#6884 THE BARRIERS TO TRANSPLANTATION IN OUR DIABETIC HAEMODIALYSIS POPULATION AT THE LEEDS TEACHING HOSPITALS NHS TRUST
Authors: Gauci Maria Angela , Ahmed Marwa , Gullapudi V R Latha , Wright Mark 
Published: June 2023

Abstract

Background and Aims
According to the 24th Annual Renal Registry Report, diabetes is the most common identified primary renal disease in patients starting renal replacement therapy (RRT). The prevalence of this underlying disease amounted to 30.5% by the end of 2020, a statistic which increased from 27% in 2015. This highlights the challenges faced by healthcare services in meeting the accrescent demands of this cohort of patients. The Renal Association and British Transplantation Society suggest that patients with a BMI &gt;30 kg/m2 are at a heightened risk of complications and is therefore discouraged. Our local transplant centre at St James's University Hospital accepts recipients with a BMI of up to 35 kg/m2 for kidney alone transplantation should no other medical/ surgical contraindications to transplantation prevail. Despite this threshold, there remains a significant proportion of patients suspended from the deceased donor transplant waiting list due to an unacceptably raised BMI.

Method
Data was collected through the use of clinic letters or GP records uploaded to Patient Pathway Manager and BHLY (Bradford, Hull, Leeds and York) Renal Patient System. Our patient population consisted of those diabetic patients on home and in-centre haemodialysis (Leeds St James's University Hospital, Pontefract, Seacroft, Beeston, Dewsbury, Calderdale and Huddersfield). The aims of our study are to assess the demographics of the diabetic haemodialysis (HD) population at the Leeds Teaching Hospitals NHS Trust, to determine the reasons for suspension from the renal transplant waiting list, with a particular interest in obesity. We also assessed the commonest treatment modality (insulin vs other) and the use of continuous glucose monitoring.

Results
The Leeds renal services provide haemodialysis for 631 patients, 248 of these being diabetic patients - 66% of whom are male, with a mean age of 60. Just over 50% of this cohort of patients are Caucasian in ethnicity, while 30% are South Asian. By the end of December 2022, just below 20% (n = 119) of all haemodialysis patients were active on the national deceased transplant waiting list. On the other hand, only 14% (n = 35) of the diabetic haemodialysis subpopulation were active by the end of 2022, while 13% (n = 31) were under assessment, 14% (n = 35) declined and/or disengaged from assessment for transplantation, while the rest were either temporarily or permanently suspended. Almost 10% (n = 24) of all diabetic haemodialysis patients are suspended due to a BMI &gt;35 kg/m2.

Conclusion
Our audit reveals that only 14% of the haemodialysis diabetic population is presently active on the deceased transplant waiting list. This remains suboptimal, as renal or simultaneous pancreas kidney transplantation is the gold standard for diabetes-induced ESKD. Obesity (BMI &gt;35) was a reason for temporary suspension in 10% of our haemodialysis diabetic population. Therefore we need to target this comorbidity in a timely manner in order to optimise patients for transplantation. NICE recommend pharmacological weight-lowering therapy for people who have failed to achieve a healthy BMI following conservative methods. Such medical therapy (eg. liraglutide) is still yet to be evaluated in depth in the ESKD-haemodialysis obese population. Only one patient in our cohort was being treated with liraglutide, while the rest was either on insulin, linagliptin, gliclazide or non-pharmacological dietary modification. The authors of this study encourage the inclusion of CKD5 patients on liraglutide, before they are started on haemodialysis, in order to pave their way to transplantation before it is too late.