Improving the access of the patients to renal trasplantation

Luis M. Pallardó MD, PhD Hospital Universitario Dr Peset

University of Valencia Valencia, Spain

Incident ESRD rates per million population by country, unadjusted. EDTA Report 2014

RRT Incidence rates (pmp) by country in 2013 Data from USRDS in 2013

Stability in the RRT incidence in some countries Data from USRDS in 2013

Canada Denmark Sweden Scotland Finland

RRT incidence rates between 1980 and 2013. The 18th Annual Report UK Renal Registry

The RRT incidence in Spain 2007-13 The Spanish Renal Registry 2013

Martín-Escobar E et al. Nefrologia 2016;36:97-120

Increasing the RRT incidence in some countries Data from USRDS in 2013

México Singapore USA Rpb Korea, Malasia Thailand Chile Croatia Phylippinas Russia Bangladesh

Incident percentages ERA-EDTA Report 2014

Incident percentages ERA-EDTA Report 2014

Prevalence rates of ESRD pmp by country, unadjusted. ERA-EDTA Report 2014

Prevalent percentages ERA-EDTA Report 2014

Modality changes in prevalent RRT patients, 1999–2014. 18th Annual Report UK Renal Registry

Age profile of prevalent RRT patients by modality on 2014

18th Annual Report UK Renal Registry

Modality changes in prevalent RRT patients, 2007-13 The Spanish Renal Registry 2013

Prevalent percentages ERA-EDTA Report 2014

Prevalent percentages ERA-EDTA Report 2014

Trends in the number of ESRD prevalent cases (in thousands) by modality, in the U.S. population, 1996-2013

2015 Annual Data Report, USRDS

17

30%

Why to do more renal transplants?

Why to do more renal transplants?

• Increase of patient survival – Wolfe RA et al. N Engl J Med 1999;341:1725-1730.

– Macrae J, et al. Int Urol Nephrol 2005; 37: 641.

– Lloveras J, et al. Transplanation 2015; 99: 991–996.

• Increase of quality of life – Laupacis A, et al. Kidney Int 1996; 50:235–242. – Tonelli M, et al. Amer J Transplant 2011; 11: 2093-2109.

– Dukes JL, et al. Clin Transplant 2013.

• Is more cost-effective than dialysis – Whiting JF, et al. Transplant Proc. 1999;31:1320–1321. – Arrieta J, et al. Nefrologia 2011;31:505-13.

Adjusted survival (after the day 91) in incident dialysis

patients and patients receiving a first transplant (between 2005 and 2009).ERA-EDTA Report 2014

Wolfe RA, et al. N Engl J Med 1999;341:1725-1730.

Adjusted Relative Risk of Death among 23,275 Recipients of a First Cadaveric Transplant

Wolfe RA, et al. N Engl J Med 1999;341:1725-1730.

Outcome among Recipients of First Cadaveric Transplants, According to Characteristics at the Time of Initial Placement on the Waiting List, 1991–1997.

ERA-EDTA Report 2014

Main determinants of renal Tx

• Organ shortage

• Medical and non-medical conditions

Deceased Donor Age in Spain 1992-2015 ONT Annual Report 2015

NHBD Renal Tx in Spain 1995-2014 ONT Annual Report 2014

Living donor renal Tx Activity ONT Annual Report 2014

Renal Transplantation in Spain 1993-2014 ONT Annual Report 2014

???Waiting list for renal transplatation ONT Annual Report 2014

Medical ad nonmedical conditions The way to ESRD

CRD ESRD RRT (TX/ PD-HD)

• Comprehensive nephrological care

• Educational and Sociological circumstancies of the patients, including understanding of the disease and their different treatments

• Programmed vs non-programmed initiation of RRT

• For profit vs non for profit dialysis Units

• Local or regional facilities for Tx

• Comorbidities

• Age

Medical ad nonmedical conditions The way to ESRD

CRD ESRD RRT (PD-HD / TX)

• Nephrological care

• Programmed vs non-programmed initiation of RRT

• For profit vs non for profit dialysis Units

• Local or regional facilities for Tx

• Educational and sociological circumstancies of the patients, including comprehension of the disease

• Comorbidities

• Age

……

• Patients older than 65 are the ones that more intensively increase

in the RRT population

• This group is underepresented in the transplanted population

• Age ‘per se’ cannot be a restrictive criteria to access to renal

transplantation, and there should be no upper limit for excluding

patients

• Older patients must be evaluated as the standard ESRD patients to

be included in the waiting list for renal transplantation, with

particular attention to the cardiovascular and malignancy riscs, and

a proper management after transplantation

‘Old for old’ renal transplantation Influence of age-matching on actual graft survival (using a cut-off age of 55 years).

Wolfgang Arns et al. Nephrol. Dial. Transplant. 2007;22:336-341

‘Old for old’ renal Tx The Eurotransplant Senior Programme

Frei et al. American Journal Transplantation 2005; 5:50-57

Patient survival in recipients of kidneys from donors >65 years old versus patients remaining on dialysis in a paired analysis

Catalan Renal Registry 1990-2010

Lloveras J, et al. Transplanation 2015; 99: 991–996

Survival Benefit From Kidney Transplantation Using Kidneys From Deceased Donors Aged ≥75 Years: A Time‐Dependent Analysis

Catalan Renal Registry 1990-2010

Pérez MJ et al. American Journal of Transplantation 2016; 16:2724-2733.

Mortality (HR) according to transplant status and CCI

Sørensen VR et al. Transplantation 2015. doi: 10.1097/TP.0000000000001002

KM patient survival of WL vs Tx patients >70 years of age

Period 1990-99 Period 2000-05

Heldal K, etal. Nephrol Dial Transplant (2010) 25: 1680–1687

Patient survival depending on the transplant era

Heldal K, etal. Nephrol Dial Transplant (2010) 25: 1680–1687

Death censored graft survival (A)

and Patient Survival in octagenarians (B)

(A) (B)

Lønning K, etal. Transplantation DOI: 10.1097/TP.0000000000001363

In conclusion:

• Conditioning circumstancies to renal Tx can vary

between different regions and countries.

• Medical and nonmedical factors can determine access

to renal Tx, and they must be evaluated in order to

find the proper solution.

• Aged population with ESRD is increasingly prevalent,

and their expectation to be transplanted depends on

taking advantage of older deceased, as well as, living

donors.

Thanks!!