“Yes Minister, we can deliver cheaper kidney care” Lisa Burnapp Lead Nurse-Living Donation, NHS Blood & Transplant Consultant Nurse-Living Donor Kidney Transplantation, Guy’s & St. Thomas NHS Foundation Trust

Face the facts

We Know That…………………………. Quality of life of transplant recipients is significantly ↑ versus dialysis 1 Survival of transplant recipients is significantly ↑ versus wait-listed candidates on dialysis 2 The longer a patient is on dialysis prior to transplant, the poorer the transplant outcome 3 1 Evans RW, et al. New Engl J Med 1985;312:553–9; 2 Wolfe RA, et al. N Engl J Med 1999;341:1725–30; 3 Meier-Kriesche HU, et al. Kidney Int 2000;58:1311–17

We Know That…………………………… Transplantation facilitates Growth and development in children Return to the workforce Having a family Cost-effective for healthcare system

We Know That ………………………………… Survival Benefit of Kidney Transplantation Applies Across age groups Across disease groups Across racial groups Across countries Long-term dialysis patients Obese patients

We Know That…………………………… We have more Patients Choice & capability Expectation Complexity Ethnically diverse

1. Transplantation is Cheaper Than Dialysis Why?

1.Costs: Transplantation v Dialysis Transplantation Work-up & surgery – £ 21, st year post Tx – £ 19,000 Subsequent year – £ 2,400 Living Donor Work-up & nephrectomy – £5,500 Total (2yrs.) £ 48,650 Dialysis (per pt./p.a) Peritoneal Dx (APD) – £ 35,000 Centre/satellite HDx – £ 31,000 Peritoneal Dx (CAPD) – £ 27,350 Home HDx (excludes set up costs) – £20, 000

Our Responsibility To optimise Patient outcome Transplant outcome Planning Opportunity & choice Use of kidneys Donor safety & well-being The health economy

2. Living Donation is More Cost Effective than Deceased Donation Why?

Outcomes are Excellent Patient survival after LD transplantation 99% at 1 yr. (DD 96%) 95% at 5yrs. (DD 86%) Graft survival after LD transplantation 95% at 1 yr. (DD 92%) 88% at 5yrs. (DD 81%) *Data courtesy of NHSBT

3. Pre-emptive Living Donation is the Most Cost Effective Option Why?

Benefits of a Pre-Emptive Transplant Improved opportunity & choice Improved patient and graft survival Reduced dialysis-related morbidity Preservation of musculoskeletal integrity Reduced CV risk factors Preservation of employment and insurance Reduced cost

Hayes R, in Abecassis M, et al. Clin J Am Soc Nephrol 2008;3:471–80 Potential Pre-Emptive Transplant Advantages Valleys represent decreases in: Functional status, Self- esteem, Employability, Insurability, Quality of life Functional status Dialysis initiation Transplant Disease course Work status Family role Mental health Self care

Functional status Dialysis initiation Transplant Pre-emptive transplant Potential Pre-Emptive Transplant Advantages Disease course Work status Family role Mental health Self care Hayes R, in Abecassis M, et al. Clin J Am Soc Nephrol 2008;3:471–80

Treatment Cycle Patient

The Circuit Breaker Patient

Cost Comparison: 12 Months of HD before Transplant versus Pre-Emptive Kidney Transplant 34% reduction in costs at 2 years HD = haemodialysis; CKD = chronic kidney disease End stage renal diseaseCKD 15,000 10,000 5,000 0 – HD Kidney transplant Transplant maintenance 15,000 10,000 5,000 0 – Kidney transplant Transplant maintenance Months before and after first service date Cost ($) End stage renal diseaseCKD Cost ($) Schweitzer EJ, in Abecassis M, et al. Clin J Am Soc Nephrol 2008;3:471–80

Pre-emptive LD Transplant

4. Nationally, There are Inconsistencies in LD Activity Why?

Barriers Logistics Organisational – Infrastructure – Processes/pathways Clinical Philosophical ??

National Initiatives 2000 & 2005 – UK Guidelines for Living Kidney Donation (BTS/Renal Association) – 2005 – Renal National Service Framework 2006 – Human Tissue Act 2008 – 18 week commissioning pathway for living donor transplantation 2 1 United Kingdom Guidelines for Living Donor Kidney Transplantation Second Edition April

Donor Pool Previous legal framework 1 – Adult siblings – Parent to child – Adult child to parent – Grandparent – Extended family – Spouse/partner – Friend i.e. proven genetic/emotional relationship Current legal framework 2 – All of the above – ‘Children’ and adults lacking capacity* Plus – Paired/pooled donors – Altruistic/non-directed donors *Except Scotland 1 Human Organ Transplant Act Human Tissue Act 2004

UK Renal Registry 11 th Annual Report 2008

5. We Need to Think Differently? How?

Pre-emptive Living Donor Transplants (% total)* *Data courtesy of UK Transplant

Historical Approach eGFR = estimated glomerular filtration rate (mL/min/1.73m 2 )

New Approach eGFR≈20 Living donor assessment Living donor transplant Vascular access Peritoneal dialysisHaemodialysis Deceased donor listing eGFR = estimated glomerular filtration rate (mL/min/1.73m 2 )

Acknowledgements: Contributors to slide set GSTT Dr. John Scoble NHSBT Rachel Johnson