Eurotransplant csatlakozás: reális lehetőség? Dr. Langer Róbert egyetemi docens, klinika igazgató Semmelweis Egyetem, Transzplantációs és Sebészeti Klinika, Budapest

Eurotransplant csatlakozás – reális lehetőség? Dr. Langer Róbert Semmelweis Egyetem Transzplantációs és Sebészeti Klinika

Balancing urgency and outcome Net benefit-/“Transplant window“-concept “too late” Mortality Med. Therapy Transplantation “Transplantation window” “too early” benefit 4 -> Increasing organ failure ->

VESETRANSZPLANTÁCIÓ MAGYARORSZÁG

HLA antigén mismatch Magyarországon MM 1 2 3 4 5 6 2009 11 45 86 65 17 2008 20 47 62 26 2007 19 66 107 51 2006 12 114 76 22 Kombinált tx-k, gyermeklista és HU nem lett figyelembe véve

ET Organ allocation - renal Highly immunized - Acceptable Mismatch (AM) - Program Zero Mismatch (“full house”) Pediatric Donor (< 10 a) to Pediatric Recipient (< 6 a) when HLA-DR-identical Eurotransplant Senior Program (ESP) ETKAS Point Score System (including HU) A B/L D HR 7 NL SLO

Kidney graft survival and HLA-ABDR mismatches Adult first cadaver kidney-only transplants % 83% P=0.0001 71% Post-transplant time (m) 8

HLA-matching in kidney transplantation ET 2000-2004, non-ESP patients No. of mismatches No. of transplantations Percentage 2176 21,6 % 1 832 8,3 % 2 2679 26,6 % 3 3043 30,2% 4 1055 10,5 % 5 244 2,4 % 6 44 0,4% total 10073 100% 9

Origin of donor organs transplanted Eurotransplant: 01. 01. 2001 – 31 10

International organ exchange in kidney transplantation Impact for selected patient groups Eurotransplant 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 [%] AM Standard allocation 12

Claas et al. Transplantation, 2004 13 Claas et al. Transplantation, 2004

MÁJTRANSZPLANTÁCIÓ MAGYARORSZÁG

Liver allocation rules ET National prioritization - Mechanisms of balancing International HU Open obligations (based on previous HU-Tx) Mechanism for balancing National Transplantable/Elective MatchMELD (= urgency) Ischemic time (regional factor) Waiting time International LabMELD Outside ET HU Elective 15

Waiting time HU Liver-transplant First HU Liver-Tx [n=1254] Pediatric (<16 yrs) Adult (16+ yrs) n=201 (16%) n=1053 (84%) 16 Median waiting time: 2 d (both groups)

PANCREAS TRANSZPLANTÁCIÓ MAGYARORSZÁG

P-PASS Item 1 point 2 points 3 points Age (years) (x2) <30 30-40 ≥ 40 BMI (kg/m2) (x2) <20 20-25 ≥ 25 ICU-stay (days) <3 3-7 ≥ 7 Cardiac arrest (min) No Yes, < 5 Yes, ≥ 5 Sodium (mmol/L) <155 155-160 ≥ 160 Amylase (U/I) or Lipase (U/I) <130 <160 130-390 160-480 ≥ 390 ≥ 480 (Nor)adrenaline (γ) or Dobuta-/Dopamine (γ) < 0.05 < 10 ≥ 0.05 ≥ 10 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. 18

Reported Pancreata: P-PASS ET, Jan 1, 2002 – Jun 30, 2005, N = 3310 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. 19

Pancreas graft survival curve Pancreas graft survival curve* stratified by P-PASS Eurotransplant, SPK transplantation, January 2002 - June 2005 [N = 174] 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. 20

SZÍVTRANSZPLANTÁCIÓ MAGYARORSZÁG

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

ET – Horvátország lépcsőzetes csatlakozás Egy évig részleges csatlakozás Speciális betegcsoportok (HU, AM, gyermekek) Zero-national balance Minden donort jelenteni ET részvétel: Organ Advisory Committees Teljes csatlakozás egy év után 25

ET – Horvátország lépcsőzetes csatlakozás HU májprogram Vese: acceptable mismatch program Szenzitizált betegek listára tétele HU szív és HU vese Elektív gyermekszív és gyermekmáj Teljes tagság 26

Összefoglalás A kollaboráció előnyei: Jobb allokáció Transparens betegorientált allokáció Zero mismatch 20%, high urgency betegek… Tudományos alapon bizonyított allokációs előnyök Elvesztett donor szervek minimalizálása Nemzetközi tudományos együttműködés A résztvevők számára elérhető adatbázisok 27

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