Changing patterns of clinical decision making: are falling numbers of antibody incompatible transplants related to the increasing success of the UK Living Kidney Sharing Scheme?

BACKGROUND Antibody incompatibility is a barrier to living kidney transplantation; antibody incompatible transplantation (AIT) is an accepted treatment modality, albeit higher risk. This study aims to determine changes to clinical decision making and access to AIT in the UK. METHODS An electronic survey was sent to all UK renal transplant centres (n=24), in 2014, and again in 2018. Questions focused on entry & duration in the UKLKSS for HLA and ABO incompatible pairs, and provision of direct AIT transplantation within those centres. RESULTS Between 2014 & 2018, the duration recommended for patients in the UKLKSS increased. In 2014, 34.8% of centres reported leaving HLAi pairs in the UKLKSS indefinitely, or reviewing on a case by case basis, by 2018 this increased to 61%. Centres offering direct HLAi transplantation reduced from 58% to 37%. For low titre (1:8) ABOi recipients, 66% of centres recommended at least 9 months (3 matching runs) in the UKLKSS scheme in 2018, compared to 47% in 2014, 50% fewer units consider direct ABOi transplantation for unsuccessful pairs with high ABO titres (> 1:512). CONCLUSIONS Over time, clinicians appear to be facilitating more conservative management of AIT patients, potentially limiting access to living donor transplantation.