Q: I am worried about the possible closure of selected UK transplant centres so that we have only a limited number of specialised centres, and the impact this will have on travelling times for living donors and all recipients. Do you think that this may end up having a negative effect on transplantation in general? My Transplant centre is Newcastle, which covers an area from the west coast of Cumbria across to the east coast and down as far as Hull. If this plan is put into action, which centres are being considered for specialised status and how will this impact upon my local Transplant centre's patients?
A: Thank you for your question. First of all, let me reassure you; I am not aware of any plans to close any UK transplant centres. The number of kidney transplants being carried out is increasing.
Data from NHS Blood and Transplant show that the annual number of kidney transplants undertaken in England grew by 25% between 2007 and 2010. We want to increase the number of kidney transplants taking place even more, so there should be no reason for any transplant centres to close. The only reason why a transplant centre might conceivably close would be if there were safety concerns – not an issue I am aware of at any of our current centres.
We have a UK Donation Taskforce plan which aims to increase kidney transplants from deceased donors by 50% over five years. That means increasing the number of people receiving a deceased donor kidney from 1450 in 2007/8 to over 2150 by 2012/13. Although it is a complex and serious operation, wherever possible a kidney transplant is the best treatment for someone with kidney failure. Quite simply it means freedom from dialysis and all the health and lifestyle limitations that dialysis entails. While we all work very hard to reduce the risks of infection for dialysis patients, it is still an unavoidable risk. A replacement kidney is a better, safer, more cost effective way for the NHS to treat people with renal failure.
Transplant rejection, greatly feared in the past, is still an issue but modern drugs have reduced the risk considerably. Patients still have to take drugs throughout their lives, but this is a much better prospect than lifetime dialysis. However, as many of us are all too aware, still too few transplants are happening.
The main challenge is that there are far more people waiting for a kidney transplant than there are donor organs available. The shortage of organs for transplantation is not unique to this country but we lag behind some other countries in the number of citizens donating organs and tissue. The problem is exacerbated because the numbers on the waiting list far exceed those being operated on each year, so every year we need to catch up with ourselves, before we can even begin to make inroads into reducing the waiting list. Black and minority ethnic groups are in double jeopardy because they have more need of organs but a reduced pool of donors.
We have a taskforce in place across the NHS to try to make donation the norm rather than the exception. We are working to make sure that all NHS staff are aware of the urgent importance of transplantation and to encourage donors to be identified. Virtually every acute hospital trust in the NHS now has a donation committee, reporting directly to the board on the hospital’s donor rates. They are responsible for closing the significant and unacceptable gap between the numbers of potential organs that could be donated each day in our hospitals with the number that actually are.
I am very aware that this is a difficult area, summarised very well in the previous Chief Medical Officer, Sir Liam Donaldson’s 2006 annual report in the chapter titled ‘The Waiting Game’. It is a highly emotive issue, combining matters of life and death with the law at what is an emotional time for the families of potential donors. So it is understandable why healthcare professionals have sometimes been reluctant to raise the subject of transplantation. However, with surveys showing that while 70% of people want to donate their organs after death only 27% are on the NHS organ donor register, healthcare staff have a responsibility to explore this possibility. For example, on intensive care units, every legitimate opportunity should be taken to retrieve organs from heart-beating donors, after brain stem death has been confirmed.
We are also doing more to promote the organ donor register. A further million people signed up during 2009/10 taking the total to nearly 17.5 million who have pledged to help others after their death. However, this is still nowhere near enough. Estimates suggest that the number on the register would need to double if we are to find organs for all those who need them. It is important that people on the organ donor register make sure that their relatives know their wishes so they can be put into effect swiftly if the need arises.
Of course, unlike other kinds of transplant, kidney transplants can also come from living donors. Living donors now make up around one third of all kidney transplants. This requires greater surgical expertise and co-ordination, with two “patients” involved rather than one, but now that all transplant centres offer this possibility we will see the numbers of transplants continue to increase. The paired donation scheme is now also up and running whereby a potential live donor for a recipient, let’s say their spouse in Newcastle, can if the match is not good enough donate to another kidney patient at the other end of the country in a similar position, in return for their live donor giving a kidney to the Newcastle patient. We are also seeing transplant centres becoming more sophisticated in other ways. For example, every centre is now offering minimally-invasive laparoscopic surgery (also known as keyhole surgery) for live kidney donation operations. Recovery times with this kind of advanced surgery are much quicker, with a lower risk of complications or infections, and patients are back on their feet much sooner. Some units are now also carrying out highly specialised blood group or ABO incompatible transplants. Previously, transplant recipients could only receive organs from a donor with the same blood type as them. This has made it harder to find suitable donors for some patients, particularly those with less common blood types. However, new techniques are making these transplants possible by suppressing aspects of the recipient’s immune system through drugs and treatments that reduce the risk of the donor organ being rejected. Similar techniques can be used for highly sensitised patients. All these new treatment options mean that patients are able to exercise far greater choice about treatment and care. For me this is crucial. For NHS patients there should be ‘no decision about me without me’ and it is vital that the NHS gives patients as much say and control about their treatment and care as possible. For kidney patients, this means that they should be offered choice about how they want to manage their kidney disease at every stage. Patients have a right to choose to be transplant listed as when they are within 6 months of needing dialysis, ideally so that they can have a transplant before they start dialysis if they wish. There is still far too much variation across the country in how long it takes people to exercise their choice to go for transplantation and then to be added to the transplant list.
The latest published data we have, albeit from 2005 shows that on average it was taking 2 years from starting dialysis to be transplant listed – I am expecting to see considerable improvement as this is an unacceptable delay. A change to the NHS 'payment by results' funding system to support more multiprofessional clinics for preparation is helping to ensure that patients get to exercise this choice sooner by introducing financial incentives for kidney units to ensure that patients get transplant listed at the right time for them. This is, I have to say, almost always earlier than currently happens. Patients can also help the NHS up its game here by asking to have these discussions as early as possible.
Therefore, going back to your original question, I see absolutely no reason why any transplant units should close unless there were any concerns about safety. Transplantation, where possible, is the best treatment for renal failure. With all the work going on to increase transplant rates, it is estimated that - if we do as well as we can - by 2018 we can expect to have turned around the steady rise in the number of people on dialysis because more people will have had transplants. As medical science continues to develop, there will be even more options for transplant than there are now. Currently, US surgeon Anthony Atala is experimenting with a ‘3D printer’ that uses living cells to create a transplantable kidney (see Print a Kidney if you don’t believe me!). Printable kidneys may be a long way off, but as we look forward, we can be certain that if we keep up the focus on transplantation and patient choice we will see more and more people receiving life-saving and life-changing kidney transplants and a continuing need for our vital network of transplant centres.
Published in Kidney Life, Spring 2011