INCOMPATIBLE LIVING DONOR KIDNEY TRANSPLANTATION
What Choices?
Lisa BurnappConsultant Nurse
Directorate of Nephrology, Transplantation and Urology Guy’s and St Thomas’ NHS Foundation Trust
London, [email protected]
Our Responsibility
To optimise• Patient outcome• Transplant outcome• Planning• Opportunity & choice• Use of kidneys• Donor safety & well-being• The health economy
The Challenge
More
• Patients
• Choice & capability
• Expectation
• Complex
• Ethnically diverse
New Trends in Living Donor Transplantation
Extended Criteria (High-Risk) Recipients
‘Recipients at a significantly higher risk ofdeath, complications or graft failure becauseof pre-existing co-morbidity orimmunological status’1
High-risk includes– Immunological/ABO incompatibility– The elderly– Significant co-morbidity– Primary disease 1 Guidelines for Living Donor Kidney Transplantation in High-
Risk Adult Recipients, 2008 www.bts.org.uk
High-Risk Recipients: Our Approach
• Living donation treatment of choice• All patients provided with information early • Evidence and/or lack of evidence shared with
recipient and donor• Risk benefit analysis discussed• Tailored management plan agreed • Peer support
Who Makes the Choice?
• Patient & family?– What is best for them
• Healthcare professionals?– Most clinically effective– Outcome reporting– What is feasible/available– Local logistics/infrastructure– Financial constraints
• Primary care Trusts/Commissioners?– Health economics– National Guidance (NICE)
Incompatible Living Kidney Donation
Tailored Option Appraisal
• Do nothing– Acceptable if recipient & donor informed of possible options
• Paired/pooled donation
• Antibody removal strategies (ABO/HLA)
• Offer neither– Lack of equity
Paired/Pooled Donation
• Compatible living donor transplant• Clinically more straightforward• Logistically challenging • Uncertainty about timing & ‘matchability’• Donors & recipients unknown to one another
– indirect donation
Antibody Removal Strategies (ABO/HLA)
• More complex scenarios• ^ intervention (recipient)• ^ immunosuppression• Higher risk of failure
– spectrum of risk
• Time specific• Donor known to recipient
– direct donation
Summary
• Evolving field• Clinically challenging• Physically & psychologically demanding for
patients & their families• Compatible transplantation always the
preferred option• Outcomes encouraging
Thank you