing

New DCD kidney allocation process Offers made to named patients

Final DCD kidney allocation scheme

Kidney donor screening

Screening and offering was one informal process for SNODs o Utilisation of kidneys not maximised o Screening and offering is separated under new DCD Kidney Allocation Scheme New formalised screening process agreed o SNODs ‘screen’ o Screening centres: Cambridge, Cardiff, Guy’s, Leeds o Duty Office do all offering of DCD kidneys DCD kidney donor screening

Number of calls to local transplant centre (forms returned) Of 73 deemed acceptable; 19 unknown, 25 no consent, 29 consent Of 29 who’s family gave consent; 26 kidneys retrieved and 20 transplanted

Number of calls and proportion of acceptable donors OOR = Out of region Of 53 deemed acceptable; 20 unknown, 18 no consent, 15 consent Of 15 who’s family gave consent; 10 kidneys retrieved and 8 transplanted

Proportion of acceptable donors by characteristics N =

Donation process time intervals for potential DCD donors, where data are complete

Transplant Activity

DCD Kidney Activity Introduction of the new DCD Kidney Allocation Scheme Donors Transplants

Sharing of DCD transplants Rest of UK (Fast track) Regional Local centre 1 Sep 2013 – 31 Aug Sep 2014 – 28 Feb 2015

Transplant Activity Northern region Belfast, Edinburgh, Glasgow, Leeds, Liverpool, Manchester, Newcastle

Introduction of the new DCD Kidney Allocation Scheme Donors Transplants DCD Kidney Activity in North

Sharing of DCD kidney only transplants in North Belfast Edinburgh Glasgow Leeds Liverpool Sep 13 – Feb 14 Sep 14 – Feb 15 Manchester Newcastle

Sharing of DCD kidney only transplants in North Edinburgh, Leeds, Liverpool, and Newcastle have supplemented their transplants with the Fast Track Scheme Sep 13 – Feb 14 Sep 14 – Feb 15 Belfast Edinburgh Glasgow Leeds Liverpool Manchester Newcastle

Shewhart Charts The charts highlight variation in adult transplant activity in each centre Proportions and not actual numbers are plotted due to variability in donor numbers For each centre, each three-month period from 1 March 2013 to 28 February 2014 is represented The solid line represents the average number of DCD kidney only transplants in a 3-month period between 2012 and 2014 The dashed lines represent the control limits and are approximately 2 and 3 standard deviations above and below the average The upper limits indicate and increased level of transplant activity and the lower limits indicate a decreased level.

DCD adult kidney only transplant activity: Mar 13 – Feb 15 Adjusted transplant rate Start date of 3-month period

DCD adult kidney only transplant activity: Mar 13 – Feb 15 Adjusted transplant rate Start date of 3-month period

Transplant Activity South West Region Bristol, Cardiff, Oxford, Plymouth, Portsmouth

Introduction of the new DCD Kidney Allocation Scheme Donors Transplants DCD Kidney Activity in South West

Sharing of DCD kidney only transplants in South West Bristol CardiffOxford PlymouthPortsmouth Sep 13 – Feb 14 Sep 14 – Feb 15

Sharing of DCD kidney only transplants in South West Cardiff and Oxford have supplemented their transplants with the Fast Track Scheme Sep 13 – Feb 14 Sep 14 – Feb 15 Bristol CardiffOxford PlymouthPortsmouth

DCD adult kidney only transplant activity: Mar 13 – Feb 15 Adjusted transplant rate Start date of 3-month period

DCD adult kidney only transplant activity: Mar 13 – Feb 15 Adjusted transplant rate Start date of 3-month period

Transplant Activity Midlands Region Birmingham, Coventry, Leicester, Cambridge, Nottingham, Sheffield

Introduction of the new DCD Kidney Allocation Scheme Donors Transplants DCD Kidney Activity in the Midlands

Sharing of DCD kidney only transplants in Midlands Birmingham Coventry Leicester Cambridge Nottingham Sheffield Sep 13 – Feb 14 Sep 14 – Feb 15

Sharing of DCD kidney only transplants in Midlands Leicester and Cambridge have supplemented their transplants with the Fast Track Scheme Sep 13 – Feb 14 Sep 14 – Feb 15 Birmingham Coventry Leicester Cambridge Nottingham Sheffield

DCD adult kidney only transplant activity: Mar 13 – Feb 15 Adjusted transplant rate Start date of 3-month period

DCD adult kidney only transplant activity: Mar 13 – Feb 15 Adjusted transplant rate Start date of 3-month period

Transplant Activity London Region Royal London, Royal Free, WLRTC, Guy’s, St George’s, GOSH

Introduction of the new DCD Kidney Allocation Scheme Donors Transplants DCD Kidney Activity in London

Sharing of DCD kidney only transplants in London Royal London Royal Free WLRTC Guy's St George's GOS Sep 13 – Feb 14 Sep 14 – Feb 15

Sharing of DCD kidney only transplants in London Royal London Royal Free WLRTC Guy's St George's GOS Royal Free and Guy’s have supplemented their transplants with the Fast Track Scheme Sep 13 – Feb 14 Sep 14 – Feb 15

Adjusted transplant rate Start date of 3-month period DCD adult kidney only transplant activity: Mar 13 – Feb 15

Adjusted transplant rate Start date of 3-month period DCD adult kidney only transplant activity: Mar 13 – Feb 15

Median waiting time to transplant

Summary of activity Overall, DCD kidney donors and transplants have increased Belfast, Royal Free and WLRTC have seen increases in activity –Belfast have made more use of local donors –Royal Free and WLRTC are now performing more in line with the size of their waiting list Glasgow, Cardiff, Cambridge, Guy’s have seen decreases –Glasgow have increased activity in March 2015 –Cardiff have performed fewer transplants through the fast track scheme –Cambridge and Guy’s are now performing more in line with the size of their waiting list

Equity of access Donors aged 5 to 49 (5 to 64 in London)

Long waiting patients <1 year 1-3 years 3-5 years <5 years Before: 1 Sep 2013 – 31 Aug 2014 After:3 Sep 2014 – 28 Feb 2015

HLA matching of DCD transplants Level 1 (best match) Level 2 Level 3 Level 4 (worst match) Before: 1 Sep 2013 – 31 Aug 2014 After:3 Sep 2014 – 28 Feb 2015

Highly sensitised patients Before: 1 Sep 2013 – 31 Aug 2014 After:3 Sep 2014 – 28 Feb 2015

Cold ischaemia times

Cold ischaemia time of DCD transplants p=0.1 p=0.4p=0.5p=0.1p=0.9

Summary (1) Scheme went live on 3 rd September 2014 Designed to - Improve equity of access to a national resource - Optimise utilisation of DCD donor kidneys through formalised offering - Maintain (or reduce) overall cold ischaemia times General feedback on the scheme is positive - Potential impact on offering times needs to be addressed A six-month review of the screening centres to be undertaken shortly - Impact on screening centres - Donor suitability - More suitable way forward?

Summary (2) DCD Kidney activity has increased Better matching achieved through sharing Highly sensitised and long waiting patients have improved access to transplant Small reduction in cold ischaemia times Should we increase the upper age limit for sharing DCD kidneys through the scheme? –5 year increments –London experience, increase to 64 years?

Acknowledgements DCD Kidney Allocation Working Party ChairSusan Fuggle, Martin Raferty Transplant Centre RepsArgiris Asderakis, Peter Friend, Lorna Marson, Justin Morgan, Chas Newstead, Gavin Pettigrew, Peter Rowe, Dominic Summers, David Talbot, John Connolly, Geoff Koffman, Keith Rigg BSHIAndrea Harmer StatisticiansAlex Hudson, Rachel Johnson, Lisa Bradbury Associate Medical DirectorJames Neuberger BAPN Jane Tizard PAG ChairChristopher Watson SNODJulie Whitney Endorsed by Members of the NHSBT Kidney Advisory Group