UK Transplant Centres Research Articles

A Retrospective View of Post Renal Transplant Urinary Tract Infections: An Experience of A UK Transplant Centre

Urinary tract infections (UTIs) are prevalent post renal transplant complication. These infections are most common in renal transplant recipient’s contrary to their incidence in general healthy population as shown by previous studies. Though the frequencies of occurrences are different in renal transplant patients. There is general lack of consensus on the risk factors associated with development of UTIs in renal transplant patients as well as effects posed by them and occurrence of mortality in patient group. This retrospective cohort study investigated and included adults’ patients who were operated for renal transplant in a single transplant center in UK from Jan 2014 to December 2023. The number of patients were 604 with two hundred and fifty-nine developed one or more UTIs in 42 months follow-up period. Significant risk factors for post-transplant UTIs were advanced age, female gender, reflux kidney disease, use of azathioprine and cadaveric donor. UTIs did not increase risk for renal graft loss, but were associated with increased mortality (3.5 odds ratio, 95% confidence interval 1.68–7.23). We conclude UTIs may be associated with an increased mortality risk in renal transplant recipients. Prevention of UTIs in high-risk renal transplant patients or those with recurrent UTIs may possibly decrease post-transplant mortality.

1087 Factors That Impact Cold Ischaemia Time for Deceased Donor Kidney Transplants: Results of a National Transplant Access to Theatre Audit (NTACT)

Abstract Aim Deceased donor kidney utilisation confronts challenges leading to prolonged cold ischemia time (CIT), affecting graft survival. Despite these challenges, an understanding of the obstacles remains unclear. This audit aims to identify the factors that prolong CIT. Method A multicentre, prospective audit of adult deceased donor kidney-only transplants spanned 14 UK transplant centres from February to September 2022. Data, encompassing time intervals between important checkpoints pre-transplantation and perceived reasons for delays, were collected through RedCap. Descriptive statistics was used for analysis. Results Data from 476 kidney-only transplants were gathered (29 excluded for incomplete/incorrect data). Of these, 230 were donations after brainstem death (DBD) organs, and 202 were donations after circulatory death (DCD) organs. Median CIT was 10:55 (IQR:08:11-15:13) for DBD organs and 11:19 (IQR:08:31-15:10) for DCD organs, with 42% of DCD and 15% of DBD organs surpassing national CIT recommendations. Median time from organ arrival to knife to skin was 04:02 (IQR:02:35-07:35). Full and virtual crossmatches constituted 35% and 65%, respectively, with 16% of results arriving after the organ arrives at centre. Anaesthetic time had a median duration of 00:55 (IQR:00:39-01:10) and Knife to skin to organ perfusion was 01:25 (01:10-01:51). Delays reported in 34% of transplant cases, most common causes were the availability of surgical and anaesthetic teams, porters, and the operating theatre. Conclusions This audit allowed us to uncover the factors that prolong CIT at each stage of the transplantation post-arrival. These findings will guide the establishment of realistic targets for optimizing processes in the future.

Development of a quality of life measure for left ventricular assist device recipients using a mixed methods approach.

Left ventricular assist device (LVAD) recipients report symptom improvement but find adjusting to life with the LVAD challenging. These challenges are unique, and existing patient-reported outcome measures (PROMs) do not reflect their experiences. This study aimed to develop a culturally relevant quality of life PROM for use with LVAD recipients in future research, design evolutions and clinical practice. A three-stage mixed-methods approach was used to develop a PROM: stage 1 included group concept mapping (GCM); stage 2 semi-structured qualitative interviews were conducted with 11 LVAD recipients and 10 clinicians, and a questionnaire was developed using a conceptual framework; and stage 3 used exploratory psychometric analysis of the PROM data using Rasch measurement theory. This paper presents stages 2 and 3. The conceptual framework consisted of four key concepts, including general health, life with the LVAD, equipment and clothing and emotional impact. Statements from interviews and GCM were used to create items for the LVAD quality of life (LVAD-QoL). Cognitive interviews tested face validity and participant comprehension. Forty-nine participants were recruited from three UK transplant centres. PROM data were collected and analysed using Rasch analysis. Four items displayed misfit; dependency between item sets was the biggest issue (57/485 pairwise differences). After restructuring and dealing with item misfit, the LVAD-QoL conformed to the Rasch model, supporting the psychometric properties and quality of the LVAD-QoL. Using a mixed-methods approach ensured the development of a robust and psychometrically sound tool for research, design evolution and clinical practice with LVAD recipients.

O197: Quality Assessment of Human Kidneys by Ex-vivo Normothermic Machine Perfusion prior to Transplantation

Abstract Introduction Ex-vivo normothermic machine perfusion (NMP) is a technique of preservation that can be used to assess the quality and suitability of a kidney for transplantation. This may prevent the unnecessary discard and increase the number of transplanted kidneys. Methods A total of 22 kidneys declined for transplant by all UK transplant centres, were assessed over a three-year period across three centres in the UK. Prior to NMP, most kidneys were declined due to poor quality cold flushing at retrieval. All kidneys were assessed during 1h of NMP. A quality assessment score (QAS) based on the appearance, blood flow and urine output was applied to each kidney. Scores ranged from 1 (best) to 5 (worst). Results Sixteen kidneys (72%) had a QAS of 1 to 3 and were transplanted into matched recipients. One patient died with a non-functioning kidney 12 days post-transplant due to a cardiac arrest. Six recipients (37.5%) had delayed graft function. The mean serum creatinine levels and estimated glomerular filtration rate at 3 months was 154±74µmol/L and 45±15mL/min/1.73m2, respectively. Graft and patient survival at 12 months were 94%. Of the 6 non-transplanted kidneys, 3 were deemed unsuitable after assessment during NMP, 1 was not transplanted due to logistical reasons and a prolonged cold ischaemic time, and the remaining 2 due to chronic degenerative changes assessed by histology scores. Conclusion This clinical research study demonstrated the ability to use NMP technology to successfully increase the number of transplants by assessing kidneys that would otherwise be discarded.

An evaluation of driveline dressing protocols and infection rates for left ventricular assist devices across UK transplant centres

Background/Aims Left ventricular assist devices are used to improve the quality of life of people waiting for heart transplantation. Driveline infections are a significant complication of these devices, occurring in 30–40% of cases, which could lead to life threatening sepsis. This study aimed to review UK driveline dressing protocols and infection rates to determine if national standardisation is possible. Methods Six UK heart transplant centres were asked to share their driveline dressing protocols for comparison. National driveline infection data were obtained from the NHS Blood and Transplant database. Infection rates, patient demographics and device types were compared using Chi squared tests, with a P value of <0.05 indicating statistical significance. Results The study found 38 driveline infections over a 3-year period, with an average infection rate was 4.4% per year. There were no significant difference in infection rates between device types. Dressing protocols varied between centres, but all centres followed international guidance. The timepoint where the highest number of infections were diagnosed was 12 months post implantations, accounting for 23.7% of infections. There were no significant differences in infection rates between centres in 2019–20 or 2021–22, but a significant difference was observed for 2020–21 (P=0.013). Conclusions UK driveline infection rates are below the average reported in the literature. Despite some differences in dressing protocols, all centres examined in this study maintained a level of infection comparable to reported rates. The feasibility of national standardisation remains uncertain, and further research is needed to determine the most effective dressing protocols for preventing driveline infections.

The UK Impact Transplant Trials Network: An Effective National Strategy to Accelerate the Delivery of Randomized Trials in Stem Cell Transplantation

Introduction: Stem cell transplantation (SCT) is an important curative modality in patients with blood cancer whose outcome with chemotherapy is predicted to be poor and is an increasingly important therapy in non-malignant disease. However, even in 2023, 50% of patients are still destined to die after either allogeneic or autologous transplantation, either of relapsed disease or treatment toxicity. In response the transplant community continue to develop innovative strategies designed to improve patient outcome. However, despite the fact that the adoption of new therapies in haemato-oncology is, almost without exception, based on evidence generated by randomized studies fewer than 5% of transplant patients are currently recruited to prospective practice informing trials. Thus, much current transplant practice is based on retrospective registry analyses whose results can often be misleading. There is therefore an urgent need for innovative trial models with the ability to accelerate transplant trial delivery if patient outcomes after SCT are to be improved. Methodology: We reasoned that limited trials capacity at busy centres coupled with the absence of a fit-for-purpose clinical trials network represented potentially tractable barriers to transplant trial recruitment. In 2018 a $5 million grant was secured from UK blood cancer charities in order to directly fund the salaries of research nurses within the IMPACT network covering 11 major UK transplant centres and a linked clinical trials hub. Critically, up-front investment into research nurses at major transplant centres created a catchment region in excess of 20 million. The pre-stated aim of the IMPACT pilot was to recruit 400 patients to 7 new transplant trials over a 4 year period. Results Opened in 2018 the IMPACT network has now randomized 1344 patients to 7 prospective transplant trials over a 5 year period. Trials delivered include COSI, a randomized trial examining the benefit of the addition of Thiotepa to a Fludarabine/Busulphan based conditioning regimen in patients allografted for acute myeloid leukemia (AML) (n=333) and AMADEUS a randomized comparison of the benefit of post-transplant CC486 maintenance (n-326). In conjunction with recruitment to the Pro-DLI trial- a randomized study of prophylactic DLI in patients allografted for high risk AML (n=150)- the IMPACT initiative has resulted in more than 900 patients being recruited to practice informing AML transplant trials over a 5 year period. Importantly, AMADEUS has been designed and delivered in order to generate registration enabling data. Additional trials delivered by the IMPACT network include ALL-RIC the first randomized comparison of reduced intensity conditioning regimens in acute lymphoblastic leukemia (n=102, now in follow-up) and the ongoing MoTD trial a randomized comparison of post-transplant cyclophosphamide GVHD prophylaxis (n=139 to date). Sample return for bolt-on scientific studies has been in excess of 85% allowing prospective analysis of the prognostic significance of pre and post-transplant MRD, molecular determinants of transplant outcome and the biology of disease relapse in patients allografted for AML and ALL. Of note the IMPACT research nurse network demonstrated impressive resilience during the COVID-19 pandemic permitting continued trial delivery despite faltering recruitment to other cancer trials. Conclusions: The funding of a national transplant trials network has transformed recruitment to prospective randomized transplant trials in the UK. The success of the IMPACT pilot, which-out-performed its recruitment metrics by 300%, confirms the importance of innovative trial delivery models in accelerating recruitment to practice informing transplant studies and is a scalable model internationally. At the same time, IMPACT has proved a highly effective mechanism to generate linked translational data with the ability to inform future trial design. Building on similar models in Europe, such as LYSARC, the IMPACT network is now funded by a not-for-profit trials delivery vehicle Accelerating Clinical Trials Ltd (www.act4patients.com) creating a financially sustainable model within the UK for the delivery of a mixed portfolio of industry sponsored and investigator initiated transplant and cell therapy trials.

SP5.6 A UK-wide audit on peri-operative practices during deceased donor kidney transplantation: Results from a prospective National Transplant ACcess to Theatre (NTACT) Audit

Abstract Background The outcomes of deceased donor kidney transplants are mainly affected by donor and recipient factors. There is little data on standard perioperative practices across the UK and whether variations in perioperative practices could affect the outcomes. This national audit aims to identify current perioperative practices. Methods We conducted a multicentre, prospective audit of adult deceased donor kidney-only transplants across 14 UK transplant centres between February and September 2022. Data was collected on pre-operative antibiotic use, clinician’s grade, fluid management, central/arterial line insertion, post-operative destination, crossmatch and advanced haemodynamic monitoring use. Data was recorded on RedCap and analysed using descriptive statistics. Results 476 kidney-only transplants were recorded (59 were excluded for incomplete/incorrect data), leaving 417 transplants. In 98.6% of transplants, patients received antibiotics pre-operatively. A wide range of antibiotics were given; the three most used were co-amoxiclav (n=135), ciprofloxacin (n=92) and amikacin (n=62). Most operations were led by a consultant surgeon (91.1% n=380). However, only 60.1% of cases were led by consultant anaesthetists. Central lines were used in 65.5% (273/417) of patients, 41.0% (171/417) used an arterial line, and 25.4% (106/417) had advanced haemodynamic monitoring. A total of 289 cases (69.3%) received goal-directed fluid therapy, of which 74.4% (215/289) used static parameters. Most common post-operative destinations were the transplant ward, 75.3% (n=314), ICU, 9.4% (n=39) and HDU, 10.1% (n=42). Conclusions We identified wide variations in certain perioperative practices. In the future, we would like to assess whether there is any relationship between the variations in practice and postoperative outcomes, such as graft function and mortality.

WTP2.9 Early Deceased Donor Kidney Transplant outcomes: Results from a Prospective National Transplant Access to Theatre (NTACT) Audit

Abstract Background Renal transplantation is increasing, yet there is a paucity of data describing post-operative complications. Therefore, this national audit aims to identify the incidence of early complications that impact patient outcomes. Methods We conducted a multicentre, prospective audit of adult deceased donor kidney-only transplants across 14 UK transplant centres between February and September 2022. Data was collected on significant checkpoints pre, intra and post-operatively, assessing for 30-day complication and mortality rates. Data was recorded on RedCap and analysed using descriptive statistics. Results 476 kidney-only transplants were recorded, (59 excluded for incomplete/incorrect data). Of 417, 215 were donation after brainstem death (DBD) organs and 202 were donation after circulatory death (DCD) organs. The 30-day mortality was 0.47% (n=2/417). The primary graft function rate was 81%. The 30-day readmission rate was 18%, and median number of readmissions was 1 (IQR: 1-3). Of the readmitted recipients, 92% were readmitted once and 8% were readmitted more than. The 30-day reoperation rate was 12%, and median number of reoperations was 1 (IQR: 1-2), of these, 91% had 1 reoperation and 9% had more than 1 reoperation. Most common indications for reoperations were bleeding 49% (n=25), assessment of graft perfusion 17% (n=9), and wound dehiscence 10% (n=5). We noted a difference in rates of reoperations between DCD and DBD organs, 16% and 9% respectively, however, this was not significant. There was no significant difference in the readmission and mortality rate between DBD and DCD organs. Conclusion The overall early postoperative complication rates and 30-day mortality following deceased donor kidney transplantation are low.

140: Safety of endoscopic surveillance of the transplanted small intestine: A 15 years experience of a large UK Transplant center

140: Safety of endoscopic surveillance of the transplanted small intestine: A 15 years experience of a large UK Transplant center

Exploring Staff Attitudes Towards Unspecified Kidney Donors in the United Kingdom: Results From the BOUnD Study.

Unspecified kidney donation (UKD) has made substantial contributions to the UK living donor programme. Nevertheless, some transplant professionals are uncomfortable with these individuals undergoing surgery. This study aimed to qualitatively explore the attitudes of UK healthcare professionals towards UKD. An opportunistic sample was recruited through the Barriers and Outcomes in Unspecified Donation (BOUnD) study covering six UK transplant centres: three high volume and three low volume centres. Interview transcripts were analysed using inductive thematic analysis. The study provided comprehensive coverage of the UK transplant community, involving 59 transplant professionals. We identified five themes: staff's conception of the ethics of UKD; presence of the known recipient in the donor-recipient dyad; need for better management of patient expectations; managing visceral reactions about the "typical" unspecified kidney donor; complex attitudes toward a promising new practice. This is the first in-depth qualitative study of attitudes of transplant professionals towards UKD. The data uncovered findings with strong clinical implications for the UKD programme, including the need for a uniform approach towards younger candidates that is adhered to by all transplant centres, the need to equally extend the rigorous assessment to both specified and unspecified donors, and a new approach to managing donor expectations.

Donating a Kidney to a Stranger: Are Healthcare Professionals Facilitating the Journey? Results From the BOUnD Study.

Unspecified kidney donors (UKDs) are approached cautiously by some transplant professionals. The aim of this study was to interrogate the views of UK transplant professionals towards UKDs and identify potential barriers. A purposely designed questionnaire was validated, piloted and distributed amongst transplant professionals at each of the 23 UK transplant centres. Data captured included personal experiences, attitudes towards organ donation, and specific concerns about UKD. 153 responses were obtained, with representation from all UK centres and professional groups. The majority reported a positive experience with UKDs (81.7%; p < 0.001) and were comfortable with UKDs undergoing major surgery (85.7%; p < 0.001). 43.8% reported UKDs to be more time consuming and 52% felt that a mental health assessment should take place before any medical tests. 77% indicated the need for a lower age limit. The suggested age range was broad (16-50years). Adjusted mean acceptance scores did not differ by profession (p = 0.68) but higher volume centres were more accepting (46.2 vs. 52.9; p < 0.001). This is the first quantitative study of acceptance by transplant professionals to a large national UKD programme. Support is broad, however potential barriers to donation have been identified, including lack of training. Unified national guidance is needed to address these.

Optimized immunosuppression to prevent graft failure in renal transplant recipients with HLA antibodies (OuTSMART): a randomised controlled trial.

3% of kidney transplant recipients return to dialysis annually upon allograft failure. Development of antibodies (Ab) against human leukocyte antigens (HLA) is a validated prognostic biomarker of allograft failure. We tested whether screening for HLA Ab, combined with an intervention to improve adherence and optimization of immunosuppression could prevent allograft failure. Prospective, open-labelled randomised biomarker-based strategy (hybrid) trial in 13 UK transplant centres [EudraCT (2012-004308-36) and ISRCTN (46157828)]. Patients were randomly allocated (1:1) to unblinded or double-blinded arms and screened every 8 months. Unblinded HLA Ab+patients were interviewed to encourage medication adherence and had tailored optimisation of Tacrolimus, Mycophenolate mofetil and Prednisolone. The primary outcome was time to graft failure in an intention to treat analysis. The trial had 80% power to detect a hazard ratio of 0.49 in donor specific antibody (DSA)+ patients. From 11/9/13 to 27/10/16, 5519 were screened for eligibility and 2037 randomised (1028 to unblinded care and 1009 to double blinded care). We identified 198 with DSA and 818 with non-DSA. Development of DSA, but not non-DSA was predictive of graft failure. HRs for graft failure in unblinded DSA+ and non-DSA+groups were 1.54 (95% CI: 0.72 to 3.30) and 0.97 (0.54-1.74) respectively, providing no evidence of an intervention effect. Non-inferiority for the overall unblinded versus blinded comparison was not demonstrated as the upper confidence limit of the HR for graft failure exceeded 1.4 (1.02, 95% CI: 0.72 to 1.44). The only secondary endpoint reduced in the unblinded arm was biopsy-proven rejection. Intervention to improve adherence and optimize immunosuppression does not delay failure of renal transplants after development of DSA. Whilst DSA predicts increased risk of allograft failure, novel interventions are needed before screening can be used to direct therapy. The National Institute for Health Research Efficacy and Mechanism Evaluation programme grant (ref 11/100/34).

Wellbeing and lifestyle in transplantation (WALT): selected themes from a qualitative study

Background: Lifestyle impacts the health of kidney transplant recipients (KTRs) who are at risk of weight gain, post-transplantation diabetes mellitus and dyslipidaemia. Their capacity to self-care is key to adapting the lifestyle choices that impact their health. Aims: This qualitative study aimed to understand KTRs’ lifestyle choices in relation to their post-transplant life and explore the impact of support provided by healthcare professionals (HCPs) and significant others on KTR's self-care. Methods: The project involved 33 participants who were involved in one of five focus groups, or 15 one-to-one semi-structured interviews. The participants were KTRs who had received a transplant over 6 months or more ago, their significant others and healthcare professionals. Participants were all selected from one UK transplant centre. Purposive sampling ensured both a diversity of KTRs and a range of professionals participating, with data analysed using thematic framework analysis. Findings: The authors report on a number of selected themes. These themes draw from a larger, more extensive analysis and conceptual framework concerning health, wellbeing and lifestyle, and they identify how effective health communicative interactions and health literacy plays an integral role in developing KTRs’ self-care. Conclusion: Supporting KTR's lifestyle choices post-transplant involves building self-care capacity through effective health communication and health literacy.

Prevalence of Sars-Cov-2 in Stem Cell Donors from Anthony Nolan UK Stem Cell Registry: Sars-Cov-2 Testing Programme, Impact on Stem Cell Collections and Managing Risk Going Forward

Introduction The SARS-CoV-2 pandemic risked significant disruption to haematopoietic cell transplantation (HCT). This led to changes in registry operations including widespread use of cryopreservation, Covid-19 screening strategies and deferral periods for positive donors or close contacts. Anthony Nolan (AN), along with UK Aligned Registry partners were some of the few organisations that instigated donor SARS-CoV-2 testing across the donor pathway from April 2020 and are in a unique position to comment on UK stem cell donor prevalence. SARS-COV-2 PCR testing of donor was performed at medical, ahead of G-CSF or BM for cryopreserved collections, before conditioning for fresh collections, and day of donation, in keeping with NICE guidance. Early guidance from JPAC recommended postponing donation three months from resolution of symptoms in donors with coronavirus, with discretionary earlier clearance depending on individual risk assessment and urgency of transplant. Deferral periods were subsequently reduced to 14 days. AN followed public health advice from UK government which included mandatory quarantine for contacts (lifted for vaccinated individuals from 16/8/21) and confirmed cases (legal requirement lifted 24/2/22). Methods Here we report for the first time our 2-year experience of the impact of Covid-19 on our large UK stem cell registry including the SARS-COV-2 prevalence in the UK donors, and impact on collections and cell infusion. This retrospective study included all UK donors (AN and BBMR) selected by UK and International Transplant centres (TCs) to donate PBSC, BM or DLI for paediatric and adult patients between 1st July 2020 and 1st July 2022. This does not include positive donors at verification typing stage or ahead of being selected as preferred donor. Results During study period AN received 1663 work up request for UK donors with 1459 of these donors attending a planned medical. There were 1071 collections (862 PBSC, 89 BM, 120 DLI). 709 (66.2%) of these were cryopreserved. 84 donors tested SARS-CoV-2 positive after being selected and scheduled as a donor giving a prevalence in this two-year period of 5.8%. This occurred before donor clearance was sent to TC in the majority of cases, 47 (56%). 25 (29.8%) occurred after clearance, of these 4 were due to be fresh collections with the intended recipients having commenced transplant conditioning (2 held conditioning and used same donor, 2 used back up donor). There were 8 donors positive on day of donation (7 PBSC, 1 DLI) amounting to 0.75% of all collections. Products were infused in 5 cases (3 fresh, 2 cryo) and discarded in three cases (all cryopreserved). 4 donors were positive within 2 days post donation. We are not aware of any complications or transmitted SARS-CoV-2 from the infused cells. 14 additional donors required mandatory isolation for Covid contact: one of which at a late stage after recipient had commenced conditioning, making a total of 5 post-conditioning cancellations/postponements. For the 84 confirmed SARS-CoV-2 donors, 49 (58.3%) went on to donate with a median deferral from time of original planned collection of 23 days (range 0-106 days). 11 were cancelled for alternative reasons and 24 (28.6%) opted for an alternative donor. During the study period there were a total 34 cryopreserved collections from UK donors not infused (3.2% of UK collections) most commonly due to change in patient circumstances (deterioration or death, 76%). Conclusion AN significantly adapted working during the Covid-19 pandemic. Both cryopreservation and the testing strategy were integral to ensuring the safety of our donors, recipients and collection centre staff and procedures. Covid-19 infection in selected donors (5.6%) led to collection delays (average 23 days) but, whilst each individual case was unfortunate and regrettable, the fact that this transpired to only 5 late-stage (post-conditioning) cancellations/postponements during the study period, does provide reassurance. This highlights during times of high community prevalence having a back-up donor option for planned fresh infusions remains valid advice, and if this cannot be assured then cryopreservation is likely to remain a valuable option. The high number of non-infused products is an area of concern and highlights importance of effective communication between TC and registry, and the importance of completing pre-transplant work up assessment ahead of donor mobilisation. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

436 Barriers for Cadaveric Kidney Organ Utilisation: Results of a National Transplant Access to Theatre (NTACT) Pilot Study

Abstract Background There are various barriers to cadaveric organ utilisation across the UK. However, there is a paucity of data on the barriers after the arrival of organ/s at the implanting centre. We set up the national “NTACT” study to identify barriers after arrival of organs at implanting centre. Method Prospective pilot study collecting data on adult kidney/pancreas cadaveric organs across five UK transplant centres in July 2021. Data collected includes time intervals between significant checkpoints prior to transplantation and perceived reasons for delays after arrival at implanting centre. Data was recorded on RedCap and analysed for delays using descriptive statistics. Results Between five transplant centres, data was entered on 27 transplants. Five patients were excluded from the study (live transplant-2, incomplete data-3). There were six donations after circulatory death (DCD) and 16 donations after brainstem death (DBD) organs. Fifty percent (n=3/6) of DCD and 12.5% (n=2/16) of DBD allografts surpassed the national recommendations for CIT. The majority of crossmatches were virtual (15 virtual and seven full). Delays included crossmatch results (median=03:37:30), time between the arrival of the kidney and patient into theatre (median=03:13:00), time between anaesthetic induction and knife to skin (median=00:52:00). The median warm ischaemia time was 00:41:30 (IQR-00:33:00–00:49:30). Qualitative answers highlight themes: “surgical team occupied in another case”, “emergency theatre occupied”, “porter availability for transporting patients”. Discussion Our pilot study identified various barriers to implantation, and a significant proportion of kidneys are implanted beyond nationally accepted CIT. Further work is required to get a national picture over an extended period.

Remote genetic counselling provision for heart failure patients at a UK transplant centre

Abstract Funding Acknowledgements Type of funding sources: None. Background Cardiomyopathy has been highlighted as one of the key drivers of heart failure, particularly dilated cardiomyopathy (DCM) (5,1). Finding the correct diagnosis for patients is not only important to their health, but to that of their family members (2). European guidelines recommend genetic counselling and testing for all patients with a cardiomyopathy diagnosis (3). Genetic counselling involves communicating complex information and providing support to patients and families with inherited conditions. It is recommended that patients undergo genetic counselling alongside genetic testing (6). Purpose historically, the heart failure team had no formal pathway in place for genetic testing. We set to establish a remote provision for genetic counselling and testing. We hoped to increase access to genetic services, without additional trips to the hospital in this already burdened patient group. Methods A genetic counsellor (GC) attended the weekly team meeting to raise awareness of the genetic service and help identify eligible patients. Eligibility was determined using criteria from the national genomic test directory (4). Eligible patients had appointments via video or phone call. Outpatients who consented to genetic testing had blood samples arranged locally or at an upcoming hospital appointment. Inpatients had blood samples taken during their hospital stay. Forty-one eligible patients were identified, the majority had DCM (n=40) and one had arrhythmogenic right ventricular cardiomyopathy (ARVC). Genetic testing was performed using a diagnostic DCM or ARVC panel. Results were classified as positive, i.e. pathogenic or likely pathogenic variant identified; negative, i.e. no pathogenic variant identified; or inconclusive, i.e. variant of unknown significance identified. Results were fed back to patients by virtual genetic counselling appointment. GCs facilitated screening of family members as appropriate. Results In the period, July 2020 to January 2022, 41 patients attended virtual genetic counselling appointments and consented to genetic testing. Of these, 19 received a positive genetic result, 4 an inconclusive result, and 18 a negative result. The majority of positive results were identified in the TTN gene (n=9) (see Figure 1). To date, six family members have been identified as gene positive and requiring ongoing screening, whilst six have now been discharged on the basis of a gene negative result. These are preliminary figures and expected to grow as more family members are able to access genetic counselling Conclusion Heart failure patients represent an underserved population who may benefit from genetic testing alongside genetic counselling. Remote genetic counselling is an effective service delivery model. A significant proportion of patients (46.3%) received a positive genetic result. This has potential benefits, not only to the patient but to family members.

From Haphazard to a Sustainable Normothermic Regional Perfusion Service: A Blueprint for the Introduction of Novel Perfusion Technologies.

Normothermic Regional Perfusion (NRP) has shown encouraging clinical results. However, translation from an experimental to routine procedure poses several challenges. Herein we describe a model that led to the implementation of NRP into standard clinical practice in our centre following an iterative process of refinement incorporating training, staffing and operative techniques. Using this approach we achieved a four-fold increase in trained surgical staff and a 6-fold increase in competent senior organ preservation practitioners in 12 months, covering 93% of the retrieval calls. We now routinely provide NRP throughout the UK and attended 186 NRP retrievals from which 225 kidneys, 26 pancreases and 61 livers have been transplanted, including 5 that were initially declined by all UK transplant centres. The 61 DCD(NRP) liver transplants undertaken exhibited no primary non-function or ischaemic cholangiopathy with up to 8 years of follow-up. This approach also enabled successful implementation of ex situ normothermic liver perfusion which together with NRP contributed 37.5% of liver transplant activity in 2021. Perfusion technologies (in situ and ex situ) are now supported by a team of Advanced Perfusion and Organ Preservation Specialists. The introduction of novel perfusion technologies into routine clinical practice presents significant challenges but can be greatly facilitated by developing a specific role of Advanced Perfusion and Organ Preservation Specialist supported by a robust education, training and recruitment programme.

Gender differences in the assessment, decision-making and outcomes for ventricular assist devices and heart transplantation: An analysis from a UK transplant center.

There are marked gender differences in all etiologies of advanced heart failure. We sought to determine whether there is evidence of gender-specific decision making for transplant assessments, and how gender effects outcomes. Retrospective analysis of adult heart transplant assessments at a single UK center between April 2015 and March 2020. Females were 32% of referrals (N = 137 females, 285 males), with marked differences between diagnoses - 11% ischemic and 43% of adult congenital. Females were younger, shorter, weighed less, and had lower pulmonary pressures. Females were much less likely to receive a ventricular assist device (13%). Blood type "O" females were relatively more likely compared to males to receive a transplant (45%). Comparing males and females who received a ventricular assist device, both had similar levels of high pulmonary pressures, indicating consistent decision-making based on hemodynamics to implant a device. Overall survival was better for females (in noncongenital patients), and this was due to female patients who were not accepted for transplant or a ventricular assist device being more often "too well for transplant," rather than in males when they were more often "unsuitable." Marked gender differences exist at all stages of the heart transplant assessment pathway. Appropriate decision-making based on clinical grounds is shown with less transplants in male blood type "O"s and hemodynamic criteria for ventricular assist device implantation in both genders. Further studies are needed to determine if there is a wider community bias in advanced heart failure treatments for females.

Extending the Transplant Practitioner Role within the National Organ Retrieval Team to Include Organ Care Practitioner

<h3>Purpose</h3> Since 2014, the Transplant Practitioner (TP) has been an established member of the National Organ Retrieval Service (NORS) at one of the UK's transplant centres. The TP is a registered nurse who is competent in perfusion and preservation of retrieved cardiothoracic organs. With the advent of novel technology such as the Organ Care System (OCS) following Donation after Circulatory Death (DCD) the need to expand the role of a senior TP to include Organ Care Practitioner (OCP) has emerged and offered solution to the skills shortfall. <h3>Methods</h3> The OCS is a portable ex-vivo organ perfusion system which can preserve a donor heart in a near-normothermic beating state from retrieval until it is disconnected for transplant. Various methods of training were launched to extend the TP's role of practice. External training to OCS headquarters in Boston, Massachusetts was undertaken in order to develop skills and expertise on how to operate this innovative technology effectively and safely. In-house teaching sessions were also initiated by other competent members of the NORS team. Moreover, further peri-operative exposure was provided to the trainees during retrievals to develop confidence and competence with the specialist equipment as well as maintain skills. TP is deemed competent upon successful completion of a DCD heart competency pack. <h3>Results</h3> This advanced competency to the role of the TP has allowed role progression and increased expertise responsibilities for non-medical nursing staff. Having this additional skill has allowed our centre to be fit for purpose prior to the introduction of the National DCD Retrieval Service in September 2020. Nineteen machine perfused hearts out of twenty-three organ retrievals that were operated by a TP were successfully transplanted. <h3>Conclusion</h3> The expanded role of the TP as both organ preservation and Organ Care Practitioner continues to be successfully expanded within NORS which ensures that a NORS team maintains resilience.

Nursing Staff at Transplant Centre Increase Their Oncall Responsibilities to Ensure National DCD Heart Pilot Can Continue

<h3>Purpose</h3> In September 2020 the UK Joint Innovation Fund commissioned a pilot in order that the UK transplant community could assess the feasibility of formally commissioning a National DCD heart transplant programme. The pilot is scheduled to finish in May/June 2022. Three transplant centres provide organ procurement support for this initiative with one centre (Centre A) providing 50% of the cover and two centres providing 25% each (Centres B and C). Centre A utilises its nursing staff to operate the organ perfusion device whilst the rest of the teams use their medical staff or perfusionists. This nurse led element is unique to Centre A and has been a great success in advancing the extended role element of our nurses. <h3>Methods</h3> Centre C was unable to continue to support the pilot due to local workforce pressures. The nursing team from Centre A proposed that they increase their oncall activity and a plan was put in place to introduce a "Hybrid" team. A ‘Hybrid' team was introduced with surgeons from Centre B attending DCD heart retrievals and all of the nursing team consisting of the perfusion practitioner, organ preservation practitioner and scrub nurse attending from Centre A during the week every month where historically Centre C would have covered the pilot. This resulted in increased activity for both remaining centres, a new and collaborative way of working between two different transplant centres and also resulted in minimising the risk of the pilot failing. <h3>Results</h3> The "hybrid era" has ensured that 9 patients in the UK have been transplant who otherwise might not have been due to the lack of an available procurement team. The table below shows some of the benefits of this new way of working. <h3>Conclusion</h3> Inter Organisational collaboration instigated and implemented at short notice by the nursing staff at one of the UK Transplant Centres has ensured that the National pilot continued and that many patients received a transplant that otherwise might not have.