Article

New perspectives for the organ transplantation market

Organ transplantation helps to save overall costs. Of all organ transplantations, kidney transplantation is the most frequent by a wide margin (66% of total transplanted organs in 2016).¹ Despite the high cost, various health economics studies found that the procedure is cost-saving. To mention one of the studies: “In conclusion, kidney transplantation is cost-effective across all donor types despite higher costs for marginal organs and innovative living donor practices.”²

September 2, 2019

Thomas Amrein

Portfolio Manager, Credit Suisse Asset Management

New perspectives for the organ transplantation market

The number of worldwide organ transplantations is rising

Between 2000 and 2016, worldwide organ transplantations have increased from around 40'000 per year to around 135'000 per year (total of kidney, heart, lung, liver, pancreas, and small bowel).³ Still, there would be many more organ transplantations if there were no severe bottlenecks present which lead to long waiting lists to receive an organ transplant. For example, the number of patients added to US transplant waiting lists each year—roughly 50,000—is dwarfed by the ~730,000 annual US deaths attributable to end-stage organ disease.⁴

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The bottlenecks to increase the number of transplants further

There are three bottlenecks that need to be addressed: Donor/recipient mapping, the shortage of available organs, and the lifespan a transplanted organ keeps working. For each of these challenges, digital health companies provide solutions. This Thematic Insight will mainly focus on how to address the shortage of available organs, and how to keep the transplanted organ working for longer.

Donor/recipient mapping

The problem of organ allocation is complicated, as there is a wide variety of factors that have to be combined. One of the limitations has been the time it takes to keep an organ outside of the donor fresh enough to bridge the distance to the recipient. This hurdle kept transplantation centers from sharing the characteristics of the patients on their waiting lists hospitals far away. However, if transportation of the organ is enhanced, there should be more matches possible on a geographically wider area.

"Every year, tens of thousands of Americans receive new organs. However, an average of about 8,000 people die every year waiting for the organs they need. " Alexandra Ossola⁵

Addressing the shortage of available organs

The global shortage of organs for transplantation has long been recognized as a major public health challenge, and the World Health Organization (Geneva) estimates that only 10% of the worldwide need for organ transplantation is being met.⁶

There are two primary reasons behind the shortage of available organs: First, not enough potential donors carry a document to allow using their viable organs in the event of brain death. Various governments have begun to raise awareness within their population towards this matter. Spain for example had great success in increasing organ donation, albeit with a somewhat controversial legislation change: When attempting to explain Spain’s success, it’s the ‘opt-out’ (or presumed consent) system for deceased organ donation that is perhaps cited more often than anything else. Opt-out means that a patient is presumed to consent to organ donation even if they have never registered as a donor.⁷

Second, current transportation methods where the organs are put on ice often cause damage to the organ, which gets worse the longer it takes before it can be implanted. Recent approaches offer promising solutions to this issue: By keeping the harvested organ alive in a healthier condition, many more organs are eligible for transplantation – thus the radius of organ supply can be greatly enhanced. An interesting and innovative technological solution towards this goal is a “Organ-in-a-Box” solution: The OCS acts as a miniature intensive care unit that keeps organs alive and healthy by preserving them in a natural state that mimics the human body so that organs can remain viable for transplant along the way to recipients.⁸

Solution from TransMedics — Source: TransMedics (2019): Discover the OCS Multi-Organ Platform Technology, URL: www.transmedics.com/ocs-hcp, 13.05.2019

Keep the transplanted organ working for longer

A transplanted kidney's lifespan is 15 to 20 years on average. If the kidney stops working, the patient is back on the waiting list for a new one. However, a second or even a third transplant is more complex, as finding a new good match between donor and recipient becomes increasingly difficult. In practice, this often results in patients having to undergo dialysis treatment for a long time, or even for the rest of their lives. To avoid this, extending the lifespan of transplant kidneys should be prioritized.⁹

Tests have recently been introduced to transplantation centers to monitor patients after transplantation. These tests are able to measure organ stress and help to take measures against organ failure. In many cases, an adjustment to the dose of immunosuppressing medication can keep the organ successfully engrafted and properly working. CareDX’s test, AlloSure, “is the first and only non-invasive test that assesses organ health by directly measuring allograft injury. AlloSure can accurately determine active rejection, enabling better management of […] kidney transplant patients. AlloSure is a clinically and analytically validated, non-invasive blood test that measures donor-derived cell-free DNA (dd-cfDNA), an indicator of kidney injury.”¹⁰

Solution from CareDx — Source: Allosure (2019): Cell-free DNA: a clear biomarker, URL: www.allosure.com, 13.05.2019

Cell-free DNA (cfDNA) is a clear biomarker: It is fragmented DNA in the bloodstream indicating cell injury and death. When graft injury occurs, donor-derived cell-free DNA increases in the blood. Measuring cfDNA is an accurate, non-invasive tool for kidney transplant surveillance – notably, it will enable the physician to adjust medication or to gauge whether the organ stress is due to any other factor, like poor medical compliance. Correcting before it’s too late enhances the long term success of the organ transplant, data that any transplantation hospital has to publicize.

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Why it matters

For end stage renal disease patients as an example, a kidney transplant is generally a lot more appealing than chronic dialysis. Even when dialysis can be done at home instead of having to go to a dialysis center (home dialysis), the process still requires time and comes at a high cost and several medical risks. However, waiting lists are long and could grow even further. Despite the high cost of a transplantation, even the payors are generally favoring transplantations as the health economics look quite positive because of lower chronic care costs. Long waiting lists are not satisfactory to anybody and also raise difficult questions on how to best allocate available organs to candidates. With better donor/recipient matching databases, progress in organ transportation which will in turn increase the number of useable organs, and tests to predict the health of the implanted organ, it should be possible to transform the organ transplantation market in a way that will enable more patients to profit from a transplanted organ.

Conclusion

Organ transplantation has been growing, but is still constrained by donor/recipient mapping, not sufficient availability of donor organs, and transplanted organs failing too soon. For all these challenges, digital health companies offer solutions to mitigate the constraints, thereby increasing the number of transplants and shortening the waiting list. It is difficult to overcome the hurdles for more widespread transplantation without taking into account these fundamentally new approaches. Only through the combination of these new approaches the whole transplantation segment can be revolutionized, and many more patients, but also the payer, can profit from transplanted organs.

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Fund Facts
Credit Suisse (Lux) Global Digital Health Equity Fund

Source: Credit Suisse, May 31, 2019

Fund management	Credit Suisse Fund Management S.A.
Portfolio manager	Credit Suisse Asset Management (Switzerland) Ltd, Zurich Thomas Amrein; Christian Schmid
Portfolio manager since	December 14, 2017
Fund domicile	Luxembourg
Fund currency	USD, EUR, CHF
Inception date	December 14, 2017
Management fee p.a.	For unit class A, B, BH and CB: 1.60%; For unit class EB and EBH: 0.90%
Management fee p.a.	For unit class IB and IBH: 0.90%; For unit class UB and UBH: 1.00%
TER (estimated)	Unit class A, B and BH 1.90%, unit class EB,EBH, IB and IBH 1.20%, unit class UB and UBH 1.30%
Maximum Sales Charge	5% for all unit classes except unit classes IB, IBH, EB and EBH (max. 3%)
Single Swinging Pricing (SSP)¹	Yes
Benchmark	MSCI World (NR)
Unit classes	Unit class B, CB, IB, UB, EB in USD, unit class BH, IBH and UBH in EUR, unit class BH and UBH in CHF
ISIN	USD unit class B:	LU1683285164	USD unit class UB³:	LU1683288424
	USD unit class IB:	LU1683285750	EUR unit class UBH³:	LU1683288770
	EUR unit class IBH:	LU1683285834	USD unit class EB²:	LU1683287707
	EUR unit class BH:	LU1683285321	CHF unit class BH:	LU1683285248
	CHF unit class UBH³:	LU1683288697	EUR unit class EBH²:	LU1683287889
	CHF unit class EBH²:	LU1796813662	EUR unit class A:	LU1877633989
	Please note that not all share classes may be available in your country.

¹ SSP is a method used to calculate the net asset value (NAV) of a fund, which aims to protect existing investors from bearing indirect transaction costs triggered by in- and outgoing investors. The NAV is adjusted up in case of net inflows and down in case of net outflows on the respective valuation date. The adjustment in NAV might be subject to a net flow threshold. For further information, please consult the Sales Prospectus.
² For Institutional clients only.
³ In Italy: For instituonal clients only.

Fund Risks
Credit Suisse (Lux) Global Digital Health Equity Fund

No capital protection: investors may lose part or all of their investment in this product.
Political developments concerning the health care sector could have a significant adverse impact on the Digital Health sector.
Exposure to small and mid caps can result in higher short-term volatility and may carry liquidity risk.
As the fund focuses on highly innovative companies, volatility can be significantly elevated.
Equity markets can be volatile, especially in the short term.

¹ www.transplant-observatory.org, last accessed on April 30, 2019
² www.ncbi.nlm.nih.gov, May 2018
³ www.transplant-observatory.org, chart section, last accessed on April 30, 2019
⁴ www.ncbi.nlm.nih.gov/pmc/articles/PMC5724041/#R1, last accessed on April 30, 2019
⁵ Source: “Crisis in America: Medical experts use new tech tools to combat the organ transplant shortage”, Alexandra Ossola, www.cnbc.com, June 21 2017
⁶ Source : www.ncbi.nlm.nih.gov/pmc/articles/PMC5724041/#R1, last accessed on April 30, 2019
⁷ Source : www.mosaicscience.com/story/spain-uk-organ-donation-transplants-liver-kidney-heart-lungs-surgery-nhs, last accessed on April 30, 2019
⁸ www.transmedics.com/ocs-heart, last accessed on April 30, 2019
⁹ Source: www.medicalxpress.com/news/2018-07-transplanted-kidneys-survive-longer.html, last accessed on April 30, 2019
¹⁰ Source : www.allosure.com, last accessed on April 30, 2019

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New perspectives for the organ transplantation market