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INCOMPATIBLE LIVING DONOR KIDNEY TRANSPLANTATION What Choices? Lisa Burnapp Consultant Nurse

INCOMPATIBLE LIVING DONOR KIDNEY TRANSPLANTATION What Choices? Lisa Burnapp Consultant Nurse Directorate of Nephrology, Transplantation and Urology Guy’s and St Thomas’ NHS Foundation Trust London, UK lisa.burnapp@gstt.nhs.uk. Our Responsibility. To optimise Patient outcome

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INCOMPATIBLE LIVING DONOR KIDNEY TRANSPLANTATION What Choices? Lisa Burnapp Consultant Nurse

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  1. INCOMPATIBLE LIVING DONOR KIDNEY TRANSPLANTATION What Choices? Lisa Burnapp Consultant Nurse Directorate of Nephrology, Transplantation and Urology Guy’s and St Thomas’ NHS Foundation Trust London, UK lisa.burnapp@gstt.nhs.uk

  2. Our Responsibility To optimise • Patient outcome • Transplant outcome • Planning • Opportunity & choice • Use of kidneys • Donor safety & well-being • The health economy

  3. The Challenge More • Patients • Choice & capability • Expectation • Complex • Ethnically diverse

  4. New Trends in Living Donor Transplantation

  5. Extended Criteria (High-Risk) Recipients ‘Recipients at a significantly higher risk of death, complications or graft failure because of pre-existing co-morbidity or immunological status’1 High-risk includes • Immunological/ABO incompatibility • The elderly • Significant co-morbidity • Primary disease 1 Guidelines for Living Donor Kidney Transplantation in High-Risk Adult Recipients, 2008 www.bts.org.uk

  6. High-Risk Recipients: Our Approach • Living donation treatment of choice • All patients provided with information early • Evidence and/or lack of evidence shared with recipient and donor • Risk benefit analysis discussed • Tailored management plan agreed • Peer support

  7. Who Makes the Choice? • Patient & family? • What is best for them • Healthcare professionals? • Most clinically effective • Outcome reporting • What is feasible/available • Local logistics/infrastructure • Financial constraints • Primary care Trusts/Commissioners? • Health economics • National Guidance (NICE)

  8. Incompatible Living Kidney Donation

  9. Tailored Option Appraisal • Do nothing • Acceptable if recipient & donor informed of possible options • Paired/pooled donation • Antibody removal strategies (ABO/HLA) • Offer neither • Lack of equity

  10. Paired/Pooled Donation • Compatible living donor transplant • Clinically more straightforward • Logistically challenging • Uncertainty about timing & ‘matchability’ • Donors & recipients unknown to one another • indirect donation

  11. Antibody Removal Strategies (ABO/HLA) • More complex scenarios • ^ intervention (recipient) • ^ immunosuppression • Higher risk of failure • spectrum of risk • Time specific • Donor known to recipient • direct donation

  12. Summary • Evolving field • Clinically challenging • Physically & psychologically demanding for patients & their families • Compatible transplantation always the preferred option • Outcomes encouraging

  13. Thank you

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