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Organ Shortage:
What Europeans Do About It


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JACQUELINE M SMITS, MD, PhD
Secretary of the Eurotransplant Thoracic Advisory Committee
Eurotransplant International Foundation
Leiden, The Netherlands

jsmits@eurotransplant.org


"Whisky is for drinking; water for fighting over." - Mark Twain



Mark Twain was a visionary. More than a century after he warned us about a war over water, the Office of the US Director of National Intelligence issued a report on Global Water Security stating that the risk of conflict would grow as water demand is set to outstrip sustainable current supplies by 40 percent by 2030.1

After having experienced Hurricane Sandy in the Caribbean and North-America, and the floods in France and Italy, water scarcity is not really a topic that causes major concern. But we can learn a lot about the worldwide efforts to come to a better resource allocation of the blue gold: by decreasing waste of fresh water, by recycling used water and by desalinating salt water. It is easy to find analogies in heart and lung transplantation; we also need improved technologies, political support, and new ideas about how to re-address our relationship with a life sustaining scant resource.

In short: it is all about making the best of what we got.

Let's begin by believing the thesis that a zero waste or a zero discard rate of all offered donor hearts will solve our problem of organ shortage.2 By stopping to blame those OPOs who have not delivered as they should, we can free up creative energy and start cleaning up our own practices and procedures.

links imageAnd, there are a lot of things we can and should all do right now.

In Eurotransplant in 2011, 325 (35%) of all reported donor hearts were not used for transplantation.3 Recipient-related medical reasons as well as logistical factors are attributable for 11% of the reasons for organ discard (Figure 1). And, as has been shown with the introduction of the LAS system in the US, an optimal wait list management can positively influence the organ placement procedures, thereby increasing transplant volume.4

In contrast to the US, transplant physicians in Europe are faced with a changing donor profile. Median donor age for heart donors in Eurotransplant has increased from 30 years in 1990, to 38 years in 2002 and to 44 years in 2011 (Figure 2). links imageGiven that donor hearts are almost exclusively offered to high urgent (HU) patients (especially in Germany), clinicians do not want to add insult to injury, and are inclined to turn down organs from non-ideal donors.6 So we need to be able to better recognize a suitable donor.

Based on Eurotransplant data a donor heart score (DHS) has been created and validated.7 This DHS is based on 10 pre-procurement variables and can predict which donors are likely to be accepted for transplantation. This knowledge on experts' perceived risk of allograft failure can help in the decision to accept the offer and travel to the donor hospital and judge on-site the suitability of the organ.

Eurotransplant is an organ exchange organization and, within the framework of the different transplant laws imposed by the eight European countries that collaborate within Eurotransplant, we try achieve a maximum placement rate of all donors offered to us. We have two systems in place for increasing this efficiency.

The first system is called the rescue allocation. Donor hearts are offered to patients on the match list, in which the rank position is determined by several match criteria, including urgency status of the recipient and waiting time. If the heart offer has been rejected by at least three different centers because of donor-related medical reasons, the standard allocation (patient-oriented offer) can be switched to a rescue allocation (center-oriented offer). In 2011, 10% of all reported donor hearts could be spared from discard via this rescue scheme.

The second system called directional matching is introduced for the allocation of a specific type of extended criteria donors (ECD). For donors with pre-defined conditions (previous history of malignancy, sepsis, meningitis, drug abuse or positive virology), the treating physician denotes whether his patient would be willing to accept an organ from a donor with any of the above listed conditions. Only patients who, at time of listing, have given their consent for the acceptance of this type of extended criteria donor will be selected in the matching process. Hence these organs will only be offered to eligible recipients. In 2011, 4% of all reported donor hearts from this type of ECD were transplanted via the directional matching scheme.

Eurotransplant is at present incorporating the DHS into the directional matching scheme in order to further increase the efficiency of the offering procedure. Based on historical data we estimate that 10% of currently discarded donor hearts could be used if better recognized and matched by DHS, leading to an additional gain in organ placement of 2% of all reported hearts.

But finally, we are still stuck with not using 22% of our reported donor hearts. Hence, creativity is of utmost importance. This is also exactly the one and only demand from the ISHLT Links editors to authors. Thinking outside the box is a conditio sine qua non for creativity, so our remaining question inevitably brings us outside the ice box: How far can the discard rate be brought down by the introduction of machine perfusion for ECD organs? 8 For lungs there is evidence; several groups (Lund, Toronto, Vienna, Harefield and Gothenburg) have now reported successful transplantation of questionable lungs after ex vivo lung perfusion with a recovery rate ranging between 46% and 86% (Dirk Van Raemdonck, Annual Eurotransplant Meeting 2012).9,10,11,12 For hearts, nobody knows, so again we must lean on Mark Twain for insight.

"You can't reason with your heart; it has its own laws, and thumps about things which the intellect scorns." — Mark Twain, from A Connecticut Yankee in King Arthur's Court



Disclosure Statement: The author has no conflicts of interest to disclose.


References:

  1. http://www.dni.gov/index.php/newsroom/press-releases/96-press-releases-2012/529-odni-releases-global-water-security-ica?highlight=YToyOntpOjA7czo1OiJ3YXRlciI7aToxO3M6Njoid2F0ZXJzIjt9
  2. Russo MJ, Davies RR, Hong KN, et al. Matching high-risk recipients with marginal donor hearts is a clinical effective strategy. Ann Thorac Surg 2009; 87: 1066- 71.
  3. Eurotransplant: Donation, waiting lists, and transplantation. In: Oosterlee A, Rahmel A, eds. Annual Report 2011 of the Eurotransplant International Foundation; 2011.
  4. Chen H, Shiboski SC, Golden JA, et al. Am J Respir Crit Care Med 2009; 180: 468-474
  5. Nativi JN, Brown RN, Taylor DO, et al. for the Cardiac Transplant Research Database Group. Temporal trends in heart transplantation from high risk donors: are these lessons to be learned? A multi-institutional analysis. J Heart Lung Transplant 2010; 29: 847-52.
  6. Smits JM. Actual situation in Eurotransplant regarding high-urgent heart transplantation. European Journal of Cardio-thoracic Surgery 2012; 42: 609-611.
  7. Smits JM, De Pauw M, de Vries E, et al. Donor scoring system for heart transplantation and the impact on patient survival. J Heart Lung Transplant 2012; 31: 387- 97.
  8. Pirenne J. Time to think out of the (ice) box. Current opinion in organ transplantation. 2010: 15: 147-149.
  9. Zych B, Popov AF, Stavri G. et al. Early outcomes of bilateral sequential single lung transplantation after ex-vivo lung evaluation and reconditioning. J Heart Lung Transplant 2012: 31: 274-81.
  10. Neyrinck A, Rega F, Jannis F, et al. Ex vivo perfusion of human lungs declined for transplantation; a novel approach to alleviate donor organ shortage? J Heart Lung Transplant 2004; 23: S172-3.
  11. Aigner C, Slama A, Hoetzenecker K et al. Clinical ex vivo lung perfusion- Pushing the limits. Am J Transplant 2012; 12: 1839-47.
  12. Cypel M, Yeung JC, Liu M, et al. Normothermic ex vivo lung perfusion in clinical lung transplantation. N Engl J Med 2011; 364: 1431-1440.