Allocation of elderly deceased donor kidneysAllocation of elderly deceased donor kidneys

Lisa Bradbury, Niaz Ahmad, Paul Gibbs, Richard Baker, Lisa Bradbury, Niaz Ahmad, Paul Gibbs, Richard Baker, Adam McLean, Adam McLean, Chris CallaghanChris Callaghan

Renal Transplant Services Meeting, 24 March 2015

A preliminary analysis from the A preliminary analysis from the Elderly Deceased Donor Kidney Allocation Working GroupElderly Deceased Donor Kidney Allocation Working Group

IntroductionIntroduction

• Rationale

• Terms of reference

• Analyses

• Conclusions

RationaleRationaleAge of deceased donors in the UK, 2002-2012

50 52 59 50 67 42 63 40 42 41 37 55

391 400 367 384419

390446 444 425 411 452

493

212 193 187 196174

210

212 229 237 267312

28498 104 113 109 106 139131 173 205

250

268284

23 26 27 28

4672

99117

143

204

25 17

0

200

400

600

800

1000

1200

1400

2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14

Nu

mb

er

of d

on

ors

70 or over

60 to 69

50 to 59

18 to 49

0 to 17

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

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

Discard rate of retrieved kidneys,1 Apr 2004 – 31 Mar 2014

Kidney fast-track scheme

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

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

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

RationaleRationale

• 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?

Terms of referenceTerms 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.

Analysis – DKT in the UKAnalysis – 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

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

Number of dual kidney transplants,Apr 2008 – Mar 2014

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

% Survival NSKT (donors≥60) 91% (90-92) 2610DKT (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)

Patient survival by transplant type, 1 Apr 2004 – 31 Mar 2014

% Survival NSKT (donors≥60) 94% (93-95) 2327DKT (donors≥18) 92% (87-95) 216

p=0.15

DBD DCD

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)

How can kidneys suitable for DKT be identified?

Analysis – selection strategiesAnalysis – selection strategies

• Donor age, co-morbidities, eGFR, prolonged CIT

• Gross appearance

• Histological analysis

• Perfusion parameters

Analysis – selection strategiesAnalysis – selection strategies

DBD DCD

% survival NSKT (donors 60-64) 93 585SKT (donors 65-69) 90 534SKT (donors 70+) 86 367DKT 93 53

% survival NSKT (donors 60-64) 93 444SKT (donors 65-69) 90 410SKT (donors 70+) 93 266DKT 88 175

Donor age – 1-yr graft survival by donor type and donor age, 1.4.08-31.3.14

Analysis – selection strategiesAnalysis – selection strategiesDonor age – 1-yr recipient eGFR by donor type and donor age, 1.4.08-

31.3.14

DBD DCD

Analysis – selection strategiesAnalysis – selection strategiesDonor age and co-morbidities – UKKDRI

Watson CJE et al, Transplantation 2012

Analysis – selection strategiesAnalysis – selection strategiesMedian (IQR) UKKDRI of discarded kidneys, SKT (donors >60 yrs),

and DKT, 1.4.04-31.3.14

Analysis – selection strategiesAnalysis – selection strategies

% survival NSKT (dri<1.5) 92 443SKT (dri1.5-1.6) 90 320SKT (dri1.6-2) 89 463SKT (dri>2) 92 256DKT 93 53

% survival NSKT (dri<1.5) 89 231SKT (dri1.5-1.6) 94 318SKT (dri1.6-2) 92 336SKT (dri>2) 91 216DKT 88 175

DBD DCD

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

Analysis – selection strategiesAnalysis – selection strategiesUKKDRI – 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)

Analysis – selection strategiesAnalysis – selection strategiesNew UKKDQI (nUKKDQI)

nUKKDQI = exp{(0.01976*donor age) +

(0.32727*history of cardiothoracic disease)

- (0.00241*(donor eGFRadm x BSA/1.73))}

1.1.06-31.12.10, training dataset n=4034,

validation dataset n=2689, 23% from donors

aged >60 years

Analysis – selection strategiesAnalysis – selection strategiesNew UKKDQI (nUKKDQI)

Analysis – selection strategiesAnalysis – selection strategiesNew UKKDQI (nUKKDQI)

Kidney allocation criteria for DKT unable to be identified

Is there a valid alternative approach?

Analysis – alternative Analysis – alternative strategystrategy

• 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?

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

ConclusionsConclusions

• 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

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

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

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