Living donor kidney transplantation
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Living Donor Kidney Transplantation accounts for 96% of living donation activity in the UK and for 32% of kidney transplants across both adult and paediatric recipients.
Between 2000-2010, Living Donor Kidney Transplantation (LDKT) activity trebled in the UK in response to excellent transplant and patient outcomes which encouraged patient choice. Advances in technology, clinical expertise and changes in the legislative framework have encouraged more opportunity and choice in the options for living donor kidney transplantation; enabling the benefits of transplantation to be extended to more clinically complex recipients. It offers the best option for achieving pre-emptive and timely transplantation because of the opportunity to plan surgery in advance.
In order to build on the success of the previous decade, to promote best practice and to ensure that the UK programme has a sustainable future, NHS Blood and Transplant formally launched a UK Strategy for Living Donor Kidney Transplantation.
The LDKT 2020 Strategy Implementation Group is a sub-group of the NHS Blood and Transplant (NHSBT) Kidney Advisory Group, Chaired by Dr Aisling Courtney, Consultant nephrologist, Belfast City Hospital, with representation from across the wider transplant community. Terms of Reference are available to view. The strategy will be implemented through four workstreams:
The Strategy Implementation Group commision the following:
- Improving access and availability to LDKT
- Donor safety and welfare
- Recipient of LDKT at higher immune risk
- Prioritisation for recipients who miss out on a transplant in the UK living kidney sharing schemes
In June 2016 Kidney Advisory Group (KAG) approved proposals to offer prioritisation for patients who miss out on a transplant when all operations in an identified paired/pooled donation or altruistic donor chain do not complete. This is a rare occurrence but it has happened in both simultaneous and non-simultaneous surgery within the schemes and it was agreed that a clear policy is necessary. The following recommendations were agreed:
- A system of prioritisation for transplantation is established for patients who miss out on a transplant in the UKLKSS when all operations in an identified exchange do not complete.
- Two options for prioritisation are offered (specified below), via the transplant team, so that patients can make an informed choice about their preferred option, tailored to their individual circumstances. The patient will be required to choose one option.
- Transplant centres are responsible for reporting all cases of missed transplant opportunities in the UKLKSS to NHSBT via ODT on-line incident reporting at www.odt.nhs.uk so that these can be investigated and learning shared. The LKD Schemes team via at email@example.com and Lead Nurse for Living Donation must also be informed. Requests for prioritisation for transplant listing can be made via Lisa Burnapp firstname.lastname@example.org or Lisa Mumford email@example.com
Prioritisation Option 1: preferred option if the patient wishes to receive a living or deceased donor kidney.
Prioritisation for any kidney offer, deceased or living, that is HLA and blood group compatible using the same blood group matching criteria that are applied to the deceased donor scheme. The patient would have an opportunity to accept or decline any offer of a matched donor until he/she accepts an offer. Although this system could be left open indefinitely, it is recommended that, if an offer has not been accepted within 3 months of prioritisation, this is reviewed with the transplant centre.
Prioritisation Option 2: preferred option if the patient only wishes to receive a living donor kidney.
Prioritisation for any living kidney offer (I.e. non-directed altruistic kidney donor) that is HLA and blood group compatible, according to deceased donation criteria, until such time as the patient accepts an offer. The patient can be registered with a preferred HLA and age match if this has previously been specified within the UKLKSS.
If the prioritised patient has not accepted an offer by the commencement of the next scheduled matching run, prioritisation would continue and include any compatible living kidneys offered at the end of an altruistic donor chain. Preferred HLA and age matching criteria would remain in place.
Prioritisation for previous living kidney donors who develop end-stage kidney disease and require transplantation
In June 2016 Kidney Advisory Group (KAG) approved proposals to revise the prioritisation criteria for previous living kidney donors who develop end-stage kidney disease and require transplantation. Given that the number of cases is small, the existing policy has been extended to include provision for any previous donor to be included. The following recommendations were agreed:
- A system of prioritisation for all living kidney donors, regardless of whether ESKD is as a direct or indirect result of donation and irrespective of the lapse of time since donation.
- The donor will be prioritised for any kidney offer, deceased or living, that is HLA and blood group compatible using the same blood group matching criteria that are applied to the deceased donor scheme. The patient would have an opportunity to accept or decline any offer of a matched donor until he/she accepts an offer. Although this system could be left open indefinitely, it is recommended that, if an offer has not been accepted within 3 months of prioritisation, this is reviewed with the transplant centre.
- Transplant centres are responsible for reporting all cases of ESKD in previous living donors to the National Transplant Database via NHSBT. For further advice or support, please contact Lead Nurse for Living Donation. Requests for prioritisation for transplant listing can be made via Lisa Burnapp firstname.lastname@example.org or Lisa Mumford email@example.com
The workshop was supported by a faculty from across NHSBT, clinical transplantation and the scientific community. It was attended by more than 70 attendees, with representation from:
- Transplant surgery
- Living donor co-ordination; specialist nursing
- Clinical Science
- NHSBT- Statistics and Clinical Studies; Scientific Support
The actions and outcomes from the workshop will be taken forward through the LDKT 2020 Strategy Implementation Group.
- Options for incompatible pairs - Nizam Mamode
- What are we aiming to do? - Lisa Burnapp
- Haemagglutination in ABO incompatible Kidney Transplantation - Andrew Bentall
- ABO titration - Jenny White UK NEQAS (BTLP)
- HLA antibodies: are we missing a trick? - Matthew Robb/Sue Fuggle
- National Living Donor Kidney Sharing Schemes: How can we make the most of our donors? - Rachel Johnson
- Outcomes and actions