INCOMPATIBLE LIVING DONOR KIDNEY TRANSPLANTATION

What Choices?

Lisa BurnappConsultant Nurse

Directorate of Nephrology, Transplantation and Urology Guy’s and St Thomas’ NHS Foundation Trust

London, UKlisa.burnapp@gstt.nhs.uk

Our Responsibility

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

The Challenge

More

• Patients

• Choice & capability

• Expectation

• Complex

• Ethnically diverse

New Trends in Living Donor Transplantation

Extended Criteria (High-Risk) Recipients

‘Recipients at a significantly higher risk ofdeath, complications or graft failure becauseof pre-existing co-morbidity orimmunological 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

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

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)

Incompatible Living Kidney Donation

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

Paired/Pooled Donation

• Compatible living donor transplant• Clinically more straightforward• Logistically challenging • Uncertainty about timing & ‘matchability’• Donors & recipients unknown to one another

– indirect donation

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

Summary

• Evolving field• Clinically challenging• Physically & psychologically demanding for

patients & their families• Compatible transplantation always the

preferred option• Outcomes encouraging

Thank you