Change in donor profile influenced the percentage of organs transplanted from multiple organ donors.

We hypothesized that the change in donor profile over the years influenced the percentage of transplantations. We reviewed medical records for all multiple-organ donors (MODs) within our network. The percentage of transplanted organs was compared between 1991-1992 (A) and 2006-2007 (B). In period A, 156 potential MODs were identified compared with 278 in period B. Fifteen potential donors (10%) in period A and 114 (41%) in period B were rejected because they were medically not suitable (40% vs 75%) or there was no family consent (60% vs 25%). Of the remaining effective MODs (141 in period A and 164 in period B), mean (standard deviation = SD) age was 34 (5) years vs 49 (17) years (P < .001). Brain death resulted from craniocerebral trauma in 69% vs 39%, cerebrovascular disease in 24% vs 46%, hypoxia in 4% vs 15%, and brain tumor in 2% vs 0.6% (P < .001). Chest trauma was present in 19% vs 9% (P < .01). The percentage of MODs who received mechanical ventilation for more than 5 days was 8% vs 24% (P < .001). The percentage of organs transplanted in periods A vs B was kidneys, 97% vs 79%; livers, 64% vs 85%; hearts, 60% vs 26%; lungs, 7% vs 35%; and pancreas, 6% vs 13% (P < .001). The number of referred potential MODs increased by 80%, resulting in a small increase in effective MOD organs (17%), mainly because of medical contraindications. The MOD profile changed to older age, fewer traumatic brain deaths, and longer ventilation time. We transplanted more livers, lungs, and pancreases but fewer kidneys and hearts.

Importance of informatics and database management in transplant coordination.

Advanced use of informatics within modern health care has become essential. Transplantation and transplant coordination, a high technically advanced and very specific niche within health care, is strongly depending on time management and exclusion of possible pitfalls within an acute organization at both the donor and the recipient sites. Based on the increased donor and transplant activity, we stratified two goals. The first goal was to improve working methods at the donor site. The second goal was to reduce administrative tasks and increase quality follow-up at the recipient side. For the donor process, we designed a Donor Database, that was created for donor registration and quality data reporting. A 24/24 h accessible website was created and was linked with clinical pathways and reports. For the liver transplant process, we built another database system in FileMaker pro, creating a quality follow-up and reporting methods. Based on a retrospective analysis and review of two executive time periods, we saw a clear improvement in the donor reporting method, and the quality of the procedure. Possible mistakes within the acute organization were easily detected based on clinical pathways provided by the website on one hand, and integrated within the database system on the other hand. We succeeded in bringing high-quality informatics to the floor of donor and transplant procedures and follow-up. Retrospective analysis showed a definite improvement, with a positive impact on data reporting, time management and administrative follow-up.

Evolution in allocation rules for renal, hepatic, pancreatic and intestinal grafts.

Organ transplantation is the victim of his own success. The results of transplantation are excellent and more patients are activated on the waiting list. The need for organs exceeds the supply. Which criteria are used to allocate available grafts to patients on the waiting list ? Organ allocation and finding the "best match" between donor and recipients, is the goal of Eurotransplant, the organ sharing organization for seven European countries (Austria, Croatia, Germany, Luxemburg, Slovenia, The Netherlands and Belgium). Last decade, the allocation system has switched from a "center-driven" (organ allocated to a center) to a "patient-driven" system (organ allocated to a particular patient). For the allocation of abdominal organs some general allocation rules are followed: blood group compatibility, priority for high urgencies. The allocation of kidneys is based on a point score system based on waiting time, HLA and donor location (to reduce the cold ischemia time). In addition to this standard allocation procedure, there are still specific procedures for pediatric recipients and for candidates > or = 65 year old. There is also an "acceptable" mismatch program for recipients at high immunological risk. The liver allocation system recently changed and is now based on the MELD score, a formula that calculates the probability of death within 3 months on the waiting list. For pancreas and intestine, the system is based on blood group, medical urgency, waiting time, donor region and weight (for intestine).

What is the limiting factor for organ procurement in Belgium: donation or detection ? What can be done to improve organ procurement rates?

In trying to overcome the growing gap between demand and offer of organs for transplantation, solutions are usually searched for by comparing successful and unsuccessful models in different countries. In particular, one element in the more successful countries such as for instance presumed consent, or one element in the less successful countries such as for instance refusal by relatives, are seen as possible reasons for these differences. This article tackles the problem of organ donor shortage through a new multi-level approach. Organ donation can indeed be analyzed on three different levels: the macro-level, the meso-level and the micro-level. The macro-level refers to the governmental structure where legislation, policies and funding are three essential elements necessary to make donation possible. The meso-level refers to the health care organization and the professionals who surround the process of organ donation and transplantation. Facilitating this process through standardized protocols and improving detection of organ donors are the two major elements. The micro-level refers to the individual believes and personal attitudes towards organ donation. This new multi-level approach gives a thorough and complete analysis of problems and allows to propose potential solutions to try to overcome the chronic organ shortage.

Abdominal Transplant Surgery and Transplant Coordination University Hospitals Leuven 1997-2007: an overview.

The transplant surgery and transplant coordination department was created in 1997 to meet up with the demand of the growing abdominal transplant surgery and organ procurement activity at the University Hospitals in Leuven. Since then, the procurement activity has increased and is currently distributed within the University Hospital Gasthuisberg and a network of approximately 25 collaborative hospitals. The profile of the donors has changed with older donors and more co-morbidity factors (obesity, hypertension, etc.). This donor activity represents approximately 30% of the national donor pool. Over the last 10 years, more than 1100 kidneys, more than 500 livers, approximately 50 pancreas, and 5 intestines have been transplanted in both adults and children. One year survival equal to- or exceeding 90% has been achieved for all abdominal organs and this compares favorably with international registries. More than 40 multi-visceral transplants {liver in combination with abdominal (kidney, pancreas, intestine) or thoracic (heart, double lung, heart-lung) organs} have been performed with results equivalent to isolated liver transplants and very little immunological graft loss (probably due to the immunoprotective effect of the liver). A live donation program was started for the kidney (40 cases) and for the liver (10 cases) in adults and children and no surgical graft loss has been seen so far. Introduction of new machine perfusion systems (and development of donor protocols) has made it possible to restart a non-heart-beating donor program for kidney transplantation. Experimental demonstration that livers tolerate short periods of warm ischemia has also allowed to start liver transplantation from non-heart-beating donors. In the future, machine perfusion of livers, viability testing, and biological modulation are likely to widen the use of marginal livers for transplantation and improve the results. An immunomodulatory protocol proven in the lab to induce the development of regulatory T cells has been applied clinically to 5 consecutive intestinal transplants. All 5--at the time of writing--have been rejection-free and have achieved nutritional independence. Continuous research and development is warranted to increase the organ donor pool (currently the solely limiting factor of transplantation) and to optimize long-term graft and patient outcome.

Donor categories: heart-beating, non-heart-beating and living donors; evolution within the last 10 years in UZ Leuven and Collaborative Donor Hospitals.

Over the past 10 years, the University Hospitals Leuven and their group of Collaborative Donor Hospitals (approximately 20) have tried to maximize their contribution to the national and Eurotransplant donor pool. In this time period, 1042 potential donors and 703 effective donors were coordinated and their organs allocated through Eurotransplant. This activity represented approximately 30% of the national donor pool and approximately 32% of the national organ pool. For Belgium, the non-heart-beating donor activity represented 11.38% of all donors in 2006. Since 1997, 167 potential live donors have been screened in our center. Of these, 48 transplants (28.74%) (39 kidneys--9 livers) have been performed. A boost of screened candidates was seen over the last 3 years, with a 500% increase of records being evaluated. Although the Belgian live donation activity remains one of the lowest in the world, there has been a clear increase over the last 3 years with about 10% of all kidney transplant activity originating now from live donors.

Liver transplantation using livers from septuagenarian and octogenarian donors: an underused strategy to reduce mortality on the waiting list.

Shortage of liver grafts is the only limiting factor for application of liver transplantation and causes an increasing mortality on the waiting list. Very old donors (>70 to 80 years old) are rarely referred to transplant centers because of the assumption that these livers will not work properly. Alternatively, transplant teams may be reluctant to use these very old livers due to the risk of poor posttransplant outcome. We reviewed our experience with seven liver transplantations using very old donor livers. We found that the results in terms of graft function and patient survival are adequate. Interestingly, the majority of these donors originated from a single referring donor unit (of more than 20 units who belong to our donor network) that systematically refers all brain-dead donors to the transplant center, independent of the age of the potential donor. This implies that many of these donors are left undetected in other units. In conclusion, very old donors should be referred to transplant centers since results of transplantation with these grafts are favorable.