Solidarity model: a way to cope with rationing problems in organ transplantation.

This short paper discusses the possibility of implementing a solidarity model as a way of improving organ allocation.

A superior approach to organ allocation and donation.

BACKGROUND: Whether the twin aims of alleviating organ shortage and of increasing justice of organ allocation necessarily conflict with each other or can be simultaneously furthered while the autonomy of patients is respected is an important question in organ transplantation. It is shown that very minor reforms of existing schemes of organ allocation could increase the scope for justice, autonomy, and beneficence simultaneously. METHOD: Willingness to donate discriminates between patients of comparable medical status in the elective category by preferring potential donors over nondonors. High urgency patients as well as children have priority over patients in the elective category. The proposed solidarity model can easily be implemented, for example, as a sixth ranking scale added to the existing allocation algorithm of Eurotransplant. RESULTS: 1. More justice and more beneficence. It is excluded that of two recipients of equal medical suitability, a patient who is unwilling to donate is unjustly preferred to one who is willing to donate, whereas enhanced solidarity with donors will increase the number of donations and, thereby, the scope for beneficence. 2. Enhanced involvement of individuals and hospitals. More people are induced to declare actively their willingness to donate which in turn enhances the moral obligation of hospitals to participate in transplantation. 3. Fair treatment of dissenting minorities, local residents, and nonresidents. The solidarity model favors altruistic contributors to the organ pool over noncontributors without discriminating against groups. CONCLUSION: A solidarity rule for organ allocation should be gradually introduced.

[Increasing organ donation by regionalization]. / Intensivierung der Organspende durch Regionalisierung.

According to the German transplantation law all hospital are obliged to report potential donors. This obligation can only become effective with comprehensive support provided by an organ procurement organization. Together with additional tasks, e.g., in the field of information and motivation, the entire service requires a financial basis which is only available in a region of a certain minimum size, minimum activity and minimum reimbursement, respectively. The regionalization of organ donation has to be considered independently from questions of allocation.

[Comprehensive range of services for general hospitals in the area of organ donation nearly doubles the number of donors in 2 years with a simultaneously economical process]. / Umfassendes Dienstleistungsangebot für Versorgungskrankenhäuser im Bereich Organspende verdoppelt nahezu die Spenderzahlen in zwei Jahren bei gleichzeitig ökonomischer Vorgehensweise.

To overcome the donor shortage, any potential donor resource must be detected. By establishing a professional service for peripheral hospitals, the numbers of donors available in small hospitals could be nearly doubled: 85% of all donors in our region come from nonuniversity hospitals. By using total quality management techniques, the time requirements for organ donation after confirmation of brain-death and given consent could be reduced to 6 h.

Auxiliary liver transplantation: regeneration of the native liver and outcome in 30 patients with fulminant hepatic failure--a multicenter European study.

Auxiliary liver transplantation (LT) is a special procedure of LT which could be proposed to patients with fulminant hepatic failure (FHF) and has for aim that complete regeneration of the native liver (NL) left in place will allow the graft recipient to resume normal liver function after allograft withdrawal. We report 30 cases of auxiliary LT performed for FHF in 12 European centers. Twenty-five of 30 patients were younger than 50 years. The cause of FHF was hepatitis A virus (HAV) in 4 patients, hepatitis B virus (HBV) in 7, paracetamol overdose in 5, ecstasy in 2, hepatotoxic drugs in 4, autoimmune hepatitis in 2, liver lesions of preeclampsia in 1 and unknown in 5. A postoperative, both clinical and histological follow-up of more than 3 weeks was obtained in 22 patients, enabling us to look for indicators predictive of NL regeneration and outcome. Histological changes observed in the NL included complete regeneration in 68%, incomplete regeneration with obvious fibrous sequelae in 14% and severe liver fibrosis or cirrhosis in 18%, of the 22 patients studied. The percentage and distribution of necrosis observed in tissue samples of the NL at the time of transplantation was not related to the final outcome. Complete NL regeneration was observed in 15 patients, out of whom 14 were younger than 40 years. Patients with complete regeneration were mainly affected by FHF due to HAV, HBV, or paracetamol overdose. After a follow-up of 18/11 (mean/median) months (range, 3 to 67 months), 19 of the 30 patients (63%) survived and 13 of them (68%), i.e., 43% of the 30 patients, had resumed normal NL function, with interrupted immunosuppression, the ultimate goal of emergency auxiliary LT. We conclude that, in patients with FHF, auxiliary LT is a procedure feasible in a number of centers and is associated with a complete regeneration capability of the NL in a majority of survivors, especially in those younger than 40 years. Confirmation of these encouraging preliminary results by large-scale prospective studies is required.

[General aspects of organ donation]. / Allgemeine Aspekte der Organspende.

The general and surgical aspects of organ donation are of great relevance for every surgeon in every hospital, as potential organ donor situations occur in every intensive care unit. Typical organ donors are patients suffering from intracerebral bleeding. There is no upper age limit. The implementation of a potential organ donor program is the indirect responsibility and task of every hospital in order to serve the patients waiting in the geographical region of the hospital; organs retrieved in another region should be available for patients in that other region. The general aspects of organ donation concern, for example, the question of the legal aspects of brain death and adequate surgical procedures concerning the dignity of the donor. The surgical aspects include a highly standardized technique using only aortal flush at an early stage of the operation without major manipulation of the organs prior to perfusion. The liver and pancreas are removed en bloc and consecutively the kidneys, one by one. This no-touch technique is rapid and safe, especially for atypical hepatic arteries, as all the tissue between the superior mesenteric artery, celiac trunk and minor curvature of the stomach is preserved with liver, irrespective of arterial anomalies.