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Great. Um So good afternoon, everyone. Er welcome to this er webinar. Er this is a state of the art and transplantation. Um And it's event that we're cohos between the um BTP T, which is British transplant, physician trainees and trots, which are training representatives in organ donation. So my name is Wakes. Er, I'm core of BTP T and Atro. Um and we organized this um webinar for the next hour to honor organ donation week. Um And we brought together training representatives from across the field of donation at transplant to give you an insight into the amazing work that's been performed um in UK transplantation. So we've got lots of really exciting talks um on organ organization or kidney, liver, heart and lung. And then at the end, we'll talk a little bit about organ donation week as well. Um So I'll get started and um if you have any questions, please put them in the chat. Um and our speakers will be more than happy to um to address them. So, first of all, um I'd like to introduce TWA who's ASDA in acute internal medicine and intensive care at um the Liverpool University Hospital and she's also um a trial dental or I MG representative of the Faculty Intensive Care Medicine. And she's going to be talking to us about all the donation. Um So thank you, I'll pass it over to you. T thank you so much. And as, as what I said, and we're going to talk to you about some updates and donation and transplant today, going to share my slides do this and I wish you all for us celebrating a happy organ donation week, right? So we're going to speak about some snapshot on donation. And instead of our transplant technologies that we're currently using and it evolve our um organ transplant field. I'm just going to start with some statistics. After this month, we have over 7700 people waiting transplant list. Around 20% of that number received transplant by April of 2024. Unfortunately, 400 people died while waiting on transplant list. This year, there is good increase in the number of deceased donor compared to the living donor. And there was um significant increase in DCD donors which eventually led to improvement of the numbers of heart transplant donor. And I will speak about this later, this slide show you how DCD donor evolved in the UK over the last two decades. Interestingly, DCD donor is now overtaken DVD donor and the ratio is 1.1 to 1 DCD to DVD. It's amazing to know that 85% of all transplant organs are reported successful and functioning by March of this year and is around 61,000 organ transplanted so far I will move into. And my next point is speak about the CT trial. CT is the largest trial in a donation field. And the research question is if we gave simvastatin single dose, 80 mg to a potential donor that declared that by neurological criteria, would that improve the transplant organ success rate? And it is mainly because the mevastatin reduced the inflammatory storm in a donor potential donor after um brain stem death. And this is mainly from a case series done in Hensin a few years ago which found that 80 it only had 85 cases in that case series, but they found simvastatin reduced primary organ dysfunction by 50%. So half of the primary organ dysfunction reduced by giving simvastatin in that case series. So we're hoping to see um a promising result mainly for heart donation. That's a primary outcome of this, of this trial. But it will also look at um lung, liver pancreas. We know the future is to have a R CS assessment, the recovery center but are still far away from that. So we have some state of arts perfusion technology like nomo region perfusion. There's two types that is thoracoabdominal and abdominal. So both of them use a circuit similar to va echo circuits. The cac abdomina, we cannulate um the aorta, the right atrium whereas the abdominal, we cannulate the femoral artery and vein and the arch of aorta get occluded by a balloon or a clip to prevent cerebral circulation. And this part of the body gets um transfused by um warm oxygenated blood. This is the comparison of DCD with N RP to conventional DCD and it improved the warm ischemic time significantly that we used to see in the conventional DCD and revolutionized transplant success rates this light um in some leading or contract. But EU countries like Spain and Italy, they do the can for N RP before withdrawal of care. But in UK, we mainly do it in the after withdrawal of care. And both of both of the two ways did reduce the warm ischemic time significantly. This is from the National N RP Protocol until it just to show you how the transplant team very meticulous in a step to achieve successful cannulation very quickly in theater after withdrawal of care. And the slide to show you the difference between the warm ischemic time in conventional DCD donor compared to an donor with N RP blue dusky. And this is almost like a um a normal living person. This video is from the UK and it show you um A Ta N RP. This transplant surgeon are cannul the heart, this cannulation of the right atrium, some hematoma here. Uh it shouldn't affect the aorta is occluded. And now you can see the heart is pumping again. After withdrawal of care, nice and pink cyst is to show you the abdominal N RP where we don't um cannulate the right atrium or the um thoracic aorta. This is the femoral artery, femoral vein and this is a folic catheter that goes in here and it, it inflates a balloon in the arch of aorta. So it will occlude the cerebral circulation and there would be no cerebral blood flow. There is a big trial um uh was published in lancet end of last year and it compared the transplant success rate of DPD to TA N RP. And interestingly, it is equal um Ta N RP transplant success rate is equal to DPD organ um outcome which is very interesting revolution revolutionized the transplant success rate. There's all there is ethical dilemma about. Um is it like CPR, are we initiating um blood flow in a person? So the N RP National Protocol have become more strict and strict. And more recently, they added the use of CT angio 30 minutes after establishing the donor on N RP to confirm that there is cessation of blood flow and the pu and Harfield uh and the pioneering that other modern modern transplant technologies like ex fever heart transplant um where the heart gets um transfused with one oxygenated blood and it stays in heart in the box. And this is allowed to reduce the time of form ischemic time, but also allow time to increase the window to transplant till the organ get assessed and the appropriate um recipient found similar to heart in the box. There is also lung in the box. Uh We don't have this in the UK. Sorry, we don't have the lung in the box in the UK yet. But um in this is, this is a video in the state and may clinic. Um It show you that's the lung in the box. Um uh get the lung in the box, get transfused by warm oxygenated blood and also it stay for assessment, waiting for recipient, increase the wind to transplant. I will conclude by saying all the previous point, the statin trials, the state of the art perfusion technologies had led to improvement of the DCD heart transplant UK is the world leader. It started over a decade mm sorry, nearly a decade ago and started in Harfield and PAP. Until now we have 100 25 functioning DCD heart transplanted and interestingly, their outcome is comparable to DPD heart transplant. Thank you to all modern state of the art proficient technologies for transplant. Big trials we are doing to improve the DCD heart outcome. Thank you very much. And this is the end of my talk. Thank you. T that's really great to see all the advances with machine perfusion and also the UK leading the way with the size of the CT trial. Um What do any questions you pop them in the chat? But otherwise we'll move on next to Eish Nemo, who's hopefully joining us here. So she is, she was previous chair of the Renal Spr Club and she's a secretary in BTP T and she is going to be talking to us about advances in renal transplantation. Uh Great, thanks so much. Um Let me just see if I can um share this. So can you see that? Ok. Yes, perfect. Yeah. Yeah, perfect. Great. Well, yeah, thank you so much. Um My name is Ailish. I'm a new kidney consultant in Bristol and I'm going to talk a little bit about advances in kidney transplantation um in the UK. So for kidney transplantation, um this is just one treatment that we have got for patients who have got established kidney failure. But compared to dialysis transplantation gives an improved quality and quantity of life and it's also a more cost effective treatment. So it's really what we want to be aiming to do for all of our patients that are fit to receive it. Um This is a slide from NHS blood and transplant and it's really just highlighting how our activity has been over the last 10 years. You'll see from this, that last year, there were just over 6000 patients in the UK awaiting a kidney transplant, which is the highest of all of our solid organ transplant numbers. And there were just under 2.5 1000 transplants performed over that same time period, which just highlights that there is a bit of a disparity between our supply and demand for organs. Um Apologies if this is a bit basic, but I thought it was worthwhile just pointing out that our kidneys can come from deceased donors either after brainstem death or circulatory death. But healthy individuals can also offer to volunteer a kidney and be a living kidney donor. And this can either be directed where people decide to donate a kidney to somebody that they know or non directed where they donate a kidney um altruistically to an individual that they don't have a prior relationship with. Um however, live donors may not be a matched with their intended recipient and that might be due to differences in their blood type or their tissue type in this situation. We've got the living kidney exchange program which started in the UK in 2007 and this offers new possibilities for living kidney transplants by allowing paired kidney donation. You'll see that the paired kidney exchanges have increased in complexity over the last 15 years with increasing numbers of pairs and now donor chains running um since 2018, all nondirected altruistic kidney donors enter the exchange program by default. And this aims to start up a longer chain um with someone at the end of it receiving a um kidney on the waiting list and these matching runs run every three months. Uh So four times a year and we've got the largest living kidney exchange program in Europe. So I guess the focus of this talk should really be thinking about advances in kidney transplantation and where things might go in the future. And I suppose I was kind of inundated with choices about the things that we could discuss in this. I think we're going to see a lot of advances. Um There will be increased use of artificial intelligence and machine learning and it's possible that this might help us in matching algorithms. Um In the future, we'll learn more about novel biomarkers of graft injury. And we might hear more about that in terms of cell free DNA. For example, in some of the other talks this evening, there'll be increased personalized or precision medicine where we may consider patients underlying genomics. Um to consider what types of immunosuppression might be most suitable for them. There'll probably be advances in different treatments. And for example, vaccinations against some of the common viral infections, which can affect her transplant recipients, for example, CMV. We might also see organ bioengineering where we try and create organs from stem cells. But for this, I'm just going to talk briefly about three areas um which I think are kind of more relevant in what we might see coming up in the future. Um The first is uh the consideration of a new treatment called Ilise, which is for desensitization of our highly sensitized uh transplant recipients. I'll then talk about xenotransplantation and finally, organ recovery centers. So highly sensitized patients are a challenge within kidney medicine. Um These are patients who have developed antibodies that can recognize proteins on uh kidneys that they receive from a donor. And the development of these antibodies might occur after patients receive a blood transfusion through pregnancy or after a prior transplant. Now, these highly sensitized patients mean that they are not able to receive kidneys from many donors because they would have an increased risk of acute rejection. This limits the organs that are available to them and results in them having higher waiting times. And because our patients have a lot of complications on the waiting list with increased risk of cardiovascular disease and mortality. It's a big challenge for us to look after these patients. Well, over the last year, we have had access to a new medication called Ilise, which is an IgG G endopeptidase. And this is now available for use in our highly sensitized patients for undergoing transplantation. I lidase is essentially a, an enzyme which breaks down the um heavy chain of I GG and prevents IgG mediated anti dependent cellular toxicity. So, we'll try and reduce the risk of these patients developing an acute antibody mediated rejection. The initial studies using this drug were performed in Sweden and the United States and good short term outcomes have been reported here both in terms of graft outcomes and patient survival. So the top part of this picture here just shows the change in serum creatinine levels at transplantation and up to six months after in these two studies. And you'll see that patients had a lovely fall in their creatinine after transplantation, which was maintained up to six months out in the UK. We've started having access to this medication over the course of this year. And the first transplants have been performed using it, but it's going to take us some time for us to be able to report on our own outcomes and learn how best we can use this drug to help our highly sensitized recipients. Now, and I'm just going to talk briefly now about xenotransplantation. So xenotransplantation literally means the transplantation of cells or organs across species. And a lot of progress has been made recently in trying to modify the pig genome to try and reduce some of the immunological barriers and uh potential incompatibilities between pigs and humans. So to um do xenotransplantation, you're we're able to take a kidney from a pig um which has uh been genetically modified for this. The pig needs to have a triple knockout, which means that all carbohydrate swine antigens need to be removed. The pig needs to be free from porcine endogenous retroviruses. And we need to have fully humanized or transgenic transmembrane proteins which are involved in the coagulation and complement pathways. But with this, a genetically modified pig can have its kidney removed and it's implanted along with the thymus and that's to try and reduce the host uh T cell activation and this can then be transplanted into a human. Um, this paper on the uh left side here um was published in 2022 and it reports two cases um of a kidney from a pig transplanted into a brain dead um human recipient in the USA. This was done as a study over 54 hours er, to assess patients um kidney function, they found that the kidneys remained well perfused, they produced urine and the uh creatinine fell in the recipients biopsies that were taken also showed that there was no evidence of hyperacute or antibody mediated rejection. Following this, we've gone on to perform the first transplant of a pig kidney into a living person, which again was performed in America in March of this year. Sadly, the recipient has subsequently passed away. But I think this was a huge step forward in terms of our um knowledge and experience in xenotransplantation. And it may well be that we continue to see this develop over the coming months and years. And finally, I was just going to mention Oregon Recovery Centers, which I know that we have just heard briefly about Oregon Recovery Centers are a centralized um hospital that can manage and optimize brain dead donors. The aim of them is to have a dedicated and highly experienced group of staff that can really work to optimize the circumstances around organ donation. With the aim of this improving long term transplant outcomes. Organ recovery centers have been well established in the USA. And although here they've been transformational, we need to consider how this would work in our country with a national organ recovery system and also increased use of DCD organs and whether we could afford the costs with uh transporting potential donors and organs across the country. Um In this report from the Department of Health and Social Care that was published last year, however, which was on honoring the gift of donation, you'll see here that one of their recommendations was for National Multiorgan Centers for Organ Assessment and repair to be established to try and help provide uh and the maximize the number and quality of organs that are available for transplant and to support logistics at transplant centers. Um So that was just a very brief overview of some of the advances that we've seen in kidney transplantation and what I think we might expect to see over the coming 5 to 10 years. Thanks so much. Thank you. That was a really great overview of um renal transplantation and you're well ahead in many areas of uh novel biomarkers of personalization and the and lia certainly has a lot of implications for many organ groups. So, thank you. Um It's my pleasure to introduce next um Doctor Yuen Chung. So she is the National BTP T lead for um liver transplantation. She's a South London Gastroenterology and Hepatology trainee taking, undertaking phd at King's College Hospital and she's going to be talking to us about updates in liver transplantation. Thanks. Ok. Yeah. So hopefully everyone can see the slides and I'm so glad to be part of this event today. So I'm going to be talking a little bit about the new things going on in liver transplantation. And there are sort of recurring themes during this event and we've heard about some of the machine perfusion techniques from T. So just to start and the number of premature deaths from liver disease in the UK is on the rise and this is dated from the last 20 years. And the main culprit driving this is related to an increase in alcohol related liver disease and steatotic liver disease. So then this is then driving the demand for liver transplantation very much like kidneys and donors from for liver transplantation can either be from living donors but predominantly for liver, these are from uh deceased donors. And within the deceased donors, predominantly they are from um DVD organs and only a small number are from DCD organs because typically these are associated with inferior outcomes, namely primary nonfunction, early allograft dysfunction and ischemic cholangiopathy. This is data from the HB N HSBC website and it shows that the number of deceased donors for liver transplantation is on the rise, especially in the last three years. Despite this, the demand for liver transplantation is unmet and so patients are still dying on the transplant waiting list or they are being delisted because they simply become too sick. When we're talking about DCD organs, they can be either from controlled death or uncontrolled death and in controlled death, this is a planned withdrawal of life sustaining treatments and the majority of DCD organs are coming from this group. So when I talk about sort of optimizing DCD organs, this is the group I'm talking about. So historically, uh liver was preserved. Um Once it's been retrieved, it's preserved in a cold preservation solution. And then this cold solution reduces the metabolic demand. And this has been the gold standard for decades because it's a relatively simple technique, it's been effective. So it hasn't really changed that much until the last 1015 years. The downside to this um static cold storage method is that the prolonged oxygen deprivation is what risks ischemic injury resulting in the poorer outcomes with the DCD organs. So this is where machine perfusion comes in because it improves the quality of these marginal organs and reduce wastage. The first technique to mention is called hypothermic oxygenated perfusion and otherwise known as hope. So, once the liver is retrieved, this is an X situ perfusion method similar to the static cold storage. But the difference is that the perfusion solution is oxygenated and the idea is that it restores the metabolic state of the mitochondria and restoring this metabolic state of the hepatocytes then reduces um the ischemic injury and the poor outcomes associated with DCD organs. The other machine perfusion technique to mention is normothermic machine perfusion and again, just perfusion method. And this time, you can see that the perfusion solution is a blood based solution. And as the name suggests, this is a normothermic procedure. So it's preserved at 37 degrees. So it simulates more in vivo conditions. So now that we have these machine perfusion techniques is trying to compare how they do to the gold standard, which is the static called storage. So this was a recent meta analysis looking at randomized controlled trials which compared hope versus static cold storage or NMP versus static cold storage. And this essentially showed that both machine perfusion techniques reduce early allograft dysfunction when compared to static cold storage. Both machine perfusion techniques also is likely to reduce il complications and then hope um device seems to show a significant reduction in graft loss and retransplantation rates when compared to static cold storage. But one thing to note about these trials is that the outcomes were based on one year post transplant, meaning as relatively short term outcomes. And so we still need more long term data from um sort of a multicenter collaborative effort. So then we already heard a little bit about normothymic regional perfusion. And as TWA said, it is essentially like an ECMO machine for the organs. So this is an in situ perfusion method. So once um soon after circulatory death, the organ is then reperfused with oxygenated blood using like an ECMO machine. And so this then really closely mimics what it's like to to retrieve ad BD organ. So how does an NMP and N RP all compare to um the gold standard static cold storage? So this was a single center retrospective data from Cambridge comparing static core storage versus in situ N RP versus the exit NNP. And much like the previous meta analysis, both machine perfusion techniques reduce early allograft dysfunction. When compared to static cold storage. The NRP um had less biliary complications compared to NM P as well. And N RP also had less transplant failure and AK when compared to static cold storage. So then this is the updated um guidelines from BT S which endorses N RP as a machine fusion method. And so just drawing this altogether. I would say that there is a rise of chronic liver disease, especially within the eye coated liver disease and steatotic liver disease. Increasing the demand for liver transplantation. There is an ongoing disparity between donor liver supply and the transplantation demand that's not going to go away. But the advances in technology including machine perfusion methods, hopefully aims to maximize the utilization of the donor organ pool and reduce this gap. Thank you. I that's a really great talk, interesting developments in organ storage and potential application of machine perfusion. I think it's quite important and how it relates to the development of organ recovery centers we were talking about earlier as well. So we'll move on to the next talk, which we're very grateful for Sally to join us as my favorite organ. And she's a National B CPT lead for Heart Transplantation and she's post CT cardiology fellow at, with Ensure Sound over to you, Sally. Ok. Uh I'll just share my slides, my signal. Let's see if this will work. Thanks. Uh You and bye bye. OK. Can you see this? Ok, great. Um So, yeah. Um I'm uh a post CCT fellow in with, in Manchester. Uh And um I'm the same, obviously, the heart is my favorite organ. So I'm gonna convince everyone um oh, try and impress everyone with what we're doing. So, uh what I'm gonna talk about is um a few different things. So uh just a bit about uh the transplant journey in general. So, you know, transplants, not just taking an organ out and putting it in to someone else. There's a lot of pre and post uh transplant optimization that involves a lot of people and a lot of different methods. Uh And I'm gonna tell you a bit about a case that we've had here in Manchester to illustrate that, learn a bit about the national activity and then uh some exciting developments on the horizon on the horizon for us. So, as I said, um transplant is, you know, a, a long journey. It's not just the, the operation of, of transplant in the organ and, and in hearts. Um We have various different methods that we use, sort of pre and POSTOP um to optimize our patient. And that's really important because obviously you want to optimize the patient's other organs prior to uh transplant. Um and things that we do uh things from medical, things like inotropes to make the heart pump better um to give the patient a period of stability to improve their end organ function. Um And also uh more advanced things like mechanical circulatory support of which there are some uh images here um of which we've talked about uh one of them, which is ECMO, uh other things start up a bit more basic. So the picture on the left is a balloon pump that augments cardiac output um echo. As we said, this is a picture of central ECMO. So this is uh draining from the right atrium, passing the blood through a pump and an oxygenator and putting it back into the er exendin aorta. So just bypassing the heart altogether and then uh on the very right, but this is a AAA so a right ventricular assist device. Um and this is similar uh in terms of bypassing a part of the heart. Um but this is done again centrally um and can stay in a bit longer than ECMO. So just to tell you a bit about a patient that we've had here recently to illustrate some of these things. This was a 31 year old female who had a three year history of a dilated cardiomyopathy with very reduced pump function. On the left side of her heart, she was having recurrent ventricular arrhythmias, low BP, limiting uh what medication we could give her for her heart failure. Very poor exercise tolerance, uh proven on the CPX and a very high uh biomarker um that we use in heart failure, which is the anti BMP. And on the right there is just illustrating that she was meeting a lot of criteria um to go on the the non urgent or the routine waiting list for, for her heart. So because she was hitting those markers, we brought her in for transplant evaluation just to make sure there was no other reason why she couldn't progress with that while she was an inpatient. She had um as part of her assessment, right, heart catheterization, which is uh a way of getting uh accurate hemodynamics on a patient. And this showed her cardiac output which was very low. Um And her liver and kidneys were not working very well. So she had to go on inotropes uh to kind of give her some stability um because she couldn't be weaned off the inotrope, she was urgently listed this time for heart transplant. So, on the right there is the urgent criteria that we use um which is patients in the hospital uh in her case, unweanable from intravenous inotropes. There's some other categories there that are mainly around congenital heart patients. So she stayed in the hospital, wait for her heart for one month. Um She was relatively stable in that period of time. On the inotropes, she had ad BD donor heart, which we've mentioned briefly what that involves. And the transplant actually went quite after the surgery was uncomplicated. However, that same night, she developed yeah, low cardiac output. Um on the monitor, increase in lactate, low urine output showed that the right ventric right ventricle had failed completely. And as a result, she had very high pulmonary artery pressures. Subsequently, she actually very quickly on the unit, an ICU lost output. And so she had um ears arrest where she ended up getting opened up on ICU and placed on VA ECMO as we er explained earlier. So this is uh just taking the hat out of the, the hat out of the equation completely. Um So she was on ECMO for about six days. We tried to wean her from that and unfortunately, we were unable to, the right ventricle was still very weak. And so she was placed on uh an A a which I explained earlier. So again, taking the right ventricle completely out of the equation and replacing it in that period of time, we managed to optimize her other organs, uh rehab her so that people could walk around the unit on these, she was weaned off a tracheostomy and then it was removed with good LV function, only mildly impaired IV function. Subsequently, she was then discharged from the ICU. And now she's on the ward, immobilizing uh with normal kidney and liver function. She subsequently had biopsies that show she's got no rejection. So she's doing really well. So that was just really to illustrate how much work sometimes goes into these patients. And it's not always straightforward to talk about a more national level um in terms of transplant in the UK patients on the routine list, that was the first one we discussed weight on average about 18 to 24 months. The entire operation when it happens, takes about 4 to 6 hours and we've talked about a bit of this. Ok. The OK. It, in one of two ways, apologies guys, I think my network connection, it's as expected. NHS Wi Fi can still, can still hear you sort of, it's better with the camera off. Can't hear you anymore. Sally, we might just stop there with you, Sally if that's alright. I think the next then I think the signal's cutting out quite a bit. Um not state of the art, it for sure, even if it's state of the art transplantation. Um and that's ok, we'll move on to the next one and thanks Sally for her talk. I think she was going to demonstrate really the power of um er DCD program that's had in the UK. It's really impressive. A significant proportion. It now contributes to heart transplantation in the UK. So really the effectiveness of using technology er in transplantation. And next, I'd like to um introduce Rup. Who's our National B TBC Lung par lead. She's a specialist vegetarian and respiratory medicine in North London, a specialist interest in interventional pulmonology. Um and she's going to be talking to us about updates in lung transplantation. Thanks. R thank you. Um and just share my screen. Um I hope it's visible now. Yes, perfect. Yeah. Fantastic, good evening everyone. I'm Dram. I'm one of the specialty registrars in respiratory medicine and uh BTP T respiratory lead representative. Uh I'm going to uh talk about lung transplantation, an overview and go through basics and talk about some advances in UK. Uh So, lung transplantation who undergoes it. Uh It's basically for chronic end stage lung disease patients who are on maximal medical therapy and they have a 50% risk of death from lung disease within two years. And they should also have high probability at least 80% of them of surviving for five years after transplantation from medical perspective. Um So, conditions which are considered for transplant. Uh There are a variety of conditions. Uh most common uh uh groups are diffuse parenchymal lung diseases, obstructive lung diseases, out of which COPD is the commonest indication for lung transplant, pulmonary vascular diseases, like idiopathic pulmonary hypertension. Um uh forms a big chunk for transplantation, suppurative lung diseases, cystic fibrosis, non CF, bronchiectasis are also considered for transplant, absolute contraindications. Um Any recent malignancy, solid or hematological malignancy in last five years is an absolute contraindication if the patients have high BMI or any significant dysfunction in another major organ system, especially heart, if they have a LV, dysfunction or coronary artery disease, which is not amenable to PCI or CBG, it's unlikely that the patient would be taken up for transplantation unless there is discussion about a double organ transplant, which has to go through the MDT teams. Any unstable medical condition like sepsis or being denied to you for a prolonged period, significant chest wall or spinal deformities, which can affect the surgical approach and postoperative complications, substance abuse, active or in last six months. Um alcohol or drug abuse. These are absolute contraindications. Um The patient need to be abstinent from these uh for at least six months. Um Just a second. I don't know why it is auto playing my slides. Um OK. Um psychiatric or psychological conditions uh that would affect uh the further uh adherence to medical therapy. Um is also a contraindication. Uh relative contraindication, especially I would like to mention uh colonization with holter species or if they have uh mycobacteria fungal or viral infections, they can be treated and then patients sometimes are accepted for transplant uh age above 60 years. Um Again, the patients have to go through uh the team meetings to make sure that they are physio they have enough physiological reserve to uh have good outcomes from the surgery. The types of transplants that are done um are either a single lung transplant or a double lung transplant. A single lung transplant is less common, but it helps to save organs because different lungs can be used for two patients. Um The outcomes are slightly less um um positive than double lung transplant where survival is higher. Uh COPD and ILD patients um usually undergo single lung transplant, can be right or left and right lung transplant have um more survival, higher survival than left lung, single transplant patients. Um Single lung transplant is performed via standard open thoracotomy and is usually performed off pump and double lung transplant is the most common type of transplant, which is uh almost 80% of transplants. Uh pulmonary hypertension, severe infections are the most common cause of uh most common indication. I'm just going to come out because it's auto playing. Sorry about that. Um double lung transplant. Uh It is a sequential procedure. Uh The first, the native lung is excised and then the first allograft is reperfused and then the second lung is um you know, transplanted. Each allograft has their own separate bronchial, pulmonary and pulmonary vein anastomosis. Avoid about donor acceptance criteria as set by is HLT ideal donor would be uh somebody whose age is less than 55. There should be A B compatibility. No chest lung infiltrates. Uh ba two more than 40 kg pass on 100%. 2 very small tobacco history, no chest traumas, no evidence of aspiration or sepsis and no prior cardiopulmonary surgery and sputum gram stain should be negative and bronchoscopy should be clear. Uh In UK, we perform around 1.4 lung transplants for a million population which is uh far behind um European populations. So the main issue is with the lack of donors. Um So the the towards uh increase in donor po via donation after circulatory death, as it has been previously discussed for other organs, that nother regional perfusion and direct procurement perfusion is being used that allows to increase the donor pool by almost 30 to 50% in lung transplantation. What we use is ex vivo lung perfusion. Um how it works is that the donor lungs are perfused outside the body using a device that can ventilate it and maintains it at normothermia. There are various protocols that are used in it. And the main advantage is that EVLP allows assessment of the donor lungs which otherwise might have been rejected. Um If not for this um perfusion modality and they can be assessed and repaired and even conditioned and sometimes they can be even superior to how they were harvested. Uh This is the EVLP machine. Uh The donor lung is connected to the uh pump where the blood is recirculated after it passes through the oxygenator and is maintained at normal the temperature, the trachea is connected to the ventilator where it it undergoes protected ventilation. Bronchoscopy can be performed through this um to uh suction out any secretions to look inside uh the bronchi for any intra bronchial obstruction. So, this is the general flow. How EVLP works. The blood is obtained goes into a sterile reservoir and via the centrifugal pump, it un um goes through the heat exchanger and the deoxygenator and via the filter, it is uh recirculated back into the circulation. So the greatest advantage of EVLP is uh that it mimics physiological conditions. And it serves primely as a thorough assessment of borderline lungs which could be otherwise rejected. And it allows um the centers to perform um a lung, higher number of lung transplant procedures by almost 15 to 30%. Another thing I wanted to talk about was uh UK lung allocation scheme. Uh So the scheme in UK uh prioritizes patients based on their clinical criteria rather than their geographical locations. And we have three tiers uh super urgent lung allocation, urgent and non urgent lung allocation system according to which the patients are categorized. And this has reduced the waiting time for sickest patients uh from almost 4, 27 days to 292 days. As shown by some of these studies, the waiting list mortality in UK is up to 10 to 20%. And uh the average waiting time in UK for lung transplant is up to 18 months. A word about opt out system in UK, it was introduced in May 2020 consent is presumed unless explicitly refused by the donor or the family. Uh Northern Island, Scotland Wales. We all have similar systems and of course, the evaluation, this uh system was put in place during COVID and hence the evaluation of it is still ongoing. Uh To conclude, we have some advances in technology which are promising, which can increase the donor pool. Uh But of course, um uh a larger donor pool is required to improve the number of transplants being done in the UK. There are multiple ethical, social and cultural issues which are a barrier to increasing the pool and of course, collaboration uh amongst various healthcare and countries will lead to a better outlook in future. Thank you. Thank you r um um really just really dramatic change since the development of cystic fibrosis treatment and a really interesting approach you discussed between single, double lung transplant and the potential of EB RP. Um So yeah, any questions do pop them in the chat and uh and the speakers will answer them. Um So the last thing I'd like to do is just introduce um Dale who is really a world expert in organ donation and ethics. He's got many roles who's been the National Clinical Lead for organ donation since 2018. Um And, and it's just transparent and he's come today to offer a reflection on the talk today and tell you more about organ donation week. Thank you very much. Well, thank you. Well, this is a real honor to actually speak and listen to the talks. I've just come back from the transplant society meeting in Istanbul, which there's more time in hotels than it was actually seeing any sights. But I think the talks I've just heard rival them if not exceed most of what I heard in Istanbul. So it really was a great state of the art. It's very exciting that this initiative with the British transplantation, physician trainees group is a really important thing to take us forward into the next steps in the UK. We often punch above our weight given our number of donors. And I think that's because we do things right, especially think about the policies and aspects. Ah, we're in a bit of a crisis at the moment. Transplant waiting list is now at a decade long decade high of 7.5 1000 as Tawa shared. And it's just very sad because in the last decade, we were seeing it steadily going, improving, improving, improving, even as donation was rising, but it was just everyone working together. But COVID'S really knocked things back. Some of it is on the donation side because post COVID, people's support for the NHS has really dropped. In fact, there is a you gov poll, you can Google which asks the public is the NHS good or bad and 70% of the public thinks bad at the moment. And we think our consent rate follows the society's attitude towards donation and the NHS wide up. Um The other aspect of course, is utilization and actually using the gifted organs. And that's so important for those who are in the transplant side that we maximize every gift. And you heard a lot about the technologies today and I won't go through all the ones we heard. But we're exploring and looking at all of these as we advance, we are like I said, this is organization week where that people are going to heading up to the peaks and going to paint the peaks pink pink is our color because apparently and good to see a few people wearing it. I've got my little badge as well. Everyone apart from teenage boys like pink. So that's why we went to pink in about 2013 and you'll see lots of sites, historical buildings that may have been lit up pink. And really, it's great. I think in the past it was called Transplant Week. And we really realized that we also need to, it was become Donation week because we had to focus in on the donors and that's what people were trying to reach. But I think we've lost something about more transplant people taking part in organ donation week and really supporting it and getting more recipient stories out there. So anything you can do you don't have to be a donation side to wear pink. Everyone else involved in this. And I just thought I'd just finish with just reflections more on a career in donation and transplantation. I think it's just astonishing for me. We're on the cutting edge of so much which has given me a career's worth of interest. Yes. The science xenotransplantation machine perfusion. Maybe we can grow organs one day immunology. So many topics we are at the cutting edge of and that's incredibly fantastic. We're at the cutting edge of ethics. When are you dead? Can we do this? Who owns the organs when they're in a box afterwards? Does it go to the recipient or is it actually the donor, their policy working with government in ways that many other specialties have no chance to even get into the room with governments? The whole communication around consent. Some of the ways the difficult consent conversations we have both on a donation side and a transplant side are just incredibly fascinating resource allocation organs as pressure resource is incredible. And I also think professionally having just come back from the TT S transplant society and all the meetings. We've got a family, we're actually quite a small worldwide group. And when I actually get up, go to an international meeting, it is like seeing old family again. And so I want to welcome you all who are going down this path to that family. And the last thing I say would just be to reflect, of course, on our families and our patients because I think none of this would be possible without them. And it's a reason we do everything and those personal stories, even on the donation side of actually seeing someone's end of life decision, respected, seeing the benefit, it can bring the comfort, it can bring to families on the donation side. And then of course, seeing the lifesaving gift on the other side of the coin and seeing lives transformed, nothing else compares. So I just want to applaud what you were doing. Welcome you to our professional family and I look forward to seeing much more and that one day one of you will have my job and all the professors jobs out there and you'll be on the world stage as well. Thank you, Dale. Um and thank you for everyone to join us today and all all our speakers who take the time to join today and share all their stories. I say if you're interested in um be joining BTP T or becoming a trod, I highly recommend it. It's a really fantastic team to work with a really rewarding bit of medicine. So do check it out. It's all, all the links are online. I hope you'll pass on the message about organ donation. We can support all the activities this week as they all said this. Um you can get all this um lovely er pink Brch from your, er, S nods, er, for your local sno if you're interested. Um, and this talk will be recorded and free to access on me with all our previous um, educational videos. So please do share with people I'll end there and I hope you all have a lovely evening. Um, and thank you for joining us.