Manchester Royal Infirmary Renal & Pancreas Transplant Unit 21 / 211 Activity Annual Report Vicki Bowman Renal Transplant Audit & Data Manager Dr Susan Martin Consultant Clinical Scientist / Transplantation Laboratory Director Mr Titus Augustine Consultant Transplant Surgeon / Clinical Manager August 211
Contact Details Central Manchester University Hospitals NHS Foundation Trust Renal and Pancreas Transplant Unit and Transplantation Laboratory Manchester Royal Infirmary Oxford Road Manchester M13 9WL Tel: 161 7 11894 Fax: 161 27 66148 Email: Vicki Bowman Renal Transplant Data & Audit Manager victoria.bowman@cmft.nhs.uk Dr Susan Martin Consultant Clinical Scientist / Transplantation Laboratory Director susan.martin@cmft.nhs.uk Mr Titus Augustine Consultant Transplant Surgeon / Clinical Manager titus.augustine@cmft.nhs.uk Copies of this report are freely available on request both in paper and electronic (pdf) format on contacting Vicki Bowman, Renal Transplant Data & Audit Manager, as above. If you wish to make use of charts from this report in a presentation, please contact Vicki, as before. 2
Introduction & Acknowledgments 21/11 proved to be another busy year for the Renal Transplant Unit. The compilers of this report acknowledge the contributions from each and every member of the transplant team: Medical, Ward, Outpatient, Donor Transplant Coordinators, Specialist Nurses, Secretarial, Clerical and Transplantation Laboratory staff of all grades, and others from associated dialysis centres who have contributed to make this another successful year. Special thanks must also go to living donors and the families of deceased donors, without whom no transplants would have been possible. 3
Table of Contents Page Abbreviations and Definitions 5 All transplants 6 Fig 1: All transplants by quarter, by type 21/11 7 Fig 2: All transplants by type 21/11 7 Kidney alone transplants Fig 3: Adult kidney alone transplants by financial year 8 Pancreas transplants Fig 4: Adult pancreas transplants by financial year 8 Paediatric Transplants Fig 5: Paediatric transplants by type, by financial year 9 Adult Living Donor Transplants Fig 6: Adult living donor transplants by quarter, 28/9-21/11 1 Fig 7: Adult living donor transplants by donor relation, 21/11 1 Pre-emptive Transplantation Fig 8: Pre-transplant renal replacement therapy, adult recipients 28/9 21/11 11 Fig 9: Pre-transplant renal replacement therapy, paediatric recipients 28/9 21/11 12 Deceased Donor Transplants Fig 1: Kidney transplants 29/1 and 21/11 by donor age 12 Fig 11: Pancreas transplants 29/1 and 21/11 by donor age 13 Fig 12: Deceased donor transplants by organ origin, 29/1 21/11 13 Fig 13: Cold ischaemia time 14 The CMFT Kidney and Pancreas Transplant Waiting List Summary tables and paediatric patients 15 Pancreatic islet cell waiting list 16 Fig 14: CMFT kidney and pancreas transplant list by organ required 16 Fig 15: CMFT kidney and pancreas transplant list by age range 17 Fig 16: Time to enter CMFT kidney and pancreas transplant waiting list 17 Fig 17: Transplants by year versus transplant waiting list 18 Fig 18: Waiting time for patients on the transplant list 18 Five Year Cohort Study on Waiting Time Fig 19: Post-registration outcome for patients listed for transplantation in 25 19 Fig 2: Percentage of patients transplanted by ABO group 19 Fig 21: Percentage of patients transplanted by HLA antibody reaction frequency range 2 Fig 22: Percentage of patients transplanted by ethnic group 2 Fig 23: Waiting time to transplant by age 21 Fig 24: Access to transplant, 25/6 21/11 22 Source of transplant referrals by referral network sector & transplant list status 23 Fig 25: CMFT transplant list 21/11 by activation status 24 Fig 26: Activation status by referral network sector 24 Transplantation and transplant listing in a population context Fig 27: Transplant listing and deceased donor transplants per million population by area 25 Fig 28: Access to transplant for patients receiving dialysis across referral network sectors 26 Graft Survival Fig 29: 1 year graft survival by transplant type, 25-28 27 Fig 3: 5 year graft survival by transplant type, 22-24 27 Patient Survival Fig 31: 1 year patient survival by transplant type, 25-28 28 Fig 32: 5 year patient survival by transplant type, 22-24 28 Appendix: Referral Network Sectors 29 4
Abbreviations Abbreviation Full Explanation DBD Heartbeating Donor Referring to a donor with confirmed brain stem death. DCD Non Heartbeating Donor Referring to a donor with confirmed cardiac death DBD Kidney Donation after brain stem Kidney transplant from a donor with death kidney confirmed brain stem death DCD Kidney Donation after cardiac Kidney transplant from a donor with death kidney confirmed cardiac death Living Donor Living donor Kidney transplant from a living donor. Donation after brain stem Simultaneous pancreas and kidney DBD SPK death simultaneous transplant from a donor with pancreas & kidney confirmed brain stem death DCD SPK DBD PAK DCD PAK DBD PAT DCD PAT DBD SHK Islets Donation after cardiac death simultaneous pancreas & kidney Donation after brain stem death pancreas after kidney Donation after cardiac death pancreas after kidney Donation after brain stem death pancreas alone Donation after cardiac death pancreas alone Donation after brain stem death simultaneous heart & kidney Pancreatic islet transplantation Simultaneous pancreas and kidney transplant from a donor with confirmed cardiac death Pancreas transplant from a donor with confirmed brain stem death with the recipient having previously received a kidney transplant Pancreas transplant from a donor with confirmed cardiac death with the recipient having previously received a kidney transplant Pancreas alone transplant from a donor with confirmed brain stem death Pancreas Alone transplant from a donor with confirmed cardiac death Simultaneous heart and kidney transplant from a donor with confirmed brain stem death Transplantation of insulin-producing Islets of Langerhans extracted from deceased donor pancreata Definitions Adult recipient Paediatric recipient A person receiving a transplant who is aged 19 years or over on the date of transplant. A person receiving a transplant who is aged under 19 years on the date of transplant. 5
All Transplants, 21/11 Summary Table by Financial Year, 27/8 21/11 27/8 28/9 29/1 21/11 All transplants 159 [-19.7%] 178 [+ 11.9%] 21 [+18.%] 27 [-1.4%] Paediatric recipient 9 (5.7%) 17 (9.6%) 15 (7.1%) 18 (8.7%) transplants (>19 years) All kidney alone 123 (77.4%) 147 (82.6%) 182 (86.7%) 181 (87.4%) transplants Pancreas alone or 36 (22.6%) 31 (17.4%) 27 (12.9%) 25 (12.1%) pancreas and kidney transplants Islet cell transplantation 1 (.5%) 1 (.5%) All DBD transplants 74 (46.5%) 11 (56.7%) 86 (41.%) 19 (52.7%) All DCD transplants* 31 (19.5% 23 (12.9%) 53 (25.2%) 19 (9.2%) Living donor transplants 54 (33.9% 54 (3.3% 68 (32.4%) 73 (35.3%) - ABO compatible Living donor transplants ABO incompatible 2 (1.%) 5 (2.4%) *In 21/11 bilateral kidneys from a DCD donor were implanted in the same recipient. This is referred to throughout this report as a single transplant. Summary Table by Calendar Year, 27-21 27 28 29 21 All transplants 165 [-12.2%] 184 [+11.5%] 173 [-6.%] 212 [+22.5%] Paediatric recipient 12 (7.3%) 16 (8.7%) 13 (7.5%) 16 (7.5%) transplants (>19 years) All kidney alone 128 (77.6%) 151 (82.1%) 146 (84.4%) 191 (9.1%) transplants Pancreas alone or 37 (22.4%) 33 (17.9%) 27 (15.6%) 2 (9.4%) pancreas and kidney transplants Islet cell transplantation 1 (.4%) All DBD transplants 83 (5.3%) 15 (57.1%) 77 (44.5%) 1 (47.2%) All DCD transplants 29 (17.6%) 25 (13.6%) 38 (22.%) 33 (15.6%) Living donor transplants 53 (32.1%) 54 (29.3%) 56 (32.4%) 75 (35.4%) ABO compatible Living donor transplants ABO incompatible 2 (1.1%) 3 (1.4%) () indicates % of total [ ] indicates % change from previous year 6
All transplants by type All transplants 21/11 by quarter, by type 7 6 46 44 59 58 Number of transplants 5 4 3 2 1 April/May/June July/August/Sept Oct/Nov/Dec Jan/Feb/March Islets 1 DBD PAT 1 DCD PAK 1 DCD SPK 1 DCD Kidney 2 3 8 4 DBD PAK 2 1 DBD SPK 6 3 3 7 DBD kidney 23 17 22 24 Living donor 13 18 25 22 Fig 1: A summary of the year s activity by transplant type. Kidney and Pancreas Transplants 21/11 by Type DBD kidney 41.1% Living donor 37.3% DCD kidney 9.1% All Pancreas 13.3% DBD SPK 9.1% DCD SPK.5% DCD PAK.5% DBD PAK 1.4% DBD PAT.5% Islets.5% Living donor DBD kidney DCD kidney DBD PAK DBD SPK DCD SPK DCD PAK DBD PAT Islets Fig 2: Kidney and pancreas transplant activity 21/11 showing relative proportion of activity by transplant type. The magnified part of the pie chart details pancreas transplant activity. 7
Kidney alone transplants Adult recipient kidney alone transplants by type, 28/9-21/11 Number of transplants 18 13 167 163 16 14 12 1 8 6 4 2 28/9 29/1 21/11 DCD kidney 19 48 17 DBD kidney 7 61 8 Living donor 41 58 66 Financial Year Fig 3: A summary of adult kidney alone transplant activity over the last 3 financial years. Pancreas transplants Adult pancreas/kidney and pancreas alone transplants, 28/9-21/11 Number of Transplants 35 3 25 2 15 1 5 31 27 25 28/9 29/1 21/11 DCD PAT 1 DBD PAT 3 3 1 DCD PAK 1 1 DBD PAK 6 3 3 DCD SPK 3 1 1 DBD SPK 18 19 19 Fig 4: A summary of pancreas transplant activity over the last 3 financial years. It is of note that a national allocation scheme for pancreas from DBD and DCD was introduced in December 21. 8
Paediatric Transplants Paediatric transplants by type, 28/9-21/11 2 18 Number of transplants 16 14 12 1 8 6 4 4 13 3 12 6 13 DBD kidney Living donor 2 28/9 29/1 21/11 Financial Year Fig 5: Paediatric kidney transplants over the last 3 financial years by type, Paediatric Recipients - Referral Origin The majority of paediatric recipients are referred for transplant from Alder Hey and Royal Manchester Childrens Hospital. There are occasionally exceptions when young adult patients around the age of 18 are referred from adult services. 28/9 29/1 21/11 RMCH 8 (47%) 8 (53%) 14 (73.7%) Alder Hey 9 (53% 5 (33%) 4 (21%) Adult services - 1 (7%) 1 (5.3%) Out of region - 1 (7%) TOTAL 17 15 19 9
Adult Living Donor Transplantation Adult living donor transplants by quarter, 28/9-21/11 25 No. of transplants 2 15 1 5 Living donor 8/9 Living donor 9/1 Living donor 1/11 April/May/June July/August/Sept Oct/Nov/Dec Jan/Feb/March Living donor 8/9 15 1 9 7 Living donor 9/1 9 12 19 17 Living donor 1/11 11 15 23 17 Fig 6: Adult living donor transplantation in 21/11 by quarter. Donor Relation Living donor transplants 21/11 by donor relation Daughter 2.6% Husband 2.6% Wife 14.1% Sister 6.4% Brother 5.1% Son 2.6% Cousin 5.1% Related other 7.7% Unrelated other 2.6% Father 16.7% Friend 2.6% Partner 2.6% Mother 19.2% Altruistic 3.8% Pooled/paired 6.4% Fig 7: An illustration of relationship of living donors to recipients, 21/11. Equal numbers of males and females (39 of each) received living donor transplants; however 44 living donors were female and only 33 male. 1
Pre-emptive Transplantation The Renal Association recommends that pre-emptive transplantation should be the treatment of choice for all suitable patients whenever a living donor is available. The table below details pretransplant renal replacement therapy for all adult kidney alone recipients transplanted during 21/11 by referral network sector. Pre transplant RRT Referral Network Sector Haemodialysis Peritoneal Dialysis Pre emptive transplant Total GM East 34 15 16 (24.6%) 65 GM West 26 9 16 (31.4%) 51 Cumbria & Lancashire 23 6 1 (25.6%) 39 ECR 6 2 8 Total 89 32 42 (25.8%) 163 () Figures in brackets denote % of transplants performed pre-emptively Pre-transplant renal replacement therapy, adult kidney alone recipients transplanted 28/9-21/11 2 18 16 14 38 47 Number of patients 12 1 8 27 43 43 36 Pre emptive transplants Peritoneal dialysis Haemodialysis 6 4 2 61 86 1 28/9 29/1 21/11 Financial Year Fig 8: RRT type prior to transplant in adults. Pre-emptive transplants accounted for 26% of kidney alone transplants in 21/11. 11
Pre-emptive Transplantation Pre-transplant renal replacement therapy, paediatric kidney alone recipients transplanted 28/9-21/11 2 18 16 3 4 14 Number of patients 12 1 8 11 5 4 6 Pre emptive Peritoneal dialysis Haemodialysis 6 4 2 3 6 8 28/9 29/1 21/11 Financial Year Fig 9: RRT type prior to transplant in paediatric patients Deceased Donors 21/11 Adult deceased donor kidney transplants by donor age, 29/1 and 21/11 4 37 35 Number of transplants 3 25 2 15 1 5 9 6 8 7 9 8 2 26 25 25 21 3 4 29/1 21/11-18 19-3 31-4 41-5 51-6 61-7 7+ Donor age range Fig 1: This graph illustrates the age of kidney donors for transplants taking place during 29/1 and 21/11. The median donor age in 21/11 was 47.6, slightly younger than the median of 54 in 29/1. 12
Deceased Donors 21/11 Adult SPK and pancreas transplants by donor age, 29/1 and 21/11 12 1 1 Number of transplants 8 6 4 2 2 6 6 7 5 3 4 4 4 29/1 21/11-18 19-3 31-4 41-5 51-6 61-7 7+ Donor age range Fig 11: This graph illustrates the age of pancreas and kidney/pancreas donors during 29/1 and 21/11. The median donor age in 21/11 was 4.4, considerably older than the median of 31 in 29/1. DBD and DCD transplants by organ origin, 29/1 and 21/11 1 9 91 8 Number of transplants 7 6 5 4 3 2 22 17 47 14 67 29/1 21/11 1 3 5 Local DBD Local DCD Import DBD Import DCD Organ type and origin Fig 12: Donor organ origin by financial year. During 21/11 a considerably higher proportion of deceased donor organs were from DBD donors than the previous year, most of these imported from elsewhere in the UK. Relatively few DCD transplants were carried out in 21/11 in comparison to the previous year. 13
Cold Ischaemia Time Cold Ischaemia Time, Deceased Donor Kidney Transplants 25/6 to 21/11 by crossmatch method XM Test Virtual XM 38:24: 33:36: 27/8 28/9 29/1 21/11 28:48: 24:: CIT time 19:12: 14:24: 9:36: 4:48: :: 24/3/27 23/5/27 Median CIT = 18:46 22/7/27 2/9/27 19/11/27 18/1/28 18/3/28 Median CIT = 17:22 17/5/28 16/7/28 14/9/28 13/11/28 12/1/29 Median CIT = 15:43 Median CIT = 14:59 13/3/29 12/5/29 11/7/29 Date Median CIT = 15:37 9/9/29 8/11/29 7/1/21 8/3/21 7/5/21 Median CIT = 15:15 6/7/21 4/9/21 3/11/21 2/1/211 3/3/211 Fig 13: Cold ischaemia time for adult DBD and DCD kidney alone transplants, April 26 March 21. The median CIT time is shown for each financial year, as well as since the introduction of virtual crossmatching in December 28. The scatter plot shows a strong trend toward shorter CIT times with virtual crossmatching, with lower median CIT times since this method was introduced. Median CIT continues to decrease. CIT time and Virtual Crossmatching Virtual crossmatching was introduced for on 1/12/28. The purpose of this approach is to reduce the cold ischaemia time without compromising the safety of transplantation. A virtual crossmatch can be performed pre-transplant whereby the donor HLA type is reviewed against the patient s HLA antibody profile to determine whether the patient has donor-directed antibodies that would cause a positive crossmatch test result. Patients who have been rigorously assessed and defined as unsensitised can safely proceed to transplant before the crossmatch test result is available. This is intended to reduce the time spent awaiting a crossmatch result and in turn cold ischaemia time. 2/5/211 From April 211, cold ischaemia time will be a QIPP measure, with a target of 9% of deceased donor cold ischaemia times in a given month to be below 18 hours. This will decrease to 16 hours from September 211. 14
CMFT Kidney and Pancreas Transplant Waiting List Demographics and Summary Table Data is based on all patients on the CMFT kidney and pancreas transplant waiting list at the end of each financial year. 28/9 29/1 21/11 Patients on list at end of year 878 [+1.2%] 919 [+4.7%] 915 [-.4%] Male 54 (57.4%) 5 (54.4%) 59 (55.6%) Age Range (in years) 4-82 6-8 6-8 Time on transplant list range in months, active patients -295-37 -319 Median time on transplant list in months, active patients 2 19 2 Patients active 572 (65.1%) 63 (65.6%) 67 (66.3%) Patients suspended 36 (34.9%) 316 (34.4%) 39 (33.7%) Patients waiting for kidney alone transplant 783 [+9.4%] 815 [+4.1%] 82 [+.6%] Patients waiting for simultaneous pancreas and kidney transplant 79 [+19.7%] 89 [+12.7%] 85 [-4.5%] Patients waiting for simultaneous heart and kidney transplant 1 1 Patients waiting for pancreas alone transplant 16 [+6.7%] 14 [-12.5%] 9 [-35.7%] () indicates % of total [ ] indicates % change from previous year Paediatric patients on CMFT Kidney and Pancreas Transplant Waiting list. In April 211 there were 21 patients aged <19 on the transplant list awaiting kidney transplants. Further details of these patients can be found in the table below. Demographics 29/1 21/11 No. of paediatric patients waiting 19 21 Active on list 11 15 Suspended on list 8 6 Male 12 14 Female 7 7 Age range (years) 6.1-17.9 6.5-18.9 Time on list range (months) 2.3 34.1 1.7-31.1 Median time on list (months) 8.2 11.5 15
Pancreatic Islet Cell Waiting List The pancreatic islet transplantation programme began in 28, but it was not until February 21 that the unit s first transplant was performed. The table below details some key information about the programme. There has been a reduction in referral activity since the initial influx of patients at the start of the programme, and this is also reflected by the reduction in number of patients on the waiting list. 28/9 29/1 21/11 Number of patients on the waiting list 1 5 7 Number of patients active on the waiting list 1 2 2 Number of islet transplants 1 1 CMFT Kidney and Pancreas Transplant List by Organ Required CMFT Kidney and Pancreas Transplant List by Organ Required Kidney and Pancreas 9.5%(85) Pancreas alone.3% (3) Kidney 89.4% (799) Other 1.% Kidney and Heart.1% (1) Pancreas after kidney.7% (6) Fig 14: Organs required by adult patients listed on the CMFT kidney and pancreas transplant list. 16
CMFT Kidney & Pancreas Transplant list, April 21 by age CMFT Kidney and Pancreas Transplant list by age range, April 211 Number of patients 25 2 15 1 5 22 29 215 84 52 37 35 43 13 2 1 19-3 31-4 41-5 51-6 61-7 71-8 8+ Kidney alone Pancreas Age range Fig 15: This graph illustrates the age distribution among potential recipients listed for kidney and pancreas transplantation. The median age for adult kidney patients was 54.4 years and for pancreas patients 41.8 years. Time to enter CMFT Kidney and Pancreas Transplant Waiting list The time taken to complete the transplant listing process is audited on an annual basis. This time period is measured by calculating the number of days elapsed between the date of the referring Nephrologist s signature on each patient s Request to List Form, the date this form is received by the Transplantation Laboratory and the date they enter the transplant list. The graph below illustrates median listing times for patients from each referral centre over the last 3 years, including the time taken for the Transplantation Laboratory to process listings. Median time to enter transplant list in days by referral centre 21/11 9 8 7 Time to list in days 6 5 4 3 2 2 4 19 16 55 53 34 2 48 5 Laboratory to list Nephrologist to laboratory 1 GM East GM West Cumbria & Lancashire Referral centre 13 ECR All adult centres PAED 6 Fig 16: Median time to enter transplant list by referral centre. Median time for all adult centres was 7 days 17
Transplants by year versus transplant waiting list Transplants by year with waiting list totals, 21-211 Number of transplants/patients 1 9 878 919 915 8 797 7 72 722 68 639 6 587 513 541 5 556 523 555 48 572 63 591 4 44 414 3 2 133 134 159 148 157 198 159 178 21 27 1 21/2 22/3 23/4 24/5 25/6 26/7 27/8 Financial Year 28/9 29/1 21/11 Transplants Performed Patients on list at end of financial year Patients on active waiting list at end of year Fig 17: A graphical representation of the increase in patients awaiting deceased donor transplant relative to transplants carried out each year over the last 1 years. The number of patients on the waiting list has almost doubled over the last 1 years whereas the number of transplants carried out has not increased to mirror this. It can also be seen that the proportion of suspended patients on the transplant list has increased over the years by the widening gap between the total number of patients and active patients on the list. Waiting Time for patients on the transplant list Time waited by patients on the CMFT kidney and pancreas transplant list on 1st April 211 4.% 35.% 3.% % of patients 25.% 2.% 15.% 1.% 5.%.% -5 months 6-12 months 13-24 months 25-36 months 37-6 months 61-84 months Kidney alone 13.8% 15.9% 2.3% 17.5% 15.1% 9.6% 3.4% 2.5% 1.1%.6%.1% All pancreas 12.8% 19.1% 35.1% 19.1% 8.5% 3.2% 2.1%.%.%.%.% Time on list Fig 18: The median waiting time for kidney patients on the list is 23.4 months (slightly shorter than last year s median of 24.3 months), and for pancreas patients the median time on the list is 15.5 months (slightly longer than last year s median of 11.5 months). 85-12 months 121-18 months 181-24 months 18 241-3 months 3 + months
Five Year Cohort Study on Waiting Time In 21, waiting time to transplant was audited by studying a cohort of patients listed in the same calendar year. The 22 adult patients who were listed for kidney alone transplantation at CMFT in 25 were followed up 5 years later in September 21 and their outcomes assessed. The aim of this audit was to identify factors likely to affect waiting time, and also to provide both clinicians and patients with realistic expectations of waiting time. Post-registration outcome for 22 patients listed for kidney transplantation in 25 1% 9% 5.% 14.8% 11.9% 11.9% % of patients 8% 7% 6% 5% 4% 3% 77.2% 25.7% 52.% 43.6% 23.8% Transplanted (living donor) Transplanted (deceased donor) Still waiting Removed Died 2% 1% % 7.9% 2.5% 7.9% 12.9% 2.5%.5% 1 year 3 years 5 years+ Time since registration Fig 19: Outcome of patients listed for transplant in 25 at 1, 3 and 5 years following registration on the transplant list. In the following 3 figures, patients who were removed, deceased or transplanted with a living donor are excluded, focusing only on patients who were either transplanted or remained on the transplant list. Percentage of each ABO group transplanted by September 21 1% 9% 8% 29.8% 47.8% 36.9% 7% % of patients 6% 5% 4% 3% 7.2% 52.2% 63.1% Still waiting Transplanted 2% 1% % A B O ABO group Fig 2: Outcome of patients by ABO group 5 years after listing, 19
Five Year Cohort Study on Waiting Time Percentage of cohort transplanted by September 21 by HLA antibody reaction frequency range 1% 21.5% 8% % of cohort 6% 4% 84 1% 72.7% 92.3% Still waiting Transplanted 2% 27.2% % 7.7% -5% 6-49% 5-85% >85% Reaction frequency range Fig 21: This figure illustrates that most patients with higher levels of antibodies waited longer for a transplant than patients who were not sensitised % of cohort transplanted by September 21 according to ethnicity 1% 8% 32.4% 4.9% 5.% 66.7% % of ethnic group 6% 4% Still waiting Transplanted 2% 67.6% 59.1% 5.% 33.3% % European Caucasian Asian Black Oriental Ethnicity Fig 22: Whilst a large proportion of the European Caucasian patients within the cohort were transplanted within 5 years, smaller percentages of other ethnic groups received a transplant during this time. 2
Waiting Time to Transplant by Age In this instance the Kaplan-Meier curve is used to illustrate time to transplant rather than survival. All patients listed for first deceased donor kidney alone transplant during 25 and 26 were followed over a 5 year period and censored for death, permanent removal from the transplant list and living donor transplant, and the results presented by age group. The percentage of each group still waiting after 5 years is given for each age range. % of group still awaiting transplant Time to first deceased donor kidney transplant; patients listed 25-26 by age group 1 75 5 25 Access to transplant 25/6 21/11 Patient age group (% still waiting at 5 years) Age 75+ years (1%) Age 65-74.9 years (72.2%) Age 35-49.9 years (47.9%) Age 5-64.9 years (46.3%) Age 18-34.9 years (18.6%) Age <18 years (%) Time since transplant listing in years Fig 23: Time to first deceased donor kidney transplant, showing considerable variation by recipient age. Whilst all paediatric recipients had received a transplant after around 3 years, the majority of recipients aged over 65 were still waiting after 5 years. 21
Access to transplant 25/6 21/11 Scatter plot showing adult recipient DBD kidney transplants 25/6-21/11 with median times to transplant Time since entering transplant list in years 25 2 15 1 5 25/6 Median=1.14 26/7 Median = 4.95 27/8 Median = 3.33 28/9 Median = 2.67 29/1 Median = 3.71 21/11 Median = 3.21 Transplant no. 1 Transplant no. 2 Transplant no. 3 Transplant no. 4 1/4/25 29/8/25 26/1/26 25/6/26 22/11/26 21/4/27 18/9/27 15/2/28 14/7/28 11/12/28 1/5/29 7/1/29 6/3/21 3/8/21 31/12/21 3/5/211 Transplant date Fig 24: This scatter plot illustrates the effect on of the change to the NHSBT (then UK Transplant) allocation scheme in April 26 on waiting time to transplant, and the effects since that time up until the present. The new allocation scheme was intended to bring about fairer access to transplantation and reduce wide variability in waiting times by allocating organs on a national basis, prioritising rarer HLA types and patients who had waited a long time. Prior to the introduction of the new allocation scheme, between April 25 and March 26, it is clearly seen at the bottom of the plot that there appears to be a dense concentration of transplants taking place within a short time of entering the transplant list, with some isolated long waits. At that point median time to transplant was 1.14 years. During the year following introduction of the new allocation scheme, the median time to transplant increased to 4.95 years. On the plot the distribution of transplants is seen to be far more homogenous after April 6. Over the next 2 years the median time to transplant is seen to fall, which may be due to long waiting patients from before implementation of the new allocation scheme having received transplants. During 29/1 and 21/11 the median time to transplant is seen to rise slightly again, but this may be due in part to several patients who had been on the waiting list for many years before finally receiving transplants during this period. 22
Source of Transplant Referrals Patients are referred to the CMFT Renal Transplant Unit from 3 network sectors, each encompassing a group of hospitals in the North West region. The Unit also receives Extra Contractual Referrals (ECRs) from outside these referral sectors. Paediatric patients aged 18 or under are referred from Alder Hey or Central Manchester Children s Hospitals, with occasional exceptions in special cases. Full lists of hospitals covered by each network sector are given in the appendix. The tables below detail the referral network origin of patients receiving kidney alone deceased donor transplants during 21/11 and also those on the transplant list as of April 211 for purposes of comparison. The bottom rows of the table express the number of patients from each area transplanted during 21/11 as a percentage of the number listed from each area, and again as a percentage of the number active on the transplant list from each area. Referral Network Sector GM East GM West Cumbria and Lancashire ECR All Areas Adults transplanted* 21/11 (29/1) 43 (28) 37 (5) 25 (24) 5 (7) 11 (19) Adults transplanted as % of total, 21/11 39.1% 33.6% 22.7% 4.5% Adults listed, April 211 (% of total) 267 (33.5%) 286 (35.9%) 221 (27.7%) 23 (2.9%) 8 Adults transplanted 21/11 as percentage of 16.1% 12.9% 11.3% 21.7% 13.8% number listed Adults transplanted 21/11 as percentage of 23.1% 2.7% 16.3% 35.7% 2.7% number active Adults newly listed for transplant, 21/11 82 88 68 6 244 Adults permanently removed from the 27 3 17 3 77 transplant list, 21/11 Adult living donor transplants, 21/11 26 19 18 3 66 *Kidney alone deceased donor transplant recipients, unless otherwise stated Transplant list status At any one time a proportion of patients on a transplant list will be temporarily suspended. On the CMFT Kidney and Pancreas Transplant list as of 1 st April 211 this proportion was 33.5% for adults awaiting kidney alone transplantation, with 13% of all patients on the list having been suspended for over 12 months. In 29/1 these figures were 34.3% and 16.1% respectively. The proportion of suspended patients, although the differences are not great, did vary by referral network sector. GM East had the highest percentage of long term suspensions (17.5%) but the lowest percentage of short term suspensions (11.9%) and overall total suspensions (29.4%). GM West had the highest overall percentage of suspended patients with 39.4%. 23
Transplant list status Adult patients on CMFT Kidney and Pancreas Transplant list April 211 by transplant list status Long term suspended (over 12 months) 13% Short term suspended (under 12 months) 21% Active 66.5% Fig 25: An overview of the CMFT Renal and Pancreas Transplant list in April 211 by transplant list status. Transplant list status of adults awaiting deceased donor kidney transplantation, CMFT kidney & pancreas transplant list, April 211 35 3 25 38 46 Number of patients 2 15 43 64 16 52 Long term suspended Short term suspended Active 1 186 179 153 5 2 GM East GM West Cumbria & Lancashire ECR 14 7 Referral sector Fig 26: A breakdown of adults awaiting kidney only transplantation on 1st April 211 by status on list. 24
Transplants and listings by referral network sector in a population context The figures below detail the numbers of adults listed for kidney alone transplantation and those transplanted during 29/1 relative to each referral network sector s total population. There is considerable variation between the areas, with the highest proportion of people both listed and and transplanted in the GM West sector, and the lowest in Cumbria and Lancashire. These differences may be due to a number of factors; demographic differences, epidemiological factors and referral patterns for transplantation. Figures in brackets denote the previous year s figures. Estimated area population, 211* GM East GM West Referral Network Sector Cumbria & Lancashire Overall 1567156 12262 19957 478956 622 Patients active on transplant list per million 118.7 (112) 146. (181) 76.7 (59) 111.1 (119) 16.8 population, 21/11 Patients transplanted per million population, 21/11 24.1 (18) 26.9 (41) 1.5 (12) 2.3 (23) 23.2 *Sources: Strategic Framework for Kidney Care in Greater Manchester 28-213 Strategic Framework for Kidney Care in Cumbria and Lancashire 28-213 ONS 24 based population projections ONS mid-26 population estimates ONS mid-21 population estimates NHSBT Annual Activity Report 21/11 UK Transplant listings and deceased donor kidney transplants per million population by area, 21/11 16 146 14 Patients per million population 12 1 8 6 4 118.7 24.2 26.9 76.7 16.8 23.2 Patients active on transplant list per million population Patients transplanted per million population 2 1.5 GM East GM West Cumbria & Lancashire UK Referral network sector/area Fig 27: Adult kidney transplant listings and transplants undertaken relative to local population in three referral network sectors, showing UK figures for comparison 25
Access to transplant for patients on dialysis across referral network sectors These figures are a guide to the number of patients on the kidney transplant list and the number receiving deceased donor kidney alone transplants relative to the number of patients receiving dialysis (including both hospital and home haemodialysis and peritoneal dialysis) from each referral network sector, as of March 211. The numbers shown cannot translate directly to the numbers of patients on dialysis either being listed for transplant or receiving transplants as they do not account for pre-emptive transplants (transplants taking place before dialysis is commenced) or listing prior to dialysis being commenced. The variations seen, as before, may be due to epidemiological and demographic factors, and referral patterns for transplantation. Patients receiving dialysis as of March 211* Patients receiving dialysis per million population Patients active on kidney transplant list as % of those receiving dialysis by area Patients transplanted 21/11 as % of those receiving dialysis by area *Source: As previous table. GM East GM West Referral Network Sector Cumbria & Lancashire All Areas 574 474 678 1726 25796 366 387 34 36 416 32.4% 37.8% 22.6% 3.8% 25.7% 6.6% 7.% 3.1% 5.6% 5.6% UK Patients on dialysis, active on transplant list and transplanted by area, 21/11 8 7 678 6 574 Number of patients 5 4 3 474 Patients on dialysis Patients active on transplant list Patients transplanted 2 186 179 153 1 38 33 21 GM East GM West Cumbria & Lancashire Referral network sector Fig 28: Patients on dialysis by referral network sector 21/11, showing numbers awaiting deceased donor kidney alone transplant and numbers transplanted during this period. 26
Graft Survival The two graphs and table below illustrate graft survival for first deceased donor kidney alone transplants at CMFT, with patient survival given overleaf. Percentage survival for both CMFT and the UK by transplant type is given in the table at the bottom of the page. Graft survival is censored for death with functioning graft. 1 year graft survival, 1st adult kidney transplant recipients 25-28 by transplant type Cumulative Survival Living donor kidney (n=17) DBD kidney (n=234) DCD kidney (n=6) P =.7(NS) Time in years Fig 29: 1 year graft survival by transplant type. There is no significant difference between living donor, DBD and DCD graft survival 5 year graft survival, 1st adult kidney transplant recipients 22-24 by transplant type Cumulative Survival Living donor kidney (n=49) DBD kidney (n=221) DCD kidney (n=6) P =.22(NS) Time in years Fig 3: 5 year graft survival by transplant type. Similarly to the previous graph, there is no significant difference between transplant types. Transplant Type 1 year graft survival Recipients transplanted 25-28 5 year graft survival, Recipients transplanted 22-24 CMFT UK* CMFT UK* Living donor kidney 97% 96% 94% 9% DBD kidney 97% 93% 86% 83% DCD kidney 95% 93% 1% 85% * Source: NHSBT ODT Activity Report 29/1 27
Patient Survival 1 year patient survival, 1st deceased donor adult kidney transplant recipients 25-28 by type Cumulative Survival Appendix: Referral Network Sectors (Adults only) Living donor kidney, (n=127) DBD kidney (n=255) DCD kidney (n=64) P =.32(S) Time in years Fig 31: 1 year patient survival by transplant type. There is a significant difference in patient survival between transplant types for this period. 5 year patient survival, 1st deceased donor adult kidney transplant recipients 22-24 by type Cumulative Survival Living donor kidney, (n=49) DBD kidney (n=221) DCD kidney (n=6) P =.18(NS) Time in years Fig 32: 5 year patient survival by transplant type. There is no significant difference in patient survival between types for this period. Transplant Type 1 year patient survival Recipients transplanted 25-28 5 year patient survival, Recipients transplanted 22-24 CMFT UK* CMFT UK* Living donor kidney 1% 99% 98% 96% DBD kidney 95% 97% 91% 88% DCD kidney 94% 96% 83% 87% * Source: NHSBT ODT Activity Report 29/1 28
Appendix: Referral Network Sectors (Adults only) This is a division of patients by grouping of referring hospital and satellite units. Referral Network Main Hospital Satellite Hospitals GM East Sector Manchester Royal Infirmary North Manchester General Hospital Wythenshawe Hospital Tameside Hospital Macclesfield General Hospital GM West Sector Cumbria & Lancashire Hope Hospital Royal Preston Hospital Birch Hill Hospital Rochdale Infirmary Wigan Infirmary Royal Bolton Hospital Chorley and South Ribble Hospital Royal Blackburn Hospital Burnley General Hospital Westmorland General Hospital Blackpool Victoria Hospital Furness General Hospital Royal Lancaster Infirmary ECR - Extra Contractual Referrals All other hospitals/trusts outside these areas 29