Organ transplantation in New Zealand: a panacea ?

Johan RosmanRenal Physician and CMO WDHB

Johan.Rosman@WaitemataDHB.govt.nz

 

•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

Rat

io to

pop

ulat

ion

aged

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

1484

139

2522

1530

114

2829

1573

115

2874

1632

171

3229

1623

140

3514

1746

225

3800

1901

170

3990

1803

195

4001

1814

237

3966

1836

250

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 24Months

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 donorsdonation 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