BTS 2016: Controversies in UK organ transplantation: have we gone too far in terms of organ quantity at the expense of organ quality? Professor Derek Manas (Newcastle upon Tyne) and Lorna Marson (Edinburgh) discuss in this video the plenary on quantity vs quality.

Controversies in UK organ transplantation: have we gone too far in terms of organ quantity at the expense of organ quality?

John Forsythe, Edinburgh Royal Infirmary and Chris Callaghan, Guy’s Hospital, London.

Overview by Maria Dalby

Outcomes after organ transplantation remain favourable despite increasing use of marginal and DCD donors, and there are no signs that a threshold has been reached in terms of quantity over quality. Having said that, there is more that transplantation professionals could be doing to optimise the system of organ allocation and utilisation. This was the key message in the first plenary session of this year’s BTS congress, delivered by Professor John Forsythe from Edinburgh and Chris Callaghan, consultant transplant surgeon at Guy’s Hospital.

Professor Forsythe began by highlighting how the age profile of the UK donor population is evolving in a similar way to organ donors in Spain, where more than half of all organ donors are aged over 60 years, almost one in three donors is aged over 70 years, and 10% are aged over 80 years. Donor age is a significant risk factor for adverse outcomes and there is considerable variation amongst UK transplant centres when it comes to accepting organs from extended-criteria donors. This risk averseness is concerning in light of data from the NHSBT UK Transplant Registry which shows that organs from extended criteria donors do well across all UK centres,¹ especially as the alternative – remaining on dialysis – is associated with worse survival rates than for most cancers.²

Another important, and modifiable, risk factor for adverse survival outcomes is cold ischaemic time (CIT). Average CITs have dropped significantly in the last decade thanks to concerted efforts across centres, and the vast majority of UK centres are now performing the lion share of their adult DBD donor kidney transplants within 18 hours of CIT.¹ Reducing CIT further is vital to ensure that donated organs are utilised in the best possible way. Other areas that could be improved, in Professor Forsythe’s opinion, include optimising the Fast Track Kidney Scheme to prevent kidneys from being discarded unnecessarily, offering dual kidney transplantations and making better use of, for example, in-situ normothermic regional perfusion, and supporting transplant centres to prevent fatigue and ensure sustainability of service.

Echoing these points, Chris Callaghan warned that clinicians are increasingly finding themselves having to weigh the potential outcome for the individual patient against the impact on the waiting list when making allocation decisions. An ageing donor population and increasing use of marginal grafts, together with increasing media interest, for example in the wake of the tragic events in Cardiff in 2013, raise concerns that patients on the waiting list may perceive transplantation with an extended-criteria kidney as greater risk compared with remaining on the waiting list. Data from the NHSBT UK Transplant Registry shows that on the contrary, accepting an extended-criteria kidney carries a significantly lower risk of death in all patient subgroups compared with remaining on the waiting list and holding out for a standard-criteria donor (hazard ratio 0.5; 95% CI 0.3-0.6).³ A similar hazard ratio has been shown for accepting a DCD liver compared with waiting for waiting for a DBD liver. A two-stage assessment of 31 discarded kidneys at Guy’s Hospital in April 2015 showed that whilst most of the decisions to discard the organs were reasonable, as many as 10 usable kidneys may have been discarded. Concluding, Mr Callaghan joined Professor Forsythe in calling for more efficient organ allocation and offering procedures, and better use of technology to improve organ utilisation and support clinicians in making difficult decisions.

References

1. NHSBT. ANNUAL REPORT ON KIDNEY TRANSPLANTATION.  2015.
2. Scottish Renal Registry Report 2010.
3. Bradbury L, Pankhurst L. EXTENDED CRITERIA DONORS: POTENTIAL FOR TRANSPLANTATION AND EFFECT ON OUTCOMES. Transplant International 2015;28:46.