- Email: [email protected]
Liver transplant in Spain: Achievements and challenges
Med Clin (Barc). 2015;144(8):360–361
www.elsevier.es/medicinaclinica
Editorial article
Liver transplant in Spain: Achievements and challenges夽 ˜ logros y retos El trasplante hepático en Espana: Rafael Matesanz Organización Nacional de Trasplantes, Madrid, Spain
Three decades since the first liver transplant was carried out in Spain, and after 20 000 procedures, this intervention has become an effective therapeutic option for the treatment of irreversible severe or chronic liver disease. Since Spain reached the highest donation rate registered at international level in the early 1990s,1 the highly qualified job of professionals involved in the transplant coordination network has allowed us to maintain our leadership exceeding 35 donors per million population (pmp), far from the rate recorded in Europe (19.1 pmp) or in the USA (25.8 pmp).2 The constant national effort made in the areas of identifying and maintaining potential donors, sustained by our social conviction of the importance of this therapeutic resource in conditions of universal access and equality for all citizens, have meant that the annual rate of liver transplants performed has held steady at around 1000 annual transplants, which places us at the top of worldwide activity, with rates exceeding 23 liver transplants pmp. Linking these efforts with improvements in surgical techniques as well as immunosuppression, perioperative care and donor-receiver selection has permitted patients in need of a liver transplant in Spain to have higher chances of obtaining one and, also, to opt for the best possible prospects of survival and quality of life. In this context, knowledge of the epidemiology of the illnesses that motivate the transplant is especially relevant as is the prevalence of the therapy and other variables that enable us to assess the results in terms of the viability of implants and the survival of transplant recipients. Hence, transplant registries constitute an essential instrument for professionals, researchers, the administration, patients and other stakeholders.3–9 In this context, the Spanish Liver Transplant Registry (Registro Espa˜ nol de Trasplante Hepático, RETH) systematically records all aspects of Spanish data, adding information about donor and recipient characteristics, technical issues or short-term immunosuppression and, even more importantly, updating information about implant and receiver evolution by recording, if they arise, cause of death or retransplantation.10
夽 Please cite this article as: Matesanz R. El trasplante hepático en Espana: ˜ logros y retos. Med Clin (Barc). 2015;144:360–361. E-mail address: [email protected] ˜ S.L.U. All rights reserved. 2387-0206/© 2014 Elsevier Espana,
Since the main purpose of the RETH is to create a cooperative environment of knowledge and expertise about liver transplants, the fact that it is kept up to date by the professionals involved ensures the achievement of goals such as knowing how the recipient’s epidemiological characteristics develop, assessing overall patient and implant survival as a function of different variables and functioning as a database for specific clinical and epidemiological studies. These features have led to the use of the RETH in the study entitled Activity and results of liver transplant in Spain, 1984–2012. Analysis of the Spanish Liver Transplant Registry (Actividad y resultados del trasplante hepático en Espa˜ na durante el período 1984–2012. Análisis del Registro Espa˜ nol de Trasplante Hepático),11 This registry is both highly thorough and consistent due to the firm commitment of all Spanish liver transplant units (40% of which have performed in excess of 1000 interventions) in a collaborative framework established between the National Transplant Organization (Organización Nacional de Trasplantes, ONT) and the Spanish nola de Trasplante Society of Liver Transplantation (Sociedad Espa˜ Hepático, SETH) which, conscious of its relevance, coordinate their efforts to maintain and develop the RETH by fostering its scientific analysis and safeguarding the quality of the information gathered. In light of the above, the recently established RETH Audit Scheme, enables us to confirm the veracity of the data collected, all of which brings greater consistency to the statistical analyses. In the results submitted by the authors, several facts require greater attention. It is important to stress that the sustained increase in the donation rate in Spain has entailed a significant change in the donor profile: average age has doubled and cause of death has changed as cardiovascular disease is now in first place displacing traumatic brain injury. This is an important issue given its impact on post-transplant survival. Two aspects regarding liver transplants should be emphasized: cirrhosis remains the main indication, representing over 60% of cases, with alcohol-related and hepatitis C virus-related cirrhosis being the most outstanding in this group and the major change has been indication for hepatocarcinoma, which has accounted for more than 35% of cases in the last three years. As the authors show, analysis of the information collected in the RETH has permitted the identification of variables with significant impact on liver transplant survival: age and cause of donor death,
R. Matesanz / Med Clin (Barc). 2015;144(8):360–361
pre-transplant situation, baseline disease, need for a re-transplant, cold ischaemia rime or C virus serology. These have all become elements to be considered by the professionals, not only in the clinical practice, but also in the information given to patients about their expectations and prognosis. One of the most relevant facts regarding the evolution of liver transplants in Spain is the significant increase recorded in survival rates—which reach 85%, 73% and 62% at one, 5 and 10 years, respectively—due to improvements in surgical techniques in recent years and in donor-recipient matching as the best long-term treatment for immunosuppression and related complications. The data places great value on the quality of the health care system as a whole and, especially, on the work of all the professionals involved: the transplant coordination team in its effort to increase donation rates in an unstable environment, the professionals of the intensive care units in the increasingly more complex maintenance of potential donors, and the liver transplant teams when adapting to this new donor profile, maintaining, and even improving, long-term results. However, we need to recognize that there are still areas subject to improvement that must be tackled in order to reducing the gap between the demand and the availability of implants. Moreover, these areas require a greater development of alternatives to the conventional liver transplant, such as the split liver transplant of a living donor and asystole donor, which nowadays barely represent 6% of the transplants performed. Due to the awareness of the need to increase the number of donors to meet current demand, various approaches have been taken in recent years within the Scheme of Action to improve donation and organ transplant: Forty Donation Scheme (Plan Donación Cuarenta). The preparation of the 2012 National Consensus on Donation in Asystole, headed by the ONT, has allowed donation in asystole to currently represent 10% of donations from cadaveric donors, and liver transplants from asystole donors have increased moderately. Nevertheless, it is likely that the spread of good preliminary results recorded by the RETH itself will encourage greater mid-term activity, always in pursuit of increased safety and quality in the procedures.
361
Furthermore, the recent implementation of the National Scheme by the ONT and the SETH for the split liver transplant entails a national system of maximum usage of liver implants through simultaneous implantation in 2 recipients. This is aimed to consolidate a fair and effective system in order to palliate infant waiting-list mortality with no detriment to adult applicants. We have already seen the advantages that derive from the maintenance and operation of the RETH and these will soon be broadened with the merging of the ONT Waiting list, Donation and Transplant databases. The project to merge these will enable the follow-up of patients from registration on the waiting list to their most recent medical consultation post-transplant. This constitutes a further improvement of the scientific value of RETH because it will facilitate the performance of complex analyses that will extend the function of RETH as a support element in clinical decision-making. References 1. Organización Nacional de Trasplantes. Dossier de actividad de trasplante hep˜ 2013. Available at: http://www.ont.es [accessed 20.10.14]. ático en Espana; 2. Global Observatory on Donation and Transplantation. Available at: http:// www.transplant-observatory.org [accessed 15.10.14]. 3. European Liver Transplant Registry. Annual report. Available at: http://www. eltr.org [accessed 20.10.14]. 4. Adam R, Karam V, Delvart V, O’Grady J, Mirza D, Klempnauer J, et al. Evolution of indications and results of liver transplantation in Europe. A report from the European Liver Transplant Registry (ELTR). J Hepatol. 2012;57:675–88. 5. United Network for Organ Sharing (UNOS). Liver Transplant Registry. Available at: http://www.unos.org [accessed 20.10.14]. 6. Scientific Registry of Transplant Recipients. Available at: http://srtr. transplant.hrsa.gov [accessed 20.10.14]. 7. Dutkowski P, de Rougemont O, Müllhaupt B, Clavien PA. Current and future trends in liver transplantation in Europe. Gastroenterology. 2010;138:802–9. 8. Duffy JP, Kao K, Ko CY, Farmer DG, McDiarmid SV, Hong JC, et al. Long-term patient outcome and quality of life after liver transplantation: analysis of 20-year survivors. Ann Surg. 2010;252:652–61. 9. Watt KD, Pedersen RA, Kremers WK, Heimbach JK, Charlton MR. Evolution of causes and risk factors for mortality post-liver transplant: results of the NIDDK long-term follow-up study. Am J Transplant. 2010;10:1420–7. ˜ 10. Sociedad Espanola de Trasplante Hepático. Memoria General del RETH 2013. Available at: http://www.sethepatico.org; http://www.ont.es [accessed 20.10.014]. 11. Cuervas-Mons V, de la Rosa G, Pardo F, San Juan F, Valdivieso A, en repre˜ de Trasplante Hepático. Actividad y resultados sentación del Registro Espanol ˜ durante el período 1984–2012. Análisis del del trasplante hepático en Espana ˜ de Trasplante Hepático. Med Clin (Barc). 2015;144:337–47. Registro Espanol
www.elsevier.es/medicinaclinica
Editorial article
Liver transplant in Spain: Achievements and challenges夽 ˜ logros y retos El trasplante hepático en Espana: Rafael Matesanz Organización Nacional de Trasplantes, Madrid, Spain
Three decades since the first liver transplant was carried out in Spain, and after 20 000 procedures, this intervention has become an effective therapeutic option for the treatment of irreversible severe or chronic liver disease. Since Spain reached the highest donation rate registered at international level in the early 1990s,1 the highly qualified job of professionals involved in the transplant coordination network has allowed us to maintain our leadership exceeding 35 donors per million population (pmp), far from the rate recorded in Europe (19.1 pmp) or in the USA (25.8 pmp).2 The constant national effort made in the areas of identifying and maintaining potential donors, sustained by our social conviction of the importance of this therapeutic resource in conditions of universal access and equality for all citizens, have meant that the annual rate of liver transplants performed has held steady at around 1000 annual transplants, which places us at the top of worldwide activity, with rates exceeding 23 liver transplants pmp. Linking these efforts with improvements in surgical techniques as well as immunosuppression, perioperative care and donor-receiver selection has permitted patients in need of a liver transplant in Spain to have higher chances of obtaining one and, also, to opt for the best possible prospects of survival and quality of life. In this context, knowledge of the epidemiology of the illnesses that motivate the transplant is especially relevant as is the prevalence of the therapy and other variables that enable us to assess the results in terms of the viability of implants and the survival of transplant recipients. Hence, transplant registries constitute an essential instrument for professionals, researchers, the administration, patients and other stakeholders.3–9 In this context, the Spanish Liver Transplant Registry (Registro Espa˜ nol de Trasplante Hepático, RETH) systematically records all aspects of Spanish data, adding information about donor and recipient characteristics, technical issues or short-term immunosuppression and, even more importantly, updating information about implant and receiver evolution by recording, if they arise, cause of death or retransplantation.10
夽 Please cite this article as: Matesanz R. El trasplante hepático en Espana: ˜ logros y retos. Med Clin (Barc). 2015;144:360–361. E-mail address: [email protected] ˜ S.L.U. All rights reserved. 2387-0206/© 2014 Elsevier Espana,
Since the main purpose of the RETH is to create a cooperative environment of knowledge and expertise about liver transplants, the fact that it is kept up to date by the professionals involved ensures the achievement of goals such as knowing how the recipient’s epidemiological characteristics develop, assessing overall patient and implant survival as a function of different variables and functioning as a database for specific clinical and epidemiological studies. These features have led to the use of the RETH in the study entitled Activity and results of liver transplant in Spain, 1984–2012. Analysis of the Spanish Liver Transplant Registry (Actividad y resultados del trasplante hepático en Espa˜ na durante el período 1984–2012. Análisis del Registro Espa˜ nol de Trasplante Hepático),11 This registry is both highly thorough and consistent due to the firm commitment of all Spanish liver transplant units (40% of which have performed in excess of 1000 interventions) in a collaborative framework established between the National Transplant Organization (Organización Nacional de Trasplantes, ONT) and the Spanish nola de Trasplante Society of Liver Transplantation (Sociedad Espa˜ Hepático, SETH) which, conscious of its relevance, coordinate their efforts to maintain and develop the RETH by fostering its scientific analysis and safeguarding the quality of the information gathered. In light of the above, the recently established RETH Audit Scheme, enables us to confirm the veracity of the data collected, all of which brings greater consistency to the statistical analyses. In the results submitted by the authors, several facts require greater attention. It is important to stress that the sustained increase in the donation rate in Spain has entailed a significant change in the donor profile: average age has doubled and cause of death has changed as cardiovascular disease is now in first place displacing traumatic brain injury. This is an important issue given its impact on post-transplant survival. Two aspects regarding liver transplants should be emphasized: cirrhosis remains the main indication, representing over 60% of cases, with alcohol-related and hepatitis C virus-related cirrhosis being the most outstanding in this group and the major change has been indication for hepatocarcinoma, which has accounted for more than 35% of cases in the last three years. As the authors show, analysis of the information collected in the RETH has permitted the identification of variables with significant impact on liver transplant survival: age and cause of donor death,
R. Matesanz / Med Clin (Barc). 2015;144(8):360–361
pre-transplant situation, baseline disease, need for a re-transplant, cold ischaemia rime or C virus serology. These have all become elements to be considered by the professionals, not only in the clinical practice, but also in the information given to patients about their expectations and prognosis. One of the most relevant facts regarding the evolution of liver transplants in Spain is the significant increase recorded in survival rates—which reach 85%, 73% and 62% at one, 5 and 10 years, respectively—due to improvements in surgical techniques in recent years and in donor-recipient matching as the best long-term treatment for immunosuppression and related complications. The data places great value on the quality of the health care system as a whole and, especially, on the work of all the professionals involved: the transplant coordination team in its effort to increase donation rates in an unstable environment, the professionals of the intensive care units in the increasingly more complex maintenance of potential donors, and the liver transplant teams when adapting to this new donor profile, maintaining, and even improving, long-term results. However, we need to recognize that there are still areas subject to improvement that must be tackled in order to reducing the gap between the demand and the availability of implants. Moreover, these areas require a greater development of alternatives to the conventional liver transplant, such as the split liver transplant of a living donor and asystole donor, which nowadays barely represent 6% of the transplants performed. Due to the awareness of the need to increase the number of donors to meet current demand, various approaches have been taken in recent years within the Scheme of Action to improve donation and organ transplant: Forty Donation Scheme (Plan Donación Cuarenta). The preparation of the 2012 National Consensus on Donation in Asystole, headed by the ONT, has allowed donation in asystole to currently represent 10% of donations from cadaveric donors, and liver transplants from asystole donors have increased moderately. Nevertheless, it is likely that the spread of good preliminary results recorded by the RETH itself will encourage greater mid-term activity, always in pursuit of increased safety and quality in the procedures.
361
Furthermore, the recent implementation of the National Scheme by the ONT and the SETH for the split liver transplant entails a national system of maximum usage of liver implants through simultaneous implantation in 2 recipients. This is aimed to consolidate a fair and effective system in order to palliate infant waiting-list mortality with no detriment to adult applicants. We have already seen the advantages that derive from the maintenance and operation of the RETH and these will soon be broadened with the merging of the ONT Waiting list, Donation and Transplant databases. The project to merge these will enable the follow-up of patients from registration on the waiting list to their most recent medical consultation post-transplant. This constitutes a further improvement of the scientific value of RETH because it will facilitate the performance of complex analyses that will extend the function of RETH as a support element in clinical decision-making. References 1. Organización Nacional de Trasplantes. Dossier de actividad de trasplante hep˜ 2013. Available at: http://www.ont.es [accessed 20.10.14]. ático en Espana; 2. Global Observatory on Donation and Transplantation. Available at: http:// www.transplant-observatory.org [accessed 15.10.14]. 3. European Liver Transplant Registry. Annual report. Available at: http://www. eltr.org [accessed 20.10.14]. 4. Adam R, Karam V, Delvart V, O’Grady J, Mirza D, Klempnauer J, et al. Evolution of indications and results of liver transplantation in Europe. A report from the European Liver Transplant Registry (ELTR). J Hepatol. 2012;57:675–88. 5. United Network for Organ Sharing (UNOS). Liver Transplant Registry. Available at: http://www.unos.org [accessed 20.10.14]. 6. Scientific Registry of Transplant Recipients. Available at: http://srtr. transplant.hrsa.gov [accessed 20.10.14]. 7. Dutkowski P, de Rougemont O, Müllhaupt B, Clavien PA. Current and future trends in liver transplantation in Europe. Gastroenterology. 2010;138:802–9. 8. Duffy JP, Kao K, Ko CY, Farmer DG, McDiarmid SV, Hong JC, et al. Long-term patient outcome and quality of life after liver transplantation: analysis of 20-year survivors. Ann Surg. 2010;252:652–61. 9. Watt KD, Pedersen RA, Kremers WK, Heimbach JK, Charlton MR. Evolution of causes and risk factors for mortality post-liver transplant: results of the NIDDK long-term follow-up study. Am J Transplant. 2010;10:1420–7. ˜ 10. Sociedad Espanola de Trasplante Hepático. Memoria General del RETH 2013. Available at: http://www.sethepatico.org; http://www.ont.es [accessed 20.10.014]. 11. Cuervas-Mons V, de la Rosa G, Pardo F, San Juan F, Valdivieso A, en repre˜ de Trasplante Hepático. Actividad y resultados sentación del Registro Espanol ˜ durante el período 1984–2012. Análisis del del trasplante hepático en Espana ˜ de Trasplante Hepático. Med Clin (Barc). 2015;144:337–47. Registro Espanol