Access to Renal Transplantation
Transcript of Access to Renal Transplantation
Access to renal transplantation
Chris Dudley
UKRR/UKT Joint analysis
Equity in renal transplantion
• Equitable organ allocation (UKT)
• Equitable access to the waiting list (unit level)
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5
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40
45
0 100 200 300 400 500 600 700
Number of patients on RRT
% o
f p
atie
nts
on
act
ive
list
(ris
k-ad
j fo
r p
atie
nt
& c
entr
e fa
cto
rs)
Renal unit
National proportion
95% confidence interval
99.8% confidence interval
771 711 741 731 705 743 734 712 765
1339 1393 1359 1313 1399 1388 1308 1326 1440
722
1472
6480
5020497049275074
463545464786
5425
5863
0
1000
2000
3000
4000
5000
6000
7000
1997-1998 1998-1999 1999-2000 2000-2001 2001-2002 2002-2003 2003-2004 2004-2005 2005-2006 2006-2007
Year
Num
ber
Donors
Transplants
Transplant list
Deceased donor kidney programme
Problems
• Point prevalence analysis– Short-term fluctuation – Enrichment with unsuitable patients
Renal Association Clinical Practice Guidelines – Transplant module
Guideline 1.4
There must be demonstrable equity of access to deceased donor kidney transplantation irrespective of gender, ethnicity or district of residence.
Renal Association Clinical Practice Guidelines – Transplant moduleAudit measures
– The time to placement on the UK Transplant national transplant list in relation to start date of dialysis
– A comparison between renal units of the proportion of dialysis patients placed on the national transplant list corrected for differences in identified unit and patient specific variables including co-morbidity.
Analysis
• Access to the waiting list– Prevalent patients– Incident patients
• Time to listing
Access to the waiting list
• Point prevalence analysisThe proportion of patients on dialysis who were also active on the waiting list on 31/12/06
• Incident patient analysisThe % of incident dialysis patients between 01/01/03 – 31/12/04 were subsequently activated on the WL within 2 years of commencing dialysis
• Only patients <65 years were considered for inclusion
Percentage of all dialysis patients by centre on the active transplant waiting list on 31/12/2006 for
patients aged under 65
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60
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Centre
Per
cent
age
of d
ialy
sis
patie
nts Upper 95% CI
% on active waiting listLower 95% CIN = 11,554
Point prevalence n = 11,554
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20
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55
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Number of patients in unit
Pe
rce
nta
ge
on
wa
itin
g li
st
% on WL LT65L99U99L95U95Mean
Percentage of incident patients aged <65 years active on the transplant waiting list
within 2 years of commencement of dialysis
Incident patient n = 4816
Funnel plot for percentage on waitlist (under 65s)
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Number of patients
% w
aitli
sted
% w aitlisted
Low er 99.9% CI
Upper 99.9% CI
Low er 95% CI
Upper 95% CI
Mean
Time to wait-listing
• Incident patients between 01/01/03 – 31/12/04 used as cohort for consideration and then followed up until 30/09/07
• Time taken to activate on WL = date of first activation – date of start of dialysis
• Patients achieving pre-emptive deceased or live donor transplantation were considered to have spent 0 days on the WL
Time to wait-listingn=4804
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250
500
750
1000
Shr
ewM
iddl
brE
dinb
Inve
rns
Glo
uclk
ings
Bris
tol
Dun
dee
Nor
wch
Bra
dfd
Yor
kD
orse
tR
edng
Not
tmP
orts
Man
Wst
Sw
anse
Car
dff
She
ffA
brdn
Oxf
ord
Der
byP
rest
ndg
all
Exe
ter
Cam
bG
lasg
wK
lmar
nkLe
icH
ull
Car
shIp
swi
Dud
ley
Dun
fnB
ango
rN
ewc
Brig
htn
lguy
sbh
eart
Leed
slb
arts
Tru
roliv
riC
ovnt
Sth
end
Sun
dC
arlis
bqeh
Wol
veP
lym
thW
irral
Bas
ldn
Clw
ydW
rexm
Ste
vng
Aird
rielw
est
Che
lms
OV
ER
ALL
Centre
Me
dia
n ti
me
to li
stin
g (
da
ys)
N = 4,804
Significant centre variation [P < 0.0001] persisted even after correcting for age, gender and PRD
Combined unit performance[Incident patients]
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80
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Median time to listing of activated patients
% l
iste
d
IDEAL SLOW
LOW LOW & SLOW
Conclusions
• Several units are significant outliers in % of both prevalent and incident patient wait-listed
• Several units are significant outliers in the time taken to activate patients on the waiting list
• Some units have both a low % of incident patients on the waiting list and take longer to work patients up for activation
• The reason for differences between units needs to be explored
Cautions
Need to correct for patient and centre specific factors
• Patient– Age– PRD– Graft number
• Centre– Size of renal unit– Size of LD programme– Listing practice of LD transplants