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Histocompatibility & Immunogenetics (H&I) Support for Transplantation in Scotland
Dr David Turner, Consultant Clinical Scientist, Scottish National Blood Transfusion Service Dr Ann-Margaret Little, Consultant Clinical Scientist, NHS Greater Glasgow & Clyde
Glasgow H&I: Fully staffed.
Edinburgh H&I: Fully staffed.
On call rotas
The one in four Consultant/Principal Clinical Scientist rota supporting deceased donor kidney, SPK, islet and cardiac transplantation in Scotland continues to work well. We will be back to a 1:4 over the next months following a return from maternity leave.
Quality in Organ Donation (QuOD) project
UK wide study, ongoing. Samples are processed by H&I staff in H&I Edinburgh. Agreement now reached between University of Oxford and Lothian Health Board to allow funding to be made available. Mechanism for payment to Edinburgh H&I for QuOD work has now been established.
Donor HLA typing
Since April 2022 this service is commissioned and funded by NHSBT in England. In devolved areas of the UK, H&I and microbiology labs are not funded centrally from NHSBT, but are obliged to sign a contract to agree to KPIs.
For the third quarter 2022-23 the H&I labs had a rate of 100% (Edinburgh) and 100% (Glasgow) for HLA types being reported within 4 hours of sample receipt (target = 90%). This has been reported to NHSBT.
Donor Characterisation Review
NHSBT hoping to introduce electronic reporting of deceased donor HLA typing and microbiology/virology results to ODT to avoid transcription errors. Go live date for HLA typing data is hoped to be in 2023-24. The NHSBT contract for providing deceased donor typing is still with Contracts departments within SNBTS and GGC for sign off.
New electronic system for managing patient information for the NKSS is now live. Will be used by H&I labs for data reporting for the April 23 run.
HNA antibody testing
HNA antibodies have been implicated in small numbers of kidney transplant AMR when HLA-DSA are absent. Two cases have been identified in the last few years in Edinburgh, and one in Glasgow. The two H&I labs are discussing the most appropriate mechanism for introducing screening for HNA antibodies into routine practice. A manuscript is being submitted to describe these cases.
HLAi transplants facilitated by Imlifidase
UK guidelines for the use of imlifidase to facilitate renal transplant for highly HLA sensitised patients with long waiting time have now been published. Imlifidase breaks down IgG antibodies and therefore reduces HLA specific antibodies that prevent transplant in sensitised patients. Patients will be at increased risk of antibody mediated rejection and extra H&I testing will be necessary pre, peri and post-transplant. Discussions on implementation in Scotland are ongoing between Lothian and GGC.
Tissue Donation Update
Dr Sharon Zahra, Clinical Lead and Mr Neil Healy, Lead Nurse - Tissues and Cells, SNBTS
The tissue donor referral rate remains lower than the pre-pandemic levels, however with the relaxation of the COVID-19 pandemic regulations the Tissue Donor Co-ordinators are now able to attend donating hospitals on a regular basis, providing teaching and training on tissue donation and helping raise awareness.
During the 3 months since the last report (Nov 2022 - Jan 2023) there were 75 referrals for consideration of multi-tissue donation, up 6 compared to the previous quarter; and a further 22 referred for eye-only donation, 2 more than the previous quarter.
Of the 75 referrals (Nov 2022 – Jan 2023), 50 donors were deferred, most due to medical unsuitability for multi-tissue donation, some due to family decline, family being unavailable or no available bloods.
Of the 75 referrals there were 13 occasions where relatives declined or were unavailable to discuss or authorise donation:
- 6 family declines to hospital staff
- 2 known unwillingness to donate
- 5 family unavailable/ uncontactable
Tissue Donation Rates
In this quarter (Nov 2022 – Jan 2023) 14 deceased donors donated multi-tissue. Eight of these 14 donors donated tissue after organ donation, while the remaining 6 donors donated tissue-only. These 14 donors donated 15 heart tissue products and 22 tendons.
In this quarter (Nov 2022 – Jan 2023) there were also 18 eyes retrieved by SNBTS from 9 eye donors. There is currently ongoing work in collaboration with NHSBT to identify ways of increasing the eye- donation rate in Scotland.
Pancreatic Islet Programme
The SNBTS Islet Isolation lab continues to provide an excellent life-saving service. In the first 10 months of this financial year (April 2022 to January 2023), 16 suitable pancreata were sent to TCAT, leading to a successful islet cell product in 10 cases (63%), and 8 of these were transplanted (50%). This success rate remains one of the best in the world.
Live Bone Donation
Live bone donation remains problematic and we have initial indications of clinical usage outstripping donation rate – SNBTS is working in collaboration with different hospitals to re-instate bone donation in hospitals who suspended donation during the COVID-19 pandemic.
In the first 10 months of the current financial year (April 2022 to January 2023) 456 femoral heads have been donated and 430 have been used clinically.
Anticipated Changes to Donor Assessments
The SaBTO recommendations re FAIR III are continuing to be progressed with draft changes being prepared and discussed for the JPAC guidelines. This work is currently ongoing.
Anthony Clarkson, Director of Organ and Tissue Donation and Transplantation, NHSBT
Dr Jo Farrar has been appointed as the new Chief Executive of NHS Blood and Transplant. Dr Farrar is an experienced senior leader having held Chief Executive roles at HM Prison & Probation Service and Bridgend and Bath and North Somerset Councils before being appointed the Second Permanent Secretary at the Ministry of Justice from where she will join NHSBT. Prior to Dr Farrar joining on 01 June NHSBT will continue to be led by Wendy Clark as Interim CEO.
NHS Industrial Action. The Royal College of Nursing undertook a first phase of strike action in December in England, Wales and Northern Ireland. Members in England then took strike action again in January and February. RCN Scotland have issued a statement indicating that ongoing negotiations with the Scottish government have meant that strike action in Scotland has not yet been called. UNISON Scotland has also recommended to members that they accept an offer of at least 6.5% increase on pay as well as a 1.5% one-off payment. Currently plans for UNISON members, including NHSBT members, to strike on 08 March in England are still in place.
In the first 3 quarters of 22/23 there has been a total of 78 deceased organ donors from Hospitals/Boards in Scotland, 43 DBD donors and 35 DCD. In the same period there were 69 Living donors. The number of patients currently active on the Transplant Waiting List in Scotland stands at 529, up from the 508 active at the end of 21/22. The breakdown of deceased organ donor transplants is as follows: 108, 14 kidney/pancreas, 6 Islets, 33 Hearts, 5 Lungs, 58 Livers, and 2 Intestinal.
On 04 March 2021 there were 2,914,130 people residing in the Scotland postcode area on the UK Organ Donor Register. This is 53% of the Scottish population.
175.081 citizens in Scotland have a recorded Opt-Out decision, this is 3% of the Scottish population.
The 2023 Joint Annual Congress of the British Transplantation Society and NHS Blood and Transplant will be taking place from 01 to 03 March at EICC, Edinburgh. The theme for Congress is ‘Time to Connect’ This will be the first face to face BTS/NHSBT Congress since 2019 and will bring Donation and Transplantation professionals from across the UK to Edinburgh to share clinical, scientific and pastoral expertise, sharing best practice and inspiring colleagues. A report on Congress will follow in the next SDTG report.
On a corporate level, NHSBT has just been announced as one of the UK’s top 100 LGBTQ+ employers as part of Stonewall’s Workplace Equality Index. Our organisation has also received the Gold Award, Stonewall’s top rating for those employers who maintain the highest standard of LGBTQ+ inclusivity at work. NHSBT has been recognised as being the 12th most inclusive employer in the UK health sector.
Human Tissue Authority
Jessica Porter, Head of Regulation, Human Tissue Authority (HTA)
BTS Congress 2023 - Edinburgh
The HTA held a stand at the BTS Congress in Edinburgh recently.
Thanks to those that came and spoke to us in person.
Jess Porter, Head of Regulation, spoke to Jen Lumsdaine and Julie Glen re issues with lack of Independent Assessors in Scotland. Jen and Jess agreed to work together to see what could be done to tackle this. More information below.
Upcoming Independent Assessor (IA) Training
The HTA will be holding an IA Training day in April/May.
The training will be held face to face in London to ensure applicants get the most out of the training by providing the opportunity to put the learning into practice by participating in practical activities.
Jess Porter is exploring whether it would be possible to arrange a training session face to face in Scotland. This would be with the intention of increasing the number of Independent Assessors accredited for Scotland, which was a concern raised at the last SDTG meeting.
Between December 2022 and the end of February 2023, we have assessed 25 living organ donation cases where the transplant was due to take place in Scotland.
Seven of these cases were for donors and recipients taking part in the National Kidney Sharing Scheme.
We continue to see increasingly complex cases, particularly those involving overseas donors. We encourage all transplant units to contact the HTA early in the process for advice and guidance on all cases involving an overseas donor: firstname.lastname@example.org
Living Donation Update
Jen Lumsdaine, Living Donor Co-ordinator, NHS Lothian
Education and Publicity
Bauer radio platform featured living kidney donation in January, on radio stations across Scotland. This, along with the campaign in December has resulted in wide multi-media coverage of selected living donation stories – including 29 print and online stories in national and local newspapers; Twitter (24 posts) and Facebook 10 posts with a combined following of 312k.
The REACH Transplant initiative was presented at The British Transplantation Society meeting in Edinburgh early March, with a poster presentation of the healthcheck questionnaire return data.
The information booklet for REACH Transplant produced locally during the pilot is currently being updated.
All REACH Transplant nurses have been appointed in all healthboards with 9 out of 10 in post. The remaining nurse will be in post by end of March 23. The induction programme is underway and evaluation tools developed.
The consultant nephrology input is complete and the transplant co-ordinator/specialist nurse information complete by end March 23.
Number of healthcheck questionnaire returns to all units
Data collection for healthcheck questionnaire returns including all units (altruistic and direct) by month.
Kidney transplants Scotland 2016-2023
Scotland Organ Donation Update
Submitted by Regional Manager Susan Hannah NHSBT
Donation Performance April 2022– January 2023
From April 2022 – January 2023 the 10 months validated potential donor audit (PDA) data taken from the donating hospitals has highlighted organ donation improvement in Scotland.
The referral rate to the organ donation service has consistently remained high between 97% – 100% and this is higher than UK average of 94%. The number of potential donor families approached for organ donation was 156 with 105 authorised (willing to donate) with a 67% combined authorisation rate and is 9% less than target of 76% with UK average of 61%.
The donation after brain-stem death (DBD) authorisation rate in Scotland remains one of the highest of all teams in the UK with 83% and UK average is 68%. However, the donation after circulatory death (DCD) authorisation rate is one of the lower teams with 57% and is the UK average.
The combined authorisation rate of DBD and DCD remains low with 67% and similar UK wide with 62%. A widening gap is noted between DBD and DCD authorisation rates with organ donor register (ODR) Opt In difference of 12% (DBD 92% and DCD 80%) and Deemed 34% difference (DBD 92% and DCD 58%). Most common reasons cited for DCD family declines is ‘wanting immediate withdrawal of treatment’ and ‘their loved one did not want to be a donor’.
The highest trend of proceeding donor numbers was in the months of July, August, and December (graph below) this correlates with improved eligibility of potential organ donors currently at 33%. Whilst continued recovery with organ donor numbers UK wide this has not returned to pre pandemic numbers.
The Specialist Nurse (SN) and Specialist Requestor (SR) combined presence when approaching potential organ donor families is 89% and whilst continued improvement for Scotland, it remains lower in comparison to UK average of 92%.
The number of ODR Opt In overrides is 12 which is 5 more than last year, and Deemed unsupported is 11 which is 4 more than last year. The most common reason cited is ‘their loved one would not have wanted organ donation’.
The UK wide number of DBD donors has declined by 17% with a drop in death by neurological criteria (DNC) testing rate from 87% to 76% pre covid. In Scotland the DNC testing rate is higher than last year with 86% (3.5%) and it is noted our number of DBD donors trending down with a current gap of only 3 donors’ difference between DBD (50) and DCD (47).
With a current total of 97 donors this is a 17% increase in last year donor numbers (graph trend below) and the number of organs taken for transplant was 305 which is a 27% increase from last year.
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