Talk Transplant at eGFR 25
The “Talk Transplant at 25” is an initiative which is still very much evolving at Salford Royal NHS Foundation Trust.
Dr Rosie Donne, Consultant Nephrologist at the Trust describes the project below:
Up until now, our culture had been to start discussing transplant at eGFR 20, but pre-emptive transplant rates had been at UK average (9% pre-emptive tx, 91% start dialysis).
My idea was based on the finding of many missed opportunities for pre-emptive transplant
- many patients were first referred for transplant workup when the eGFR was about 15, but were deteriorating rapidly.
- this was particularly true for patients with diabetes and glomerulonephritis, who were already under specialist care.
Patients found it difficult to process all the information they needed at eGFR 15
- transplant
- the need to approach live donors
- home dialysis options,
- multiple appointments etc.
I therefore wanted to change the culture in the department to start discussing the need for transplant at a much earlier stage for patients who were likely to need it and benefit.
I suggested eGFR of 25 as it has the following advantages:
- gives patients time to approach donors before they had to deal with everything else
- allows time for donors to come forward, decide who is ABO compatible or whether need to use kidney sharing scheme, progress with appropriate workup tests
- increased chance of pre-emptive transplant for rapidly-progressing patients
- more time for patient to be psychologically prepared
Potential disadvantages:
- breaking bad news at an earlier stage than usual
- increased appointment time needed on that day
- patients need access to support straight away – how can this be provided locally
- need adequate live donor nurse resources to cope with the increase in contacts / workup.
It has therefore taken some time to plan, but we have had many informal discussions at consultant meetings, which has already changed the culture.
I am in the process of implementing the following plan in our centre, preceded by training of medical and nursing staff:
1. At eGFR 25 – trigger to discuss likely future need for transplant & benefits of living donation – (for potentially suitable patients including those with high BMI)
a. take blood for ABO group, tissue typing
b. give info leaflet with contact details of live donor nurses to give to potential donors
c. book into CKD specialist nurse “early transplant education clinic” – we are just setting ours up now
d. discuss lifestyle measures to achieve goal of transplant eg. smoking cessation, weight loss
e. offer renal psychologist / counsellor referral
f. involve peer supporters if you have them
g. if Type 1 diabetes and suitable kidney-pancreas transplant, start workup tests – aim to list at eGFR 20
h. patient may stay in their existing renal clinic, especially if they are still on immunosuppression, but can continue with transplant preparation in parallel
2. At eGFR 20 – start transplant workup tests
3. Refer for transplant, aiming for live donor transplant / deceased donor listing at eGFR 15
At the moment, staff shortages have meant a delay in setting up the “early transplant education” clinic.
We also have a significant wait for renal psychology.
However, I am now getting earlier referrals and am in the process of re-auditing this so it has been a gradual process.
It would work differently in different places but I would love to hear any thoughts / concerns / ideas you have.
Dr Rosie Donne
