Deutsche Stiftung Organtransplantation Research Articles

Development and outcomes of surgical and urological kidney transplantation programs in Germany: a total population analysis from 2006 to 2021

PurposeKidney transplantation (KT) is the most frequently performed organ transplantation. In Germany, KT is performed in urology and surgery departments with unknown consequences of this parallel structure. The aim of the study was to compare the development and outcome of KT in urology and surgery departments.MethodsOn an institutional level, we analyzed the annual caseload from 2006 to 2021 with the reimbursement. INFO tool based on hospitals’ quality reports (Reimbursement Institute, Hürth, Germany). For outcome comparison we extracted raw data from the transplantation centers' quality reports (Deutsche Stiftung Organtransplantation, DSO).ResultsA total of 23,599 cases (17,781 deceased donor and 5,818 living donor KTs) were included. The total number of KTs decreased from 1851 in 2006 to 1701 in 2021 (− 8%; p = 0.12). The total number of urological KTs decreased from 592 cases in 2006 to 395 cases in 2021 (− 33.3%; p = 0.01). Further analysis revealed no significant differences between intra- and postoperative complications and graft quality at one year for deceased donor KTs (DDKT) although differences in immediate renal function and graft quality at discharge could be observed. There were no significant differences in immediate renal function and graft quality at discharge for living donor KTs (LDKT) between the specialties.ConclusionKTs performed in urology departments declined between 2006 and 2021. Nevertheless, intra- and postoperative complications as well as long-term function did not differ between surgical and urological KT programs. Hence, an interdisciplinary approach, especially considering the upcoming challenges in KT as, e.g., robot-assisted surgery seems reasonable.

Impact of the SARS-CoV-2 Pandemic on Liver Surgery and Liver Transplantations in Germany

The SARS-CoV-2 pandemic has led to restrictions in surgical care worldwide and therefore also posed new challenges to liver surgery. The respective procedures often entail high perioperative risks and resource requirements. However, the indication for liver surgery is frequently without alternatives. To date, there is little knowledge about the impact of the pandemic on liver surgery in Germany. A retrospective data analysis of liver surgery procedures in Germany as well as transplantations was conducted. Evaluations were based on procedure codes recorded between 2010 and 2020 according to diagnosis-related groups (DRG) by the Federal Statistical Office of Germany (Destatis) and data from the German Organ Procurement Organization (Deutsche Stiftung Organtransplantation; DSO). According to DRG procedure codes relating to liver surgery recorded between 2010 and 2020 in Germany, the annual fluctuation for the first year of the pandemic 2020 remained comparable to previous years. Furthermore, the development of post-mortem liver transplantations as well as living liver donations remained stable in Germany in 2020 and 2021. The number of liver surgery procedures in Germany was subject to a dynamic development until 2020, without apparent changes in the first year of the SARS-CoV-2 pandemic. The most frequently performed liver procedures, as well as liver transplantations, remained stable with respect to their annually recorded numbers. Publication of data regarding procedures in liver surgery and transplantation in 2021 need to be awaited and analyzed to evaluate whether the observations presented in this article prove stable any further.

An Automated Electronic Screening Tool (DETECT) for the Detection of Potentially Irreversible Loss of Brain Function.

A major reason for the low number of organ donors in Germany is a deficit in the recognition of patients who may have impending irreversible loss of brain function (ILBF) in hospitals capable of organ retrieval. We used anonymized data from the German Organ Procurement Organization (Deutsche Stiftung Organtransplantation, DSO) to compare two 12-month periods (a reference period and an evaluation period) before and after the implementation of an electronic screening tool (DETECT) at the University Hospital Dresden (UKD) with four other university hospitals without tool implementation (comparative cohort). DETECT is intended to aid in the recognition of potentially impending ILBF. The study endpoints encompassed patients with potentially unrecognized ILBF, patients with recognized ILBF, organ donations performed, and reports to the DSO. Changes in absolute risk were compared with Breslow-Day tests. 309 patients who died with primary or secondary brain lesions were identified in the UKD in the reference and evaluation periods (164 and 145 patients, respectively), and 1060 (529, 531) in the comparative cohort. In the UKD, the number of unrecognized cases of possibly impending ILBF was 14/164 (8.54%) in the reference period and 1/145 (0.69%) in the evaluation period, yielding an absolute reduction of 7.85% (95% confidence interval [--3.36; --12.33]); by contrast, in the comparative cohort, there was a 0.55% absolute increase between the two periods ([--2.21; 3.30]; p = 0.002 for the comparison between the two cohorts). Only minor differences in absolute risk change were seen with regard to the probability of recognized ILBF (7.09% [0.29; 13.88] vs. 2.42% [1.18; 6.01]; p = 0.234), organ donation (4.70% [--0.89; 10.28] vs. 0.55% [--2.17; 3.26]; p = 0.214), or reporting to the DSO (4.17% [--1.77; 10.11] vs. 2.22% [--1.44; 5.89; p = 0.447); these changes may have arisen by chance. These findings suggest that the use of DETECT can help to reduce the deficit in the recognition of patients with impending or manifest ILBF.

Transplant Coordinators in Germany – Function, Qualification and Options of Education and Certification (Sponsor: Novartis Pharma GmbH, Nürnberg)

AbstractTransplant coordinators play a central role in the coordination of the organ donation process and identification of potential donors in the hospital. Their responsibility is to identify potential donors, report them to the DSO (“Deutsche Stiftung Organtransplantation”).

The Role of the Organ Procurement Organization (DSO) in Coordinating Organ Donation in Germany and the Organ Donation Initiative Plan (Sponsor: Novartis Pharma GmbH, Nürnberg)

AbstractOrgan donation in Germany started to decline in 2010 and dropped to a 20-year low of 797 organ donors in 2017. The rate of 9.7 organ donors per million population is far below donor rates in other European countries. The Deutsche Stiftung Organtransplantation (DSO, German Organ Procurement Organization) has been concerned about this development for many years and, in cooperation with German donor hospitals, has conducted extensive analyses to identify possible causes. While the causes are multifarious, the DSO sees the improvement of the identification and referral of potential organ donors in hospitals as a key factor in enhancing organ donation rates.

Organ donation : Update 2019

The number of organ donors in Germany has been falling since 2010. In 2017, it reached its lowest level in 20years with 797 organ donors. With 9.7organ donors per million inhabitants, Germany lags far behind other European countries. The development of the donor numbers has long been an issue of concern for the Deutsche Stiftung Organtransplantation (DSO). Together with the donor hospitals, DSO has carried out extensive analyses on the possible causes. Though causes are multiple and complex, one important lever for improving the situation is seen in better detection and consistent reporting of possible organ donors. This is considered the best way to meet the patient's desire regarding organ donation. With reference to the dramatic development, DSO calls for abroad social debate and ajoint initiative involving medical associations, contractors, patient associations and policymakers. Getting organ donation back on track in Germany for the benefit of patients on the waiting lists can only be achieved by ajoint effort.

Influence of Deceased Donor and Pretransplant Recipient Parameters on Early Overall Kidney Graft-Survival in Germany.

Background. Scarcity of grafts for kidney transplantation (KTX) caused an increased consideration of deceased donors with substantial risk factors. There is no agreement on which ones are detrimental for overall graft-survival. Therefore, we investigated in a nationwide multicentre study the impact of donor and recipient related risks known before KTX on graft-survival based on the original data used for allocation and graft acceptance. Methods. A nationwide deidentified multicenter study-database was created of data concerning kidneys donated and transplanted in Germany between 2006 and 2008 as provided by the national organ procurement organization (Deutsche Stiftung Organtransplantation) and BQS Institute. Multiple Cox regression (significance level 5%, hazard ratio [95% CI]) was conducted (n = 4411, isolated KTX). Results. Risk factors associated with graft-survival were donor age (1.020 [1.013–1.027] per year), donor size (0.985 [0.977–0.993] per cm), donor's creatinine at admission (1.002 [1.001–1.004] per µmol/L), donor treatment with catecholamine (0.757 [0.635–0.901]), and reduced graft-quality at procurement (1.549 [1.217–1.973]), as well as recipient age (1.012 [1.003–1.021] per year), actual panel reactive antibodies (1.007 [1.002–1.011] per percent), retransplantation (1.850 [1.484–2.306]), recipient's cardiovascular comorbidity (1.436 [1.212–1.701]), and use of IL2-receptor antibodies for induction (0.741 [0.619–0.887]). Conclusion. Some donor characteristics persist to impact graft-survival (e.g., age) while the effect of others could be mitigated by elaborate donor-recipient match and care.

Access to brain death diagnostics

In Germany the diagnosis of brain death must strictly adhere to the expert guidelines of the German chamber of physicians. For patients with primary supratentorial or hypoxic brain injury aged 2 years or more, repeat clinical examinations or one complete examination combined with an ancillary test are equally accurate. This study aimed to identify factors with potential impact on whether and by which means a formal brain death examination is pursued. A retrospective analysis was carried out of recorded data of all patients who died in the acute phase after severe brain injury during mechanical ventilation in an intensive care unit and who were registered at the north east regional bureau of the German organ procurement organization (Deutsche Stiftung Organtransplantation) between 2001 and 2010. Of 5988 reported patients, a protocol-specified brain death examination was initiated in 3023, leading to a diagnosis of brain death in 2592. All other patients died due to permanent cardiac arrest. Patients were less likely to undergo brain death examinations in the presence of one or more of the following characteristics: perceived medical contraindication for organ donation, patient age greater than 69 years, hypoxic brain damage, treatment in a hospital without neurological and neurosurgical departments and death on a weekend or public holiday. In 2192 patients (72.5%), neurologists or neurosurgeons participated in the diagnostic procedures and in 926 of these cases members of specialized external diagnostic expert teams were involved. Ancillary tests were rarely used by physicians based at the treating hospitals (31.1%) but on a regular basis by members of the external teams (93.4%). The risk of death due to permanent cardiac arrest before completion of the brain death examination was increased approximately 7-fold when a neurological or neurosurgical consultation with ancillary studies was not performed. Access to neurological expertise and to ancillary tests has a significant impact on the provision of guideline-specified diagnostic procedures for suspected brain death. Centralized diagnostic teams offer an effective means to support qualified brain death examinations.

Lung Transplantation

Lung transplantation is the final treatment option in the end stage of certain lung diseases, once all possible conservative treatments have been exhausted. Depending on the indication for which lung transplantation is performed, it can improve the patient's quality of life (e.g., in emphysema) and/ or prolong life expectancy (e.g., in cystic fibrosis, pulmonary fibrosis, and pulmonary arterial hypertension). The main selection criteria for transplant candidates, aside from the underlying pulmonary or cardiopulmonary disease, are age, degree of mobility, nutritional and muscular condition, and concurrent extrapulmonary disease. The pool of willing organ donors is shrinking, and every sixth candidate for lung transplantation now dies while on the waiting list. We reviewed pertinent articles (up to October 2013) retrieved by a selective search in Medline and other German and international databases, including those of the International Society for Heart and Lung Transplantation (ISHLT), Eurotransplant, the German Institute for Applied Quality Promotion and Research in Health-Care (Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen, AQUA-Institut), and the German Foundation for Organ Transplantation (Deutsche Stiftung Organtransplantation, DSO). The short- and long-term results have markedly improved in recent years: the 1-year survival rate has risen from 70.9% to 82.9%, and the 5-year survival rate from 46.9% to 59.6%. The 90-day mortality is 10.0%. The postoperative complications include acute (3.4%) and chronic (29.0%) transplant rejection, infections (38.0%), transplant failure (24.7%), airway complications (15.0%), malignant tumors (15.0%), cardiovascular events (10.9%), and other secondary extrapulmonary diseases (29.8%). Bilateral lung transplantation is superior to unilateral transplantation (5-year survival rate 57.3% versus 47.4%). Seamless integration of the various components of treatment will be essential for further improvements in outcome. In particular, the follow-up care of transplant recipients should always be provided in close cooperation with the transplant center.

The joint impact of donor and recipient parameters on the outcome of heart transplantation in Germany after graft allocation

Organ shortage in heart transplantation (HTx) results in increased use of grafts from donors with substantial risk factors. It is discussed controversially which donor characteristics may be detrimental. Therefore, we evaluated the joint impact of donor- and patient-related risk factors in HTx on patient survival by multiple analysis in a nationwide multicentre study after donor selection was carried out. The research database consists of data concerning hearts donated and transplanted in Germany between 2006 and 2008 as provided by Deutsche Stiftung Organtransplantation and the BQS Institute. Multiple Cox regression (significance level 5%, hazard ratio [95% CI]) was conducted (n = 774, recipient age ≥ 18 years). Survival was significantly decreased by donor age (1.021 [1.008-1.035] per year), nontraumatic cause of death (1.481 [1.079-2.034]), troponin >0.1 ng/ml (2.075 [1.473-2.921]), ischaemia time (1.197 [1.041-1.373] per hour), recipient age (1.017 [1.002-1.031] per year) and in recipients with pulmonary vascular resistance ≥ 320 dyn*s*cm(-5) (1.761 [1.115-2.781]), with ventilator dependency (3.174 [2.211-6.340]) or complex previous heart surgery (1.763 [1.270-2.449]). After donor selection had been conducted, multiple Cox regression revealed donor age, nontraumatic cause of death, troponin and ischaemia time as well as recipient age, pulmonary hypertension, ventilator dependency and previous complex heart surgery as limiting risk factors concerning patient survival.

The organ crisis: a disaster of our own making

It is difficult to say how many people have died to date as a direct consequence of the shortage of suitable organs for transplantation. But even under conservative assumptions, this number must exceed 200,000 since 1984 in the USA and EU alone. Those needing solid organ transplantation who have not yet died—a group composed overwhelmingly of end-stage renal disease (ESRD) patients receiving dialysis—suffer greatly diminished qualities of life, face very uncertain futures, and require many billions of dollars or euros to support their treatment. This trifold crisis of cost, suffering, and death will—in the absence of radical reform or spectacular science—grow even worse in the years to come, presenting public health authorities and insurance funds with very difficult choices. The most extraordinary aspect of this entire issue, though, is that it has arisen as a direct consequence of our organ procurement policies and can therefore be fairly termed a disaster of our own making. If we have made this disaster, can we unmake it? And, if the answer to this question is ‘‘yes,’’ what system could credibly replace the current one? These topics are the focus of this editorial. It is our position that the primary—though by no means sole—reason for the shortages is the almost universal prohibition on compensation for organ provision. By introducing appropriate compensation for both deceased and (where necessary) living donation of solid organs, a large increase in transplantation is possible. In the important case of kidneys, this expansion will result in the savings of thousands of lives and many billions of dollars or euros. Further, we believe the introduction of compensation can be done in an ethically acceptable and even laudable manner: It must be transparently administered within tightly controlled public monopsonies based on the current national organ procurement organizations, such as the Deutsche Stiftung Organtransplantation (DSO) in Germany and the United Network for Organ Sharing (UNOS) in the USA. Moreover, the relationship of the organ donor to the broader society needs an appropriate recharacterization. This transition in our conceptualization of organ supply, long overdue, can take us from the moral strictures of the ‘‘family model’’ of donation to one far more compatible with the realities of contemporary transplantation medicine. Compensating organ suppliers has long been rejected by many medical authorities, and almost all countries now have laws that strictly prohibit any form of commercialization for human solid organs—though not, curiously

Univariate Analyses of the Impact of Donor and Recipient Related Parameters on Early Outcome of Kidney Transplantation in Germany

Introduction: The aim of kidney transplantation is to provide renal replacement therapy by functioning grafts at low recipient mortality. Thereby the rate of delayed graft function should be low (DGF definition: post-operative dialysis>1). In this analysis, the impact of several donor (D) and recipient (R) related parameters on in-hospital mortality (M), death-censored graft survival (GS) and the incidence of DGF was investigated. Methods: Data concerning kidney donation (provided by Deutsche Stiftung Organtransplantation) and kidney transplantation (provided by BQS Institute for Quality and Patient Safety) were merged. In the resulting database, 4471 anonymized datasets of deceased D kidneys donated and transplanted in Germany into adult R during 2006 to 2008 are available. R with combined transplantations were excluded. To obtain independent observation units necessary for statistical analyses, for each R only the first (if more than one) transplantation in the study period as well as only one randomly selected kidney per D were considered. For later model building and validation purposes, data were randomly subdivided into a learning (n = 1621, 66%) and a validation sample (n = 810, 33%). Based on the learning sample, the impact of several D and R related parameters on M, GS and DGF was analysed by means of univariate logistic regression at a significance level of 5% (OR; p-value). Results: In the learning sample 1621 R were analysed with a mean age of 53.98y (SD=12.58), (62.6% m, 37.4% f). The mean age of D was 52.59y (SD=16.74), (52.6% m, 47.4% f), mean value of donor Serum-creatinine (S-creaa) on admission and before organ retrieval (S-crear) was 83.55mmol/l (SD=42.71) and 96.47mmol/l (SD=68.73), respectively. In-hospital mortality (M) was 1.4%, the incidence of delayed graft function (DGF) 28.1% and death-censored graft survival (GS) 94.3%. In-hospital mortality is significantly influenced by R age (1.069; 0.004) and to a lesser degree by D age (1.032; 0,040). DGF was determined by D age (1.010; 0.005) and D S-crea, particularly by S-crear before organ retrieval (1.003; < 0.001), but also by cold ischemia time (1.001; < 0.001). Concerning recipient-related factors, immunised patients (1.006; 0.007) seem to have a higher rate of DGF. Graft survival (GS), however, is influenced by D age (0.984; 0.019) and D S-crea (0.998; 0.049). Interestingly, the use of arterenol (1.676; 0.034) and steroids (1.739; 0.030) in the D before explantation of the organs had a positive impact on GS. Conclusion: In-hospital mortality after kidney transplantation was low and related to R and D age. The effect of D age might disappear in a multiple logistic regression model, as due to the European-Senior-Programme in Germany a strong relation between R and D age exists. Graft survival was determined by donor factors, such as D age and S-crea. Moreover our results indicate, that the incidence of DGF may be reduced by shortening cold ischemia time. These preliminary results are based on univariate analyses. Multivariate analysis considering the above described and several other risk factors simultaneously is currently performed and needed for further conclusions.

Estimated Organ Donor Potential in German Maximum Care Hospitals

Background: The lack of suitable organs remains one of the major problems transplantation medicine. One step to solve this problem is the increase in the identification of potential organ donors. An previously published American analysis has shown that clinics with more than 350 beds have an average potential of 0.015 organ donors/bed. Adopting this model to our german conditions, the potential of organ donors for maximum care hospitals was estimated. Methods: The bed capacity of university hospitals (A-hospitals) and hospitals providing a neurosurgical department (B-hospitals) was determined by internet search. The number of beds was multiplied by factor 0.015 (if bed capacity was >350 beds) or factor 0.012 (if bed capacity was 150-349 beds). Based on this data, the organ donor potential for every clinic was calculated. Data about the number of organ donors were ascertained by the annual reports of the Deutsche Stiftung Organtransplantation and compared to the calculated organ donor potential in 2010. Results: At all 397 organ donations were realized in 35 university clinics whereas 107 B-hospitals accounted for 555 organ donors in 2010. Total bed capacity for university clinics was 46240 beds according to 0.008 organ donors/bed while B-clinics with a total of 77720 beds provided 0.07 donors/bed. Comparing calculated organ donor potential to actual organ donors in 2010, university clinics have a potential of 694 organ donors whereas only 57% of the calculated potential is utilized. B-clinics have only reached 48% of their calculated potential of 1156 organ donors. Considering the range of variation between individual clinics a potential use of 9-128% with 1-20 organ donors can be pointed out for university hospitals. B-clinics showed even a greater variety of potential use with 7-250% identifying 1-18 organ donors in 2010. Conclusions: These results indicate that there is still a potential to increase the rate of organ donors in Germany with regard to university hospitals and B-Hospitals. Single clinics seem to face more difficulties with the process of identification of organ donors than others. Actual changes in organizational structure with implementation of inhouse-coordinators are expected to achieve further improvement in number of organ donations.

Joint Impact of Donor and Recipient Parameters on the Outcome of Liver Transplantation in Germany

The shortage of donor organs in Germany has led to the use of organs from donors with extended donor criteria (EDC). EDC have been defined on the basis of expert opinions, but their clinical relevance is controversial. This may cause loss of organs otherwise available for transplantation. We evaluated the impact of donor and recipient factors in liver transplants on patient and graft survival in a nationwide multicenter analysis, with special focus on EDC and donor risk index. A database was created from data on livers donated and transplanted in Germany between 2006 and 2008 as provided by Deutsche Stiftung Organ transplantation and BQS Institute. Cox regression (significance level 5%, risk ratio [95% confidence interval]) was used for calculating the impact on patient survival (n=2095) and on graft survival (n=2175). Patient and graft survival were significantly affected only by donor age (1.012 and 1.011/year), recipient age (1.019 and 1.014/year), creatinine (1.248 and 1.205/mg/dL), bilirubin (1.022 and 1.023/mg/dL), and high urgency status (1.783 and 1.809). Inferior organ quality resulted in lower graft survival (1.243) and donor history of smoking in lower patient survival (1.249). Multiple Cox regression revealed no significant impact of EDC or donor risk index on patient and graft survival except for donor age after donor selection at recovery. Among recipient variables, only age, creatinine and bilirubin, and high urgency status were associated with poorer outcome.

FAQs zur Hirntoddiagnostik: Empfehlungen zur Verfahrensweise

In Germany, the diagnosis of brain death is based on the guidelines of the Scientific Board of the „Bundesarztekammer”, third edition from the year 1998. The Mobile Consultant Service of Neurologists and Neurosurgeons in the Northern Region of the Deutsche Stiftung Organtransplantation (Schleswig-Holstein, Hamburg, Bremen, Niedersachsen) performed 708 examinations in order to investigate brain death between January 1997 and December 2008. On this occasion several questions arose which could not clearly be answered by the guidelines. In the present review recommendations for the management of complex investigation situations are presented.

Routine Screening of Donor Hearts by Coronary Angiography Is Feasible

Background Because of the shortage of donor hearts, the criteria for acceptance have been considerably extended. Meanwhile every fourth heart donor in Europe is over 50 years old. As we have previously demonstrated, transmission of preexisting coronary atherosclerosis (CAS) by means of transplantation is not rare. Transmitted CAS results in a 2- to 3-fold increased risk for early graft failure after heart transplantation (HTX). Nevertheless, in most cases donor angiograms are not considered feasible. Methods In May 2003 in the northeast region of the Deutsche Stiftung Organtransplantation (DSO-NO), we introduced the guideline that every donor over 40 years old must be screened by angiography. Results Up to May 2003, fewer than 5% of donors had been screened by angiography; this situation is the rule in most Eurotransplant regions at present. Since May 2003 in the DSO-NO region, 85% of all donors over 40 years old were screened by angiography. Seventy percent of all donor hospitals—offering 90% of all donors—had an angiography facility. The additional costs of approximately € 800 per donor angiogram were compensated by fewer fruitless airplane missions when CAS was diagnosed by the surgeon on the spot, which cost on average about € 5,000 each. In conclusion, from a logistical as well as from a financial point of view, almost comprehensive angiographic donor screening is feasible. It reduces the risk of a recipient suffering from early graft failure.

E-alert 18 February: Cases of rabies in Germany following organ transplantation

On 16 February 2005, the Deutsche Stiftung Organtransplantation (German Foundation for Organ Transplantation, http://www.dso.de/) announced possible rabies cases in three of six patients who received organs from a donor who died in late December 2004

Successful transplantation of a liver from a donor with fatal ethylene glycol poisoning

Successful transplantation of a liver from a donor with fatal ethylene glycol poisoning