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)

0

5

10

15

20

25

30

35

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

0

10

20

30

40

50

60

70

80

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

10

15

20

25

30

35

40

45

50

55

0 50 100 150 200 250 300 350 400 450 500 550 600

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)

0

10

20

30

40

50

60

70

80

90

100

0 100 200 300

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

0

250

500

750

1000

Shr

ewM

iddl

brE

dinb

Inve

rns

Glo

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ings

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orse

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orts

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rest

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bG

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ango

rN

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Brig

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lguy

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eart

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arts

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irral

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ldn

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ydW

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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]

0

10

20

30

40

50

60

70

80

0 100 200 300 400 500 600

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