Arie OosterleeArie Oosterlee

Dinner debateDinner debate

EUROPEAN PARLIAMENT EUROPEAN PARLIAMENT

Bruxelles, December 3th, 2008Bruxelles, December 3th, 2008

Coordination of European Coordination of European transplant systemstransplant systems

Leiden6666

3737

44

3939

2525

3838

Total population: 124,5 Mill.

ET Transplant ET Transplant ProgramsPrograms

Mission Mission StatementStatement

ET is a service organization for

transplant patients through the

collaborating the transplant

programmes within the organisation

Donation, waiting lists and Donation, waiting lists and transplantationtransplantation

Kidney waiting list and transplantsKidney waiting list and transplants Eurotransplant 1969 - 2007Eurotransplant 1969 - 2007

11308

3703

1032

Each day, Each day, 9 European citizens9 European citizens die whilst die whilst waiting for a suitable organ transplant*waiting for a suitable organ transplant*

*3.262 deaths on the waiting list in 2007, Council of Europe data 2008*3.262 deaths on the waiting list in 2007, Council of Europe data 2008

Grim facts…Grim facts…

Based on: Leo Roels, Donor Action

Allocation principlesAllocation principles

Organ Allocation PrinciplesOrgan Allocation Principles

• Equity: every patient the same chanceEquity: every patient the same chance

• Queuing: longest waiting firstQueuing: longest waiting first

• Need/urgency: sickest patient firstNeed/urgency: sickest patient first

• Utility: best post-Tx outcome firstUtility: best post-Tx outcome first

• Net benefit: balancing urgency and Net benefit: balancing urgency and

outcomeoutcome

Urgency Outcome

Kidney graft survival and HLA-ABDR mismatchesKidney graft survival and HLA-ABDR mismatches Adult first cadaver kidney-only transplantsAdult first cadaver kidney-only transplants

50

60

70

80

90

100

0 1 3 6 9 12 24 36

0 N=1009 1 N=408 2 N=1209 3 N=1316

4 N=464 5+6 N=75

Post-transplant time (m)

P=0.0001

%

83%

71%

No. of No. of MismatchesMismatches

No. of No. of transplantstransplants

percentagepercentage

00 21762176 21,6 %21,6 %

11 832832 8,3 %8,3 %

22 26792679 26,6 %26,6 %

33 30433043 30,2%30,2%

44 10551055 10,5 %10,5 %

55 244244 2,4 %2,4 %

66 4444 0,4%0,4%

totaltotal 1007310073 100%100%

HLA-matching in kidney transplantationHLA-matching in kidney transplantationET 2000-2004, non-ESP patientsET 2000-2004, non-ESP patients

Organ exchange in the ET areaOrgan exchange in the ET areaKidney transplantation 2000-2004Kidney transplantation 2000-2004

The Netherlands

Austria Belgium

Germany Slovenia8668

1358 1386

103

1919

245303

95

63

1616

10

12283256

102

101

4549

4457

36

12460

493

Directive & Action plan

• Quality:1.1. Reduce organ shortageReduce organ shortage

• Awareness in ICU’s & public Awareness in ICU’s & public • Exchange of Best practicesExchange of Best practices

2.2. Combat traffickingCombat trafficking

3.3. Improve transplant outcomeImprove transplant outcome• Registry Registry

• transplanted patients transplanted patients • living donorsliving donors

• OrganovigilanceOrganovigilance

Stakeholders stay alert!

1st reading should not result in:

• Increase Shortage:• Risk management: no elimination!

• Delay Process:• Accountability: no bureaucracy!

• Hinder Transport:• “Special” patients: no borders!

Thank you for your attention

Balancing urgency and outcomeBalancing urgency and outcome“Transplant window“-concept“Transplant window“-concept

-> Increasing organ failure ->

Mortality

Med. TherapyTransplantation

benefit

“too early”

“too late”

“Transplantation window”

Queuing: longest waiting firstQueuing: longest waiting firstEmergency departmentEmergency department

?

Organ allocation principlesOrgan allocation principles

• Equity: every patient the same chanceEquity: every patient the same chance• Sense of fairness or impartialitySense of fairness or impartiality

• Lack of bias or discriminationLack of bias or discrimination

• Queuing: longest waiting firstQueuing: longest waiting first

• Need/urgency: sickest patient firstNeed/urgency: sickest patient first

• Utility: best post-Tx outcome firstUtility: best post-Tx outcome first

• Net benefit: balancing urgency and Net benefit: balancing urgency and

outcomeoutcomeLotteryLottery

Equal/similar patientshave to be treated

equal/similar

• Equity: every patient the same chanceEquity: every patient the same chance

• Queuing: longest waiting firstQueuing: longest waiting first• Waiting time is easy to understandWaiting time is easy to understand• ““first come first served” is a fair way to do first come first served” is a fair way to do

thingsthings

• Need/urgency: sickest patient firstNeed/urgency: sickest patient first

• Utility: best post-Tx outcome firstUtility: best post-Tx outcome first

• Net benefit: balancing urgency and Net benefit: balancing urgency and outcomeoutcome

Organ Allocation PrinciplesOrgan Allocation Principles

ET organ allocation - renalET organ allocation - renal

Highly immunized - Acceptable Mismatch (AM) - Program

Zero Mismatch (“full house”)

ETKAS Point Score System (including HU)

A

Pediatric Donor (< 10 a) to Pediatric Recipient (< 6 a) when HLA-DR-identical

Eurotransplant Senior Program (ESP)

B/L D HR NL SLO

International organ exchange in kidney International organ exchange in kidney transplantationtransplantation

Impact on selected patient groupsImpact on selected patient groupsEurotransplant 01.01.2002 -31.12.2006 Eurotransplant 01.01.2002 -31.12.2006

0%

20%

40%

60%

80%

100%

Outside ET 0 1 0 0 44

Other ET country 121 1022 141 87 1422

Recipient country 60 1420 336 271 9106

Highly immunized

000- HLA MM

PaediatricHigh

UrgencyOther