review of dcd allocation scheme: the first 6 months lisa bradbury statistics and clinical studies...

Review of DCD allocation scheme: the first 6 months

Lisa BradburyStatistics and Clinical Studies

Renal Transplant Services Meeting 2015

Introduction

• Organs donated for transplantation are a national resource

• Kidneys should be allocated in an open, objective and transparent way

• DCD donor kidneys are the ‘norm’ rather than the ‘exception’

90 8983 81 77

70 66 63 6156 58 61

10 1117 19 23

30 34 37 3744 42 39

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Year

Pe

rce

nt

DCD donors

DBD donors

Deceased kidney donors Deceased kidney-only transplants

91 8983 80 75

68 66 64 62 58 61 64

9 1117 20 25

32 34 35 38 42 39 36

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Year

Pe

rce

nt

•DBD kidneys Formalised national allocation scheme for both kidneysDCD kidneys Non-standardised local arrangements

•Some centres were ‘pairing-up’ to share DCD kidneys For example: North Thames area, Edinburgh and Glasgow

•Local sharing arrangements may reflect difficulty in performing two same

centre concurrent kidney transplants?

Allocation prior to implementation of the scheme

• One kidney retained locally, second kidney shared regionally within four pre-defined regions

• Both kidneys to be prioritised according to the 2006 DBD donor kidney allocation scheme principles

• To avoid significant changes to centre activity, donor age criteria will apply to manage the ‘phasing-in’ process

New DCD kidney sharing scheme

Region Patients listed at any one time

North 1911 (30%)Midlands 1642 (25%)London 1704 (27%)South West 1100 (17%) Gla Edi

BelNew

Lee

Liv Man

Shef

Not

Lei CamBir Cov

NT

ST

Car

PlyPor

BriOxf

DCD donor kidney sharing regions

Donor age criteria

Year Minimum age (years)

Maximum age (years)

% of kidneys shared

One 5 50 19%

Two 5 55 25%

Three 5 60 30%

Four 5 65 37%

Five 5 70 43%

• In the first year one kidney from donors aged 5 to 49 will be shared regionally (5 to 64 in London)

• Donors aged under 5 yearsAutomatically offered for en bloc transplantation – local first

• Upper age limit reviewed regularly - guide increments:

Phasing-in DCD kidney sharing

New DCD kidney allocation process

Kidney 1

Kidney 2

Local kidney matching run

Regional kidney matching run

DCD Fast Track Scheme

Donoraged 5-50

years?

No

Yes

Offers made to named patients

Final DCD kidney allocation scheme

Kidney donor screening

• Screening and offering was one informal process for SNODs

o Utilisation of kidneys not maximised

o Screening and offering is separated under new DCD Kidney

Allocation Scheme

• New formalised screening process agreed

o SNODs ‘screen’

o Screening centres: Cambridge, Cardiff, Guy’s, Leeds

o Duty Office do all offering of DCD kidneys

DCD kidney donor screening

Belfast

Birm

ingham

Bristol

Cam

bridge

Cardiff

Coventry

Glasgow

Guy's

Leeds

Leicester

Liverpool

Manchester

New

castle

Nottingham

Oxford

Plym

outh

Portsm

outh

Royal F

ree

Royal London

Sheffield

St G

eorge's

WLR

TC

0

10

20

30

40

50

60

70

1317

6

36

18

3

125

22

10 712

37

813

95

1217

11

35

6

1

3

1

3

1

1

1

4

6

35

6

21

51

22

7

Acceptable

Not acceptable

Transplant centre

Nu

mb

er

of

calls

(fo

rms

retu

rne

d)

Number of calls to local transplant centre (forms returned)

Of 73 deemed acceptable; 19 unknown, 25 no consent, 29 consentOf 29 who’s family gave consent; 26 kidneys retrieved and 20 transplanted

Re

gio

na

l

First O

OR

Se

con

d O

OR

Re

gio

na

l

First O

OR

Se

con

d O

OR

Re

gio

na

l

First O

OR

Se

con

d O

OR

Re

gio

na

l

First O

OR

Se

con

d O

OR

Leeds Cambridge Guy's Cardiff

0

10

20

30

40

50

60

70

80

90

63

46

20

66

50

18

6051

33

51 49

28

6

2

6

1

7

1

6

6

5

3 4

3

14

4

3

12

5

6

3

4

115

1

Acceptable

Did not respond

Not acceptable

Screening call

Nu

mb

er

of

calls

(fo

rms

retu

rne

d)

Number of calls and proportion of acceptable donors

OOR = Out of region

Of 53 deemed acceptable; 20 unknown, 18 no consent, 15 consentOf 15 who’s family gave consent; 10 kidneys retrieved and 8 transplanted

Proportion of acceptable donors by characteristics

Past history (P

H)

Age>

60 + P

H

Septicaem

ia ...

Kidney functio...

Kidney functi...

Kidney functio...

Cardiac arrest...

Kidney function...

Ischaemic bow

el

Pneum

onia + P

H

Pneum

onia + S

...

Pneum

onia + ki...

Other

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1835

1528 14

11

26

14

17

8

1344

21

1641

39 4

2

20

2

0

12

24

11

Acceptable

Not acceptable

Pro

po

rtio

n

N = 34 76 18 37 18 13 46 16 17 20 15 48 32

Donation process time intervals for potential DCD donors, where data are complete

Bef

ore

Aft

er

Bef

ore

Aft

er

Bef

ore

Aft

er

Bef

ore

Aft

er

Bef

ore

Aft

er

Bef

ore

Aft

er

Discussion with SNOD to SNOD at-

tendance

SNOD attendance to family ap-

proached

Family approached to decision made

Consent to first re-trieval team left

base

First retrieval team left base to last re-trieval team arrives

Last retrieval team arrives to operation

start/treatment withdrawn

0

2

4

6

8

10

12

14

16

Q1

Time interval by year

Ho

urs

Transplant Activity

DCD Kidney Activity

Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-150

10

20

30

40

50

60

70

80

90

100

44 43

37 37 3834 36 35

45 4339

50 4952

65 65

58 5861

54 55

63

6964 66

82

70

86

Year

Nu

mb

er

Introduction of the new DCD Kidney Allocation

Scheme

Donors

Transplants

Sharing of DCD transplants

Rest of UK(Fast track)

Regional

Local centre

1 Sep 2013 – 31 Aug 2014 3 Sep 2014 – 28 Feb 2015

Transplant ActivityNorthern regionBelfast, Edinburgh, Glasgow, Leeds, Liverpool, Manchester, Newcastle


5

10

15

20

25

30

35

15

12

10

15

17

11

14 14

18

11

1314

17

12

23

19

2122

30

21 21

26

29

19

23

26

28

21

Year

Nu

mb

er


Scheme

Donors

Transplants

DCD Kidney Activity in North

1 2 3 4 5 6 7 8 9 10 11 12 13 140

5

10

15

20

25

30

35

40

3

11

15 1619

16

3836

1513

22

33 34

21Nu

mb

er o

f tr

ansp

lan

tsSharing of DCD kidney only transplants in North

Belfast Edinburgh

Glasgow Leeds Liverpool

Sep 13 – Feb 14

Sep 14 – Feb 15

Manchester Newcastle

1 2 3 4 5 6 7 8 9 10 11 12 13 140

5

10

15

20

25

30

35

40

3

11

15 15

1916

33

26

1512

22

33 32

20

1

5

10

1

2

1

Nu

mb

er o

f tr

ansp

lan

tsSharing of DCD kidney only transplants in North

Edinburgh, Leeds, Liverpool, and Newcastle have supplemented their transplants with the Fast Track Scheme

Sep 13 – Feb 14

Sep 14 – Feb 15

Belfast Edinburgh

Glasgow Leeds Liverpool Manchester Newcastle

Shewhart Charts

The charts highlight variation in adult transplant activity in each centre

Proportions and not actual numbers are plotted due to variability in donor numbers

For each centre, each three-month period from 1 March 2013 to 28 February 2014 is represented

The solid line represents the average number of DCD kidney only transplants in a 3-month period between 2012 and 2014

The dashed lines represent the control limits and are approximately 2 and 3 standard deviations above and below the average

The upper limits indicate and increased level of transplant activity and the lower limits indicate a decreased level.

DCD adult kidney only transplant activity: Mar 13 – Feb 15

Adj

uste

d tr

ansp

lant

rat

e

Start date of 3-month period

Transplant ActivitySouth West RegionBristol, Cardiff, Oxford, Plymouth, Portsmouth


2

4

6

8

10

12

14

16

18

20

1211

8 8

6

9

5

3

9

13

6

11

5

8

11

15

12

14

7

12

7 78

16

13

18

8

13

Year

Nu

mb

er


Scheme

Donors

Transplants

DCD Kidney Activity in South West

1 2 3 4 5 6 7 8 9 100

5

10

15

20

25

30

35

40

1210

25

14

26

35

19

1013

7

Nu

mb

er o

f tr

ansp

lan

tsSharing of DCD kidney only transplants in South West

Bristol Cardiff Oxford Plymouth Portsmouth

Sep 13 – Feb 14

Sep 14 – Feb 15

1 2 3 4 5 6 7 8 9 100

5

10

15

20

25

30

35

40

1210

1513

1922

19

1013

7

10

1

7

13

Nu

mb

er o

f tr

ansp

lan

tsSharing of DCD kidney only transplants in South West

Cardiff and Oxford have supplemented their transplants with the Fast Track Scheme

Sep 13 – Feb 14

Sep 14 – Feb 15

Bristol Cardiff Oxford Plymouth Portsmouth


Adj

uste

d tr

ansp

lant

rat

e


Transplant ActivityMidlands RegionBirmingham, Coventry, Leicester, Cambridge, Nottingham, Sheffield


5

10

15

20

25

30

89

12

9

12 12

7

98 8

1110

17

20

15 15

12 12

16

14

12

14

10

12 12 12

17

27

Year

Nu

mb

er


Scheme

Donors

Transplants

DCD Kidney Activity in the Midlands

1 2 3 4 5 6 7 8 9 10 11 120

5

10

15

20

25

30

35

40

45

50

59

46

1216

43

35

1315

59

Nu

mb

er o

f tr

ansp

lan

tsSharing of DCD kidney only transplants in Midlands

Birmingham Coventry Leicester Cambridge Nottingham Sheffield

Sep 13 – Feb 14

Sep 14 – Feb 15

1 2 3 4 5 6 7 8 9 10 11 120

5

10

15

20

25

30

35

40

45

50

59

46

812

39

33

1315

59

4

4

4

2

Nu

mb

er o

f tr

ansp

lan

tsSharing of DCD kidney only transplants in Midlands

Leicester and Cambridge have supplemented their transplants with the Fast Track Scheme

Sep 13 – Feb 14

Sep 14 – Feb 15

Birmingham Coventry Leicester Cambridge Nottingham Sheffield


Adj

uste

d tr

ansp

lant

rat

e


Transplant ActivityLondon RegionRoyal London, Royal Free, WLRTC, Guy’s, St George’s, GOSH


5

10

15

20

25

30

9

11

7

5

32

109

1011

9

15

10

13

16 16

13

10

87

1516

22

1718

26

17

25

Year

Nu

mb

er


Scheme

Donors

Transplants

DCD Kidney Activity in London

1 2 3 4 5 6 7 8 9 10 11 120

5

10

15

20

25

30

35

1114 15

25

10

23

33

29

2023

2 1

Nu

mb

er o

f tr

ansp

lan

tsSharing of DCD kidney only transplants in London

Royal London

Royal Free

WLRTC Guy's St George's

GOS

Sep 13 – Feb 14

Sep 14 – Feb 15

1 2 3 4 5 6 7 8 9 10 11 120

5

10

15

20

25

30

35

1114

12

16

10

2321

14

2023

2 1

3

9

12

15

Nu

mb

er o

f tr

ansp

lan

tsSharing of DCD kidney only transplants in London

Royal London

Royal Free

WLRTC Guy's St George's

GOS

Royal Free and Guy’s have supplemented their transplants with the Fast Track Scheme

Sep 13 – Feb 14

Sep 14 – Feb 15

Adj

uste

d tr

ansp

lant

rat

e



Median waiting time to transplant

Summary of activity

• Overall, DCD kidney donors and transplants have increased

• Belfast, Royal Free and WLRTC have seen increases in activity

– Belfast have made more use of local donors

– Royal Free and WLRTC are now performing more in line with the size of their waiting list

• Glasgow, Cardiff, Cambridge, Guy’s have seen decreases

– Glasgow have increased activity in March 2015

– Cardiff have performed fewer transplants through the fast track scheme

– Cambridge and Guy’s are now performing more in line with the size of their waiting list

Equity of accessDonors aged 5 to 49 (5 to 64 in London)

Before After Before After Before After Before After Before AfterUK Northern South West Midlands London

0

10

20

30

40

50

60

70

80

90

100

3225

33 29 2921

4029 27

21

46

48

48 54 5059

40

43 47

41

1921

15 1315 17 19

14

25

31

4 7 5 4 6 3 2

15

17

Transplant centre

Per

cen

tata

ge

Long waiting patients

<1 year

1-3 years

3-5 years

<5 years

Before: 1 Sep 2013 – 31 Aug 2014After: 3 Sep 2014 – 28 Feb 2015

HLA matching of DCD transplants

Level 1(best match)

Level 2

Level 3

Level 4(worst match)


0

10

20

30

40

50

60

70

80

90

100

2 3 4 410

3

24

34

16

38

21 2433

1927

41

59

57

63

46

56

6653

67 63

59

146

1813

23

10 145 7

Transplant centre

Per

cen

tata

ge


Highly sensitised patients

Highly sensitised patients


0

10

20

30

40

50

60

70

80

90

100

95 95 95 94 94 97 10090 93 97

5 5 5 6 6 310 7 3

Transplant centre

Per

cen

tata

ge


Cold ischaemia times

Cold ischaemia time of DCD transplants


6

8

10

12

14

16

18

20

Q1

Transplant centre

Co

ld i

sc

ha

em

ia t

ime

(h

ou

rs)

p=0.1 p=0.4 p=0.5 p=0.1 p=0.9

Summary (1)

• Scheme went live on 3rd September 2014

• Designed to- Improve equity of access to a national resource- Optimise utilisation of DCD donor kidneys through formalised offering- Maintain (or reduce) overall cold ischaemia times

• General feedback on the scheme is positive- Potential impact on offering times needs to be addressed

• A six-month review of the screening centres to be undertaken shortly- Impact on screening centres- Donor suitability- More suitable way forward?

Summary (2)

• DCD Kidney activity has increased

• Better matching achieved through sharing

• Highly sensitised and long waiting patients have improved access to transplant

• Small reduction in cold ischaemia times

Should we increase the upper age limit for sharing DCD kidneys through the scheme?

– 5 year increments

– London experience, increase to 64 years?

AcknowledgementsDCD Kidney Allocation Working Party

Chair Susan Fuggle, Martin RafertyTransplant Centre Reps Argiris Asderakis, Peter Friend,

Lorna Marson, Justin Morgan, Chas Newstead, Gavin Pettigrew, Peter Rowe, Dominic Summers, David Talbot, John Connolly, Geoff Koffman, Keith Rigg

BSHI Andrea HarmerStatisticians Alex Hudson, Rachel Johnson,

Lisa BradburyAssociate Medical Director James NeubergerBAPN Jane TizardPAG Chair Christopher WatsonSNOD Julie Whitney

Endorsed by Members of the NHSBT Kidney Advisory Group

review of dcd allocation scheme: the first 6 months lisa bradbury statistics and clinical studies...

Documents

process new dcd kidney

transplanted slide

complete slide

transplant activity

potential dcd donors

kidneys shared one550

snods o utilisation

national resource kidneys