organ transplantation in new zealand: a panacea ? johan rosman renal physician and cmo wdhb...
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Organ transplantation in New Zealand: a panacea ?
Johan RosmanRenal Physician and CMO WDHB
•Panacea:
noun a solution or
remedy for all
difficulties or
diseases.
— ORIGIN Greek panakeia,
from panakes ‘all-
healing
Mechanisms of graft rejection
Solid organ transplantation and the treatment of terminal organ failure
• Definitions– Solid organs (kidney, liver, heart, lungs): restrictive– Tissue transplantation (eyes, skin, bone, bone marrow,
heart valves, tendons):less restrictive
The painting in its three parts:– Transplantations’ global history– The current situation– The future
Tissue Donation(all ‘non solid organs’)
• tissues include eyes, heart valves, bone, tendons and skin• tissues do NOT need oxygen to remain suitable for
transplant – do NOT need to have an active blood supply• can occur following death regardless of whether death
was determined by neurological (brain death) or cardiac (heart stops) assessment
• almost everyone can be considered for tissue donation after death
• 1682 - bone
• 1881 - skin
• 1906 - corneal
• 1908 - knee joint
• 1954 - kidney transplant
• 1966 - pancreas transplant
• 1967 - liver transplant
• 1967 - heart transplant
History of TransplantationThe1st recorded transplants occurred in the 17th century. The 1st successful organ transplant, a kidney, was performed by a team led by Dr. Joseph Murray on December 23, 1954 between identical twin brothers in Boston. Dr. Murray went on to receive the Nobel Prize in Medicine for this accomplishment.
8
Dr. Christian Bernard became a household name when in 1967 he performed the world’s 1st successful heart transplant in Capetown, South Africa.
• revolutionized transplantation
• increased survival rates• 1st in a new generation of
anti-rejection drugs
Introduced in 1978, the drug cyclosporine revolutionized transplantation by depressing T cell activation and reducing organ rejection.
• 1981 - heart-lung transplant
• 1986 - lung transplant
• 1988 - liver/bowel transplant
• 1988 - split liver transplant
• 1989 - living related liver transplant
• 1995 - cluster (liver,bowel,stomach,pancreas &
kidney) transplant
Further Successful Firsts in Transplantation
Multi organ donation and -reception
Transplant Successes
Snowboarder, Chris Klug, won a bronze medal at the 2002 Olympics, two years after his liver transplant.
Now 22 years post liver transplant, Heather Fisher climbed Mount Kilimanjaro .
Transplanted with a liver, bowel, stomach and pancreas at age 5.5 months, Sarah has a spot in the Guiness Book of World Records as the youngest multi-organ recipient.
Todays’ situation in organ transplantation
• There is an increasing number of patients with end organ failure (kidney, liver, heart, lung etc)
• There is an increasing demand for organ transplantation– Improvement of technology– Patient expectations– Increase in life expectancy and comorbidities– Diabetes !!!!
• There is a finite pool of organs available, even if all potential donors could be used, increasing mismatch demand/supply of organs
• Although there is significant progress in the prevention and treatment of acute rejection, hardly any improvement in chronic rejection is made, this limits the long term outlook for transplanted patients
The challenge
NZ’s Mounting Demographic Pressures
0.0
0.1
0.2
0.3
0.4
0.5
0.6
1880 1900 1920 1940 1960 1980 2000 2020 2040 2060 2080 2100
Older (65+)Projection
Ra
tio t
o p
op
ula
tion
ag
ed
15
-64
Source: Statistics New Zealand
2009
Ratio of those aged 65+ to 15-64
Costs per Patient Year
Modality Degree of patient independence
Cost per patient per
year
Average cost over 3
years
Variance to Incentre HD
Renal Transplant Independent - $105,000 - 46%
Peritoneal Dialysis Independent $36,614 $109,842 - 43%
Home Haemodialysis Independent $33,585 $100,755 - 48%
Satellite Haemodialysis Assisted $48,172 $144,516 - 25%
Incentre Haemodialysis Dependent $64,318 $192,954 -
Aus – NZ Waiting List
Figure 118
Waiting List
AUST NZ * *
Number of Patients with Diabetes Type 1 on dialysis (December 2007) * 244 46
Patients < 45 years of age 109 24
Patients < 55 years of age 182 38
Number of patients on the Kidney Transplant Waiting List * 1298 570
Number of patients on the I slet Transplant Waiting List 11 0
Reference: * ANZDATA Registry NOMS (National Organ Matching Service) National Pancreas Registry and Dr Kanellis (Pancreas-Victoria)
** NZ Donor Coordinators
Number of patients on the Kidney Pancreas Transplant Waiting List 31 5
Number of patients on the Pancreas only Waiting List 4 0
Canadian Transplant Numbers(1994 – 2003)
2159
14
84
13
9
2522
15
30
11
4
2829
15
73
11
5
2874
16
32
17
1
3229
16
23
14
0
3514
17
46
22
5
3800
19
01
17
0
3990
18
03
19
5
4001
18
14
23
7
3966
18
36
25
0
0
500
1000
1500
2000
2500
3000
3500
4000
4500
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Waiting Transplanted Died While Waitingstatistics provided by the Canadian Institute for Health Information
301 339433
559 570
57 47 41 65 53
2004 2005 2006 2007 2008
Kidneys Waiting List *Tx Performed **
** Not included kidneys sent to Australia: 2004 (1) 2005 (4)
Waiting List vs Deceased Donor TransplantsNew Zealand 2004 - 2008
* Source of Waiting List – NZ Donor Coordinators
Patient and graft survivalOrgan 1 year 5 year
Patient survival
Heart 86% 75%
Lungs 80% 40%
Liver 95% 87%
Graft survival
Pancreas 92% 87%
Kidneys 94% 78%
Primary Deceased Patient and Graft Survival New Zealand 2002 - 2007
Kidney
60%
70%
80%
90%
100%
0 3 6 9 12 24
Months
60%
70%
80%
90%
100%
Patient (n=300)
Graft (n=300)
Are we getting better at it ?One year patient survival USA
(kidney)
Are we getting better at it ?USA Graft Survival(kidney)
1 Year
5 Year
BUT: hardly any improvement since 1998 !!
2008: NZ 1 year graft survival 94%5 year graft survival 78 %
NZ 2008
NZ 2008
Types of Donation
two types of donors:deceased (dead) donors
– donor has been declared dead by two physicians independent of the transplant team
– usually occurs only in cases of neurologically determined death (the brain stops working 1st but the donor is still on artificial support such as a ventilator to allow the other organs to maintain a blood supply and remain suitable for transplant)
live donors– patient chooses to donate one or part of an organ to someone on
a transplant waiting list– can only occur with organs when removal will NOT cause grave
harm to the donor
Numbers of (all) transplant surgery2003 2004 2005 2006 2007 2008
Hearts 22 4 13 8 9 8
Lungs 14 9 8 10 9 12
Liver (deceased donors
38 36 24 36 30 31
Livers (living donors)
1 0 4 4 4 7
Pancreas 6 2 2 6 1 3
Kidneys (deceased donors)
67 58 47 41 65 53
Kidneys (Living donors)
44 48 46 47 58 69
Deceased Donation
neurologically determined death
• usual case
• also referred to as brain death
• intact heartbeat & circulation
• on ventilator
• less than 3% of all deaths
One the reasons that there are so few organ donors in New Zealand is that very few people die under circumstances that allow them to donate their organs.
New Zealand Deceased Donors
Deceased organ donors in New Zealand
International donor rates
Figure 7
Donors per Million Population and Donors per Thousand Deaths ( ) Australian States - Australia and New Zealand 2003 - 2007
Year QLD NSW * ACT * VIC TAS SA NT WA AUST NZ
2003 11 (1.6) 7 (0.9) 25 (5.8) 9 (1.2) 4 (0.5) 14 (1.8) 5 (1.1) 9 (1.6) 9 (1.3) 10 (1.4)
2004 10 (1.6) 9 (1.4) 19 (4.2) 9 (1.4) 4 (0.5) 25 (3.4) 5 (1.1) 12 (2.1) 11 (1.6) 10 (1.4)
2005 9 (1.5) 8 (1.2) 28 (6.0) 10 (1.5) 4 (0.5) 13 (1.7) 20 (4.1) 15 (2.6) 10 (1.6) 7 (1.1)
2006 9 (1.5) 7 (1.1) 12 (2.7) 9 (1.3) 16 (2.0) 23 (3.0) 10 (2.1) 10 (1.8) 10 (1.5) 9 (0.9)
2007 9 (1.5) 8 (1.1) 3 (0.6) 11 (1.6) 2 (0.2) 17 (2.1) 14 (3.0) 9 (1.5) 9 (1.4) 9 (1.3)
Figure 8
Donors per Thousand Deaths Aged < 75 years 2003 - 2007 ( ) Represents % of Total Deaths Aged < 75 years *
Year QLD NSW ACT VIC TAS SA NT WA AUST NZ
2003 4.1 (40% ) 2.5 (37% ) 8.3 (42% ) 3.5 (36% ) 1.3 (38% ) 5.0 (34% ) 1.5 (76% ) 3.9 (40% ) 3.4 (38% ) 3.4 (40% )
2004 4.0 (39% ) 3.7 (35% ) 10.1 (42% ) 3.7 (34% ) 1.4 (36% ) 9.8 (34% ) 1.4 (78% ) 4.8 (40% ) 4.3 (37% ) 3.4 (48% )
2005 3.6 (39% ) 3.2 (36% ) 16.5 (36% ) 4.4 (35% ) 1.3 (37% ) 4.8 (34% ) 5.1 (78% ) 6.3 (39% ) 4.1 (37% ) 2.7 (40% )
2006 3.8 (38% ) 2.9 (34% ) 7.0 (38% ) 4.0 (33% ) 5.6 (36% ) 9.0 (32% ) 2.8 (76% ) 4.6 (39% ) 4.1 (36% ) 2.3 (39% )
2007 3.9 (38% ) 3.0 (34% ) 1.6 (40% ) 4.9 (33% ) 0.6 (35% ) 5.9 (32% ) 3.9 (77% ) 3.9 (39% ) 4.0 (35% ) 3.4 (38% )
Donor age
Ethnicity of Donors
1010 ICU deaths and brain damage
Non heart-beating donors
donation after cardiac death• currently being explored in New Zealand as the number of classic donors is finite
and not sufficient even if used to the max• common in countries such as Spain and the Netherlands• occurs in hopeless cases in the hospital where the decision to withdraw life-
support is made (decision is independent of the decision to donate)• organ donation occurs immediately once the heart has stopped and the patient is
declared dead• Problem: the treating team is also the team deciding when the patient is formally
deceased• Can come with consent issues and sometimes procedures necessary before
consent can be obtained
Live Donation
• kidney – most common
• living liver donation on the rise
• living lung donation – not as common
due to more people on the waiting list and a severe shortage of organs for transplant – more emphasis is being put on living donation
Live Donation
• usually occurs between related individuals (blood or emotionally)
• NEVER involves payment to the donorBenefits:• can allow for pre-emptive transplant (before
recipient requires dialysis)• allows for a planned transplant procedure• has improved graft survival (often genetic
compatibilities and always short time between harvesting and transplantation)
• shortens time on the waiting list for the recipient• increases the total number of organs available for
transplant
Kidney Transplantation NZ
Liver Transplantation
Live Donation(risks to the donor ?)
• 40 years experience with kidneys show no significant long term risks
• any patient undergoing surgery faces risks – the dilemma with living donation is that a healthy patient is undergoing surgery with no direct health benefit to themselves
• every attempt is made to minimize risks to the donor
• informed consent is required
The donor shortage
• Optimise recruitment campaign• Use live donors• Use ‘non heart beating donors’• Use animals• Innovation: ‘pooled live donors’• Change legislation ?• Improvement in graft survival will have positive
impact on demand, improvement in patient survival will not
Legislative approach ?
• Sweden and Israel:presumed consent, still donor rates only 15 resp 8 per million
• Most succesful: Spain, 34, with opt-out legislation, with however family override,still 10% dies on waiting list
• The key to success ?
Drivers licence status of donors
Figure 39
Driver’s Licence Intention Status 2004 - 2008
Intention Australia New Zealand
2004 2005 2006 2008 2004 2005 2006 2007 2008
Yes 53
(24% ) 48
(24% ) 57
(28% ) 67
(26% ) 10
(25% ) 4
(14% ) 5
(20% ) 13
(34% ) 2
(6% )
No 36 31 23 55 0 1 0 0 1
Age / Not Applicable 24 35 38 56 6 1 1 2 2
Unknown 105 90 84 81 24 23 19 23 26
Total 218 204 202 259 40 29 25 38 31
2007
68 (34% )
50
35
45
198
Other solutions
• Allow controlled ‘selling of organs’• Allow controlled ‘organ tourism’ (unethical for
you and me, but for the poor ?)• Improve donorcampaigns ? More transplant
coordinators ?• Improve our prevention program, not
becoming sick in the first place ?
The ‘portable kidney’
Problems with live donorshipthe gift of life
• Fear• Interfamilial problems (“I want my kidney
back”), creating ‘dependency’• Donor losing his one kidney• Especially in NZ: reimbursement and insurance
issues
Ethical issuesdifferent societies – different values
• Ethical issues around harvesting and distribution• Can we ‘take’ organs from those who died from capital
punishment ?• Can we ‘buy’ organs from those who offer them for sale ?• Should we feel an ‘obligation’ to make our organs available to
others ?• Should only those willing to donate be allowed to receive ?• Should prison inmates receive transplants ?• Should patients with alcoholic liver disease receive a transplant?• Should patients with a failed transplant have a second chance?• Should children on the waiting list be prioritised ?
www.tsanz.com.au/downloads/
We have to ask ourselves the hard questions
• Should we accept New Zealand patients buying organs in slums ?
• Should we support a foreign system that intermediates these transactions ?
• If your chances of getting a kidney were low would you go buy yourself a kidney ?
• If you lived in a slum and your family would starve unless you sold your kidney, would you sell it ?
• So are we ‘ethical hypocrites ?
Organ transplantation: Future• Newer Immunosuppressive medication will improve,
changing patient- and graft survival, and get a grip on chronic rejection
• Organs may become ‘wearable’ with improving technology• Optimisation of immunosuppression• Exploiting ‘tolerance’ • Xenotransplantation ? (ethics of this ?)• Stem cells ? • Better donor and recipient preparation• Expansion of the donor pool (‘pooled transplants’, just
started in NZ)• Donation registry ? ODNZ: no proven benefit, may be
counterproductive
Take home messages• Transplantation as a treatment for organ failure has come a
long way, New Zealand is a global leader• The short term prospects are still improving; long term results
show hardly any improvement over the last 10 years• Even if the current deceased donor pool could be fully used, it
would not be enough to make waiting lists disappear• New ways of organ harvesting need to be explored (e.g. non
heart beating donors, ‘paid donors’ ?)• Ethical issues need to be discussed and fronted• New Zealand should look better after its people who are
willing to spend an organ, the financial ‘punishment’ for the gift of life is not acceptable.
Don’t take your organs to Heaven;Heaven knows we need them here
Discussion