1. Allocation of elderly deceased donor kidneys Lisa Bradbury, Niaz Ahmad, Paul Gibbs, Richard Baker, Adam McLean, Chris Callaghan Renal Transplant Services Meeting, 24 March 2015 A preliminary analysis from the Elderly Deceased Donor Kidney Allocation Working Group

2. Introduction Rationale Terms of reference Analyses Conclusions

3. Rationale Age of deceased donors in the UK, 2002-2012

4. Median donor age by donor type, 1 Apr 2004 – 31 Mar 2014

5. Proportion of high risk (>1.35) kidney donors,1 Apr 2004 – 31 Mar 2014

6. Discard rate of retrieved kidneys, 1 Apr 2004 – 31 Mar 2014 Kidney fast-track scheme

7. Discard rate of retrieved kidneys from deceased donors, Apr 2009 – 31 Mar 2014

8. Discard rate of retrieved kidneys from DBD donors, Apr 2009 – 31 Mar 2014

9. Discard rate of retrieved kidneys from DCD donors, Apr 2009 – 31 Mar 2014

10. Rationale Changing deceased donor demographics and patterns of organ usage Need to minimise discard and optimise organ utilisation No existing mechanisms to identify kidneys suitable for DKT Changing age thresholds for regional DCD schemes?

11. Terms of reference To review outcomes of transplants from elderly donors to determine whether allocation of a single kidney is always appropriate, and, if not, to identify which kidneys could be allocated for dual transplantation. If current allocation is not deemed appropriate, to identify the appropriate recipient group for such kidneys. The aim would be to produce a set of principles, or a scheme, that might be easily incorporated into the next kidney allocation scheme.

12. Analysis – DKT in the UK Heterogeneous indications, varying between centres (and surgeons) – Donor age, co-morbidities, eGFR, prolonged CIT – Gross appearance – Histological analysis – Perfusion parameters No widely accepted recipient selection criteria – >60 years old, dialysis >1 year? – Cardiorespiratory and technical considerations

13. Number of kidney transplants, 1 Apr 2004 – 31 Mar 2014

14. Number of dual kidney transplants, Apr 2008 – Mar 2014

15. Age group for single and dual transplants, Apr 2008 – 31 Mar 2014

16. % Survival N SKT (donors≥60) 91% (90-92) 2610 DKT (donors≥18) 90% (85-93) 225 p=0.5 Graft survival by transplant type, 1 Apr 2004 – 31 Mar 2014 After risk-adjustment, no difference in 1-yr graft survival between SKT 60+ and DKT (p=0.32)

17. Patient survival by transplant type, 1 Apr 2004 – 31 Mar 2014 % Survival N SKT (donors≥60) 94% (93-95) 2327 DKT (donors≥18) 92% (87-95) 216 p=0.15

18. DBDDCD 1 year eGFR by transplant type and donor age, 1 Apr 2008 – 31 Mar 2014 After risk-adjustment, 1-yr graft function (CKD stage) was better in DKT vs SKT 60+ (p=0.01)

19. How can kidneys suitable for DKT be identified?

20. Analysis – selection strategies Donor age, co-morbidities, eGFR, prolonged CIT Gross appearance Histological analysis Perfusion parameters

21. Analysis – selection strategies DBD DCD % survivalN SKT (donors 60-64)93585 SKT (donors 65-69)90534 SKT (donors 70+)86367 DKT9353 % survivalN SKT (donors 60-64)93444 SKT (donors 65-69)90410 SKT (donors 70+)93266 DKT88175 Donor age – 1-yr graft survival by donor type and donor age, 1.4.08- 31.3.14

22. Analysis – selection strategies Donor age – 1-yr recipient eGFR by donor type and donor age, 1.4.08- 31.3.14 DBDDCD

23. Analysis – selection strategies Donor age and co-morbidities – UKKDRI Watson CJE et al, Transplantation 2012

24. Analysis – selection strategies Median (IQR) UKKDRI of discarded kidneys, SKT (donors >60 yrs), and DKT, 1.4.04-31.3.14

25. Analysis – selection strategies % survivalN SKT (dri<1.5)92443 SKT (dri1.5-1.6)90320 SKT (dri1.6-2)89463 SKT (dri>2)92256 DKT9353 % survivalN SKT (dri<1.5)89231 SKT (dri1.5-1.6)94318 SKT (dri1.6-2)92336 SKT (dri>2)91216 DKT88175 DBDDCD Mean (SD) UKKDRI all DKT = 1.7 (0.4), all SKT = 1.2 (0.4) UKKDRI – 1-yr graft survival by donor type and UKKDRI (donors >60 yrs), 1.4.08-31.3.14

26. Analysis – selection strategies UKKDRI – 1-yr recipient eGFR by donor type and UKKDRI (donors >60 yrs), 1.4.08-31.3.14 DBD DCD Mean (SD) UKKDRI all DKT = 1.7 (0.4), all SKT = 1.2 (0.4)

27. Analysis – selection strategies New UKKDQI (nUKKDQI) nUKKDQI = exp{(0.01976*donor age) + (0.32727*history of cardiothoracic disease) - (0.00241*(donor eGFR adm x BSA/1.73))} 1.1.06-31.12.10, training dataset n=4034, validation dataset n=2689, 23% from donors aged >60 years

28. Analysis – selection strategies New UKKDQI (nUKKDQI)

29. Analysis – selection strategies New UKKDQI (nUKKDQI)

30. Kidney allocation criteria for DKT unable to be identified Is there a valid alternative approach?

31. Analysis – alternative strategy Rather than offering for DKT, offer both kidneys and let the centre decide usage – SKT x 2 or DKT – DBD donor: offer to national centre with highest- ranking patient – DCD donor: offer to regional centre with highest- ranking patient Which metric? Impact on CIT?

32. Discard rate of retrieved kidneys from deceased donors, Apr 2009 – 31 Mar 2014

33. Conclusions Kidneys from elderly deceased donors are increasingly common, but with a high rate of discard DKT may be a valid strategy to increase utilisation Using data available, no clear metric to identify kidneys best used as DKT – Limitations Alternative strategy proposed Recipient selection not yet addressed

36.  US  ECD program no longer (Dec 2014) – KDPI  OPTN dual kidney criteria (2 or more)  Age >60  eGFR <65 ml/min on admission creatinine  Creat >220 μmol/L  Long-standing HT or DM  15%<glomerulosclerosis<50%  Local/regional offering if KDPI >85%  Inconsistent offering practices (Tanriover B, AJT 2014) Systems elsewhere

37.  Eurotransplant Senior Program  Donors 65 years or older  Loco-regional, no HLA  2013 – 515/2967 (17%)  Outcomes (Frei U, AJT 2008)  Shorter wait, less CIT, less DGF  More AR  Worse GS and PS c.f. O/A, A/O  Benefits for younger patients… Systems elsewhere

38.  DBD NKAS  Always single kidney offered, regardless of donor age  Age points: = -1/2 (donor-recip age difference) 2  DCD regional allocation by donor age  Outside London: >50 years retained locally (x 5 years/year?)  London: >65 years offered as pair  Influence of KFTS  Maximum flexibility  If one kidney accepted by non-KFTS centre? Current UK allocation policies