Update on organ donation in British Columbia Jagbir Gill MD MPH FRCPC Associate Professor of Medicine, UBC Vice President, CORR Board 2017 BC Kidney Days October 5, 2017 Canadian Institute for Health Information September 25, 2017 cihi.ca @cihi_icis
Overview Why is this important? Trends in organ donation in British Columbia, Canada, and elsewhere Barriers to donation (living and deceased) Mechanisms to expand deceased and living kidney donation
Why is this important? Canadian Institute for Health Information cihi.ca @cihi_icis
Transplantation is the best treatment for our patients
High demand for transplantation USRDS 2016 ADR
Number of Wait-Listed Transplant Candidates by Organ Type, 2007 2016, Canada (preliminary) 4000 3500 3000 2500 2000 1500 1000 500 0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Kidney Kidney-Pancreas Liver Heart Lung Note: Excludes Quebec because of under-reporting between 2011 and 2016 Source: Canadian Organ Replacement Register, 2017, CIHI 6
Number of Kidney Transplant Candidates and Death Rates on the Waiting List, 2007 2016 (preliminary) 3,000 50% 45% 2,500 40% 2,000 35% 30% 1,500 25% 20% 1,000 15% 500 10% 5% 0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Kidney 2,159 2,026 1,981 2,399 2,431 2,505 2,629 2,665 2,766 2,840 Deaths 2% 2% 2% 3% 2% 2% 3% 2% 2% 3% 0% Note: Excludes Quebec because of under-reporting between 2011 and 2016 Source: Canadian Organ Replacement Register, 2017, CIHI 7
Duration of Dialysis prior to first kidney transplant, Adults (18+) by Blood type, 2014 to 2016 (preliminary) Type A Type AB Type B Type O Total Duration on Dialysis (Median Days), Deceased Donor Duration on Dialysis (Median Days), Deceased Donor, No Pre- Emptive Duration on Dialysis (Median Days), Living Donor Duration on Dialysis (Median Days), Living Donor, No Pre- Emptive Note: Excludes Quebec because of under-reporting between 2011 and 2016 Source: Canadian Organ Replacement Register, 2017, CIHI 1,093 842 1,943 1,739 1,448 1,112 961 1,967 1,744 1,468 269 380 341 297 300 525 548 642 553 551 8
Number of Liver Transplant Candidates and Death Rates on the Waiting List, 2007 2016, Canada (preliminary) 600 500 400 300 200 100 30.0 25.0 20.0 15.0 10.0 5.0 0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Liver 512 464 431 397 402 374 395 399 382 329 Death Rate 12.7 16.6 17.6 14.9 19.2 11.5 20.0 26.1 15.4 23.7 0.0 Note: Excludes Quebec because of under-reporting between 2011 and 2016 Source: Canadian Organ Replacement Register, 2017, CIHI
Deceased Donation Canadian Institute for Health Information cihi.ca @cihi_icis
Number of Canadian Organ Donors by Donor Source, 2007 2016, Canada (preliminary) 800 700 600 500 400 300 200 100 0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Living 554 546 516 557 521 538 585 553 563 544 Deceased 485 481 487 466 515 541 553 591 649 758 Source: Canadian Organ Replacement Register, 2017, CIHI 11
Deceased Donor Rate (PMP) by Year, 2007 2016, Canada (preliminary) 25.0 20.0 Rate per million population 15.0 10.0 14.7 14.5 14.5 13.7 15.0 15.6 15.7 16.6 18.1 21.1 5.0 0.0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Source: Canadian Organ Replacement Register, 2017, CIHI 12
Deceased Donor Rate (PMP) by country Source: Organ Donation and Transplantation Services Report, CBS 2016 13
Deceased Donor Rate (PMP) by Region, 2007 2016, Canada (preliminary) Rate per million population 30.0 25.0 20.0 15.0 10.0 5.0 0.0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 BC/YK 8.8 12.3 7.2 10.9 12.3 15.3 14.5 14.8 20.1 20.5 AB/NT/NU 13.5 11.3 10.5 8.7 10.2 9.9 11.8 13.7 12.5 16.5 MB/SK 13.2 12.2 12.0 14.5 9.6 7.7 7.2 6.2 10.7 11.9 ON 15.5 13.7 16.8 15.2 16.5 18.8 16.6 19.3 19.4 25.5 QC 18.2 19.5 17.6 15.0 17.1 14.8 20.2 18.7 20.8 20.6 Atl. 13.8 13.7 14.1 13.6 17.7 17.7 13.1 13.5 15.2 16.9 Source: Canadian Organ Replacement Register, 2017, CIHI 14
Deceased organ donation rates in BC Source: 2016 BCT Kidney Annual Report (Preliminary) 15
Why has deceased donation increased so much in BC? Investment in identification and referral of potential deceased donors Increased Donation after Circulatory Death Increased acceptance of higher risk donors Higher infectious risk Older donors 16
Key events/initiatives that have impacted deceased donation Engagement of critical care community In-house deceased donor coordinators Expansion of DCD 17
Donation after circulatory death Now makes up over 20% of all deceased donors 18
Proportion of DCD among all deceased donors, 2007-2016, Canada 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 NDD 471 446 444 423 446 456 486 473 514 585 DCD 22 40 43 45 67 86 66 125 138 173 Source: Canadian Organ Replacement Register, 2017, CIHI. 19
DCD in British Columbia Source: 2016 BCT Kidney Annual Report (Preliminary) 20
Donation after circulatory death outcomes - takes longer to start working - do well in the long run Summers et al. KI 2015
Increased acceptance of older aged donors
Proportion of deceased donors, by age, 2007-2016, Canada 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 1 2 3 4 5 6 7 8 9 10 60+ 55-59 50-54 40-49 18-39 0-17 Note: Excludes Quebec because of under-reporting between 2011 and 2016 Source: Canadian Organ Replacement Register, 2017, CIHI 23
Deceased donors, by age, BC Source: 2016 BCT Kidney Annual Report (Preliminary) 24
Should we use organs from older donors? HOW WELL DO THEY WORK? WHO SHOULD WE ALLOCATE THEM TO? 25
Outcomes by donor age Source: 2016 BCT Kidney Annual Report (Preliminary) 26
Proportion of patients that are alive (adjusted) USRDS ADR 2016 27
Longevity matching = matching the life expectancy of the kidney and the patient Efficiency Equity Utility
If we never longevity match Efficiency Equity Utility Ex. 19 yo donor kidney to: a 70 yo recipient
If we always longevity match Efficiency Equity Utility 19 yo donor kidney to: a 23 yo recipient
Age-matching in BC YOUNG DONORS <35 YRS YOUNG RECIPIENTS <55 YRS ECD/OLD DONORS >60YRS OLD RECIPIENTS >60YRS MIDDLE AGED DONORS 36-59 YRS ALL AGES
Survival benefit of transplantation in elderly patients WL patients aged >65 Gill JS, Shaeffner E, Chadbad S, Dong J, Rose C, Johnson O, Gill J. AJT 2012
~1500 kidneys per year in the US are discarded due to concerns of poor quality Many of these could have been used Could translate into ~7500 years of kidney life
Organ recovery Ex vivo lung Perfusion
High infectious risk donors
Risk per 10,000 donors of an HIV infection occurring during the window period, by ELISA and NAT Risk Category Men who have sex with men ELISA Per 10,000 5.8 (5.2-6.6) Intravenous drug use 6.6 (6.1-7.2) Commercial sex worker 3.7 (3.0-4.8) Sex with a partner in above categories 0.7 (0.5-0.9) NAT Per 10,000 2.4 (2.1-2.7) 2.7 (2.5-3.0) 1.5 (1.2-2.0) 0.3 (0.2-0.4) Risk of window period infection expressed as ratio 1: 4167 1:3704 1:6667 1:33,333 HIV Exposed through blood 1.5 (0.8-2.4) Incarcerated 1.0 (0.8-1.2) 0.6 (0.4-1.0) 0.4 (0.3-0.5) 1:16,667 1: 25,000 Courtesy A. Humar CST/CNTRP Consensus guideline; Transplantation 2014
Risk per 10,000 donors of an HCV infection occurring during the window period, by ELISA and NAT Risk Category ELISA Per 10,000 Men who have sex with men 14.3 (10.7-17.3) Intravenous drug use 377.4 (346.0-412.1) Commercial sex 270.8 worker (242.6-298.9) Sex with a partner in 168.3 above categories (157.7-191.4) Exposed through 13.9 blood (2.9-44.6) Incarcerated 107.8 Courtesy A. Humar (102.4- NAT Per 10,000 1.5 (1.1-1.8) 40.8 (37.4-44.6) 29.1 (26.1-32.2) 18.0 (16.9-20.5) 1.4 (0.3-4.3) 11.5 (10.9-12.5) Risk of window period infection expressed as ratio 1: 6667 1:245 1:344 1:556 1:7143 1: 870
HOWEVER HCV NOW VERY TREATABLE Risk Category Men who have sex with men Intravenous drug use Commercial sex worker Sex with a partner in above categories Risk of window period infection expressed as ratio Chance of cure with DAA Chance of chronic HCV infection 1: 6667 95 1: 133,340 1:245 95 1: 4,900 1:344 95 1: 6,800 1:556 95 1: 11,120 Exposed through 1:7143 95 1: 142,860 blood Courtesy Incarcerated A. Humar 1: 870 95 1: 17,400
Deceased Donation Summay More than a 3 fold increase in deceased donation in BC Increased DCD, utilization of older donors and higher infectious risk donors have been part of this Investment in ID and offering organ donation has been key
Living Donation Canadian Institute for Health Information cihi.ca @cihi_icis
Donor Rate (PMP) by Donor Source (Deceased vs. Living), 2007 2016, Canada (preliminary) 22.0 Rate per million population 20.0 18.0 16.0 14.0 12.0 10.0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Deceased Donor 14.7 14.5 14.5 13.7 15.0 15.6 15.7 16.6 18.1 21.1 Living Donor 16.8 16.4 15.3 16.4 15.2 15.5 16.6 15.6 15.7 15.2 Source: Canadian Organ Replacement Register, 2017, CIHI 48
Living Donor Rate (PMP), by country Source: Organ Donation and Transplantation Services Report, CBS 2016 49
Living Donor Rate (PMP) by Region, 2007 2016, Canada (preliminary) 30.0 25.0 Rate per million population 20.0 15.0 10.0 5.0 0.0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 BC/YT 25.9 18.5 20.5 23.1 23.2 19.7 28.1 22.9 23.7 20.1 AB/NT/NU 20.8 17.3 14.2 21.7 17.5 20.1 20.7 16.6 18.6 20.3 MB/SK 13.2 15.8 9.8 10.1 9.6 13.3 11.8 13.7 7.4 13.6 ON 20.7 21.3 21.2 20.1 19.1 19.0 19.0 20.3 20.3 18.6 QC 6.0 7.0 5.2 6.9 6.0 6.6 6.4 5.7 6.7 6.8 Atl. 12.5 16.7 14.1 12.3 11.0 12.6 13.9 8.4 8.0 7.6 Source: Canadian Organ Replacement Register, 2017, CIHI 50
Living donation in British Columbia Source: 2016 BCT Kidney Annual Report (Preliminary) 51
US has seen a significant decline in living donation Rodrigue et al. Trans 2013 52
Living donor transplantation is the best option Source: 2016 BCT Kidney Annual Report (Preliminary) 53
What is limiting living donation in BC? MEDICAL >25% of wait-listed patients are highly sensitized Kidney Paired Donation 77.3% of transplant candidates 63.4% of potential living donors WILLING to enroll in KPD as a compatible pair 55
What is limiting living donation in BC? MEDICAL FINANCIAL ~$5000 costs associated with living kidney donation Gill et al. JASN 2014 56
What is limiting living donation in BC? MEDICAL FINANCIAL GEOGRAPHICAL 57
What is limiting living donation in BC? MEDICAL FINANCIAL GEOGRAPHICAL CULTURAL Source: 2016 BCT Kidney Annual Report (Preliminary) 58
What is limiting living donation in BC? MEDICAL FINANCIAL GEOGRAPHICAL CULTURAL NOT BEING ASKED (OR NOT IN THE OPTIMAL WAY) <25% of ESRD patients in BC are willing to discuss donation with family and friends Lack of knowledge and not knowing where to start is a major barrier for ESRD patients Gill et al. CST 2016 Gill et al. CST 2016 59
Can patients get a living donor transplant sooner? Source: 2016 BCT Kidney Annual Report (Preliminary) 60
Transplant First Initiative New clinical pathway which integrate a transplantation first philosophy including the following key initiatives Early confirmation of transplant eligibility Dedicated appointment to review transplantation and living donor potential Direct assistance in identification and approach of potential living donors using various tools developed by BC Transplant Mandatory longitudinal documentation on living donor potential and progress through LDKT workup Early expedited referral and review for transplantation 61
Summary The demand for transplantation remains high Deceased donation has increased > 3 fold in BC in the last 8 years Living donation has stagnated and is starting to decline Increased support of ESRD patients and developing novel strategies to expand living donation needs to be a key priority in BC to ensure the best care for our patients 62