“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
1
significantly ↑ versus dialysis
Survival of transplant recipients is significantly
↑
2
versus wait-listed candidates on dialysis
The longer a patient is on dialysis prior to
3
transplant, the poorer the transplant outcome
1Evans
RW, et al. New Engl J Med 1985;312:553–9;
RA, et al. N Engl J Med 1999;341:1725–30;
3Meier-Kriesche HU, et al. Kidney Int 2000;58:1311–17
2Wolfe
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.
• 95% at 5yrs.
(DD 96%)
(DD 86%)
• Graft survival after LD transplantation
• 95% at 1 yr.
• 88% at 5yrs.
(DD 92%)
(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
Functional status
Potential Pre-Emptive Transplant Advantages
•
•
•
•
Work status
Family role
Mental health
Self care
Transplant
Dialysis initiation
Disease course
Valleys represent decreases in: Functional status, Selfesteem, Employability, Insurability, Quality of life
Hayes R, in Abecassis M, et al.
Clin J Am Soc Nephrol 2008;3:471–80
Potential Pre-Emptive Transplant Advantages
Functional status
Pre-emptive
transplant
•
•
•
•
Work status
Family role
Mental health
Self care
Transplant
Dialysis initiation
Disease course
Hayes R, in Abecassis M, et al.
Clin J Am Soc Nephrol 2008;3:471–80
Treatment Cycle
Dialysis
3
Transplantation
2
Dialysis
1
Transplantation
6
Transplantation
4
Patient
Dialysis
5
The Circuit Breaker
Pre-emptive
LD
Transplantation
1
Patient
Dialysis ?
2
Cost Comparison: 12 Months of HD before
Transplant versus Pre-Emptive Kidney Transplant
CKD
End stage renal disease
CKD
15,000
End stage renal disease
15,000
Kidney
transplant
Kidney
transplant
10,000
Cost ($)
Cost ($)
10,000
5,000
5,000
HD
Transplant
maintenance
Transplant maintenance
0
0
–6
0
6
12
18
24
30
36
42
Months before and after first service date
48
–6
0
6
12
18
24
30
36
42
48
Months before and after first service date
34% reduction in costs at 2 years
HD = haemodialysis;
CKD = chronic kidney disease
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)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
– Friend
i.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 Scotland
1Human Organ Transplant Act 1989
2Human Tissue Act 2004
Figure 3.8: RRT modality at day 90 in incident patients in 2007
Cycling PD < 6
nights/wk
0.5%
Unknown PD
0.3%
Transplant
5.5%
Home HD
0.2%
Cycling PD ≥ 6
nights/wk
6.8%
Hospital HD
50.3%
CAPD
disconnect
14.6%
CAPD connect
0.5%
Unknown HD
2.0%
Satellite HD
19.3%
UK Renal Registry 11th Annual Report 2008
5. We Need to Think Differently?
How?
Pre-emptive Living Donor Transplants (% total)*
% Pre-emptive LDTx.
60
50
40
Guy's
UK
30
20
10
0
2001
2002
2003
*Data courtesy of UK Transplant
2004
2005
2006
2007
Historical Approach
eGFR≈20
Pre-dialysis assessment
Access
Haemodialysis
Peritoneal dialysis
Transplant listing
Deceased donor
? Living donor
eGFR = estimated glomerular filtration rate (mL/min/1.73m2)
New Approach
eGFR≈20
Living donor
assessment
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