Impact of the Eurotransplant High-Urgency Heart Allocation System on the Outcome of Transplant Candidates in Germany

Abstract

Background: In 2000, the Eurotransplant Foundation changed the allocation criteria following the enactment of the German Transplantation Law (GTL). Our study investigated the impact of the new allocation system on outcomes after heart transplantation (HTx) in Germany. Methods: We compared 2 cohorts of patients who underwent HTx at our institution in two different 3-year periods before (Group 1: 01/1995–12/1997) and after (Group 2: 01/2003–12/2005) implementation of the new system. Results: An increase in the ratio of HTx performed on an urgency basis was found in Group 2 (8.3 % vs. 87.2 %; p < 0.001). The median waiting time and the ischemia time were significantly lower in Group 1 (p < 0.05). Postoperatively, the length of ICU stay was significantly higher in Group 2 (p = 0.04). Conclusion: The new allocation system decreased the proportion of local and regional organ harvesting. It generates a higher ischemia time without increasing the number of transplantations and without improving the clinical outcome after HTx. The severity of heart failure, rate of secondary organ impairment, and comorbidity is markedly elevated in patients waiting for HTx on HU.

Key words

heart and lung transplantation - cardiomyopathy - heart disease - heart transplantation - HU allocation - Eurotransplant Foundation

References

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Invited Commentary

The article published by Haneya and colleagues [1] reports on a single Center experience examining the impact of the Eurotransplant High-Urgency Heart Allocation System on the outcome on heart transplant candidates. The main conclusions of the manuscript are that the new allocation system decreases the proportion of local and regional organ harvesting without increasing the total number of transplantations and without improving clinical outcome after heart transplantation.

In 1997 a new transplantation-law was implemented in Germany. The main goal of this new transplantation-law was to give everybody who is waiting for organ transplant in Germany the same chance independently of where the potential recipient is located. In addition, a very urgent candidate should have priority over elective transplant candidates and certain quality standards should be achieved after any organ transplantation. As a reaction to this law, the regional organ allocation changed into a national organ allocation organized by Eurotransplant in the Netherlands. In order to give very urgent candidates a priority, a new high-urgency (HU) status was created and the application for this HU-status must fulfill several certain HU-criteria. The HU-applications are collected by Eurotransplant and sent to three national and international auditors for review. The HU-status will be granted if a majority of the auditors votes for it. Re-evaluation of this status takes place every two weeks.

In parallel with this development, the number of heart donors decreased significantly and continuously over the last 15 years from over 550 in 1995 to less than 350 in 2009. Also the age and quality of heart donors changed significantly. While 15 years ago there was still a majority of young and healthy organ donors who usually suffered from a car or a motorbike accident, today the organ donors are older and carry significant cardiovascular risk factors such as arterial hypertension, leading to intracranial hemorrhage as cause of brain death in the majority of organ donors.

As a result from organ shortage the numbers of potential recipients on our waiting list increases continuously. In addition the number of HU-applications also raised drastically over the last years reaching a maximum of almost 80 % of all heart transplantations performed in HU-candidates over the last few years. Subsequently the waiting time for HU-listed patients increased as well as the risk profile of these hospitalized patients. This might well result in inferior survival rates after heart transplantation in Germany. The last reported data reported within our German quality insurance reported a one year survival of 76.7 % after heart transplantation in Germany in 2009. This compares with almost 90 % according to the registry of the International Society for Heart and Lung Transplantation. There is no doubt that the results of the heart transplantation need to be improved and the probability of survival after transplantation would optimally be part of an accurate allocation system.

For lung transplantation, a potential solution has been found in the United States by introducing the so-called LAS (Lung Allocation Score) as part of their allocation process. The LAS is calculated based on the urgency of the necessary transplantation as well as the probability of survival after transplantation. Since the different primary diagnoses for lung transplantation have different probabilities of survival after the transplant procedure, this calculation can well be done in the field of pulmonary transplantation. After the LAS was introduced in US, mortality on waiting lists decreased, at the same time maintaining excellent survival results after lung transplantation. For this reason a new allocation system has been proposed to the “Ständige Kommission für Organtransplantation der Bundesärztekammer” and has meanwhile been approved. After implementation by Eurotransplant, the allocation process in lung transplantation will start in the second half of 2011. After evaluation of the first phase of the new allocation system in lung transplantation, the whole data will be reevaluated and a possible transfer onto the field of cardiac transplantation will be discussed. This, however, will be more difficult, since the different primary diagnoses for heart transplantation do not really have a different probability of survival after the transplant.

The main problem of heart transplantation in Germany, which must be emphasized over and over again, is the significant organ shortage. The new transplantation law and its implementation led to the fact that there was a decrease of almost 40 % of heart transplantations over the last 15 years! Any effort needs to be undertaken in order to increase organ donations and this is mainly a political and financial issue. Our neighbors in Europe have proven that this is definitely possible. Perfect examples, such as Spain, presently present an organ donation rate of over 32 per million people compared to 14.6 in Germany. Unless we are not able to improve organ donation, the future of heart transplantation will be limited, at least in Germany.

Hermann Reichenspurner, M. D., Ph.D.
University Heart Center Hamburg
Martinistr. 52, 20246 Hamburg
Germany
Phone: [phone]
Fax: + 49 4 07 41 05 49 31
Email: [e-mail]

References

• 1 Haneya A, Haake N, Diez C et al. Impact of the Eurotransplant high-urgency heart allocation system on outcome of transplant candidates in Germany.  Thorac Cardiovasc Surg. 2011;  59 93-97