[show abstract][hide abstract] ABSTRACT: The 2 main indications for emergency liver transplantation are severe acute hepatic insufficiency and emergency retransplantation. In Spain, since the creation of the National Transplant Organisation (NTO), known as "the Spanish model," there have been high rates of donation, with a mean of 33.9 donors per million inhabitants in 2003 and 34.6 donors per million inhabitants in 2004. According to data provided by the NTO, there were 169 liver emergencies in the 2-year period 2003-2004. The time on the waiting list in an emergency situation was limited; 82.8% of cases were resolved in less than 48 hours. During this 2-year period, there were 2077 liver transplantations, including 128 emergence patients, which accounted for 6.1% of transplantations.
[show abstract][hide abstract] ABSTRACT: Organ availability is affecting the development of liver transplantation in its entirety, leading to transplant teams expanding the criteria for accepting organ donors. In these circumstances, analysis of the impact of the donor's characteristics on graft survival becomes mandatory.
Fifty-two donor variables from 5,150 liver transplants performed in Spain between 1994 and 2001 were analyzed through a univariate analysis. Those with statistically significant impact on graft survival were entered in a Cox regression model with the recipients' characteristics and other factors linked to the graft technique.
Several donor factors negatively affect graft survival: donor age, cause of death, body mass index, vasoactive drug administration, prolonged intensive care unit (ICU) stay, increased alkaline phosphatase and liver enzyme levels, low bicarbonate level, and antecedents of hypertension. However, only four can be mentioned as representing a risk for losing the graft when donor variables are controlled with recipient or technique variables in a Cox regression model: donor age, antecedents of hypertension, prolonged ICU stay, and low bicarbonate level. In the same analysis, norepinephrine administration has a relative risk less than 1.
The multivariate analysis of the impact of 52 donor characteristics on liver graft survival showed the negative effect of an elderly donor, with hypertension combined with the presence of metabolic acidosis, or a prolonged ICU donor stay. The administration of norepinephrine alone during donor management showed a protective effect.
[show abstract][hide abstract] ABSTRACT: The maintenance of an equitable system for access to transplantation is a matter of concern to all professionals involved in this field. Any national system must ensure equity.
The rates of indication for liver transplantation have been reviewed for all Spanish regions. The time to transplantation was evaluated with respect to different recipient characteristics and donor rates. The indication rates for liver transplantation are similar in the different countries with liver transplant programs but are far from similar among different regions in Spain. This suggests that there is not equity in the access to liver transplantation.
A review of the factors affecting the waiting times to transplantation after being registered for the waiting list shows that some groups of patients are currently waiting less time than others. Shorter waiting times occur in patients of the AB group, children, patients with hepatocarcinoma, and patients living in the zone of Valencia, despite similar organ donation rates in all transplant zones.
Neither the rate nor the probability of liver transplantation is affected exclusively by the organ donation rate in Spain but also depends on the number of patients admitted to the waiting list. Despite the existence of an organ allocation system that is center-oriented, liver patients are receiving grafts mainly based on the severity of the illness, because clearance rates from the waiting list of both dead patients and grafted patients are the same.
[show abstract][hide abstract] ABSTRACT: During recent years organ donation in Spain has increased by 100%, with important changes seen in the donor profile. Mean age has increased by more than 10 years, being nowadays more than 33% of our donors over 60 years. Ten years ago road traffic trauma was the main cause of death, while now most of our donors die due to stroke and only 21% die in a traffic accident. This changes lead to an increase in the number of kidneys discarded for transplantation every year. Among the 2517 kidneys retrieved during 2001, 567 were discarded, mainly due to different glomerular, interstitial or vascular pathologic damage. The older is the donor the higher is the percentage of kidneys discarded. It has to be underlined that an increased number of livers from donors, whose kidneys could not be used, are being grafted (141 in 2001 over 281 donors from whom no kidney could be grafted and over a total number of 1335 donors). Only 5% of kidneys were discarded due to technical problems. An important number of kidneys were discarded due to malignancy suspicion or diagnosis (12.3%). Organ donation has improved but kidney transplantation did not in parallel, due to the increasing number of kidneys discarded for transplantation in close relation with the evolution of donor's characteristics. Organ donation rate is around 33 donors per million population while efficient organ donation rate is around 30 donors per million. Only from 67% of donors both kidneys can be grafted and from 20% of donors no kidney can be used. These data will not change our policy, at least by the moment, we will continue to evaluate every potential brain death donor with the aim of studying if organs can be used. It is true that in 50% of cases over 70 years no organ can be used after retrieval and microscopic exam, but in the other 50% we can proceed.
Annals of transplantation: quarterly of the Polish Transplantation Society 02/2003; 8(2):9-16. · 0.82 Impact Factor
[show abstract][hide abstract] ABSTRACT: Examining life expectancy and general mortality rates, the health of the population of Geneva can be described as one of the best in the world. However, in some areas Geneva fares worse than the rest of Switzerland or Europe. To re-appraise the current health priorities of the Genevan population, we analysed the relative importance of specific diseases and injuries calculating DALYs.
We followed the procedures developed for the Global Burden of Disease (GBD) study to ensure comparability. Some adaptations were made for mortality coding. Disability was estimated based on data for countries classified as Established Market Economies (EME) in the GBD study.
Non-communicable diseases accounted for 79% of the disability adjusted life years (DALY), injuries represented 12%, and communicable diseases and other disorders 9%. Ischaemic heart disease was the largest single contributor to DALY, followed by unipolar major depression. Neuropsychiatric disorders and mental health accounted for more than 23% of DALY.
Some of the most important problems identified-depression, osteoarthritis and alcohol abuse-would have been overlooked in an analysis based solely on mortality data. The most striking finding is the importance of mental health problems. The main limitation is the lack of morbidity data for Geneva.
International Journal of Epidemiology 11/2000; 29(5):871-7. · 6.98 Impact Factor
[show abstract][hide abstract] ABSTRACT: Despite excellent mortality indicators, there is clear evidence that the health status of the population of Geneva could be improved if more attention and resources were devoted to prevention strategies. To identify a set of robust health priorities an original approach was used triangulating results between three methods.
The study calculated potential years of life lost, disability adjusted years of life lost, and conducted a Delphi survey to gather the opinion of health professionals and the general public.
Several health conditions were unanimously selected by all three methods as top priorities: cardiovascular diseases, AIDS, respiratory cancer, breast cancer for women, suicide and traffic accidents. In addition, two determinants-alcohol abuse and tobacco abuse-for which a clear conceptual link could be established between all methods were chosen. Connections between priorities identified through the DALY and the Delphi method lead to further inclusion of chronic back pain and depression. Some issues solely identified through the Delphi survey were included as they were consistently considered important by professionals and the lay public alike-violence in the family, unemployment, social exclusion.
These results indicate that health priorities, and by extension health care priorities, would benefit from using a mix of quantitative and qualitative research methods. The triangulation of results allows for a broader perspective and makes results more acceptable.
Journal of Epidemiology & Community Health 06/2000; 54(5):388-93. · 3.39 Impact Factor
[show abstract][hide abstract] ABSTRACT: At the end of 1989, the Organización Nacional de Trasplantes (ONT) was created within the Spanish Department of Health. It has become a common meeting place for professionals involved in all types of transplantation, the central and autonomous administrations, the media, and Spanish society in general. It has a formal but flexible management structure, which ensures that the transplant coordinators working at the grass-roots level have a sense of involvement and are accountable for performance. These coordinators are responsible for the process of organ donation and procurement within hospitals. The ONT deals with organ sharing and management of waiting lists, arranges for transplant teams or organ transport, maintains the official statistics on organ donation and transplantation activity, and keeps interested groups informed. It maintains a telephone line 24 hours a day, 7 days a week, to address any doubts or answer any questions about organ procurement or transplantation. The ONT is concerned with training programs and research in the field of organ donation and transplantation. It is the unit in charge of official reports in the field of organ donation and transplantation, and it guarantees the complete equity and transparency of the system. Spain currently has 139 hospital coordinating teams, one in each hospital, authorized to develop donation and organ procurement processes. Within this framework, the average rate of solid-organ donation increased from 14 donors per million population in 1989 to 31.5 donors per million population in 1998. The average age of donors has increased year after year, and more than 25% of current donors are older than 60 years of age. Most donors (53.5%) now die of cerebrovascular accident, and only 25% die in car accidents (in 1992, 43% died in car accidents). In Spain, the rate of family refusal of donation was 21.3% in 1998, a decrease from the 30% rate seen in the early 1990s. All of these changes are the result of efforts to overcome various obstacles, such as untrained or undertrained staff, unidentified donors, and reluctance to approach grieving families.
Current Opinion in Organ Transplantation 05/1999; 4(2):109. · 3.27 Impact Factor