Can we improve deceased donor kidney utilisation?

1. Can we improve deceased donor kidney utilisation? Chris Callaghan National Clinical Lead for Abdominal Organ Utilisation, NHSBT Consultant Transplant Surgeon, Guy’s Hospital Renal Transplant Services Meeting, March 2016

2. Introduction • How has UK deceased donor kidney transplantation changed? • Can we improve kidney utilisation? • If so, how?

3. How has deceased donor kidney transplantation changed?

9. Variation in appetite for risk High risk Standard risk

12. Can we improve kidney utilisation?

13. Transplantation pathway DBD donors Organs consented? Organs transplanted? Organs suitable? Organs accepted? Organs retrieved? SNOD SNOD/ Tx centre Transplant centres NORS teams/ tx centres Transplant centres DCD donors Organs consented? Organs suitable? Organs accepted? Organs retrieved? Organs transplanted? SNOD SNOD/ Tx centre Transplant centres NORS teams/ tx centres Transplant centres Death in timeframe?

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

16. Deceased donor kidneys retrieved but not transplanted – reasons for non-use

18. NHSBT service evaluation:discarded donor kidneys Shruti Mittal, Chris Callaghan On behalf of NHSBT

19. Methods • 30 consecutive discarded kidneys; April 2015 • Assessed at Guy’s Hospital • EOS core donor data form (CIT ignored) • Macroscopic appearance • Histology: Remuzzi/Karpinski score (0-12) • Usable / probably usable / not usable

20. Characteristics of discarded kidneys

21. Kidney 5 & 6 (113734) • 72F DCD, intracranial haemorrhage, weight 71kg • PMH: Hypertension • UO 8105 ml/24 hours, creatinine 55 K-score 5 and 6

22. Kidney 11 (113929) • 67M DCD, intracranial haemorrhage, weight 104kg • PMH: haematuria, atrial flutter • UO 1520 ml/24 hours, creatinine 100 K-score 3 +

23. Kidney 10 (113900) • 72M DBD, hypoxic brain injury (anaphylaxis), weight 90kg • PMH: hypertension, renal calculi, • UO 3790 ml/24 hours, creatinine 97 K-score 4

24. Analysis of discarded kidneys • 10 (32%) were considered usable • Equates to 75 discarded kidneys in 2014/15 • Are discarded kidneys really usable?

25. Quality Assessment of Discarded Human Kidneys - Recruitment

26. Quality Assessment of Discarded Human Kidneys - Outcome

27. How do we improve kidney utilisation?

29. Improving organ utilisation • General • Engagement with colleagues to identify barriers to utilisation • Recent survey to surgeons

30. Improving organ utilisation • General • Engagement with colleagues to identify barriers to utilisation • Raise awareness of utilisation issues

31. Improving organ utilisation • General • Engagement with colleagues to identify barriers to utilisation • Raise awareness of utilisation issues • Provide an evidence-base to enable better decision-making

32. Improving organ utilisation • General • Engagement with colleagues to identify barriers to utilisation • Raise awareness of utilisation issues • Provide an evidence-base to enable better decision-making • Improve data on utilisation practices to centres

33. Improving organ utilisation • Kidney • Analyses of discarded kidneys • Better data on reasons for organ decline / discard • More efficient organ offering / allocation policies for marginal kidneys • Minimising cold time before kidney inspection • Provision of organ images with fast-track offers • Use of warm perfusion technology to enable viability assessment

34. Conclusions • Rapid changes in donor type and demographics • Transplant outcomes are stable • Variation in clinical decision-making • Likely that usable organs are being discarded • Multiple approaches needed to improve organ utilisation and support clinicians to make difficult decisions

35. Acknowledgements • Lisa Bradbury • Rachel Johnson • Sarah Hosgood • Mike Nicholson • ShrutiMittal • Sally Rushton • James Neuberger