J De Meester

The new eurotransplant kidney allocation system : Report one year after implementation

BACKGROUND Upon the availability of a cadaveric donor kidney, a delicate allocation process precedes every transplantation. A remodeled Eurotransplant Kidney Allocation System (ETKAS)-derived from simulation studies-was installed in March 1996. The purpose was to adjust long waiting times and international exchange balances, while aiming at an optimal HLA-mismatch distribution. The new ETKAS consisted of a point-score system that was 100% patient oriented. METHODS The impact of the new ETKAS on the composition of the waiting list, and the outcome of the allocation procedures during its first year, were evaluated and compared with the results obtained in 1995. RESULTS The percentage of long-waiting patients and of patients with poorly matchable HLA phenotype increased significantly, from 9% to 19% and from 19% to 29%, respectively. Zero HLA-A-, HLA-B-, HLA-DR-mismatched patients still comprised 23% of the kidney transplant activity. The kidney exchange of the different Eurotransplant countries became balanced within 4 months; this persisted during the rest of the year. Pediatric patients had a high transplantation rate due to an assignment of extra points. The composition of the waiting list showed, after 1 year, fewer long-waiting patients and fewer patients with rare HLA phenotypes. CONCLUSIONS The new ETKAS was able in its first year to meet the goals set at its introduction. In comparison with the old ETKAS, there was a better trade-off between HLA matching and waiting time. The value of computer simulation studies has been demonstrated impressively in the context of organ allocation.

Changing patterns in organ donation in Eurotransplant, 1990–1994

Abstract Organ transplantation has become the treatment of choice for patients with end‐stage organ failure and has led to progressive increases in the size of waiting lists over the past decade. Unfortunately, from 1990 to 1994, the number of organ donors remained stable while the number of organs transplanted from these donors increased by only 10 %. In view of the severity of the current organ shortage, elderly individuals are increasingly being accepted as organ donors. The graft survival rate with kidneys from donors older than 55 years is 5 % lower than that with kidneys from younger donors at 1 year and 9 % lower at 3 years post‐transplantation. Graft survival is also significantly lower with organs from donors who die from cerebrovascular accidents than it is with organs from donors whose cause of death is cerebral trauma. The number of patients waiting for a nonrenal donor organ has increased rapidly in the past 5 years, and an increasing number of donor kidneys are now being provided by multior‐gan donors. The favorable graft survival rate with multiorgan donor kidneys, which is significantly better than that obtained with single organ donor kidneys, confirms their suitability for renal transplantation.

Outcome of machine-perfused non-heart-beating donor kidneys, not allocated within the Eurotransplant area

Abstract Eleven non‐heart‐beating (NHB) donor kidneys considered vital during machine perfusion (MP), could not be allocated inside Eurotransplant (ET). With the help of ET, five kidneys were transplanted in Karachi and six in Basel. Our goal was to prove that NHB kidneys successfully passing MP viability tests can be transplanted safely. Methods: Donor age, serum creatinine (some post‐mortem) and warm ischaemic time were, respectively, (mean and range): 44 (14–70) years, 137 μmol/1, and 44 (9–80) min. Reasons for refusal were: bold ureter (one), suboptimal flush (one), relatively long hypotensive phase (seven), and donor age of 70 years (two). After 8 h of MP, mean lactate dehydrogenase, intrarenal resistance and alpha glutathione S‐transferase were (including range): 556 U/l (range 366–819 U/l), 0.86 mmHg/ml per min (0.41‐1.15 mmHg/ml per min) and 1188 μg/1 (575–2677 μg/1), respectively. Mean cold ischaemic time was 45 (range 28–72) h. Results: Two kidneys showed immediate function, and nine showed delayed function. Mean creatinine levels after 1, 3 and 6 months were 295, 200 and 206 μmol/1, respectively. Four patients died for reasons not related to their kidney transplantation. Conclusions: We claim that MP can successfully assess viability of NHB donor kidneys. The reluctance to accept MP, and judged vital, NHB donor kidneys is no longer justified.

Renal retransplantation of children: Is a policy ‘first cadaver donor, then live donor’ an acceptable option?

Abstract: Retransplantation is often a necessity for children with end‐stage renal disease (ESRD), as kidney graft survival is still not infinite. If a suitable live donor is present, the current policy is to use the live donor first, in order to obtain excellent long‐term outcome and to prevent human leucocyte antigen (HLA) sensitization. Data from the Eurotransplant International Foundation were analyzed to determine whether the sequence, first a cadaveric donor then a live donor, is acceptable. Between January 1 1983 and December 31 1995, 1305 children received a first renal transplant; 269 of them had a second transplant during the same period. Follow‐up of at least 1 yr was available. Categories were made according to the sequence of renal donor source: 217 patients were classified as first cadaver and second cadaver (1cad‐2cad) transplant, 26 as first cadaver and second live (1cad‐2liv) donor transplant, 23 as first live donor and second cadaver (1liv‐2cad) transplant and three patients had two subsequent live donor transplants (1liv‐2liv). When a live donor transplant was carried out, either first or second, the donor age was always higher, and the chance of a pre‐emptive transplantation or short stay on dialysis was higher, compared with a cadaver transplant. The re‐graft survival rate of the ‘1cad‐2liv’ was better than the ‘1cad‐2cad’ and ‘1liv‐2cad’ transplants. At 5 yr, the survival was 76%, 49%, and 61%, respectively. These data suggest that, when a suitable live donor is not available for a first transplantation owing to medical and/or familial reservations, a policy of ‘first a cadaver donor then a live donor’ transplantation is a viable option and should even be promoted. The pre‐emptive stage of the second transplant, probably with a live donor, is additionally advantageous.

Multiorgan donation in the Netherlands : Limited by consent and policy

The percentage of multiorgan donors (MOD) versus single organ donors of kidneys only (SOD-K) has remained markedly low in the Netherlands compared to the other countries in the Eurotransplant region. This suggests a possible loss of donor organs. We investigated the causes of this persisting low percentage of MOD by studying the reasons for kidney donation only. All kidney donors in the Eurotransplant region in 1992 were studied retrospectively. In order to be able to make a comparison between all countries investigated, non-heart-beating donors and donors older than 55 years were excluded. Medical reasons were the most frequent cause for kidney donation only in the Netherlands, but this was not significantly different from the other countries in the Eurotransplant region. Multiorgan donation in the Netherlands was restricted by upper age limits for heart and liver transplantation and by the consent system.

Facts and Figures of Eurotransplant

In 1967, a proposal was made to set up an international structure to be called Eurotransplant (ET) to organize organ exchange and organ transplantation [1]. The main reason for such an international non-profit organization was based on the prediction that optimal tissue typing, i.e. typing for the antigens of the Major Histocompatibility Complex, the so-called HLAantigens, and matching of donor and recipient for these antigens would improve the outcome of organ transplants. The original goals of ET are: to ensure optimal use of donor organs to help to improve transplant results through HLA-typing and matching of donors and recipients to support these aims through careful follow-up analyses of the transplantation results.