“Yes Minister, we can deliver cheaper kidney care”
Lisa Burnapp
Lead Nurse-Living Donation, NHS Blood & TransplantConsultant 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 outcome3
1Evans RW, et al. New Engl J Med 1985;312:553–9;2Wolfe RA, et al. N Engl J Med 1999;341:1725–30;
3Meier-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, 750
• 1st 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 TransplantImproved 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
Func
tiona
l sta
tus
Dialysis initiationTransplant
Disease course
•Work status•Family role•Mental health•Self care
Func
tiona
l sta
tus
Dialysis initiationTransplant
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 diseaseCKD15,000
10,000
5,000
0 –6 0 6 12 18 24 30 36 42 48
HD
Kidneytransplant
Transplantmaintenance
15,000
10,000
5,000
0 –6 0 6 12 18 24 30 36 42 48
Kidneytransplant
Transplant maintenance
Months before and after first service date 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 TransplantPre-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)1
2004–2005– Renal National Service Framework
2006– Human Tissue Act
2008– 18 week commissioning pathway for living donor transplantation2
1 United Kingdom Guidelines for Living Donor Kidney Transplantation Second Edition April 2005 www.bts.org.uk
2www.18weeks.nhs.uk
Donor Pool
Previous legal framework1
– Adult siblings– Parent to child– Adult child to parent– Grandparent– Extended family– Spouse/partner– Friendi.e. proven genetic/emotional
relationship
Current legal framework2
– All of the above– ‘Children’ and adults lacking
capacity*
Plus – Paired/pooled donors– Altruistic/non-directed donors
*Except Scotland1Human Organ Transplant Act 1989
2Human Tissue Act 2004
UK Renal Registry 11th Annual Report 2008
Figure 3.8: RRT modality at day 90 in incident patients in 2007
Home HD0.2%
Satellite HD19.3%
Hospital HD50.3%
Cycling PD ≥ 6 nights/wk6.8%
Unknown PD0.3%
CAPD connect0.5%
Unknown HD2.0%
CAPD disconnect14.6%
Transplant5.5%
Cycling PD < 6 nights/wk0.5%
5. We Need to Think Differently?
How?
Pre-emptive Living Donor Transplants (% total)*
0
10
20
30
40
50
60
2001 2002 2003 2004 2005 2006 2007
% P
re-e
mpt
ive
LDTx
.
Guy'sUK
*Data courtesy of UK Transplant
Historical ApproacheGFR≈20
Pre-dialysis assessment
Access
Haemodialysis Peritoneal dialysis
Transplant listing
Deceased donor ? Living donor
eGFR = estimated glomerular filtration rate (mL/min/1.73m2)
New ApproacheGFR≈20
Living donorassessment
Living donor transplant
Vascular access
Peritoneal dialysis Haemodialysis Deceased donor listing
eGFR = estimated glomerular filtration rate (mL/min/1.73m2)
Acknowledgements: Contributors to slide set
GSTT• Dr. John Scoble
NHSBT• Rachel Johnson