Advancing Organ Donation: can we really make it happen? · • Donation rates should be monitored....

Advancing Organ Donation: can we really make it happen?

Current Strategy and thoughts out of the box……

Mr Chris Rudge FRCSNational Clinical Director for Transplantation

Agenda

• Current Strategy• Is it working?• What more do we know?• How can we improve it?• What else could we do?

Agenda

• Current Strategy• Is it working?• What more do we know?• How can we improve it?• What else could we do?

• Legal and ethical issues• Clarified roles

– Acute hospital Trusts– Departments of Health/NHS

• Review of co-ordination & retrieval• Training• Public promotion

Target – 50% increase in donation over 5 years

Organs for TransplantsJanuary 2008

14 Recommendations

A UK Model for Donation

NHS Blood & Transplant

Department of Health

Acute Hospital Trusts

More donors

National ODOEffective co-ordination and retrieval Education, training and auditPublic engagement

FundingResolution of ethical and legal issuesPerformance Management TrainingPublic recognition

Clinical leadsEmbedded co-ordinatorsDonation committees

A UK Model for Donation

NHS Blood & Transplant

Department of Health

Acute Hospital Trusts

More donors

National ODOEffective co-ordination and retrieval Education, training and auditPublic engagement

FundingResolution of ethical and legal issuesPerformance Management TrainingPublic recognition

Clinical leadsEmbedded co-ordinatorsDonation committees

Review of Donor Transplant Coordination

Recommendation• The current network of Donor Transplant

Co-ordinators should be expanded and strengthened through central employment by a UK-wide Organ Donation Organisation

Well underway: 189/246 DTCs & 13/29 team managers now recruited; all new teams now established

Ethical, Legal and Professional Issues

Recommendation• Urgent attention is required to resolve

outstanding legal, ethical and professional issues to ensure that clinicians are able to work within a clear and unambiguous framework of good practice

• Additionally, an independent UK-wide Donation Ethics Group should be established

Ethical issues: Donation Ethics Committee established, first meeting held Feb 2010

Legal matters: Guidance published

• Guidance published in England and Wales (November 2009) and Scotland (May 2010)

Legal guidance

Donation Champions

Recommendation• Each Trust should have an

identified clinical donation champion and a Trust donation committee to help achieve this

Well underway. 185/191 Clinical Leads appointed. 155/177 Donation Committees in place

Donation CommitteeLocal governance

Recommendation• Donation rates should be monitored.

Rates of potential donor identification, referral, family approach and consent should be reported.

• The Trust Donation Committee should report to the Trust Board and the reports should be part of the assessment of Trusts through the relevant healthcare regulator

Underway. Donation Activity supplied to all Trusts from August 2009

Summary 1

• Good progress with the “infrastructure”– Coordinators– Clinical Leads– Donation Committees

• Good progress with legal and ethical support– Legal Guidance– Donation Ethics Committees

• Progress with everything else– Training– Public awareness (>17m on ODR)– Research

Agenda

• Current Strategy• Is it working?• What more do we know?• How can we improve it?• What else could we do?

Trends in donation and transplantation

773 745 777 770 751 764 793 809 899 959

2311 2247 2388 2396 2241 21962385 2381

2552 2645

78777655

7219

5673565456045532

6142

6698

7997

0

1000

2000

3000

4000

5000

6000

7000

8000

2000-2001 2001-2002 2002-2003 2003-2004 2004-2005 2005-2006 2006-2007 2007-2008 2008-2009 2009-2010Year

Num

ber

DonorsTransplantsTransplant list

Trends in donation and transplantation

773 745 777 770 751 764 793 809 899 959

2311 2247 2388 2396 2241 21962385 2381

2552 2645

78777655

7219

5673565456045532

6142

6698

7997

0

1000

2000

3000

4000

5000

6000

7000

8000

2000-2001 2001-2002 2002-2003 2003-2004 2004-2005 2005-2006 2006-2007 2007-2008 2008-2009 2009-2010Year

Num

ber

DonorsTransplantsTransplant list

0

100

200

300

400

500

600

700

800

900

1000

2000 -2001

2001 -2002

2002 -2003

2003 -2004

2004 -2005

2005 -2006

2006 -2007

2007 -2008

2008 -2009

2009 -2010*

Year

Num

ber

Deceased Donors

736 703 716 697 664 637 634 609 611 623

3742 61 73 87 128 159 200

288336

0

100

200

300

400

500

600

700

800

900

1000

2000 -2001

2001 -2002

2002 -2003

2003 -2004

2004 -2005

2005 -2006

2006 -2007

2007 -2008

2008 -2009

2009-2010

Year

Num

ber

DBD DCD

Deceased Donors

Agenda

• Current Strategy• Is it working?• What more do we know?• How can we improve it?• What else could we do?

The falling potential for DBD

0200400600800

1000120014001600

2004/5 2005/6 2006/7 2007/8 2008/9 2009/10

BSD Patients DBD donors

Predicted “steady-state” DBD donors

500550600650700750800850900950

1000

2004/5 2005/6 2006/7 2007/8 2008/9 2009/10

Predicted

Potential for DBD donation -Trends in key rates

7275

60

46

7578

61

48

8083

61

49

76

85

62

50

78

88

63

51

75

89

61

49

0

10

20

30

40

50

60

70

80

90

100

BSD testing rate Referral rate Family consent /authorisation rate

Conversion rate(potential to actual)

Perc

enta

ge (%

)

2004-2005 2005-2006 2006-20072007-2008 2008-2009 2009-2010 (Apr - Sep)

30

40

50

60

70

80

90

2007/2008 2008/2009 2009/2010 (Apr - Sep)

Year

Per

cent

age

(%)

East of England

DBD conversion rate by English SHA

0

10

20

30

40

2007/2008 2008/2009 2009/2010 (Apr - Sep)

Year

Per

cent

age

(%)

North East

DCD conversion rate by English SHA

What more do we know?Summary

• There are:– Fewer patients with BSD likely– Fewer patients with BSD diagnosis– Fewer possible DBD donors– Static number of actual DBD donors– Large variations across the UK in both DBD

and DCD performance

Agenda

• Current Strategy• Is it working?• What more do we know?• How can we improve it?• What else could we do?

How can we improve it?

• More DBD donors– Admit more patients to ICU– Diagnose BSD in emergency medicine– Understand the variation across the UK

How can we improve it?

• More DCD donors– Understand the variation across the UK

• Consensus Report in preparation– Donation from emergency medicine

• Consensus Meeting held on 4th October

How can we improve it?

• More organs– Better donor management for DBD donors– Perfusion systems

• Hypothermic perfusion• Normothermic perfusion• “re-conditioning”

– Ex vivo lung perfusion

ExEx‐‐vivo lung perfusion (EVLP) vivo lung perfusion (EVLP) –– the Newcastle the Newcastle experienceexperience

Program started in 2008Program started in 2008

PrePre‐‐clinical phase of program included 5 lungsclinical phase of program included 5 lungs

Clinical phase of the program so far 11 lungsClinical phase of the program so far 11 lungs

4 lung transplants performed from donor lungs 4 lung transplants performed from donor lungs originally clinically rejected for transplantation originally clinically rejected for transplantation 

Institute of Institute of Cellular MedicineCellular Medicine

Cardiopulmonary Transplantation Unit

Freeman HospitalNewcastle Upon Tyne

ExEx‐‐vivo lung perfusion modelvivo lung perfusion model

Improvement of lung graft during EVLPImprovement of lung graft during EVLP

1 hour post perfusion1 hour post perfusion 6 hours post perfusion6 hours post perfusion

Clinical Transplant from EVLPClinical Transplant from EVLP

Marginal OrgansMarginal Organs

EVLP September 2010EVLP September 2010Lund 7 PatientsLund 7 Patients

All Early SurvivorsAll Early Survivors

Toronto 27 Toronto 27 

25 Survivors (NB 17 DCD)25 Survivors (NB 17 DCD)

EuropeEurope

Madrid 6 Madrid 6 –– all Cat 2 DCD all Cat 2 DCD 

Vienna 6Vienna 6

UK 12 PatientsUK 12 Patients

2 Manchester2 Manchester

6 6 HarefieldHarefield

4 Newcastle4 Newcastle

Agenda

• Current Strategy• Is it working?• What more do we know?• How can we improve it?• What else could we do?

What else could we do?

• Move potential donors to a dedicated donation “facility”

What else could we do?

• Move potential donors to a dedicated donation “facility”

• Move a donation “facility” to the donor

What else could we do?

• Move potential donors to a dedicated donation “facility”

• Move a donation “facility” to the donor• Limit transplants to people who are

registered on the ODR

What else could we do?

• Move potential donors to a dedicated donation “facility”

• Move a donation “facility” to the donor• Limit transplants to people who are

registered on the ODR• Lower our expectations

What else could we do?

• Move potential donors to a dedicated donation “facility”

• Move a donation “facility” to the donor• Limit transplants to people who are

registered on the ODR• Lower our expectations

– Accept a lower transplant success rate– Measure outcomes from the time of listing, as well as

from transplantation

What else could we do?

• Move potential donors to a dedicated donation “facility”

• Move a donation “facility” to the donor• Limit transplants to people who are

registered on the ODR• Lower our expectations• Put ICU doctors in charge of donation