Eurotransplant csatlakozs:relis lehetsg? Dr. Langer Rbertegyetemi docens, klinika igazgatSemmelweis Egyetem, Transzplantcis s Sebszeti Klinika, Budapest

Eurotransplant csatlakozs relis lehetsg?Dr. Langer Rbert Semmelweis Egyetem Transzplantcis s Sebszeti Klinika

Balancing urgency and outcomeNet benefit-/Transplant window-concept-> Increasing organ failure -> MortalityMed. TherapyTransplantationbenefittoo earlytoo lateTransplantation window

n= 5782VESETRANSZPLANTCI MAGYARORSZG

HLA antign mismatch Magyarorszgon

ET Organ allocation - renalAB/LDHRNLSLO

Kidney graft survival and HLA-ABDR mismatches Adult first cadaver kidney-only transplantsPost-transplant time (m)P=0.0001%83%71%

100%10073total0,4%4462,4 %244510,5 %1055430,2%3043326,6 %26792832121760PercentageNo. of transplantationsNo. of mismatchesHLA-matching in kidney transplantationET 2000-2004, non-ESP patients21,6 %8,3 %

Origin of donor organs transplantedEurotransplant: 01.01.2001 31.12.2005

Diagramm5

256127770

13481266465

46751327117

1562227171

130035231

own country

other ET country

outside ET

Tabelle1

HeartKidneyLiverLungPancreas

bad donor quality138917419437

no recipient9421147714

logistical problem6221156528

recipient problem21

other25822677

32114212540386

706511717131

HeartKidneyLiverLungPancreas

elective recipients3910215029

HU recipients3115212

Tabelle2

HeartKidneyLiverLungPancreas

not accepted32114212540386

transplanted706511717131

Tabelle2

not accepted

transplanted

Tabelle4

HeartKidneyLiverLungPancreas

own country256113481467515621300

other ET country27726641327227352

outside ET706511717131

Kidney

own country-other recipients9743

own country-ESP recipients1887

own country-HU recipients285

own country-AM recipients85

own country-000 HLA recipients1481

exchanged - other recipients1406

exchanged- HU recipients73

own country-elective recipients140841649281262exchanged-AM recipients147

own country-HU recipients115351163438exchanged-000 HLA recipients1038

exchanged - elective recipients130769142314

exchanged- HU recipients1475588538

Tabelle4

own country

other ET country

outside ET

Tabelle3

HeartKidneyLiverLungPancreas

bad donor quality138917419437

no recipient9421147714

logistical problem6221156528

recipient problem21

other25822677

Tabelle3

bad donor quality

no recipient

logistical problem

recipient problem

other

International organ exchange in kidney transplantationImpact for selected patient groupsEurotransplant 01.01.2002 -31.12.2006

Chance of every new highly sensitized patient to receive a suitable crossmatch negative organ within 12 months (real life data)Offer[%]Standard allocationAM

Claas et al. Transplantation, 2004

n=427MJTRANSZPLANTCI MAGYARORSZG

Liver allocation rules ETNational prioritization - Mechanisms of balancing

HUElectiveInternational HU Open obligations (based on previous HU-Tx)Mechanism for balancing

National Transplantable/ElectiveMatchMELD (= urgency)Ischemic time (regional factor)Waiting timeInternationalLabMELDIschemic time (regional factor)Waiting timeOutside ET

n=201 (16%)n=1053 (84%)Waiting time HU Liver-transplantFirst HU Liver-Tx [n=1254]Pediatric (

PANCREAS TRANSZPLANTCI MAGYARORSZG

P-PASS

Item1 point2 points3 pointsAge (years) (x2)

Reported Pancreata: P-PASS ET, Jan 1, 2002 Jun 30, 2005, N = 3310

Pancreas graft survival curve*stratified by P-PASS Eurotransplant, SPK transplantation, January 2002 - June 2005 [N = 174]

p = 0.02

post-transplant time (months)

*-Death censored

We used the first 48 returned questionairres combined with the information present in ENIS to estimate a Kaplan-Meier survival curve between 2 PASS-groups, which we see on this slide. All transplantations took place in the study period, we censored the graft survival by death and stratified the curve by PASS. We set our cut-off point at 14 derived from the PAS-Score which was mentioned before.On this slide we see the rates of pancreas survival between the two groups, which were composed by setting the PASS-cut-off-point at 14. All the cases mentioned here consists of all transplanted pancreas combined with kidney post-listing. But what we see is a difference between survival in the groups, however the The p-value is only 0.2, the low number of significance can be explained by the low power of the test, because we didnt include so many cases yet. and therefore the value is not significant. Correlation between PASS cut-off point en survival with first 48 returned questionairres

SZVTRANSZPLANTCI MAGYARORSZG

Average waiting time in HU-status until first heart offerEurotransplant - 01.01.-31.07.2008

ET Horvtorszglpcszetes csatlakozsEgy vig rszleges csatlakozsSpecilis betegcsoportok (HU, AM, gyermekek)Zero-national balanceMinden donort jelenteniET rszvtel: Organ Advisory CommitteesTeljes csatlakozs egy v utn

HU mjprogram Vese: acceptable mismatch programSzenzitizlt betegek listra tteleHU szv s HU veseElektv gyermekszv s gyermekmjTeljes tagsgET Horvtorszg lpcszetes csatlakozs

sszefoglalsA kollaborci elnyei:Jobb allokciTransparens betegorientlt allokci Zero mismatch 20%, high urgency betegekTudomnyos alapon bizonytott allokcis elnyk Elvesztett donor szervek minimalizlsaNemzetkzi tudomnyos egyttmkdsA rsztvevk szmra elrhet adatbzisok

ORSZGOS VRELLT SZOLGLAT http://www.ovsz.hu Szervkoordincis Iroda http://donacio.ovsz.hu %-14,7%-2%-5,4%

**********On this slide we see the PPASS-factors on the left.The Eurotransplant Pancreas advisory committee has already composed a prognostic score which means that they have already weighted each individual factor based on literature review and medical expertise, where the weight should reflect the likeliness of pancreas unsuitability, so high PASS means not likely to be PA donor. Before starting the investigation, we divided all pre-procurement factors into ranges with cut-off points.

*Using the P-PASS, we gave all reported pancreata retrospectively a score, according to the pre-procurement PASS. We then looked if we could conclude anything about the allocation algorithm. Red bars represent pancreata not accepted for transplantation; Green bars represent pancreata that are ultimately transplanted. And yes, what we see here, is a correlation between PASS and transplantation. For example: the group of reported PASS 13, 60 % is finally used for transplantation. And pancreas donors reported with a high PASS, a much lower rate is finally used for transplantation, as we can see here. With help of a logistic regression model, we calculated that pancreata with a P-PASS same or higher than 17 were significantly negative associated with pancreas acceptance, these donors were 3 times more likely to be refused as a pancreas donor.

*In order to evaluate outcome after pancreas transplant, we started a retrospective study of all transplanted pancreata in the time-period 2002 2005. We sent questionairres to the Eurotransplant pancreas transplantation centres and used them to estimate a Kaplan-Meier survival curve of the 2 PASS-groups, which we see on this slide. All transplantations took place in the study period, we censored the graft survival by death and stratified the curve by PASS. We set our cut-off point at 17 derived from the PAS-Score which was mentioned before. Blue line pancreas transplantations of donors with P-PASS lower than 17, red same or higher than 17.What we see is a significant difference in graft survival in both pancreas groups. ***