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Organ Transplantation in the Madrid Autonomous Region
Organ Transplantation in the Madrid Autonomous Region C. Chamorro, M. Aparicio, G. Marmisa, and J.L. Martinez-Urrialde ABSTRACT The Madrid Autonomous Region, a Spanish area with 6,200,000 inhabitants, has 7 hospitals authorized for organ transplantation, with 25 active programs for carrying out various transplantations: 18 for adults and 7 for children. Most of these hospitals are reference transplant centers for other Spanish regions. Between 715 and 760 transplantations are performed annually, which represents between 19% and 22% of Spanish activity. During 2007, 395 kidney, 220 liver, 55 heart, and 35 lung transplantations were performed, as well as 23 isolated or combination transplantations of other abdominal organs (pancreatic, intestinal, or multivisceral). Kidney, liver, heart, and children’s intestinal transplant activity in 2007 represented 37%, 63%, 80%, and 100%, respectively, of all pediatric national activity. The Madrid Autonomous Region has a donation rate of 34.2 donors per million inhabitants. Of these, 30% are from non– heart-beating donors (NHBD), Maastrich criteria category 1 or 2. Various hospitals perform kidney, liver, and lung transplantations with these organs, representing 11% of the lung transplantations carried out in recent years, with this being a pioneer procedure worldwide. Despite the important transplant activity, we are working to increase donations, to improve organ donor detection and management protocols, as well as to reach a consensus on criteria to decrease the nonviability rates of potential transplant organs. HE MADRID AUTONOMOUS REGION a Spanish area with 6,200,000 inhabitants, has 21 public hospitals, 6 newly inaugurated in 2008. Seven of these hospitals are authorized for organ transplantation, with 25 active programs for carrying out various transplantations: 18 for adults and 7 for children. Between 715 and 760 transplantations are performed annually, which represents between 19% and 22% of Spanish activity. One hospital performs more than 200 transplantations annually and 5 others around 100; many of them are reference transplant hospitals for other parts of the country. Until 2008, Madrid was the only Spanish Region where any type of transplantation could be performed.
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KIDNEY TRANSPLANTATION
In 1965, the first kidney transplantation was performed in the Madrid Autonomous Region, and in recent years there have been between 390 and 417 procedures carried out at the 7 authorized hospitals. Since 1998, the number of transplantations performed has leveled off, despite the progressive opening of transplant centers in other parts of Spain. Most of the transplantations undertaken are from cadaveric kidney donors following brain death or from
non– heart-beating donors (NHBD); 19% of all kidney transplantations are performed with the latter type of donation.1 Only 5.6% are from living donors, although this activity has grown in recent years. There are centers specializing in double or in block transplantation.2 In 2007, pediatric transplant activity represented 37% of all national activity. LIVER TRANSPLANTATION
This activity began in 1984, and since 1994, slightly more than 200 transplantations have been performed annually at the 5 authorized centers. In 2007, 220 liver transplantations were carried out, the maximum annual number achieved to date, which represented 20% of national activity, with Madrid being the Spanish Region where the greatest number of transplantations were performed. Nine transplantations were carried out with NHBD livers. One pediatric From the Regional Transplant Coordination Office, Madrid, Spain. Address reprint requests to Carlos Chamorro, Regional Transplant Coordination Office, C/Plaza Trias Bertrán 7, 28020 Madrid, Spain. E-mail: [email protected]
0041-1345/09/$–see front matter doi:10.1016/j.transproceed.2009.06.102
© 2009 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
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Transplantation Proceedings, 41, 2302–2303 (2009)
TRANSPLANTATION IN MADRID AUTONOMOUS REGION
liver transplant center is a national reference and its activity during 2007 represented 59% of all national activity. Split hepatic and living donor transplantations are closely related with the children’s activity, as there is a close relationship between adult and children’s hospitals in order to undertake these transplantations.3 HEART TRANSPLANTATION
In 1984 the activity began, subsequently being extended to 4 hospitals, with 3 adult and 2 pediatric transplant programs. The activity has decreased in recent years, in accordance with the trend in the rest of the country and worldwide, but also due to the progressive opening of programs in other parts of the country.4 In 1997, 109 transplantations were performed, and in 2007, only 55. Nevertheless, in the last year Madrid has been the region where the greatest number of cardiac transplantations have been performed; in addition, pediatric activity represented 80% of national activity. In 2008, along with the National Transplant Organization, new cardiac donor selection, evaluation, and management protocols were implemented, which to date have resulted in an increase in activity of up to 60% compared with 2007. LUNG TRANSPLANTATION
In 1990, the first pulmonary transplantation was performed, and in 1997, the first cardiopulmonary transplantation. Only 1 center undertakes this activity, with an annual number of transplantations which varies between 35 and 46. In 2006, 46 were performed, which represented the greatest number of transplantations carried out annually by a single Spanish center. It is noteworthy that 11% of these were from NHBD, Maastrich criteria category 1 or 2, with this type of transplant being a pioneer worldwide.5 In 2007, 35 transplantations were performed, which has meant an increase in patients on the waiting list and has caused the activity to be initiated at an additional center in 2008. OTHER ABDOMINAL ORGANS
In 1998 and 1999, pancreas and intestinal transplant programs were started, whether isolated or combined in pancreaskidney or multivisceral intestinal transplantations. The activity has been consolidated in recent years with 18 to 22 pancreatic transplantations being carried out, which is 23% of the national activity. The Madrid Autonomous Region has 2 hospitals, 1 for children and 1 for adults, which are the only reference centers in the entire country for performing isolated or multivisceral intestinal transplantations.6 From 7 to 13 procedures are performed annually, depending on the number of valid donors and potential recipients. ORGAN DONATION AND PROJECTS
Transplant activity depends on the number of organ donors. It is important to detect all the deceased with potential
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organ donor status. The Madrid Autonomous Region has registers to detect any deficiency in this regard. Each hospital has a transplant coordination team in charge of the donation process and organ procurement. These hospitals regularly undergo audits from the Region itself or from other parts of the country to detect and correct any deficiencies.7 The Madrid Autonomous Region works jointly with the other Spanish Regions in the benchmarking process, directed by the National Transplant Organization, to determine the best hospital processes in detection, evaluation, family request, and donor management, as well as to implement them at our hospitals. Annually in Madrid there are slightly more than 200 cadaveric organ donors; in 2007, these were 208, which represents a donor rate of 34.2 donors per million inhabitants. Of these, 30% are from uncontrolled NHBD. This type of donation is a worldwide model and is carried out at 2 hospitals, representing a perfect coordination between these hospitals and out-ofhospital emergency medical services.8 Likewise, it is important to promote living donation and to undertake donor awareness and promotion campaigns to decrease the negative attitudes toward donation and refusal, which presently is 14% in this region. We are working to update management protocols, especially those for intrathoracic organ donors, as well as to equalize use protocols for each organ to decrease the number of donation exclusions.9 It is important to remember that an organ donor offers 31 years in expected life-year gain for wait-listed patients and up to 55.8 years if all organs can be used.10
REFERENCES 1. Sánchez-Fructuoso Al: Kidney transplantation from non– heart-beating donors. Transplant Proc 39:2065, 2007 2. Andrés A, Morales JM, Herrero JC, et al: Double versus single renal allografts from aged donors. Transplantation 69:2060, 2000 3. Vicente E, Santamarı´a ML, Nuño J, et al: A two-center, adult/pediatric transplant unit cooperation program for cadaveric/ living donor liver transplantation and intestinal transplantation. Transplant Proc 34:295, 2002 4. Matesanz R, Valentin M: Cardiac transplantation in Spain. Have we reached our peak? Rev Esp Cardiol 59:193, 2006 5. de Antonio DG, Marcos R, Laporta R, et al: Results of clinical lung transplant from uncontrolled non– heart-beating donors. J Heart Lung Transplant 26:529, 2007 6. López-Santamarı´a M, Gámez M, Murcia J, et al: Intestinal transplantation in children: differences between isolated intestinal and composite grafts. Transplant Proc 37:4087, 2005 7. Cuende N, Cañón JF, Alonso M, et al: ONT quality control programme for the donation process evaluation. Nefrologia 23 (suppl 5):28, 2003 8. Del Rı´o-Gallegos F, Núñez-Pena JR, Soria-Garcia A, et al: Non– heart-beating donors. Successfully expanding the donor pool. Ann Transplant 9:19, 2004 9. Chamorro C, Romera MA, Silva JA, et al: Can heart donation exclusion factors be overcome? Rev Esp Cardiol 59:232, 2006 10. Schnitzler MA, Whiting JF, Brennan DC, et al: The lifeyears saved by a deceased organ donor. Am J Transplant 5:2289, 2005
T
KIDNEY TRANSPLANTATION
In 1965, the first kidney transplantation was performed in the Madrid Autonomous Region, and in recent years there have been between 390 and 417 procedures carried out at the 7 authorized hospitals. Since 1998, the number of transplantations performed has leveled off, despite the progressive opening of transplant centers in other parts of Spain. Most of the transplantations undertaken are from cadaveric kidney donors following brain death or from
non– heart-beating donors (NHBD); 19% of all kidney transplantations are performed with the latter type of donation.1 Only 5.6% are from living donors, although this activity has grown in recent years. There are centers specializing in double or in block transplantation.2 In 2007, pediatric transplant activity represented 37% of all national activity. LIVER TRANSPLANTATION
This activity began in 1984, and since 1994, slightly more than 200 transplantations have been performed annually at the 5 authorized centers. In 2007, 220 liver transplantations were carried out, the maximum annual number achieved to date, which represented 20% of national activity, with Madrid being the Spanish Region where the greatest number of transplantations were performed. Nine transplantations were carried out with NHBD livers. One pediatric From the Regional Transplant Coordination Office, Madrid, Spain. Address reprint requests to Carlos Chamorro, Regional Transplant Coordination Office, C/Plaza Trias Bertrán 7, 28020 Madrid, Spain. E-mail: [email protected]
0041-1345/09/$–see front matter doi:10.1016/j.transproceed.2009.06.102
© 2009 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
2302
Transplantation Proceedings, 41, 2302–2303 (2009)
TRANSPLANTATION IN MADRID AUTONOMOUS REGION
liver transplant center is a national reference and its activity during 2007 represented 59% of all national activity. Split hepatic and living donor transplantations are closely related with the children’s activity, as there is a close relationship between adult and children’s hospitals in order to undertake these transplantations.3 HEART TRANSPLANTATION
In 1984 the activity began, subsequently being extended to 4 hospitals, with 3 adult and 2 pediatric transplant programs. The activity has decreased in recent years, in accordance with the trend in the rest of the country and worldwide, but also due to the progressive opening of programs in other parts of the country.4 In 1997, 109 transplantations were performed, and in 2007, only 55. Nevertheless, in the last year Madrid has been the region where the greatest number of cardiac transplantations have been performed; in addition, pediatric activity represented 80% of national activity. In 2008, along with the National Transplant Organization, new cardiac donor selection, evaluation, and management protocols were implemented, which to date have resulted in an increase in activity of up to 60% compared with 2007. LUNG TRANSPLANTATION
In 1990, the first pulmonary transplantation was performed, and in 1997, the first cardiopulmonary transplantation. Only 1 center undertakes this activity, with an annual number of transplantations which varies between 35 and 46. In 2006, 46 were performed, which represented the greatest number of transplantations carried out annually by a single Spanish center. It is noteworthy that 11% of these were from NHBD, Maastrich criteria category 1 or 2, with this type of transplant being a pioneer worldwide.5 In 2007, 35 transplantations were performed, which has meant an increase in patients on the waiting list and has caused the activity to be initiated at an additional center in 2008. OTHER ABDOMINAL ORGANS
In 1998 and 1999, pancreas and intestinal transplant programs were started, whether isolated or combined in pancreaskidney or multivisceral intestinal transplantations. The activity has been consolidated in recent years with 18 to 22 pancreatic transplantations being carried out, which is 23% of the national activity. The Madrid Autonomous Region has 2 hospitals, 1 for children and 1 for adults, which are the only reference centers in the entire country for performing isolated or multivisceral intestinal transplantations.6 From 7 to 13 procedures are performed annually, depending on the number of valid donors and potential recipients. ORGAN DONATION AND PROJECTS
Transplant activity depends on the number of organ donors. It is important to detect all the deceased with potential
2303
organ donor status. The Madrid Autonomous Region has registers to detect any deficiency in this regard. Each hospital has a transplant coordination team in charge of the donation process and organ procurement. These hospitals regularly undergo audits from the Region itself or from other parts of the country to detect and correct any deficiencies.7 The Madrid Autonomous Region works jointly with the other Spanish Regions in the benchmarking process, directed by the National Transplant Organization, to determine the best hospital processes in detection, evaluation, family request, and donor management, as well as to implement them at our hospitals. Annually in Madrid there are slightly more than 200 cadaveric organ donors; in 2007, these were 208, which represents a donor rate of 34.2 donors per million inhabitants. Of these, 30% are from uncontrolled NHBD. This type of donation is a worldwide model and is carried out at 2 hospitals, representing a perfect coordination between these hospitals and out-ofhospital emergency medical services.8 Likewise, it is important to promote living donation and to undertake donor awareness and promotion campaigns to decrease the negative attitudes toward donation and refusal, which presently is 14% in this region. We are working to update management protocols, especially those for intrathoracic organ donors, as well as to equalize use protocols for each organ to decrease the number of donation exclusions.9 It is important to remember that an organ donor offers 31 years in expected life-year gain for wait-listed patients and up to 55.8 years if all organs can be used.10
REFERENCES 1. Sánchez-Fructuoso Al: Kidney transplantation from non– heart-beating donors. Transplant Proc 39:2065, 2007 2. Andrés A, Morales JM, Herrero JC, et al: Double versus single renal allografts from aged donors. Transplantation 69:2060, 2000 3. Vicente E, Santamarı´a ML, Nuño J, et al: A two-center, adult/pediatric transplant unit cooperation program for cadaveric/ living donor liver transplantation and intestinal transplantation. Transplant Proc 34:295, 2002 4. Matesanz R, Valentin M: Cardiac transplantation in Spain. Have we reached our peak? Rev Esp Cardiol 59:193, 2006 5. de Antonio DG, Marcos R, Laporta R, et al: Results of clinical lung transplant from uncontrolled non– heart-beating donors. J Heart Lung Transplant 26:529, 2007 6. López-Santamarı´a M, Gámez M, Murcia J, et al: Intestinal transplantation in children: differences between isolated intestinal and composite grafts. Transplant Proc 37:4087, 2005 7. Cuende N, Cañón JF, Alonso M, et al: ONT quality control programme for the donation process evaluation. Nefrologia 23 (suppl 5):28, 2003 8. Del Rı´o-Gallegos F, Núñez-Pena JR, Soria-Garcia A, et al: Non– heart-beating donors. Successfully expanding the donor pool. Ann Transplant 9:19, 2004 9. Chamorro C, Romera MA, Silva JA, et al: Can heart donation exclusion factors be overcome? Rev Esp Cardiol 59:232, 2006 10. Schnitzler MA, Whiting JF, Brennan DC, et al: The lifeyears saved by a deceased organ donor. Am J Transplant 5:2289, 2005