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Invited Commentary
The article published by Haneya and colleagues [1] reports on a single Center experience examining the impact of the Eurotransplant
High-Urgency Heart Allocation System on the outcome on heart transplant candidates.
The main conclusions of the manuscript are that the new allocation system decreases
the proportion of local and regional organ harvesting without increasing the total
number of transplantations and without improving clinical outcome after heart transplantation.
In 1997 a new transplantation-law was implemented in Germany. The main goal of this
new transplantation-law was to give everybody who is waiting for organ transplant
in Germany the same chance independently of where the potential recipient is located.
In addition, a very urgent candidate should have priority over elective transplant
candidates and certain quality standards should be achieved after any organ transplantation.
As a reaction to this law, the regional organ allocation changed into a national organ
allocation organized by Eurotransplant in the Netherlands. In order to give very urgent
candidates a priority, a new high-urgency (HU) status was created and the application
for this HU-status must fulfill several certain HU-criteria. The HU-applications are
collected by Eurotransplant and sent to three national and international auditors
for review. The HU-status will be granted if a majority of the auditors votes for
it. Re-evaluation of this status takes place every two weeks.
In parallel with this development, the number of heart donors decreased significantly
and continuously over the last 15 years from over 550 in 1995 to less than 350 in
2009. Also the age and quality of heart donors changed significantly. While 15 years
ago there was still a majority of young and healthy organ donors who usually suffered
from a car or a motorbike accident, today the organ donors are older and carry significant
cardiovascular risk factors such as arterial hypertension, leading to intracranial
hemorrhage as cause of brain death in the majority of organ donors.
As a result from organ shortage the numbers of potential recipients on our waiting
list increases continuously. In addition the number of HU-applications also raised
drastically over the last years reaching a maximum of almost 80 % of all heart transplantations
performed in HU-candidates over the last few years. Subsequently the waiting time
for HU-listed patients increased as well as the risk profile of these hospitalized
patients. This might well result in inferior survival rates after heart transplantation
in Germany. The last reported data reported within our German quality insurance reported
a one year survival of 76.7 % after heart transplantation in Germany in 2009. This
compares with almost 90 % according to the registry of the International Society for
Heart and Lung Transplantation. There is no doubt that the results of the heart transplantation
need to be improved and the probability of survival after transplantation would optimally
be part of an accurate allocation system.
For lung transplantation, a potential solution has been found in the United States
by introducing the so-called LAS (Lung Allocation Score) as part of their allocation
process. The LAS is calculated based on the urgency of the necessary transplantation
as well as the probability of survival after transplantation. Since the different
primary diagnoses for lung transplantation have different probabilities of survival
after the transplant procedure, this calculation can well be done in the field of
pulmonary transplantation. After the LAS was introduced in US, mortality on waiting
lists decreased, at the same time maintaining excellent survival results after lung
transplantation. For this reason a new allocation system has been proposed to the
“Ständige Kommission für Organtransplantation der Bundesärztekammer” and has meanwhile
been approved. After implementation by Eurotransplant, the allocation process in lung
transplantation will start in the second half of 2011. After evaluation of the first
phase of the new allocation system in lung transplantation, the whole data will be
reevaluated and a possible transfer onto the field of cardiac transplantation will
be discussed. This, however, will be more difficult, since the different primary diagnoses
for heart transplantation do not really have a different probability of survival after
the transplant.
The main problem of heart transplantation in Germany, which must be emphasized over
and over again, is the significant organ shortage. The new transplantation law and
its implementation led to the fact that there was a decrease of almost 40 % of heart
transplantations over the last 15 years! Any effort needs to be undertaken in order
to increase organ donations and this is mainly a political and financial issue. Our
neighbors in Europe have proven that this is definitely possible. Perfect examples,
such as Spain, presently present an organ donation rate of over 32 per million people
compared to 14.6 in Germany. Unless we are not able to improve organ donation, the
future of heart transplantation will be limited, at least in Germany.
Hermann Reichenspurner, M. D., Ph.D.
University Heart Center Hamburg
Martinistr. 52, 20246 Hamburg
Germany
Phone: +49 4 07 41 05 24 40
Fax: + 49 4 07 41 05 49 31
eMail: hcr@uke.de
References
- 1
Haneya A, Haake N, Diez C et al.
Impact of the Eurotransplant high-urgency heart allocation system on outcome of transplant
candidates in Germany.
Thorac Cardiovasc Surg.
2011;
59
93-97
Dr. Assad Haneya, MD
Department of Cardiothoracic Surgery
University Medical Center Regensburg
Franz-Josef-Strauss-Allee 11
93053 Regensburg
Germany
Telefon: +49 94 19 44 98 01
Fax: +49 94 19 44 98 11
eMail: assadhaneya@web.de
