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Nephrology 20 (2015) 227–228
Editorial
Thai transplant registry: An important resource for the Asia Pacific region In high-income nations including the USA, UK, Australia, New Zealand and the majority of European countries, most patients with end-stage kidney disease are considered potential candidates for transplantation. Transplantation, in particular deceased organ donation, is organized and in most cases funded through publicly regulated health systems. One of the important aspects of such systems’ organisation has been the prospective and systematic collection of comprehensive patient and centre data regarding all aspects of dialysis and transplantation in registries. Such registries are well established in these countries.1–3 More recently, registries collecting data from other regions including Latin America4 and China5 have become established. By prospectively collecting together data on outcomes from many centres, registries overcome the limitations of single-centre reports and small case series, with their inherent risk of publication and other biases. Regular publication and analysis of registry data have provided the basis of much of our current understanding of transplant outcomes and current practice patterns, and underpinned many of the important and critical epidemiological studies in this field. This is particularly important, as randomized controlled trials to evaluate the efficacy and safety of different approaches to transplantation have not been possible in many instances. For example, registry data have provided important assurance of the safety of transplanting kidneys from donors after circulatory or cardiac death, an increasingly important source of organs.6 Important observational findings can lead to hypothesis generation for possible interventions to improve transplant outcomes. Data can also be used to inform discussions with patients about prognosis. By tracking transplant activity and outcomes, registries can assist in the future planning of health care and can provide important data for quality assurance. Recently, registry data have begun to be used as a basis for evaluating individual transplant programmes, facilitating increased reporting to stakeholders including health funders and consumers. In many middle-income and newly industrialized nations, including in South East Asia, transplantation activity has been increasing. However, to date, there has been relatively limited collection of data into transplant registries and very few studies reporting on these data. The paper by Noppakun et al.7 featured in this issue of the journal reports on transplant outcomes from the Thai Transplant Registry, which was established in 2002. The publication of this study reporting on 25 years of kidney transplantation in Thailand represents a significant achievement for the collaborative efforts of the Thai transplant community who have worked to collect and © 2015 Asian Pacific Society of Nephrology
analyse this data, and provides a vital resource for ongoing analysis, and to enable continued improvement in transplant outcomes. The majority of kidney transplants in Thailand are now funded through government-funded universal health care schemes, with less than 10% of transplants being performed in private hospitals. Brain death criteria were originally established in 1989 and later amended in 1996, and a regulated system for organ donation is now well established. Transplantation from both living and deceased donors is increasing, although access to transplantation for patients with ESKD remains limited overall (7.0 transplants per million population) compared with high-income countries such as New Zealand, Australia, United Kingdom or the USA (between 27.0 and 56.5 per million). In their study, Noppakun et al. report 5-year patient survival for recipients of live and deceased donor transplants in the period 2007–2012 of 96.6% and 93.1% respectively.7 These outcomes have improved steadily over time and compare favourably with other jurisdictions. This is reassuring, as the mean age of recipients at transplant was a relatively young 42 years. Similarly, the mean donor age was 36 years overall – 35 years for deceased (brain dead) donors – and extended criteria donors were fewer than 3%. Most Thai organ donors die following road traffic trauma; Thailand has the second highest rate of road traffic deaths per million population in the world,8 in part due to a longstanding low rate of motorcycle helmet use. This is in contrast to many high-income countries where the majority of organ donors are older people who have died following a cerebrovascular accident and the age of recipients is somewhat higher. Additionally, the most frequent cause of ESKD was glomerulonephritis, in contrast to other countries with much higher rates of diabetic nephropathy and the cardiovascular disease that accompanies this. Several other findings are worth pointing out as they present potential areas to focus improvement efforts. A relatively small number of centres (six of the 26 reporting data) have undertaken the majority of transplants; nearly half (n = 12) of centres have performed less than 50 transplants over the entire time period. The multidisciplinary and steep learning curve nature of transplantation means that, inevitably, centres with less experience and volumes may well have inferior outcomes, and centre effects could be investigated in future analyses. Whether rationalisation of the number and distribution of centres is warranted is a matter for transplant professionals and health administrators in Thailand, but these effects might well be reflected in the 227
Editorial
relatively high rate of delayed graft function in both live and deceased donors (11% and 34%, respectively), although other factors that might be relevant such as ischaemic time are not reported. There is also a high rate of recipient death due to infection, and further analysis of this to identify potential areas for intervention is warranted. There are a number of limitations to this study that need to be taken into account in any consideration of its findings. Data were only collected prospectively from 2002 onwards; prior data are thus likely to be less reliable. There was a 6.2% loss to follow-up in the 25-year analysis period although most of this was of patients transplanted prior to 2002. There is a large amount of missing data on causes of death and graft loss, and minimal data on rejection episodes. There is also a lack of reliable data for live donor transplants undertaken in private hospitals. More importantly, the extent of capture of information on graft loss and deaths from linkage with national records (e.g. where patients are no longer under the care of a transplant centre) is unclear. Similarly, systemic audit of data accuracy is not yet in place, although this is not necessarily standard practice in registries elsewhere.9 In conclusion, the report by Noppakun et al. represents an important milestone in the establishment of a transplant registry from a large South East Asian nation with an evolving transplant programme. Other countries in the region with developing transplant programmes that have not yet established a registry will, it is hoped, be inspired to emulate this success. Taking into account differences in the ESKD population, and the limitations of the data, transplantation outcomes in Thailand appear comparable with other countries. Challenges remain however. Establishment of procedures to ensure complete collection of information from all transplant centres are necessary, and the auditing of data accuracy would be desirable. Linkages with other sources of health information including national death data and the Thai dialysis registry would be of great value. Important future initiatives could include the collection of data on outcomes for live donors, the establishment of a registry of data on organ donors and collaboration with other transplant registries to harmonize data collection practices and facilitate
228
international comparisons. With improvements in data accuracy and completeness, this registry will become an important resource for epidemiological and observational research in transplantation in the Asia Pacific region. MICHAEL G COLLINS1,2 and PHILIP A CLAYTON3,4 1
Department of Renal Medicine, Auckland City Hospital, 2School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand, 3Australia and New Zealand Dialysis and Transplantation (ANZDATA) Registry, Adelaide, South Australia, and 4Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
REFERENCES 1. Collins AJ, Foley RN, Chavers B et al. US Renal Data System 2013 Annual Data Report. Am. J. Kidney Dis. 2014; 63: A7. 2. McDonald SP, Russ GR. Australian registries-ANZDATA and ANZOD. Transplant. Rev. (Orlando). 2013; 27: 46–9. 3. Pruthi R, Casula A, MacPhee I. UK Renal Registry 15th annual report: Chapter 3 demographic and biochemistry profile of kidney transplant recipients in the UK in 2011: National and centre-specific analyses. Nephron Clin. Pract. 2013; 123 (Suppl 1): 55–80. 4. Cusumano AM, Gonzalez Bedat MC, Garcia-Garcia G et al. Latin American Dialysis and Renal Transplant Registry: 2008 report (data 2006). Clin. Nephrol. 2010; 74 (Suppl 1): S3–8. 5. Liu L, Zhang H, Fu Q et al. Current status of pediatric kidney transplantation in China: Data analysis of Chinese Scientific Registry of Kidney Transplantation. Chin. Med. J. (Engl) 2014; 127: 506–10. 6. Summers DM, Johnson RJ, Hudson A, Collett D, Watson CJ, Bradley JA. Effect of donor age and cold storage time on outcome in recipients of kidneys donated after circulatory death in the UK: A cohort study. Lancet 2013; 381: 727–34. 7. Noppakun K, Ingsathit A, Pongskul C et al. A 25-year experience of kidney transplantation in Thailand: Report from the Thai Transplant Registry. Nephrology (Carlton) 2015; 20: 177–83. 8. Sivak M, Schoettle B. Mortality from Road Crashes in 193 Countries: A Comparison with Other Leading Causes of Death. Ann Arbor, MI: The University of Michigan Transportation Research Institute, 2014. 9. Gray NA, Mahadevan K, Campbell VK, Noble EP, Anstey CM. Data quality of the Australia and New Zealand Dialysis and Transplant Registry: A pilot audit. Nephrology (Carlton) 2013; 18: 665–70.
© 2015 Asian Pacific Society of Nephrology
Nephrology 20 (2015) 227–228
Editorial
Thai transplant registry: An important resource for the Asia Pacific region In high-income nations including the USA, UK, Australia, New Zealand and the majority of European countries, most patients with end-stage kidney disease are considered potential candidates for transplantation. Transplantation, in particular deceased organ donation, is organized and in most cases funded through publicly regulated health systems. One of the important aspects of such systems’ organisation has been the prospective and systematic collection of comprehensive patient and centre data regarding all aspects of dialysis and transplantation in registries. Such registries are well established in these countries.1–3 More recently, registries collecting data from other regions including Latin America4 and China5 have become established. By prospectively collecting together data on outcomes from many centres, registries overcome the limitations of single-centre reports and small case series, with their inherent risk of publication and other biases. Regular publication and analysis of registry data have provided the basis of much of our current understanding of transplant outcomes and current practice patterns, and underpinned many of the important and critical epidemiological studies in this field. This is particularly important, as randomized controlled trials to evaluate the efficacy and safety of different approaches to transplantation have not been possible in many instances. For example, registry data have provided important assurance of the safety of transplanting kidneys from donors after circulatory or cardiac death, an increasingly important source of organs.6 Important observational findings can lead to hypothesis generation for possible interventions to improve transplant outcomes. Data can also be used to inform discussions with patients about prognosis. By tracking transplant activity and outcomes, registries can assist in the future planning of health care and can provide important data for quality assurance. Recently, registry data have begun to be used as a basis for evaluating individual transplant programmes, facilitating increased reporting to stakeholders including health funders and consumers. In many middle-income and newly industrialized nations, including in South East Asia, transplantation activity has been increasing. However, to date, there has been relatively limited collection of data into transplant registries and very few studies reporting on these data. The paper by Noppakun et al.7 featured in this issue of the journal reports on transplant outcomes from the Thai Transplant Registry, which was established in 2002. The publication of this study reporting on 25 years of kidney transplantation in Thailand represents a significant achievement for the collaborative efforts of the Thai transplant community who have worked to collect and © 2015 Asian Pacific Society of Nephrology
analyse this data, and provides a vital resource for ongoing analysis, and to enable continued improvement in transplant outcomes. The majority of kidney transplants in Thailand are now funded through government-funded universal health care schemes, with less than 10% of transplants being performed in private hospitals. Brain death criteria were originally established in 1989 and later amended in 1996, and a regulated system for organ donation is now well established. Transplantation from both living and deceased donors is increasing, although access to transplantation for patients with ESKD remains limited overall (7.0 transplants per million population) compared with high-income countries such as New Zealand, Australia, United Kingdom or the USA (between 27.0 and 56.5 per million). In their study, Noppakun et al. report 5-year patient survival for recipients of live and deceased donor transplants in the period 2007–2012 of 96.6% and 93.1% respectively.7 These outcomes have improved steadily over time and compare favourably with other jurisdictions. This is reassuring, as the mean age of recipients at transplant was a relatively young 42 years. Similarly, the mean donor age was 36 years overall – 35 years for deceased (brain dead) donors – and extended criteria donors were fewer than 3%. Most Thai organ donors die following road traffic trauma; Thailand has the second highest rate of road traffic deaths per million population in the world,8 in part due to a longstanding low rate of motorcycle helmet use. This is in contrast to many high-income countries where the majority of organ donors are older people who have died following a cerebrovascular accident and the age of recipients is somewhat higher. Additionally, the most frequent cause of ESKD was glomerulonephritis, in contrast to other countries with much higher rates of diabetic nephropathy and the cardiovascular disease that accompanies this. Several other findings are worth pointing out as they present potential areas to focus improvement efforts. A relatively small number of centres (six of the 26 reporting data) have undertaken the majority of transplants; nearly half (n = 12) of centres have performed less than 50 transplants over the entire time period. The multidisciplinary and steep learning curve nature of transplantation means that, inevitably, centres with less experience and volumes may well have inferior outcomes, and centre effects could be investigated in future analyses. Whether rationalisation of the number and distribution of centres is warranted is a matter for transplant professionals and health administrators in Thailand, but these effects might well be reflected in the 227
Editorial
relatively high rate of delayed graft function in both live and deceased donors (11% and 34%, respectively), although other factors that might be relevant such as ischaemic time are not reported. There is also a high rate of recipient death due to infection, and further analysis of this to identify potential areas for intervention is warranted. There are a number of limitations to this study that need to be taken into account in any consideration of its findings. Data were only collected prospectively from 2002 onwards; prior data are thus likely to be less reliable. There was a 6.2% loss to follow-up in the 25-year analysis period although most of this was of patients transplanted prior to 2002. There is a large amount of missing data on causes of death and graft loss, and minimal data on rejection episodes. There is also a lack of reliable data for live donor transplants undertaken in private hospitals. More importantly, the extent of capture of information on graft loss and deaths from linkage with national records (e.g. where patients are no longer under the care of a transplant centre) is unclear. Similarly, systemic audit of data accuracy is not yet in place, although this is not necessarily standard practice in registries elsewhere.9 In conclusion, the report by Noppakun et al. represents an important milestone in the establishment of a transplant registry from a large South East Asian nation with an evolving transplant programme. Other countries in the region with developing transplant programmes that have not yet established a registry will, it is hoped, be inspired to emulate this success. Taking into account differences in the ESKD population, and the limitations of the data, transplantation outcomes in Thailand appear comparable with other countries. Challenges remain however. Establishment of procedures to ensure complete collection of information from all transplant centres are necessary, and the auditing of data accuracy would be desirable. Linkages with other sources of health information including national death data and the Thai dialysis registry would be of great value. Important future initiatives could include the collection of data on outcomes for live donors, the establishment of a registry of data on organ donors and collaboration with other transplant registries to harmonize data collection practices and facilitate
228
international comparisons. With improvements in data accuracy and completeness, this registry will become an important resource for epidemiological and observational research in transplantation in the Asia Pacific region. MICHAEL G COLLINS1,2 and PHILIP A CLAYTON3,4 1
Department of Renal Medicine, Auckland City Hospital, 2School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand, 3Australia and New Zealand Dialysis and Transplantation (ANZDATA) Registry, Adelaide, South Australia, and 4Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
REFERENCES 1. Collins AJ, Foley RN, Chavers B et al. US Renal Data System 2013 Annual Data Report. Am. J. Kidney Dis. 2014; 63: A7. 2. McDonald SP, Russ GR. Australian registries-ANZDATA and ANZOD. Transplant. Rev. (Orlando). 2013; 27: 46–9. 3. Pruthi R, Casula A, MacPhee I. UK Renal Registry 15th annual report: Chapter 3 demographic and biochemistry profile of kidney transplant recipients in the UK in 2011: National and centre-specific analyses. Nephron Clin. Pract. 2013; 123 (Suppl 1): 55–80. 4. Cusumano AM, Gonzalez Bedat MC, Garcia-Garcia G et al. Latin American Dialysis and Renal Transplant Registry: 2008 report (data 2006). Clin. Nephrol. 2010; 74 (Suppl 1): S3–8. 5. Liu L, Zhang H, Fu Q et al. Current status of pediatric kidney transplantation in China: Data analysis of Chinese Scientific Registry of Kidney Transplantation. Chin. Med. J. (Engl) 2014; 127: 506–10. 6. Summers DM, Johnson RJ, Hudson A, Collett D, Watson CJ, Bradley JA. Effect of donor age and cold storage time on outcome in recipients of kidneys donated after circulatory death in the UK: A cohort study. Lancet 2013; 381: 727–34. 7. Noppakun K, Ingsathit A, Pongskul C et al. A 25-year experience of kidney transplantation in Thailand: Report from the Thai Transplant Registry. Nephrology (Carlton) 2015; 20: 177–83. 8. Sivak M, Schoettle B. Mortality from Road Crashes in 193 Countries: A Comparison with Other Leading Causes of Death. Ann Arbor, MI: The University of Michigan Transportation Research Institute, 2014. 9. Gray NA, Mahadevan K, Campbell VK, Noble EP, Anstey CM. Data quality of the Australia and New Zealand Dialysis and Transplant Registry: A pilot audit. Nephrology (Carlton) 2013; 18: 665–70.
© 2015 Asian Pacific Society of Nephrology
