Transplantation

Recognising the commonly faced obstacles in establishing kidney transplant programmes, TLC has developed an innovative model that supports units in LMICs as they progress through the stages of development (Fig. 1). In most instances, local clinicians who recognise the clinical needs will contact TLC, having heard of its developments in other countries. These motivated champions of local patients with CKD then liaise with TLC to establish whether their centre is likely to be able to initiate and maintain a kidney transplant programme. Scoping visits to potential units by TLC are fundamental to this process. Such visits include the following:

(a)

Assessing the experiential base of existing nephrology, surgical, and nursing personnel regarding kidney transplantation.

(b)

Reviewing the appropriateness of medical facilities, including clinical areas, anaesthetic rooms, and operating theatres; identifying radiology and laboratory resources, including vascular imaging, tissue typing, and drug level monitoring.

(c)

Supporting the local team in their interactions to obtain senior managerial and political support for their programme.

Fig. 1

The six phases of development in the TLC model. MoU - memorandum of understanding; Tx - transplant

Paediatric kidney transplant services are invariably lacking in the early stages of unit development and must be set up de novo. To this end, TLC encourages the development of paediatric transplantation alongside adult transplant programmes. The availability of experienced paediatric nephrologists is a frequently encountered challenge; it is rare for units to have a resident paediatric nephrologist. However, some centres have started paediatric programmes with older paediatric patients who are faring poorly on dialysis and who may be managed by adult nephrologists as they progress toward a parent-donated live donor kidney transplant.

Once initial assessments are complete, central to TLC’s approach is ensuring local skills in kidney transplantation are developed and sustained. This is initially achieved by providing support and logistical guidance to establish the necessary infrastructure. After that, in-person TLC visits occur alongside frequent remote mentoring meetings online to assist local clinicians in arranging and then performing paediatric kidney transplants. TLC relies on a group of NHS specialists in transplantation (surgeons, nephrologists, nurses, and operating theatre technicians) who donate their time to travel to partner countries to share their skills in kidney transplantation and to provide significant remote support in the work-up, postoperative, and long-term phases.

Remote, Internet-based teaching and frequent clinical discussions complement such visits. In addition, opportunities are provided for multidisciplinary transplant team members to undertake learning visits to high-volume kidney transplant centres in the UK, involving a mixture of hands-on experience and observerships for both nurses and doctors.

Mentorship then becomes continuous, open-ended, and tailored to the specific needs of each partner centre until a point of sustainability is achieved. The more specialist nature, and lower caseload of paediatric kidney transplantation for individual units, mean such services are more complex to establish than their adult equivalents, with self-sufficiency being a greater challenge. The absence of paediatric nephrologists means care of the children falls to adult nephrologists. In one instance, TLC has facilitated the development of a consultant-led paediatric nephrology service by supporting the training of a paediatric nephrologist through a 2-year hands-on training programme at a UK tertiary nephrology centre, before taking up the first paediatric nephrologist consultant post in their home nation. Such specialist training takes considerable planning, resources, and identification of a suitable placement at an appropriate time for the trainee. It is therefore important that partner centres are aware of these factors and are committed from the outset to a long-term vision of paediatric transplantation development.

A bespoke approach is taken with each partner centre to overcome hurdles specific to their country, to match local needs, and to address skill transfer requirements. Each new transplant programme moves through six phases of progress, as outlined in Fig. 1.

The overall goal is the establishment of sustainable transplant programmes to ensure patients can continue to benefit in the future, with TLC acting as the catalyst but not the effector of progress. TLC does not measure the success of its partner centres by the number of transplants performed each year but rather on the progression through the development phases outlined above. Partnerships with TLC are long-term, with ongoing support throughout all developmental stages. One TLC partner unit has now progressed to phase 6; this progression took over 10 years to achieve. Such progress depends on teamwork, communication, and managerial and government support. Also, there must be fundraising to cover the costs of TLC support, teaching, visits, and, crucially, the generosity of NHS volunteers using their vacation time to travel and share skills.

Patient and public involvement

As well as working closely with the selected centres, TLC strives to support local colleagues impacting their local kidney healthcare landscape. TLC has helped partner colleagues increase public and patient awareness of the benefits of kidney transplantation over other forms of KRT. This has included recruiting vital political and managerial support for kidney transplant programmes and helping to create demand for transplant programmes at other sites. Since children with CKD may often not progress to dialysis in LMICs, kidney centres have the challenges of establishing KRT services and potentially identifying children, not on dialysis, who would benefit from preemptive transplantation. Increasing awareness in patients and families, as well as politicians, healthcare managers, and hospital staff, of the benefits of kidney transplantation is vital in helping to facilitate treatment for those children in or approaching kidney failure [18]. Looking to the future, TLC is actively exploring the establishment of networks between partner centres so that new transplant units can ultimately act as referral centres for countries with too small a population to establish a transplant centre.

TLC has also worked with local clinicians to engage with politicians and policymakers, advocating for financial investment to ensure that programmes mentored by TLC are maintained, trained staff are retained, and teams are expanded as demand increases. TLC supports such lobbying in partner countries through assisting with the preparation of policy and strategy documents and attendance at stakeholder meetings, working alongside key members of the local clinical teams.

The achievements of centres mentored by TLC have helped prove that the blocks to developing successful paediatric transplantation services can be overcome, even though this may take time. Indeed, the model adopted by TLC has been shown to work when there is a long-term commitment from all stakeholders. However, despite frequent contact and continued channels of communication with politicians, TLC’s experience has frequently been that such long-term commitment from policymakers is very difficult to obtain. Paediatric kidney transplantation remains low on the political agenda in many of the countries in which TLC has worked, emphasising the absolute need for ongoing and persistent lobbying of politicians and policymakers.