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Eurotransplant csatlakozás: reális lehetőség?. Dr. Langer Róbert. egyetemi docens, klinika igazgató. Semmelweis Egyetem, Transzplantációs és Sebészeti Klinika, Budapest. Eurotransplant csatlakozás – reális lehetőség?. Dr. Langer Róbert. - PowerPoint PPT Presentation
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Eurotransplant csatlakozs:relis lehetsg? Dr. Langer Rbertegyetemi docens, klinika igazgatSemmelweis Egyetem, Transzplantcis s Sebszeti Klinika, Budapest
Eurotransplant csatlakozs relis lehetsg?Dr. Langer Rbert Semmelweis Egyetem Transzplantcis s Sebszeti Klinika
Balancing urgency and outcomeNet benefit-/Transplant window-concept-> Increasing organ failure -> MortalityMed. TherapyTransplantationbenefittoo earlytoo lateTransplantation window
n= 5782VESETRANSZPLANTCI MAGYARORSZG
HLA antign mismatch Magyarorszgon
ET Organ allocation - renalAB/LDHRNLSLO
Kidney graft survival and HLA-ABDR mismatches Adult first cadaver kidney-only transplantsPost-transplant time (m)P=0.0001%83%71%
100%10073total0,4%4462,4 %244510,5 %1055430,2%3043326,6 %26792832121760PercentageNo. of transplantationsNo. of mismatchesHLA-matching in kidney transplantationET 2000-2004, non-ESP patients21,6 %8,3 %
Origin of donor organs transplantedEurotransplant: 01.01.2001 31.12.2005
Diagramm5
256127770
13481266465
46751327117
1562227171
130035231
own country
other ET country
outside ET
Tabelle1
HeartKidneyLiverLungPancreas
bad donor quality138917419437
no recipient9421147714
logistical problem6221156528
recipient problem21
other25822677
32114212540386
706511717131
HeartKidneyLiverLungPancreas
elective recipients3910215029
HU recipients3115212
Tabelle2
HeartKidneyLiverLungPancreas
not accepted32114212540386
transplanted706511717131
Tabelle2
not accepted
transplanted
Tabelle4
HeartKidneyLiverLungPancreas
own country256113481467515621300
other ET country27726641327227352
outside ET706511717131
Kidney
own country-other recipients9743
own country-ESP recipients1887
own country-HU recipients285
own country-AM recipients85
own country-000 HLA recipients1481
exchanged - other recipients1406
exchanged- HU recipients73
own country-elective recipients140841649281262exchanged-AM recipients147
own country-HU recipients115351163438exchanged-000 HLA recipients1038
exchanged - elective recipients130769142314
exchanged- HU recipients1475588538
Tabelle4
own country
other ET country
outside ET
Tabelle3
HeartKidneyLiverLungPancreas
bad donor quality138917419437
no recipient9421147714
logistical problem6221156528
recipient problem21
other25822677
Tabelle3
bad donor quality
no recipient
logistical problem
recipient problem
other
International organ exchange in kidney transplantationImpact for selected patient groupsEurotransplant 01.01.2002 -31.12.2006
Chance of every new highly sensitized patient to receive a suitable crossmatch negative organ within 12 months (real life data)Offer[%]Standard allocationAM
Claas et al. Transplantation, 2004
n=427MJTRANSZPLANTCI MAGYARORSZG
Liver allocation rules ETNational prioritization - Mechanisms of balancing
HUElectiveInternational HU Open obligations (based on previous HU-Tx)Mechanism for balancing
National Transplantable/ElectiveMatchMELD (= urgency)Ischemic time (regional factor)Waiting timeInternationalLabMELDIschemic time (regional factor)Waiting timeOutside ET
PANCREAS TRANSZPLANTCI MAGYARORSZG
P-PASS
Item1 point2 points3 pointsAge (years) (x2)
Reported Pancreata: P-PASS ET, Jan 1, 2002 Jun 30, 2005, N = 3310
Pancreas graft survival curve*stratified by P-PASS Eurotransplant, SPK transplantation, January 2002 - June 2005 [N = 174]
p = 0.02
post-transplant time (months)
*-Death censored
We used the first 48 returned questionairres combined with the information present in ENIS to estimate a Kaplan-Meier survival curve between 2 PASS-groups, which we see on this slide. All transplantations took place in the study period, we censored the graft survival by death and stratified the curve by PASS. We set our cut-off point at 14 derived from the PAS-Score which was mentioned before.On this slide we see the rates of pancreas survival between the two groups, which were composed by setting the PASS-cut-off-point at 14. All the cases mentioned here consists of all transplanted pancreas combined with kidney post-listing. But what we see is a difference between survival in the groups, however the The p-value is only 0.2, the low number of significance can be explained by the low power of the test, because we didnt include so many cases yet. and therefore the value is not significant. Correlation between PASS cut-off point en survival with first 48 returned questionairres
SZVTRANSZPLANTCI MAGYARORSZG
Average waiting time in HU-status until first heart offerEurotransplant - 01.01.-31.07.2008
ET Horvtorszglpcszetes csatlakozsEgy vig rszleges csatlakozsSpecilis betegcsoportok (HU, AM, gyermekek)Zero-national balanceMinden donort jelenteniET rszvtel: Organ Advisory CommitteesTeljes csatlakozs egy v utn
HU mjprogram Vese: acceptable mismatch programSzenzitizlt betegek listra tteleHU szv s HU veseElektv gyermekszv s gyermekmjTeljes tagsgET Horvtorszg lpcszetes csatlakozs
sszefoglalsA kollaborci elnyei:Jobb allokciTransparens betegorientlt allokci Zero mismatch 20%, high urgency betegekTudomnyos alapon bizonytott allokcis elnyk Elvesztett donor szervek minimalizlsaNemzetkzi tudomnyos egyttmkdsA rsztvevk szmra elrhet adatbzisok
ORSZGOS VRELLT SZOLGLAT http://www.ovsz.hu Szervkoordincis Iroda http://donacio.ovsz.hu %-14,7%-2%-5,4%
**********On this slide we see the PPASS-factors on the left.The Eurotransplant Pancreas advisory committee has already composed a prognostic score which means that they have already weighted each individual factor based on literature review and medical expertise, where the weight should reflect the likeliness of pancreas unsuitability, so high PASS means not likely to be PA donor. Before starting the investigation, we divided all pre-procurement factors into ranges with cut-off points.
*Using the P-PASS, we gave all reported pancreata retrospectively a score, according to the pre-procurement PASS. We then looked if we could conclude anything about the allocation algorithm. Red bars represent pancreata not accepted for transplantation; Green bars represent pancreata that are ultimately transplanted. And yes, what we see here, is a correlation between PASS and transplantation. For example: the group of reported PASS 13, 60 % is finally used for transplantation. And pancreas donors reported with a high PASS, a much lower rate is finally used for transplantation, as we can see here. With help of a logistic regression model, we calculated that pancreata with a P-PASS same or higher than 17 were significantly negative associated with pancreas acceptance, these donors were 3 times more likely to be refused as a pancreas donor.
*In order to evaluate outcome after pancreas transplant, we started a retrospective study of all transplanted pancreata in the time-period 2002 2005. We sent questionairres to the Eurotransplant pancreas transplantation centres and used them to estimate a Kaplan-Meier survival curve of the 2 PASS-groups, which we see on this slide. All transplantations took place in the study period, we censored the graft survival by death and stratified the curve by PASS. We set our cut-off point at 17 derived from the PAS-Score which was mentioned before. Blue line pancreas transplantations of donors with P-PASS lower than 17, red same or higher than 17.What we see is a significant difference in graft survival in both pancreas groups. ***
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