What can we do to address the drop in living kidney transplants in the UK?

Kirit Modi, Life Vice President, National Kidney Federation (NKF)

This article is a summary of a presentation to the All Party Parliamentary Kidney Group in the House of Commons on 7 December 2016.

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Agi and Kirit at the House of Commons

There are two ways in which kidneys can be donated; one is donation after death and the other is a live donation. Live kidney donations can be made by close family (including partners), friends as well as by strangers. There is a wellestablished rigorous process to go through before anyone can make a live kidney donation and not everyone wishing to make such a donation is able to do so. The selling of organs is, of course, both illegal and immoral.

The number of living transplants, mostly kidneys, following a live donation, has gone down for two consecutive years in the UK. The actual figures published by NHS Blood and Transplant (NHSBT) are worrying. The number of these transplants in 2015/16 was 1075 compared to the target of 1223; i.e. a shortfall of 148 transplants which means there was a gap of 12%. In addition it is highly unlikely that we will reach the 2020 target of 1608 living transplants which is an increase of 49% (523 transplants) on the current figure.

This has happened in the context of the national strategy (Living Donor Kidney Transplantation 2020) published by the four UK governments and NHSBT since 2014. NHSBT and the four governments have time and opportunity to address this now so that we do not fail to meet the 2020 target. The impact of this downward trend on the lives of patients waiting for a kidney transplant is very significant.

Living kidney transplants make a significant contribution to the overall number of kidney transplants. 2015/16 figures show that nearly a third of the adult kidney transplants were living transplants and around two thirds are transplants resulting from a donation after death. This means we need to make progress on both live donations as well as donations after death to reduce the time kidney patients have to wait for a transplant.

The reasons for the number of live kidney donations going down are complex and there will be a variety of views on this from different perspectives. I have highlighted some reasons below and am requesting the APPKG for its help in addressing them.

Firstly, the overall responsibility to ensure that the targets set in the LDTS 2020 strategy rests with the Implementation Oversight Group which has representation from all four UK governments, NHSBT and others.

The APPKG is requested to write to the Chair of the Implementation Oversight Group to explain the reasons for the drop in the number of live kidney donations over the last two years and to outline what steps it is taking to ensure that the targets set for 2020 in the Strategy are met.

Secondly, there is significant variation in the number of living transplants taking place in the transplant centres across the UK. While some variation is inevitable and can be explained, there seems to be unexplained variation. One measure is the proportion of living kidney transplants compared to all kidney transplants (both living and after death). The highest proportion of adult living transplants in 2015/16 took place at Belfast (57%), Coventry (53%) and Newcastle (41%) while the lowest proportions were at Nottingham (20%) and North West London (21%). Each transplant centre covers a region and potential live donors are first seen by all hospitals with a renal unit. NHSBT has recently started work to address these variations including publication of centre- specific information, regional learning events and peer review with specific indicators linked to living transplants. This is a welcome development. However, it is important to publish the outcome from these developments as well as its impact on reducing variations as soon as possible so that good practice can be established throughout the country.

The APPKG is requested to write to the Chief Executive of NHSBT to report fully on the outcome and the impact of the actions being taken to reduce variations in living transplants among centres by March 2017.

Thirdly, key staff responsible for living transplants in hospital are the Organ Transplant Coordinators (OTCs) who are employed by the hospital trusts with renal units. This means that responsibility for living transplants largely rests at a local level. This has resulted in the number of OTCs employed by some hospitals being less than the number indicated by using the workforce calculator produced by NHSBT. In addition, the training available to OTCs is not coordinated at a national level. There is a strong case for NHSBT directly employing all OTCs. This already takes place for donations after death whereby Specialist Nurses for Organ Donation are directly employed by NHSBT.

The APPKG is requested to write to the Chief Executives of NHS England and NHSBT to review the current arrangements for employing OTCs to improve staffing levels and training arrangements.

Finally, the commissioning of living donor kidney transplantation is currently being reviewed with a view to introducing new arrangements from April 2017. There is a unique opportunity now to use this review to introduce commissioning arrangements to set benchmarks to promote good practice and allocate funding when centres reach these benchmarks.

The APPKG is requested to write to the Chief Executive of NHS England asking him to provide details of how the new commissioning arrangements will help address the drop in living transplants and ensure that the target set in the Living Donor Kidney Transplantation Strategy 2020 is met.

Conclusion

We are currently not in a good position in relation to live donor transplants in the UK. There is time and opportunity to change this and take action so that the targets set for 2020 are met. Clearly this needs a strong commitment to take action by those responsible for the implementation of the Strategy. The APPKG is in a unique position to make a significant contribution and I very much hope that they will support the requests outlined in this article.