Presidential address 2002: organ transplantation as a patient service worldwide

Abstract

The future depends on what we do in the present– Mahatma Gandhi Dr. Salvatierra, thank you for your kind introduction. Dr. Oscar Salvatierra is, as you know, the past president of our society. To be your successor, Oscar, is a special privilege. A highly pertinent question that the president of a worldwide transplantation society might ask is what is the role of organ transplantation today seen from a global perspective. One way to find an answer to this question would be to survey the transplantation numbers in different regions of the world. In three regions of the world, the United States (1), Europe (2,3), and Asia (4), annual transplantation numbers have been accumulated since the late 1980s. In this survey, the number of kidney, liver, and heart transplants in these three regions have been compared. Also, the use of cadaveric versus living donors has been assessed. NUMBER OF TRANSPLANTATIONS During the study period, there has been a steady increase in the amount of kidney transplantation in all the three regions, with Asia catching up in recent years. In the year 2000, close to 15,000 renal transplantations were performed in each of the regions (Figure 1). Figure 1: Annual number of kidney transplantations from 1989 to 2001 in the United States, Europe, and Asia.With regards to liver transplantation, there has been a similar progressive expansion in Europe and the United States with the annual number of liver transplantations now being close to 5,000 in both regions. In Asia, the number has been considerably lower; however, recently, there has been an increase, and in the year 2000, just over 1,000 liver transplants were performed (Figure 2). Figure 2: Annual number of liver transplantations from 1989 to 2001 in the United States, Europe, and Asia.The evolution of heart transplant has not followed the pattern of kidney and liver transplants. In the United States and Europe, the number of heart transplants has remained close to 2000 per annum. In Asia, the figures for heart transplants have remained low throughout the study period (Fig. 3). Figure 3: Annual number of heart transplantations from 1989 to 2001 in the United States, Europe, and Asia.When the number of transplantations per million population (PMP) in the year 2000 were calculated, it was found that the numbers in the United States were approximately twice those in Europe. The figures in Asia were far lower (Table 1). In this context, it should be emphasized that whereas the United States is a relatively homogenous region, the situation is different in Europe and Asia; in both regions, there are countries with high transplant activity, whereas other countries have low or very low activity. Table 1: The number of transplantations per million population (PMP) in the three regions studiedTHE USE OF LIVING VERSUS CADAVERIC DONORS In the United States, the number of cadaveric kidney transplants has leveled out over the last 10 years. During this time period, living donor kidneys have become progressively more used. In Europe, the number of cadaveric kidney transplants is still slowly increasing. The number of living donor kidney transplants is also on the increase, although the increase is less marked than in the United States. In Asia, the use of kidneys from living donors has dominated throughout the study period; however, in the last few years, the use of cadaveric organs has increased (Fig. 4). Figure 4: Number of kidney transplantations from 1989 to 2001 in the United States, Europe, and Asia. (Black shading) cadaveric donors; (grey shading) living donors.In the United States, the number of cadaveric organ liver transplants increased until recently, when the figures leveled out. In the mean time, living donor liver transplants, using a part of the donor’s liver, has emerged as a way of increasing the supply of livers for transplantation. In Europe, the evolution has been similar. In Asia, most transplanted livers derive from living donors, although there has been an increase in the use of cadaveric donors during the last few years (Fig. 5). Figure 5: Number of liver transplantations from 1989 to 2001 in the United States, Europe, and Asia. (Black shading) cadaveric donors; (grey shading) living donors.In the United States, the number of living donations surpassed the number of cadaveric donations in 2001, the actual numbers being 6,439 and 6,708, respectively (5). These figures include the donation of both kidneys and livers. The Situation in Asia Regarding Cadaveric Versus Living Donation In the two countries with the largest numbers of kidney transplants being performed in Asia (i.e., India and China), there was a marked discrepancy with respect to the source of the kidneys used for transplantation. In India, most of the patients were given a living donor kidney, whereas cadaveric kidneys were used only in a few patients. In China, the figures were the opposite, in that most of the patients were given a cadaveric donor kidney (Table 2). Table 2: The source of the kidneys used for transplantation in India and China (year 2000)A comparison with regards to the source of livers used for transplantation in Japan and China revealed a similar wide discrepancy. In Japan, only a few of the liver transplants were performed with a cadaveric organ, and in most of the cases, living donor organs were used. In China, all patients were given a cadaveric liver (Table 3). Table 3: The source of the livers used for transplantation in Japan and China (year 2000)Some important underlying reasons for these discrepancies can be identified. Thus, for cultural reasons, cadaveric donation is not generally accepted by the public in many Asian countries, which has prompted the wide use of living donor organs. Also, there is the fact that in some Asian countries, there is a lack of intensive care unit facilities and other resources required for cadaveric organ procurement. A living donor kidney transplantation can be performed during business hours by a single surgeon with some technical assistance, whereas the procurement and transplantation of cadaveric organs requires services around the clock including an on-call team and operating room services. In China, organs are frequently obtained from executed criminals. This practice seems to have its roots in the belief that an individual who has committed an evil act will receive redemption through an altruistic act. CONCLUSION The number of renal transplantations is steadily increasing in the three regions studied. However, there is a marked disparity between the regions with regards to the number of patients PMP being treated. The ever-increasing gap between the number of patients waiting for organ replacement and the number of cadaveric organs procured has prompted an increased use of living donor organs in the United States and Europe. In Asia, the previously very low figures for cadaveric organ donation is currently on the rise. The fact that an increasing number of patients are offered organ transplantation around the world is gratifying. However, efforts have to be made to reduce the marked disparity that exists between different regions of the world. A Global Partnership for Organ Transplantation Our common goal is to make organ transplantation available as a patient service worldwide. To improve on the current state of affairs, the Transplantation Society should initiate a global partnership in transplantation. A steering group should be recruited among members in the major international societies involved in the field. The steering group should develop an agenda and appoint a task force. The partnership should seek affiliation with industry and with international governmental organizations, such as the World Health Organization and United Nations Educational, Scientific, and Cultural Organization. FIGUREFigure