“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