Medical Director Bulletin

December 2022

A message from Professor Derek Manas, OTDT Medical Director

Hi all,

It's amazing how time flies. Another year has almost gone, and Christmas is around the corner. We say goodbye to Alex Manara and thank him for his amazing expertise and support over the years and wish him well for the future, he will be sorely missed. We also say goodbye to Jeremy Prydal as outgoing chair of OTAG and thank him for his excellent work over the last three years. His successor is Parwez Hossein; welcome and we look forward to working with you over the next three years.

In recent months, most advisory groups have been able to meet face to face for the first time in over a year, which has been a welcome change from remembering to 'raise your hand' or take yourself 'off mute'. I would like to thank the advisory group chairs for the amazing commitment they have shown over the past 18 months and congratulate them on the innovative work they are doing to support OTDT and the transplant community.

Even though the COVID-19 pandemic has subsided, the virus remains with us and COVID-positive donors and recipients continue to be a vexing clinical problem. Thanks to Chris Callaghan and Ines Ushiro-Lumb, the policy (POL 304) on COVID positive donor and recipient management has been recently updated. The policy is a very permissive one for all except for lung transplantation – allowing for clinical decision making to take priority. 

View the policy on COVID positive donor and recipient management (PDF, 839KB)

The OUG recommendations have been completed and recently reviewed by ministers and we hope the launch will be early in the new year. This was a mammoth piece of work lead by John Forsythe (my predecessor) and Claire Williment with widespread stakeholder engagement. I’d like to thank them and congratulate them for their tireless persistence in delivering this and to all of you who contributed. A special thanks to Professor Sir Steve Powis for chairing the group and in helping to get it ‘over the line’. Now my work begins. . .

The national expert group has just completed writing draft guidance on implementation of imlifidase in the kidney transplantation pathway. This follows NICE and SMC guidance publication in summer 2022. The guidance document will be out for consultation, and we would be grateful for active participation in the feedback. The final version of the guidance document will be available on the BTS and BSHI websites from Jan 2023. Thank you to Rommel Ravanan for leading on this.

The new cancer indications for liver transplantation have gone live including, NE Tumours, Intra-hepatic cholangiocarcinoma, and colorectal metastases. Hilar cholangiocarcinoma for PSC patients is still in process but will be active soon. Thank you to Doug Thorburn, Krish Menon, Raj Prasad and Tahir Shah and all members of the working groups for their hard work.

Lung transplantation numbers have been sorely affected by COVID-19 and workforce issues, but unlike other organs, numbers have not recovered and the resultant impact on waiting list patients goes without saying. On the 22^nd of February we plan to have a mini ‘lung summit’ for all the lung transplant units to consider how we move forward and get back to where we expect to be.

I would also like to announce two other meetings:

1. NORS Masterclass 9-11^th January in Edinburgh (see details from Ian Currie and Marius Berman further down)
2. The Living donor Liver Transplantation stakeholder engagement meeting on the 10^th of February at the Royal Free Hospital, London. (See message from Lisa Burnapp further down)

Finally, the OUG implementation will be starting in the New Year, and I will be asking for help from the clinical community. Ongoing work includes: Early recovery after surgery for Kidney and Liver transplantation, Sustainability (net zero) working group, Xenotransplantation scoping work stream, Photography to support organ offering, Clinical leads in organ utilization and Transplant collaboratives. Thank you to all my team for their leadership in running all these initiatives.

Obituary

Sir Peter John Morris, AC, FRS, FMedSci, FRCP, FRCS (17 April 1934 – 29 October 2022)

Sir Peter was an Australian surgeon and Nuffield professor of surgery at the University of Oxford. His professional scientific career revolved around transplantation and transplantation biology, with a major interest in the immune response to histocompatibility antigens and their suppression. One of his key contributions was the discovery of cytotoxic antibodies in patients after renal transplantation and their association with graft failure. Other research interests included extensive studies of HLA and disease and the use of HLA as a genetic marker in anthropology. His clinical interests were in transplantation and vascular surgery. He was a former President of The Royal College of Surgeons of England, The Transplantation Society (International), the British Transplantation Society, the European Surgical Association, and the International Surgical Society. He was the editor of Kidney Transplantation: Principles and Practice, which is now in its 6th edition, and the widely acclaimed Oxford Textbook of Surgery, which is in its 2nd edition. He  was also the founder of the Oxford Transplant Centre and director of the Centre for Evidence in Transplantation at the Royal College of Surgeons of England. He will be sorely missed. Rest in peace Sir Peter.

Hope you all have a merry Christmas and a Happy new Year.

 Yours sincerely,

Professor Derek Manas

Medical Director – OTDT

NHS Blood Transplant

Message from Lisa Burnapp, Associate Medical Director - Living Donation & Transplantation

Living Donation:  Kidney

Living donor kidney transplantation continues to make a steady recovery and the October matching run for the UK Living kidney Sharing Scheme (UKLKSS) identified 89 transplants, the highest number since 2019. The most recent runs have seen a consistent improvement in the proportion of identified transplants that actually proceed- up to 85% in January and April.

The digital transformation programme to automate the processes that are currently paper-based and performed manually within the UKLKSS, is progressing well and due to be released in two phases – the first in February 2023 in time for the April matching run and the second in late Spring ahead of the July matching run, when we will aim to have the new platform fully deployed. Interim, please keep an eye out for key communications, updates and training dates for key workers as we get closer to the ‘go live’ date. Please contact lisa.burnapp@nhsbt.nhs.uk, AMD Living Donation and Transplantation or Michael.gumn@nhsbt.nhs.uk, Product Owner- Living Donation Digitisation, if you have any queries about the project.

The living donor liver transplantation project is progressing to plan and a wider stakeholder engagement event is planned for February 2023 to share recommendations and seek endorsement for the proposals agreed by the project board. ‘Save the date’ and venue details will be circulated in due course.

Finally, the Enhanced Recovery After Surgery (ERAS) steering group is preparing to meet again at the end of November to discuss progressing the initial roll-out for kidney transplant recipients and living kidney donors but with a view to working with other organ groups in future to achieve the same. Watch this space for further updates.

Message from Rommel Ravanan, Associate Medical Director - Transplant Medicine

Update on SARS-CoV-2 Treatment

NHSBT and BTS have recently published a joint statement on SARS-CoV-2 vaccination and anti-viral therapy

Read the statement on the Organ Donation website

NHSBT in partnership with UKHSA have submitted a manuscript for peer reviewed publication describing vaccine efficacy in recipients of zero vs 2 vs 3 vs 4 vaccine dose recipients. The outcome of interest includes risk of testing positive for SARS-CoV-2, hospitalisation within 14 days or death within 28days of testing positive for SARS-CoV-2. The analysis time spans the Omicron dominant period of Dec 2021 – March 2022. The results demonstrate an incremental dose dependent protection against hospitalisation and death after SARS-CoV-2 infection in Solid Organ and islet Transplant recipients (SOT). Due to the discontinuation universal access to free SARS-CoV-2 PCR testing after 31^st March 2022, it has not been possible to report on events after 31^st March 2022 including whether additional protection was conferred by 5^th or 6^th vaccine dose – SOT recipients would have bene eligible to have received up to six doses by Dec 2022. With the finding of incremental protection, we strongly encourage SOT recipients to receive all vaccine doses they are eligible to receive to maximally reduce risk of severe outcomes following SARS-CoV-2 infection.

In addition to vaccination, specific anti-viral treatments and other interventions such as Dexamethasone have helped to improve outcomes for pre-hospital and hospitalised patients with COVID-19. NICE have recently released draft guidance for public consultation on anti-viral treatments for COVID-19.

Read the guidance on the NICE website

The draft guidance recommends nirmatrelvir/ritonavir in the pre-hospital and tocilizumab or baricitinib as treatments in the hospitalised (if also needing supplemental oxygen) settings. All other treatments have been deemed not meeting NICE thresholds of clinical and/or cost effectiveness for currently circulating SARS-CoV-2 variants. DHSC have concluded there is currently in-sufficient evidence to recommend Tixagevimab plus cilgavimab (also known as Evusheld) for use either as treatment or prophylaxis but have commissioned a NICE review on use as prophylaxis – the review is expected to be published in Spring 2023

Read the government decision on Evusheld

Nirmatrelvir plus Ritonavir (also known as Paxlovid) is the NICE recommended pre-hospital treatment for COVID-19 and if confirmed in the post-consultation final guidance, is likely to be made available to patients via CMDU (or equivalents in the devolved administrations). Whilst Paxlovid is deemed to have met the required clinical & cost effectiveness thresholds for currently circulating variants, Ritonavir is a significant inhibitor of CYP3A4, the main metabolising enzyme for tacrolimus/ciclosporin/sirolimus. Therefore, significant increase in these drug levels and associated adverse events are anticipated if there is co-prescription of Paxlovid. Due to this potentially harmful and likely drug interaction, transplant clinical teams who know the patient well and/or have detailed knowledge of the relevant avoidable drug interaction are likely to be better placed to make individualised risk-vs-benefit decisions on treatment using Paxlovid in SOT recipients. Early engagement with local CMDUs (or equivalents in the devolved administrations) to enable mechanisms for CMDUs to seek and obtain this specialist advice from transplant teams should be considered. 

Message from Chris Callaghan, Associate Medical Director - Organ Utilisation

In association with Claire Williment, John Forsythe and Derek Manas we have held a series of meetings with colleagues from other national organ donation and transplantation organisations to explore international perspectives on organ utilisation. More efficient and effective means of encouraging organ transplantation from deceased donors are needed, as changing donor types and demographics mean that rising organ donation rates do not always lead to rapidly falling transplant waiting lists.

Meetings have been held with colleagues from 11 other countries, with the aims of raising the profile of utilisation-related issues, establishing international frameworks to help measure utilisation rates, and to share experiences and learning. The group is currently called the 'International Organ Utilisation Collaborative' or IOUC.

It is hoped that IOUC meetings will lead to greater co-operation between NHSBT and similar organisations worldwide, and a better understanding of how national organisations can positively influence deceased donor organ utilisation.

Message from Ian Currie, Associate Medical Director - Organ Retrieval & Marius Berman, Chair of RAG

The NHSBT NORS Masterclass is upon us once more!  This will again be held on a virtual basis, improving opportunities for a wide range of delegates to attend.  The Masterclass will take place from Mon Jan 9th -Wed Jan 11th 2023, webcast from the Royal College of Surgeons of Edinburgh, where we will have a strong Faculty of national and international experts.

Aside from the conventional routes to attendance, we are also offering ‘refresher’ rates for all those who have attended in past years.  These refresher rates are around a quarter of the full price and are a very useful way of keeping up to date in this rapidly moving field.

We will also be welcoming a cadre of military surgeons who wish to learn some key techniques used in organ retrieval surgery which will be of use in battlefield injuries.  Furthermore, we will be welcoming a range of members from the organ donation community (SNODs, CLODs and TRODs) who wish to gain an overview of retrieval practice.

Overall, we hope to provide the best ever Masterclass for the widest range of delegates.

See you there!

Register for the NHSBT NORS Masterclass

Message from Richard Baker, Associate Medical Director - Clinical Governance

Greetings from the Governance Grotto!

2023 has been a difficult year as the UK transplant community struggles to recover from the effects of the pandemic. Despite these demands colleagues have continued to engage with the governance process which makes it such an enjoyable job to do. Without your help the governance team would really struggle so thank you!

It is notable that despite the operational difficulties over the last twelve months there has not been any discernible increase in the number of incidents which is testament to the dedication and resilience of the clinical teams. Something that I had not realised when I started the job was that 99% of the governance process revolves around education with the aim of improving performance by shared learning. To that end I have selected a few themes from the year.

Transport

Several cases have been reported relating to flight availability for organ transportation. Since the beginning of the year there has been an increased demand within the UK and across Europe for chartered flights. On occasions there have been difficulty in reopening or extending the opening of airports due to staff sickness and shortages amongst handling agents and security staff as activity resumes. We have initiated joint visits to transplant centre sites to meet staff and explore the issues fully. The teams have put together an action plan to mitigate against impact on the service.

Donor Derived Disease

We continue to see cases of donor transmitted disease which is a reminder that transplantation can never be a risk-free endeavour. We have seen cases of donor derived metabolic, infectious and neoplastic diseases over the last twelve months. Unfortunately, we continue to see severe disease following transmission of disease caused by human herpes viruses despite thorough screening carried out during donor characterisation. During the next year I hope we will see the first regular donor testing for HHV-8. I would like to thank Ines Uchiro-Lumb, our microbiology expert without whose expertise we would undoubtedly struggle.

Retrieval

We do continue to receive reports of organ damage and less frequently organ loss. However given the volume of work that is taking place it represents a tiny percentage. This is testament to the skill and flexibility of the retrieval teams. We have registered a number of issues relating to pancreas retrieval and in particular the need for healthy accompanying vessels with which to fashion the Y-graft. These are learning points that we intend to consolidate at the retrieval forum in January.

The governance team remain here to work with you and provide support if required so if you have query then please ask. I wish you all a very happy festive period and look forward to a successful 2023 that allows us to deliver more transplants to those who need them.

Organ transplantation from deceased donors with primary brain tumours

The following information has been provided by Dale Gardiner, Associate Medical Director - Deceased Organ Donation.