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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