Transplantation in Australia and New Zealand
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1 Transplantation in Australia and New Zealand Matthew D. Jose MBBS (Adel), FRACP, FASN, PhD (Monash), AFRACMA Professor of Medicine, UTAS Renal Physician, Royal Hobart Hospital
2 Overview CKD in Australia & NZ Transplantation decisions in A & NZ Kidney donors Current immunosuppression Morbidity & mortality Questions
3 Overview CKD in Australia & NZ
4 Stages of CKD Stage 1 90 Stage 2 egfr Stage 3 Stage 4 Stage 5 Time Months/years
5 ANZDATA report 2010
6 Incidence of end-stage CKD AIHW CKD report 2005
7 Age-specific incidence rate of treated ESKD AIHW Cat PHE 150, 2011
8 Overview CKD in Australia & NZ Transplantation decisions in A & NZ
9 Per million population International comparisons
10 Transplant economics Chapman J, Transplant Res 2013; 2: S1
11 Figure 8.23 Prevalence of Functioning Transplants As mode of RRT, Australia 2011 Age Living donor Deceased donor Percentage of patients ANZDATA Registry Annual Report 2012
12 Figure 8.24 Prevalence of Functioning Transplants As mode of RRT, New Zealand 2011 Age Living donor Deceased donor Percentage of patients ANZDATA Registry Annual Report 2012
13 Overview CKD in Australia & NZ Transplantation decisions in A & NZ Pre-emptive, living donor transplant
14 ANZDATA Registry Annual Report 2012
15 ANZDATA Registry Annual Report 2012
16 Overview CKD in Australia & NZ Transplantation decisions in A & NZ Pre-emptive, living donor transplant Living donor transplant ABO-compatible or incompatible
17 ANZDATA Registry Annual Report 2012
18 Overview CKD in Australia & NZ Transplantation decisions in A & NZ Pre-emptive, living donor transplant Living donor transplant ABO-compatible or incompatible Paired kidney exchange
19 Overview CKD in Australia & NZ Transplantation decisions in A & NZ Pre-emptive, living donor transplant Living donor transplant ABO-compatible or incompatible Paired kidney exchange Deceased donor transplant waiting list
20 ANZDATA Registry Annual Report 2012
21 ANZDATA Registry Annual Report 2012
22 ANZDATA Registry Annual Report 2012
23 Figure 8.10 Transplant Operations (per million) 2011 Australia Age ANZDATA Registry Annual Report 2012
24 Figure 8.11 Transplant Operations (per million) 2011 New Zealand Age ANZDATA Registry Annual Report 2012
25 Figure 8.7 Ratio of Transplantation Australia Related to patients dialysed Age ANZDATA Registry Annual Report 2012
26 % transplanted Figure 8.8 Ratio of Transplantation New Zealand Related to patients dialysed Age ANZDATA Registry Annual Report 2012
27 Figure 8.2 Deceased and Living Donor Transplants 600 Australia Living donor Deceased donor ANZDATA Registry Annual Report 2012
28 Figure 8.3 Deceased and Living Donor Transplants New Zealand Living donor Deceased donor ANZDATA Registry Annual Report 2012
29 Number of transplants Figure 8.4 Transplants from Non-Heart Beating Donors Transplants from Heart Beating Donors 150 Australia Australia ANZDATA Registry Annual Report 2012
30 Transplants per million population Figure 8.26 Age Distribution of Functioning Transplants Australia 2011 (n=8753) Age Distribution of Functioning Transplants Per million population, Australia ,500 2,000 1, , , Age Age ANZDATA Registry Annual Report 2012
31 Transplants per million population Figure 8.27 Age Distribution of Functioning Transplants Age Distribution of Functioning Transplants 400 New Zealand 2011 (n=1481) Per million population, New Zealand Age Age ANZDATA Registry Annual Report 2012
32 < Figure 8.29 Number and Duration of Functioning Grafts Australia 2011 (n=8753) 800 Deceased Living Duration (years) ANZDATA Registry Annual Report 2012
33 < Figure 8.30 Number and Duration of Functioning Grafts New Zealand 2011 (n=1481) 100 Deceased Living 50 0 Duration (years) ANZDATA Registry Annual Report 2012
34 Overview CKD in Australia & NZ Transplantation decisions in A & NZ Kidney donors
35 International comparisons
36 ANZDATA Registry Annual Report 2012
37 ANZDATA Registry Annual Report 2012 Decreased in Living donors
38 ANZDATA Registry Annual Report 2012
39 ANZDATA Registry Annual Report 2012
40 ANZDATA Registry Annual Report 2012
41 Overview CKD in Australia & NZ Transplantation decisions in A & NZ Kidney donors Current immunosuppression
42 Figure 8.34 Australia Immunosuppressive Therapy - Primary Deceased Donor Graft Year Aza CyA Tacrol MMF MPA Sirol Everolimus Pred Number of Deceased Donor Grafts (2%) 212 (59%) 136 (38%) 309 (85%) 25 (7%) 10 (3%) 1 (<1%) 360 (99%) (3%) 131 (41%) 172 (54%) 299 (94%) 4 (1%) 17 (5%) (97%) (51%) 139 (45%) 260 (85%) 24 (8%) 3 (1%) 19 (6%) 296 (97%) 306 Initial treatment (1%) 139 (48%) 140 (49%) 244 (85%) 36 (13%) - 5 (2%) 285 (99%) (1%) 137 (35%) 240 (61%) 364 (93%) 22 (6%) (99%) (1%) 62 (16%) 310 (82%) 356 (95%) 13 (3%) - 3 (1%) 375 (100%) (14%) 409 (86%) 426 (89%) 37 (8%) 1 (<1%) 3 (1%) 477 (100%) (<1%) 51 (10%) 443 (87%) 309 (60%) 189 (37%) (97%) (7%) 129 (39%) 162 (49%) 236 (72%) 46 (14%) 31 (9%) 1 (<1%) 304 (93%) (8%) 83 (29%) 172 (59%) 229 (79%) 21 (7%) 29 (10%) 3 (1%) 262 (90%) 291 Treatment at 12 months (4%) 94 (34%) 145 (52%) 216 (78%) 27 (10%) 21 (8%) 20 (7%) 259 (93%) (5%) 86 (32%) 149 (56%) 189 (71%) 51 (19%) 12 (5%) 14 (5%) 252 (95%) (5%) 84 (23%) 251 (70%) 288 (80%) 37 (10%) 12 (3%) 9 (2%) 345 (96%) (5%) 40 (11%) 283 (80%) 282 (80%) 39 (11%) 18 (5%) 9 (3%) 341 (96%) (5%) 51 (11%) 364 (81%) 332 (73%) 65 (14%) 16 (4%) 10 (2%) 430 (95%) (9%) 116 (36%) 154 (48%) 219 (68%) 45 (14%) 41 (13%) 5 (2%) 283 (88%) (8%) 76 (27%) 156 (55%) 220 (78%) 23 (8%) 45 (16%) 5 (2%) 238 (84%) 282 Treatment at 24 months (6%) 81 (30%) 144 (53%) 207 (76%) 31 (11%) 23 (8%) 25 (9%) 248 (92%) (5%) 79 (31%) 152 (59%) 181 (70%) 54 (21%) 14 (5%) 13 (5%) 243 (94%) (6%) 80 (23%) 238 (68%) 275 (79%) 39 (11%) 12 (3%) 9 (3%) 324 (93%) (6%) 36 (10%) 268 (78%) 257 (75%) 43 (13%) 18 (5%) 11 (3%) 322 (94%) 343 ANZDATA Registry Annual Report 2012 Aza = Azathioprine CyA = Cyclosporine Tacrol = Tacrolimus MMF = Mycophenolate Mofetil MPA = Mycophenolic Acid (Enteric Coated) Sirol = Sirolimus Pred = Prednisolone
43 Figure 8.35 New Zealand Immunosuppressive Therapy - Primary Deceased Donor Graft Year Aza CyA Tacrol MMF MPA Sirol Everolimus Pred Number of Deceased Donor Grafts Initial treatment Treatment at 12 months Treatment at 24 months (94%) 3 (6%) 49 (98%) (100%) (76%) 8 (19%) 41 (98%) (98%) (68%) 11 (30%) 34 (92%) (8%) 37 (100%) (74%) 15 (26%) 57 (98%) (2%) 58 (100%) (67%) 15 (33%) 42 (93%) 3 (7%) (100%) (78%) 10 (20%) 49 (98%) (98%) (71%) 13 (29%) 45 (100%) (100%) (71%) 17 (29%) 58 (100%) (100%) (19%) 30 (64%) 17 (36%) 37 (79%) (96%) (5%) 21 (55%) 16 (42%) 33 (87%) 1 (3%) 2 (5%) 1 (3%) 35 (92%) (53%) 15 (45%) 29 (88%) (9%) 32 (97%) (6%) 31 (60%) 20 (38%) 43 (83%) - 2 (4%) 1 (2%) 48 (92%) (5%) 21 (48%) 23 (52%) 39 (89%) 1 (2%) (93%) (50%) 23 (48%) 48 (100%) - 1 (2%) - 45 (94%) (5%) 16 (37%) 26 (60%) 40 (93%) (95%) (27%) 27 (60%) 18 (40%) 30 (67%) (91%) (6%) 18 (50%) 17 (47%) 30 (83%) 1 (3%) 2 (6%) 1 (3%) 29 (81%) (50%) 16 (50%) 28 (88%) (6%) 30 (94%) (6%) 29 (58%) 20 (40%) 41 (82%) - 2 (4%) 1 (2%) 45 (90%) (5%) 20 (48%) 22 (52%) 37 (88%) - 1 (2%) - 40 (95%) (43%) 24 (52%) 44 (96%) - 1 (2%) - 41 (89%) 46 Aza = Azathioprine CyA = Cyclosporine Tacrol = Tacrolimus MMF = Mycophenolate Mofetil MPA = Mycophenolic Acid (Enteric Coated) Sirol = Sirolimus Pred = Prednisolone ANZDATA Registry Annual Report 2012
44 Figure 8.36 Antibody Use for Induction Immunosuppression Australia and New Zealand Number of Kidney Transplant Recipients Receiving Each Agent by Year (% Total New Transplants) Australia Muromonab-CD3 2 (0.3%) - 1 (0.1%) - - Intravenous immunoglobulin 14 (2.3%) 25 (3.1%) 28 (3.6%) 39 (4.6%) 40 (4.8%) Anti-CD (86.5%) 740 (91.0%) 715 (92.5%) 798 (94.3%) 748 (90.7%) Rituximab 7 (1.1%) 21 (2.6%) 17 (2.2%) 9 (1.1%) 9 (1.1%) T cell depleting polyclonal Ab 17 (2.8%) 22 (2.7%) 40 (5.2%) 52 (6.1%) 33 (4.0%) Total new transplants ANZDATA Registry Annual Report 2012 New Zealand T cell depleting polyclonal Ab (0.9%) 1 (0.8%) Anti-CD25 47 (38.2%) 74 (60.7%) 63 (52.1%) 65 (59.1%) 110 (93.2%) Rituximab - 1 (0.8%) 2 (1.7%) 1 (0.9%) 3 (2.5%) Intravenous Immunoglobulin Muromonab-CD Total new transplants
45 Figure 8.37 Antibody Use as Treatment for Acute Rejection Australia and New Zealand Number of Kidney Transplant Recipients Receiving Each Agent by Year (% Total New Transplants) Australia Muromonab-CD3 9 (1.5%) 10 (1.2%) 12 (1.6%) 2 (0.2%) - Intravenous immunoglobulin 70 (11.4%) 89 (10.9%) 105 (13.6%) 92 (10.9%) 104 (12.6%) Anti-CD25-1 (0.1%) 1 (0.1%) - - Rituximab 16 (2.6%) 24 (3.0%) 26 (3.4%) 15 (1.8%) 11 (1.3%) T cell depleting polyclonal Ab 14 (2.3%) 19 (2.3%) 27 (3.5%) 41 (4.8%) 42 (5.1%) Total new transplants Total transplants at risk ANZDATA Registry Annual Report 2012 New Zealand Muromonab-CD3 10 (8.1%) 10 (8.2%) 8 (6.6%) 4 (3.6%) - Intravenous immunoglobulin 3 (2.4%) 2 (1.6%) 7 (5.8%) 3 (2.7%) 3 (2.5%) Anti-CD25 1 (0.8%) 1 (0.8%) (0.8%) Rituximab (2.5%) - - T cell depleting polyclonal Ab 3 (2.4%) 3 (2.5%) 2 (1.7%) 12 (10.9%) 11 (9.3%) Total new transplants Total transplants at risk
46 Overview CKD in Australia & NZ Transplantation decisions in A & NZ Kidney donors Current immunosuppression Morbidity & mortality
47 Figure 8.38 Australia and New Zealand Rejection Rates at Six Months Post Transplant Donor Source Living Donor First graft 27.5% 27.7% 21.6% 19.6% 19.6% 21.1% 17.0% 16.8% 17.8% 16.1% Second and subsequent grafts 13.0% 33.3% 34.8% 18.5% 33.3% 34.3% 30.0% 24.3% 12.9% 18.5% Deceased Donor First graft 22.9% 26.8% 22.8% 18.6% 16.3% 17.7% 22.0% 20.9% 18.7% 17.9% Second and subsequent grafts 24.1% 25.0% 27.5% 31.7% 36.4% 32.8% 32.9% 36.5% 27.3% 16.1% ANZDATA Registry Annual Report 2012
48 Figure 8.31 Graft Loss Rate Australia Death with Function 2.3% 2.3% 2.2% 2.4% 2.0% 2.2% 2.2% 1.8% 2.0% 2.2% Loss of Graft Function 2.9% 2.7% 3.1% 2.8% 2.5% 2.5% 2.9% 2.8% 2.3% 2.3% All Losses 5.2% 4.9% 5.3% 5.1% 4.5% 4.7% 5.1% 4.5% 4.3% 4.5% New Zealand Death with Function 2.7% 2.2% 2.2% 2.3% 2.6% 3.2% 1.9% 2.3% 2.3% 2.6% Loss of Graft Function 2.7% 2.5% 1.8% 3.3% 3.5% 2.9% 2.1% 2.4% 2.1% 2.0% All Losses 5.4% 4.7% 4.0% 5.6% 6.0% 6.1% 3.9% 4.7% 4.4% 4.6% ANZDATA Registry Annual Report 2012
49 ANZDATA Registry Annual Report 2012
50 Figure 8.32 Year of Graft Loss Due to Death or Failure Loss Cause of Failure Total Australia Death with Function Rejection - Acute Chronic Allograft (CAN) Failed Rejection - Hyperacute Vascular Technical Problems Glomerulonephritis Non Compliance Other Total New Zealand Death with Function Rejection - Acute Chronic Allograft (CAN) Failed Rejection - Hyperacute Vascular Technical Problems Glomerulonephritis Non Compliance Other Total ANZDATA Registry Annual Report 2012
51 Figure 8.33 Graft Losses Cause of Loss Australia Graft Function New Zealand Graft Function <1 year >= 1 year Any Time <1 year >= 1 year Any Time Death with functioning Graft Cardiac 21 (30%) 191 (24%) 212 (25%) 4 (36%) 47 (28%) 51 (28%) Vascular 5 (7%) 70 (9%) 75 (9%) 1 (9%) 7 (4%) 8 (4%) Infection 29 (42%) 130 (17%) 159 (19%) 1 (9%) 27 (16%) 28 (16%) Social 3 (4%) 53 (7%) 56 (7%) 1 (9%) 8 (5%) 9 (5%) Malignancy 5 (7%) 262 (33%) 267 (31%) 3 (27%) 60 (36%) 63 (35%) Miscellaneous 6 (9%) 77 (10%) 83 (10%) 1 (9%) 19 (11%) 20 (11%) Total 69 (100%) 783 (100%) 852 (100%) 11 (100%) 168 (100%) 179 (100%) Graft Failure Rejection - Acute 30 (23%) 25 (3%) 55 (5%) - 6 (4%) 6 (4%) Rejection - Chronic Allograft (CAN) 9 (7%) 734 (78%) 743 (69%) 1 (6%) 100 (67%) 101 (60%) Rejection - Hyperacute 2 (2%) - 2 (<1%) Vascular 41 (31%) 15 (2%) 56 (5%) 8 (44%) 3 (2%) 11 (7%) Technical Problems 10 (8%) 5 (1%) 15 (1%) 1 (6%) - 1 (1%) Glomerulonephritis 9 (7%) 59 (6%) 68 (6%) 3 (17%) 15 (10%) 18 (11%) Non Compliance 1 (1%) 37 (4%) 38 (4%) 1 (6%) 15 (10%) 16 (10%) Other 30 (23%) 64 (7%) 94 (9%) 4 (22%) 10 (7%) 14 (8%) Total 132 (100%) 939 (100%) 1071 (100%) 18 (100%) 149 (100%) 167 (100%) ANZDATA Registry Annual Report 2012
52 ANZDATA Registry Annual Report 2012
53 Transplantation in Australia And New Zealand CKD in Australia & NZ Transplantation decisions in A & NZ Kidney donors Current immunosuppression Morbidity & mortality Questions Matthew.Jose@utas.edu.au
54 Transplantation in Australia And New Zealand
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