J. Smits

How to Recognize a Suitable Pancreas Donor: A Eurotransplant Study of Preprocurement Factors

INTRODUCTION Because of the increasing demand for pancreas transplantation, more marginal donors are offered to Eurotransplant. The aim of this study was to validate a donor quality score that would facilitate recognition of a suitable pancreas donor among all reported donors. MATERIALS AND METHODS We analyzed all 3180 consecutively reported pancreas donors for the period between January 1, 2002 and June 30, 2005 and determined the influence of the preprocurement pancreas suitability score (P-PASS) on the acceptance of a pancreas. We defined a range and point weight for each variable based on clinical expertise and known literature. RESULTS Multiple regression analysis using pancreas acceptance as an outcome variable identified P-PASS > or = 17 as a significant cutoff point (P < .001). Pancreata from donors with P-PASS > or = 17 were three times more likely to be refused. CONCLUSION The donor score can help in screening for potential pancreas donors, where an ideal donor has a P-PASS < 17. Our data demonstrate that consideration of a combination of preprocurement factors can help identify a suitable pancreas donor. Therefore, we recommend that a pancreas donor score be calculated for each potential pancreas donor, and all donors with a P-PASS < 17 should be considered for pancreas donation.

Predictors of lung transplant survival in eurotransplant.

This study was undertaken to assess the influence of patient/donor and center factors on lung transplantation outcome. Outcomes of all consecutive first cadaveric lung transplants performed at 21 Eurotransplant centers in 1997–99 were analyzed. The risk‐adjusted center effect on mortality was estimated. A Cox model was built including donor and recipient age and gender, primary disease, HLA mismatches, patients residence, cold ischemic time, donors cause of death, serum creatinine, type of lung transplant, respiratory support status, clinical condition and percentage predicted FEV1. The center effect was calculated (expressed as the standardized difference between the observed and expected survival rates), and empirical and full Bayes methods were applied to evaluate between‐center differences. A total of 590 adults underwent lung transplantation. The primary disease (p=0.01), HLA‐mismatches (p = 0.02), clinical condition(p < 0.0001) and the patients respiratory support status (p = 0.05) were significantly associated with survival. After adjusting for case‐mix, no between‐center differences could be found. An in‐depth empirical Bayes analysis showed the between‐center variation to be zero. Similar results were obtained from the full Bayes analysis. Based on these data, there is no scientific basis to support a hypothesis of possible association between center volume and lung survival rates.

Proposition: the benefit of cardiac transplantation in stable outpatients with heart failure should be tested in a randomized trial

Recent data suggest that cardiac transplantation is associated with a survival benefit only in patients at high risk for dying of advanced heart failure without this procedure. To test the hypothesis that survival and quality of life advantages associated with cardiac transplantation exist in stable outpatients, a 3-stage approach is proposed: 1). to establish a database within the International Society for Heart and Lung Transplantation/United Network for Organ Sharing/Eurotransplant infrastructure that will provide an estimate of the survival benefit of heart transplantation in various heart failure risk strata by prospectively following cohorts of patients listed for heart transplantation; 2). to organize an international consensus conference that will define, based on the review of the Stage 1 data, the feasibility of a prospective randomized trial; and 3). pending consensus, to perform a clinical trial, perhaps with an augmented, randomized design that allocates cardiac transplantation to all patients at high risk for dying of heart failure while randomizing patients at low risk to either conventional treatment or cardiac transplantation. Generating such scientific evidence is important in light of todays donor organ crisis and the associated difficulties of equitable resource allocation.

Introduction of the lung allocation score in Germany.

The aim of this study was to assess performance of the new lung allocation system in Germany based on lung allocation score (LAS). Retrospective analysis of waitlist (WL) outflow, lung transplantation (LTx) activity and 3‐month outcomes comparing 1‐year pre‐ and post‐LAS introduction on December 10, 2011 was performed. Following LAS introduction, WL registrations remained constant, while WL mortality fell by 23% (p = 0.04). Reductions in WL mortality occurred in patients with cystic fibrosis (CF; −52%), emphysema (chronic obstructive pulmonary disease [COPD]; −49%) and pulmonary hypertension (PH; −67%), but not idiopathic pulmonary fibrosis (IPF; +48%). LTx activity increased by 9% (p = 0.146). Compared to pre‐LAS, more patients with IPF (32% vs. 29%) and CF (20% vs. 18%) underwent transplantation and comparatively fewer with COPD (30% vs. 39%). Median LAS among transplant recipients was highest in PH (53) and IPF (49) and lowest in COPD (34). Transplantation under invasive respiratory support increased to 13% (in CF 28%, +85%, p = 0.017). Three‐month survival remained unchanged (pre: 96.1% and post: 94.9%, p = 0.94). Following LAS implementation in Germany, reductions in waiting list size and WL mortality were observed. Composition of transplant recipients changed, with fewer COPD and more IPF recipients. Transplantation under invasive respiratory support increased. Reductions in WL mortality were most pronounced among CF and PH patients.

Which ABO-matching rule should be the decisive factor in the choice between a highly urgent and an elective patient?

Abstract ABO blood group matching policy between donor and recipient is a key element of organ allocation. Unequal distribution of the ABO blood groups in the population can lead to inequities in the distribution of organs to potential recipients. Furthermore, High Urgency liver transplant candidates might compromise the chances of transplantation for the elective patients. To compare the influence of the various ABO blood group matching policies on the transplantation rate of HU patients and on the subsequent donor liver availability for elective patients, a simulation study was undertaken. The study shows that in the Eurotransplant liver allocation program, a restricted ABO‐compatible matching policy for HU liver patients offers the highest probability of acquiring a liver transplant, for both high Urgency‐ and elective patients, irrespective of their ABO blood group. A simulation study once again proved to be an elegant tool for objectively analysing various options in a complex organ allocation algorithm.

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.

Kidney preservation and graft outcome: Eurotransplant experience

In organ transplantation, preservation techniques are used to counteract loss of functional and structural integrity of the organ during the period starting with its removal from the donor and ending with its implantation into the recipient. Successful preservation would enable maximum utilization of donor organs, and organ allocation schemes to be in compliance with medical and ethical principles. It also would allow surgery to be scheduled as a semi-elective procedure instead of an emergency operation, providing more time for immunological monitoring and recipient preparation. Last but not least, it would secure the immediate and optimal re-functioning of the transplanted organ.

Heart re-transplantation in Eurotransplant

Internationally 3% of the donor hearts are distributed to re‐transplant patients. In Eurotransplant, only patients with a primary graft dysfunction (PGD) within 1 week after heart transplantation (HTX) are indicated for high urgency listing. The aim of this study is to provide evidence for the discussion on whether these patients should still be allocated with priority. All consecutive HTX performed in the period 1981–2015 were included. Multivariate Cox’ model was built including: donor and recipient age and gender, ischaemia time, recipient diagnose, urgency status and era. The study population included 18 490 HTX, of these 463 (2.6%) were repeat transplants. The major indications for re‐HTX were cardiac allograft vasculopathy (CAV) (50%), PGD (26%) and acute rejection (21%). In a multivariate model, compared with first HTX hazards ratio and 95% confidence interval for repeat HTX were 2.27 (1.83–2.82) for PGD, 2.24 (1.76–2.85) for acute rejection and 1.22 (1.00–1.48) for CAV (P < 0.0001). Outcome after cardiac re‐HTX strongly depends on the indication for re‐HTX with acceptable outcomes for CAV. In contrast, just 47.5% of all hearts transplanted in patients who were re‐transplanted for PGD still functioned at 1‐month post‐transplant. Alternative options like VA‐ECMO should be first offered before opting for acute re‐transplantation.

Unlocking the Potential of Organ Donation

And that is exactly what the organizers of the American Society of Transplantation Conference on Donor Heart Selection in Adult Cardiac Transplantation in the United States did (2). On May 1, 2015, a conference took place to provide a forum for discussing donor management and donor heart selection. The conference, which was endorsed by the American Society of Transplantation was attended by 66 participants from 41 heart transplant centers across the United States.