Alex Hudson

Pancreas Transplantation From Donors After Circulatory Death From the United Kingdom

This study reports the comparative short‐term results of pancreas transplantation from donors after circulatory death (DCD) (Maastricht III & IV), and pancreases from brainstem deceased donors (DBD). Between January 2006 and December 2010, 1009 pancreas transplants were performed in the United Kingdom, with 134 grafts from DCD and 875 from DBD. DCD grafts had no premortem pharmacological interventions performed. One‐year pancreas and patient survival was similar between DCD and DBD, with pancreas graft survival significantly better in the DCD cohort if performed as an SPK. Early graft loss due to thrombosis (8% vs. 4%) was mainly responsible for early graft loss in the DCD cohort. These results from donors with broader acceptance criteria in age, body mass index, premortem interventions, etc. suggest that DCD pancreas grafts may have a larger application potential than previously recognized.

The discard of deceased donor kidneys in the UK

It is essential to minimize the unnecessary discard of procured deceased donor kidneys, but information on discard rates and the extent to which discard can be avoided are limited. Analysis of the UK Transplant Registry revealed that the discard rate of procured deceased donor kidneys has increased from 5% in 2002‐3 to 12% in 2011‐12. A national offering system for hard‐to‐place kidneys was introduced in the UK in 2006 (the Declined Kidney Scheme), but just 13% of kidneys that were subsequently discarded until 2012 were offered through the scheme. In order to examine the appropriateness of discard, 20 consecutive discarded kidneys from 13 deceased donors were assessed to determine if surgeons agreed with the decision that they were not implantable. Donors had a median (range) age of 67 (31–80) yr. Kidneys had been offered to a median of 3 (1–12) centers before discard. Four (20%) of the discarded kidneys were thought to be usable, and nine (45%) were possibly usable. As a result of these findings, major changes to the UK deceased donor kidney offering system have been implemented, including simultaneous offering and broader entry criteria for hard‐to‐place kidneys. Organizational changes are necessary to improve utilization of deceased donor kidneys.

Kidney Transplantation Significantly Improves Patient and Graft Survival Irrespective of BMI: A Cohort Study

Obesity and end‐stage renal disease (ESRD) are on the increase worldwide. Kidney transplantation is the treatment of choice for ESRD. However, obesity is considered a contraindication for transplantation. We investigated the effect of BMI on mortality in transplanted and patients remaining on the waiting list in the United Kingdom. We analyzed the UK Renal Registry (RR) and the National Health Service Blood and Transplant (NHSBT) Organ Donation and Transplantation data for patients listed from January 1, 2004 to December 31, 2010, with follow‐up until December 31, 2011. Seventeen thousand six hundred eighty‐one patients were listed during the study period, with BMI recorded for 13 526 (77%). One‐ and five‐year patient survival was significantly better in all BMI bands (<18.5, 18.5–<25, 25–<30, 30–<35, 35–<40, and 40+kg/m2) in the transplant group when compared to those who remained on the waiting list (p < 0.0001). The analyses were repeated excluding live donor transplants and the results were essentially the same. On analyses of patient survival with BMI as a continuous variable or using 5 kg weight bands, there was no cut‐off observed in the higher BMI patients where there would be no benefit to transplantation. For transplanted patients (N = 8088), there was no difference in patient or graft survival between the defined BMI bands. Thus, irrespective of BMI, patient survival is improved if transplanted.

Living Donation Has a Greater Impact on Renal Allograft Survival Than HLA Matching in Pediatric Renal Transplant Recipients.

Background Living donor (LD) kidney transplantation accounts for around half of all pediatric renal transplant recipients and results in improved renal allograft survival. The aim of this study was to determine the effect of HLA matching on deceased and LD renal allograft outcomes in pediatric recipients. Methods Data were obtained from the UK Transplant Registry held by NHS Blood and Transplant on all children who received a donation after brain death (DBD) or LD kidney-only transplant between 2000 and 2011. HLA-A, HLA-B and HLA-DR mismatches were categorized into 4 levels and 2 groups. Data were fully anonymized. Results One thousand three hundred seventy-eight pediatric renal transplant recipients were analyzed; 804 (58%) received a DBD donor kidney, 574 (42%) received an LD kidney. Five-year renal allograft survival was superior for children receiving a poorly HLA-matched LD kidney transplant (88%, 95% confidence interval [95% CI], 84-91%) compared with children receiving a well HLA-matched DBD kidney transplant (83%, 95% CI, 80-86%, log rank test P = 0.03). Five-year renal allograft survival was superior for children receiving an LD kidney with 1 or 2 HLA-DR mismatches (88%, 95% CI, 84-91%) compared with children receiving a DBD kidney with 0 HLA-DR mismatches (83%, 95% CI, 80-86%, log rank test P = 0.03). Conclusions In children, poorly HLA-matched LD renal transplant outcomes are not inferior when compared with well HLA-matched DBD renal transplants. It is difficult to justify preferentially waiting for an improved HLA-matched DBD kidney when a poorer HLA-matched LD kidney transplant is available.

Standardized deceased donor kidney donation rates in the UK reveal marked regional variation and highlight the potential for increasing kidney donation: a prospective cohort study

Background The UK has implemented a national strategy for organ donation that includes a centrally coordinated network of specialist nurses in organ donation embedded in all intensive care units and a national organ retrieval service for deceased organ donors. We aimed to determine whether despite the national approach to donation there is significant regional variation in deceased donor kidney donation rates. Methods The UK prospective audit of deaths in critical care was analysed for a cohort of patients who died in critical care between April 2010 and December 2011. Multivariate logistic regression was used to identify the factors associated with kidney donation. The logistic regression model was then used to produce risk-adjusted funnel plots describing the regional variation in donation rates. Results Of the 27 482 patients who died in a critical care setting, 1528 (5.5%) became kidney donors. Factors found to influence donation rates significantly were: type of critical care [e.g. neurointensive vs general intensive care: OR 1.53, 95% confidence interval (CI) 1.34–1.75, P<0.0001], patient ethnicity (e.g. ‘Asian’ vs ‘white’: OR 0.17, 95% CI 0.11–0.26, P<0.0001), age (e.g. age >69 vs age 18–39 yr: OR 0.2, 0.15–0.25, P<0.0001), and cause of death [e.g. ‘other’ (excluding ‘stroke’ and ‘trauma’) vs ‘trauma’: OR 0.04, 95% CI 0.03–0.05, P<0.0001]. Despite correction for these variables, kidney donation rates for the 20 UK kidney donor regions showed marked variation. The overall standardized donation rate ranged from 3.2 to 7.5%. Four regions had donation rates of >2 standard deviations (sd) from the mean (two below and two above). Regional variation was most marked for donation after circulatory death (DCD) kidney donors with 9 of the 20 regions demonstrating donation rates of >2 sd from the mean (5 below and 4 above). Conclusions The marked regional variation in kidney donation rates observed in this cohort after adjustment for factors strongly associated with donation rates suggests that there is considerable scope for further increasing kidney donation rates in the UK, particularly DCD.

Strategies for expanding the UK pool of potential intestinal transplant donors.

Background The pool of suitable donors and listed recipients for intestinal transplantation is small, resulting in difficulties in donor-to-recipient matching and significant mortality on the waiting list. This study aims to help define the pool of potential donors for intestinal transplantation and propose methods for an increased utilization of donor bowels in the United Kingdom. Methods Data on bowel offering from 657 donors after brain stem death (DBD) and on 46 patients on the active intestinal transplant list over 12 months from 14 April 2011 were obtained from the UK Transplant Registry. Results Family consent for bowel donation was lower than for the other transplantable organs. Only 57% of bowels from DBD donors with consent and meeting the bowel offering criteria were offered for transplantation. A lack of suitable recipients was the most common reason cited for not offering. Only 10% of offered bowels were accepted and transplanted by centers. Donor size discrepancy and human leukocyte antigen incompatibility were common reasons for declining offers of the bowel. There was a scarcity of young and small donors compared with the number of young and small patients requiring a transplant. Two patients who were on the active list during the time period died. Conclusions An increased awareness of bowel donation is needed to improve the low offering rate of bowels from DBD donors. A more robust UK bowel allocation system and a formalized European-wide intestinal donor organ sharing program should lead to an increased utilization of available donor bowels and a lower waiting list mortality rate.

Uk National Registry Study of Kidney Donation After Circulatory Death for Pediatric Recipients

Background Donation after circulatory death (DCD) kidney transplantation has acceptable renal allograft survival in adults but there are few data in pediatric recipients. The aim of this study was to determine renal allograft outcomes for pediatric recipients of a DCD kidney. Methods Data were collected from the UK Transplant Registry held by National Health Service Blood and Transplant. Kidney transplants performed for pediatric recipients (age, <18 years) in the United Kingdom from 2000 to 2014 were separated into DCD, donation after brain death (DBD), and living donor (LD) transplants, analyzing 3-year patient and renal allograft survival. Results One thousand seven hundred seventy-two kidney only transplants were analyzed. Twenty-one (1.2%) of these were from DCD donors, 955 (53.9%) from DBD donors, and 796 (44.9%) from LDs. Patient survival is 100% in the DCD group, 98.7% in the DBD group, and 98.9% in the LD group. Three-year renal allograft survival was 95.2% in the DCD group, 87.1% in the DBD group, and 92.9% in the LD group. There was no significant difference in 3-year renal allograft survival between the DCD and DBD groups (P = 0.42) or DCD and LD groups (P = 0.84). For DCD, the primary nonfunction rate was 5% and delayed graft function was 25%. Conclusions Children receiving a DCD kidney transplant have good renal allograft survival at 3-year follow-up, comparable to those receiving a kidney from a DBD donor or a LD. This limited evidence encourages the use of selected DCD kidneys in pediatric transplantation, and DCD allocation algorithms may need to be reviewed in view of this.

Renal function and cardiovascular outcomes after living donor nephrectomy in the UK: quality and safety revisited

To determine renal function and cardiovascular outcomes after living donor nephrectomy (LDN). Living donor kidney transplantation has become established as the treatment of choice for end‐stage renal failure. Benefits to the recipient have to be balanced against perioperative and long‐term health risks to the donor.

Pancreas Transplantation From Donors After Circulatory Death From the United Kingdom: Pancreas Transplantation From Donors

Our report on DCD pancreas transplantation in the United Kingdom (2) was based upon information supplied by the centers to the UK Transplant Registry. The assumption stated in our paper of a maximum of 60 min from withdrawal to cardiac arrest reflected a general consensus amongst the centers involved in DCD pancreas transplantation in the United Kingdom and we accept both that this is an arbitrary stipulation and that there were exceptions to this rule.

UK REGISTRY OF ANTIBODY INCOMPATIBLE KIDNEY TRANSPLANTATION 2001–2010: 3280

R. Higgins1, A.J. Hudson2, R.J. Johnson2, S.V. Fuggle3, J. Galliford4, D. Taube4, N. Mamode5, S. Ball6, R. Ravanan7, N. Torpey8, R. Thuraisingham9, A. Gupta9, C. Newstead10, J.A. Bradley11 1Department Of Renal Medicine, University Hospital Coventry & Warwickshire, Coventry/UNITED KINGDOM, 2Statistics And Clinical Audit, NHS Blood and Transplant (UK), Bristol/UNITED KINGDOM, 3Scientific Advisor, NHS Blood and Transplant (UK), Bristol/UNITED KINGDOM, 4Wlrtc, Hammersmith Hospital, London/UNITED KINGDOM, 5Mrc Centre For Transpantation, King’s College London, London/UNITED KINGDOM, 6Nephrology And Transplantation, Queen Elizabeth Hospital, Birmingham/UNITED KINGDOM, 7Renal And Transplant Unit, Southmead Hospital, Bristol/UNITED KINGDOM, 8Transplant Unit, Addenbrookes Hospital, Cambridge/UNITED KINGDOM, 9Transplant Unit, Royal London Hospital, London/ UNITED KINGDOM, 10Nephrology, St James’s University Hospital, Leeds/UNITED KINGDOM, 11Department Of Surgery, University of Cambridge, Cambridge/UNITED KINGDOM