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d7759 - ESC 2016 European Hospital-v1.indd 1 03/02/2016 13:56 EUROPEAN HOSPITAL  Vol 25 Issue 1/16 4 NEWS & MANAGEMENT Still ranking 1st for organ donations and transplants The gruelling fight for trust Spain: 24 years on top of the world Organ donation in Germany With 4,360 transplant operations from 1,682 donations in 2014, Spain broke the country’s own record and confirmed its place as the world leader in organ donations, a position it has held for the past 24 years. Our correspondent in Spain Mélisande Rouger spoke with Dr Rafael Matesanz, founder and direc- tor of the Spanish National Transplant Organisation (ONT), to understand this undisputed achievement. Whilst Spain has announced a new record for organ donations the number in Germany is sta- bilising at a ‘low level’. The good news? The number did not fall any further following scandals surrounding the manipulation in the allocation of donor organs. What is the key to your success? Dr Matesanz: ‘When the ONT was created in 1989, donations were fall- ing and waiting lists were very long. So we broke with tradition: instead of being a non-profit foundation, like every other transplant organi- sation back then, we became a Report: Sylvia Schulz The German Organ Transplantation Foundation (DSO), the coordination centre for post-mortem organ dona- tions in this country, reports the number of organ donors nationally increased slightly from 1.5% in 2014 to 877 in 2015 – 10.8 donors per one million inhabitants (2014: 10.7) compared to Spain with 39.7 organ donors per one million inhabitants. Thus the dramatic decline in willingness to donate halted, for now. Although 1,296 donor organs were available in 2010, the number decreased continuously over fol- lowing years. There are currently around 12,000 patients await donor organs. According to the DSO, the reason for the drastic decline is transplant scandals uncovered in four hospitals – in Göttingen, Regensburg, Munich and Leipzig. They are accused of manipulating patient data and misrepresenting the severity of patients’ conditions to improve their allocation ranking . ‘In the third year following the transplant scandal no end to the problems is in sight. The legal fol- low-up to the scandal continues at the forefront,’ said Professor Björn Nashan, President of the German Transplant Society (DTG), during the society’s congress a few months ago. Both politicians and the media reacted: A number of fundamental changes to improve transparency and quality assurance have now occurred in transplantation work. The Transplant Law, which came into effect in August 2012, has been modified several times in the light of the above events of 2013. Along with extended governmental control over transplants, the law also intro- duced a statutory offense to address potential future manipulations. A nationwide transplant register is also envisaged. This law also cre- ated the legal necessity to employ- ment of transplant coordinators, to be employed by all donor hospitals. Additionally, the law has intro- duced a formalisation of processes and continuous monitoring, as well as the implementation and expan- sion of quality assurance procedures for organ removal, donor hospitals and transplant centres. Living kidney donors have a slight- ly increased risk of developing kid- ney disease or even needing dialysis compared to healthy non-donors. Younger women donating a living kidney are at higher risk of compli- cations during pregnancy. Further effects can be raised blood pres- sure and protein secretion in urine. As German Transplant Law stipu- lates regular medical follow-ups for all living kidney donors, transplant centres offer annual examinations. However, Banas emphasises,‘If there were sufficient post mortem organs available we’d only advise living donations in certain people.’ part of the Spanish Health Ministry. Another move was to place an intensivist, instead of a nurse or technician, to coordinate donations directly in the hospital and detect potential donors. ‘We have trained over 14,000 spe- cialists involved in organ transplant – from detecting donors to talking to relatives. We also work to keep the public informed. In 1992, three years after we started, we became the world leader in organ donations. People are generous but you can’t expect donations to fall from the heavens. A good system must train and motivate professionals; what works in the end is organisation.’ Why should the coordinator be a doctor? ‘A nurse is crucial at the time to talk with relatives; but an intensivist is on the same level as a surgeon and will understand all the clinical questions. Our coordinators work directly within the intensive care unit (ICU), so that they can influ- ence donation very early. ‘87% of our coordinators are intensivists but they can come from any other medi- cal specialty. ‘Presumed consent is very charac- teristic of southern European coun- tries and informed consent is more common across northern Europe. But even with presumed consent, relatives are consulted and have the final say. Only in Singapore do they enforce presumed consent. ‘According to Eurostat, those most in favour of donations are northern countries. ‘But, once faced with a relative’s death, how you conduct the inter- view matters much more than previ- ous beliefs. ‘Presumed consent doesn’t nec- essarily lead to more donations. For instance, attempts to switch to presumed consent in Brazil led to a backlash against organ donations. Who are Spain’s donors? More than half of them are over 60 and die following brain death. Traffic accident victims, who used to represent over 40% of donors, now only account for 4%.’ What are the most transplanted organs? ‘Kidney transplants represent three quarters of the 120,000 transplants performed in the world annually, followed by liver, heart, lungs, pan- creas and intestine. In 2014 there were 2,678 kidney transplants, 1,068 liver transplants, 265 heart transplants, 262 lung transplants, 81 pancreas transplants and six intestine transplants in Spain.’ Has the economic crisis affected donations? ‘The number of airplanes used for transplants has reduced by 20% since the crisis began. As a result, paradoxically, we’ve become more efficient and transplant more than in 2009. That’s because our system is very solid.’ ‘It could have serious consequenc- es for both Catalonia and Spain. Our current system is well balanced. There’s a fluid exchange of organs and a fifth of transplanted organs come from a different region. ‘Catalonia has a lot of cutting edge and specialised teams; but it has fewer donors than regions, such as La Rioja or Cantabria.’ How do you tackle transplant tourism? ‘There isn’t any black market within the EU because it’s very controlled. Outside, that’s another story. It’s a North-South problem; people from high-income countries buying from low-income countries. ‘According to the WHO, five to 10% of all transplant operations originate from trade. Some peo- ple also buy their way up into waiting lists. Internet enables those exchanges.’ Spain attracts many EU citizens who want to benefit from its effi- cient public healthcare system… ‘As long as they can validate a sec- ond residency in Spain, all EU citi- zens can enjoy our health benefits, including organ transplant. ‘This works both ways: eight to 10% of our donors are not Spanish, which matches the proportion of foreigners living in the country. ‘Interestingly, when asked if they’d agree to donate a deceased relative’s organs, 40% of the British who live in the UK said no; but when they live in Spain, only 8% refuse to donate. The British donate far more in Spain, and this is also true for other communities living here. This proves that consent is not based on cultural beliefs but on the system.’ What are your plans for the future? ‘We expected more donations than ever in 2015, and we plan to increase the number of donors by 10% and transplanted patients by 20% within the next five years. ‘We’re implementing the EU’s ACCORD programme, which we developed with the UK to involve emergency physicians in donor detection. ‘Globally, we expect donation after cardiac death to continue to augment the number of donations and to become the main expansion strategy in deceased donors.’ Nephrologist Rafael Matesanz is founder and director of the Spanish National Transplant Organisation (ONT), part of Ministry of Health, Social Services and Equity. ONT plans and coordinates cells, organ, tissue and bone marrow transplants. He is responsible for the ‘Spanish Model’, which led Spain from mid-to low- donation levels in the ‘80s to world leader from 1992, with rates more than double EU rates. He presides over the Spanish National Transplant Committee, and the IberoAmerican Council of Organ Donation and Transplantation, and advises he USA’s Institute of Medicine (IOM) and the WHO on global transplantation strategy. d7759 - ESC 2016 European Hospital-v1.indd 103/02/201613:56

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