Scottish Donation and Transplant Group meeting - written updates: December 2022

Items and actions

Histocompatibility and Immunogenetics Services update

Submitted by David Turner and Ann-Margaret Little.

Staffing

Glasgow H and I: Fully staffed.

Edinburgh H and I: Vacancies for temporary (three year) Band 6 post and permanent Band 6 post; recruitment in progress. Two supernumerary Clinical Scientist trainees, funded by NES, started Oct 22 for 3 years.

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, although we are currently down to a 1:3 rota due to maternity leave.

Quality in Organ Donation (QuOD) project

UK wide study, ongoing. Samples are processed by H and I staff in H and I Edinburgh. Agreement now reached between University of Oxford and Lothian Health Board to allow funding to be made available. Still establishing the mechanism for this to come to SNBTS H and I.

Donor HLA typing

Since April 2022 this service is commissioned and funded by NHSBT in England. In devolved areas of the UK, H and I and microbiology labs are not funded centrally from NHSBT, but are obliged to sign a contract (signing of which is outstanding for SNBTS after changes were requested by SNBTS Contracts team) to agree to KPIs.

For the second quarter 2022-23 the H and I labs had a rate of 89% (Edinburgh) and 100% (Glasgow) for HLA types being reported within four 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. New go live date for HLA typing data is 2023. The NHSBT contract for providing deceased donor typing is with Contracts departments within SNBTS and GGC for sign off.

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 and I labs are discussing the most appropriate mechanism for introducing screening for HNA antibodies into routine practice. A poster was presented at the BTS meeting.

HLAi transplants facilitated by Imlifidase

Discussions are ongoing on a UK basis to produce guidelines for the use of imlifidase to facilitate renal transplant for highly HLA sensitised patients with long waiting time. 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 and I testing will be necessary pre, peri and post-transplant. DT is representing Scotland H and I in the writing of the Imlifidase guidelines, which are due to be finalised in January 2023.

Tissue Donation update

Submitted by Dr Sharon Zahra and Mr Neil Healy, Clinical Lead and Lead Nurse, TCAT, SNBTS.

Deceased tissue donation

Tissue referrals

The stresses on the NHS are still being felt with the referral rate for consideration of tissue donation still being lower than pre-pandemic. Tissue Donor Co-ordinators are however now able to attend donating hospitals regularly and work is ongoing to raise the profile of tissue donation with the clinical staff, including re-starting delivering grand round presentations and also face to face training sessions.

During the 3 months since the last report (Aug-Oct 2022) there were 69 referrals for consideration of multi-tissue donation, up 17 compared to the previous quarter; and a further 20 referred for eye-only donation, down from 29 the previous quarter.

Figure 1: Referral for tissue donation, April 2019 – October 2022

Of the 69 referrals (Aug-Oct 2022), 40 donors were deferred, most due to medical unsuitability for multi-tissue donation, some due to lack of suitable blood samples for donation or due to the nearest relative being unavailable or declining donation.

Of the 69 referrals there were 3 occasions where relatives declined or were unavailable to discuss or authorise donation:

• 2 overrides for all donation – Deemed Authorisation
• 1 nearest relative admitted to hospital and unable to authorise

In addition

• 2 no Authorisation provided to move donor to retrieve tendons – Expressed Decision
• 6 Partial overrides for eye or tendon donation - 2 Deemed Authorisation; 4 Express Decision

Tissue donation rates

In this quarter (Aug-Oct 2022) 14 deceased donors donated multi-tissue. Eight of these 14 donors donated tissue after organ donation, while the remaining six donors donated tissue-only. These 14 donors donated 10 heart tissue products and 43 tendons.

Figure 2: Tissue donors by type of donor April 2022 - October 2022

Figure 3 Heart valve and tendon donation April 2022 - October 2022

In this quarter (August to October 2022) there were also 16 eyes retrieved by SNBTS from 8 eye donors. There is currently a significant amount of work going on in the background with the aim of increasing eye-donation rate in Scotland, including actively engaging with hospices and also SNBTS looking into taking on responsibility for competency assessment of ophthalmologists to increase the resilience of the eye-retrieval service.

Pancreatic Islet Programme

The SNBTS Islet Isolation lab continues to provide an excellent life-saving service. In the first 7 months of this financial year (April 2022 to October 2022), 12 suitable pancreata were sent to TCAT, leading to a successful islet cell product in 6 cases (50%), and 5 of these were transplanted (42%). This success rate remains one of the best in the world.

Live bone donation

Live bone donation remains complex due to many NHS hospitals still struggling to achieve pre-pandemic rates of elective orthopaedic surgery. As a consequence of the significant delays in many elective operations, the quality of the bone retrieved from those patients currently having surgery is less good than pre-pandemic. This means that maintaining a sufficient donation rate to meet the clinical demand remains problematic.

In the first 7 months of the current financial year (April to October 2022) 321 femoral heads have been donated and 273 have been used clinically.

Figure 4 Bone retrieved and used April 2022 – October 2022

Anticipated changes to donor assessments

SaBTO has recently recommended a change to how donor characterisation is carried out for both live and deceased tissue and cell donors, so that instead of applying risk assessments at population level a more individualised risk assessment is carried out based on the individual donor’s history.

These recommendations were recently approved by Scottish Ministers. SNBTS is currently engaging with JPAC to ensure that the UK-wide guidelines for tissue/cell donor characterisation that underpin the safety of donated substances of human origin are updated to then allow a safe change in practice to be trained out to relevant staff. This will require significant changes to the donor assessment questionnaires used for all types of live and deceased tissue and cell donors and detailed training sessions for staff, with engagement required across the UK for deceased donation.

NHS blood and transplant

Submitted by Anthony J. Clarkson, Director of Organ and Tissue Donation and Transplantation.

Performance

From 01 April 2022 to 02 December 2022 there have been 923 deceased organ donors in the UK and 2318 deceased donor organ transplants. Donor numbers are equal to those for the same period in 2021/22. There are currently 6830 people in the UK on the active Organ Transplant Waiting List, a 13.1% increase on numbers at the same point in 21/22.

NHSBT leadership

Following the resignation of Betsy Bassis, Wendy Clark continues as Interim Chief Executive. The process to recruit and appoint a substantive Chief Executive has commenced with the closing date for applications being the 16 December 2022.

CQC report

The CQC ‘Well Led’ Inspection Report was published on the 27 October 2022. The report highlights issues about discrimination, bullying and racism. NHSBT were aware of these serious issues and are taking action to make NHSBT a fully inclusive, anti-racist organisation. The report highlights that the Executive Team’s recruitment and checks weren’t done as they should have been and have taken immediate steps to rectify this. The CQC also made suggestions around our clinical and nursing leadership, and we have put in place a new Clinical Governance sub-committee, chaired by a Non-Executive Director and are preparing to recruit a Director of Nursing. 

The report also highlights positive findings including that everyone they spoke to during the inspection demonstrated a personal commitment to providing high quality services. Staff were proud to work in the organisation and people told the CQC that “we save and improve lives”. This was a message they heard consistently. They found that we communicate well with donors, staff, the public, and local organisations and we collaborate with partner organisations to help improve services for patients. They found we maintained a safe service during the pandemic with staff contributing to decision-making and changes to routines to help avoid pressures from the pandemic. They found we have a solid strategy with the board and executive leadership team setting a vision and values that were at the heart of the organisation.

An action plan has been developed with the relevant colleagues across the organisation and returned to the CQC. 

Finances

ODT funding for 2022/23 has now been agreed with England confirming flat funding with additional funding provided for DCD Hearts in 2022/23. Funding projections see ODT go into a deficit position next year and plans for 2023/24 are in the final stages of development. Currently DCD Hearts and ANRP in England is unfunded beyond the end of March 2023.

Human Tissue Authority

Submitted by Jessica Porter, Head of Regulation, Human Tissue Authority (HTA).

Organ tourism

In line with the amendment that was made to Section 32 of the Human Tissue Act 2004 and Section 20 of the Human Tissue (Scotland) Act 2006 in July, we are in the process of updating our existing guidance for transplant units and Independent Assessors (IA).

Living donation

Since the last SDTG meeting in August, we have assessed 26 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 a rise in the number of cases submitted for the National Kidney Sharing Scheme.

Living donation update

Submitted by Jen Lumsdaine, Living Donor Co-ordinator, NHS Lothian.

Education and publicity

The living donation media campaign in early December is based on a selection of donor and recipient case studies. A YouGov poll is providing a reflection of the general public’s view of living kidney donation.

At the Living Donation Forum in Stirling on 02 December 2022 it was agreed to pilot a draft of core competencies for specialist nurses and coordinators involved in living donor assessments in line with the Transforming Roles programme.

Videos will shortly be available on the living donation website by the transplant unit’s mental health specialists, with advice and support for recipients and living donors.

REACH transplant

We are delighted to announce that Orla Hobson has been appointed as the REACH Transplant Programme Lead. Orla is liaising with Healthboard managers to recruit the Specialist Nurses. The majority of nurses will be appointed by the end of December 2022. Work is ongoing to develop programme evaluation. 

Workforce planning

This was the main focus of the Living Donor Forum on 02 December 2022. The nephrology data has been completed (Dr Walbaum) and revision of the nursing/coordinator data agreed. Other rate limiting factors identified.

The 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 2016-2022

Deceased organ donation update

Submitted by Regional Manager Susan Hannah NHSBT.

Deceased organ donation performance

Previous year total Donors pmp was 18 which was from Oct 2020 to September 2021 with 97 donors and from Oct 2021 - Sept 2022 with 81 donors is 15 Donors pmp. In comparison to other UK teams, Scotland is the lowest team as unable to demonstrate any recovery in donor numbers in this period.

Donation performance April – October 2022

NHSBT set targets for this financial year with consent/authorisation rates and donor numbers, the Scotland target is 102 donors with a combined authorisation rate of 76%.

From April – October 2022 the seven months data has highlighted some improvement in donor numbers below. The most donors in month were July and August, this correlates with improved eligibility and similar lower eligibility with less donors. As a result, with 55 donors we are 5 donors less than target. which is five more than last year and an overall increase in eligibility by 20% (34). This improvement is noted UK wide but has not returned to pre pandemic numbers.

 

The Referral rate has consistently remained high between 97 – 100% and this is higher than UK average of 95%. The number of potential donor families approached was 100 with 65 authorised with a 65% combined authorisation rate and is 11% less than target of 76% and UK average is 62%.             

The DBD authorisation rate in Scotland is highest of all teams in the UK with 83% and in contrast the DCD is one of the lower teams with 52%. The Scotland team are reviewing all DCD approaches and have given feedback many families have declined as wanting immediate withdrawal of treatment.

The Specialist Nurse (SN) and Specialist Requestor (SR) involvement rate is 89% whilst continued improvement for Scotland remains lower in comparison with UK average of 92%.

A breakdown of authorisation routes highlighted Deemed and ODR/Expressed both have 80% with other 40%. The number of ODR/Expressed overrides is 10 which is six more than last year and Deemed unsupported is six which is two more than last year.

There was a 17% increase in the number of organs transplanted with 135 from April – Sept 2022 which was from the same number of donors last year 48.