Transplantation in Ireland
My name is David Hickey. I am the Director of the National Kidney and Pancreas Transplant Programme, this national programme also has responsibility for Organ Procurement.
I have been committed to this programme for thirty years, personally performing over 1,500 transplants and 500 0rgan procurements, so I am in the unique position to comment on the global picture pertaining to all transplantation, but in particular my own area, kidney and pancreas transplantation and organ procurement.
The National Transplant Programme started in Jervis St in 1964 and this year will complete it 4000th transplant. Every initiative and advance in this area has been through the hard work of a few committed individuals, there has never been a national approach to the problem. For example in the move to Beaumont in 1987, they forgot that a transplant programme needed to be catered for. We ended up with an ad hoc arrangement which has continued to the present day.
I am here today to talk about legislating for organ procurement, however, I cannot let the opportunity pass without commenting on the overall picture in kidney and pancreas transplantation currently in Ireland, as any increase in organ procurement is going to have a significant knock on effect in a currently under performing service.
There are essentially four issues that I need to bring to your attention.
- Lack of Organ Donors
- Poor infrastructure in which are transplant patients are housed
- Shortage of Transplant Surgeons
- Ideal situation that we should be striving for
Increasing Organ Donation, Investment & Legislation
Obviously, the more donors we have, the more organs are available for our patients in end organ failure – liver, kidney, pancreas, heart and lung. However, as my area of expertise is kidney and pancreas transplantation and its procurement, I am going to confine my specific comments to this area.
There is a global shortage of organs for transplantation, particularly kidneys, as renal failure is increasing at an alarming rate, it is accepted that it will bankrupt most health services in the next 20 years if not addressed in a radical fashion now. Without a significant increase in both deceased organ and living donors, we are going to be at a situation in the very near future where dialysis is going to be rationed ie. Nobody over 55 being dialysed leading to as already happens in the developing world, reliance on commercial illegal (backstreet) transplantation.
Over the past ten years, there has been an explosion in the number of patients coming onto the transplant waiting list. This has not been matched by an increase in our deceased donor transplants. In fact we have reached a plateau with this, which without significant infrastructural change, will not be improved.
We have essentially been stuck at 21 donors pmp for the past 20 years, and whilst this was in the top 5 in Europe for a long time, we have now fallen significantly in the league table, as other countries have grasped this nettle and invested in the infrastructure that has resulted in their organ procurement rates being significantly higher, e.g. Spain, Austria, Belgium, Croatia etc.
We urgently need to move towards a transplant situation where we are performing 300 transplants per year in Ireland. This is going to come from an increased living related programme, but significantly from increased procurement of deceased donor organs. This can only be done by an actual investment in this area. No publicity campaign, no wringing of the hands, no sad stories in the papers, can achieve this. More moneyneeds to be invested in Organ Procurement. More donors mean more transplants and we currently cannot deal with what we have. Sixty five patients ( livedonors) have been fully worked up at great personal and public expense and cannot be given a date for transplant. The wait for a living donor transplant is longer than waiting on the deceased donor list. The maximum waiting time for this procedure once worked up should be 3 months (Norway)
There are two problems with this,
- The Donor & Recipient will have to be re-evaluated after 2yrs.
- The recipient may have actually received a deceased donor Transplant, depriving another patient (without a living donor) of a transplant.
The other area that will certainly help increase donation rates has been Joe Brolly’s initiative re the so called ‘presumed consent’ or ‘opt out’ option. Much has been said about the unfortunate wording of presumed consent, and I believe that this has to be removed from the lexicology. The presumption should be that the medical and nursing staff bring the topic to the awareness of the potential donor family to allow them the opportunity to think about this process and decide whether it is suitable for them. It must also be remembered that this is a service to the donor family and immense consolation can be derived from donating. Conversely there is also immense desolation derived from not being afforded the opportunity.
Whilst it is understood that the family will always be asked and their wishes will always be respected, this legislation will normalise the concept of organ donation. The fact that organ donation has been brought to this forum for discussion in itself will generate a lot of positive awareness about the current situation and will help significantly promote our enterprise. However, it has to be accepted, that the countries that have seen significant increase in organ donation and this increase has been attributed to the adoption of presumed consent, in reality has been the result of massive investment in both physical and personnel infrastructure, e.g. the Spanish Model of which you are well aware and of which I can answer questions afterwards.
Infrastructure
Hospitals are a place where we experience some of our saddest and happiest moments in our lives. It is generally accepted in modern architecture that they should be amongst the most inspiring public buildings in civilised society.
The current situation in the National Kidney Transplant Centre, unfortunately falls far short of this and cannot be improved without a radical rethink of how organ transplant services should be delivered for a country of 4.6 million people.
I believe a good model to look at would be Norway, a country similar in population, where all transplants are housed in a National Transplant Institute situated in the University of Oslo. This country performs twice as many kidneys and six times as many lung transplants as Ireland. In Norway all transplants are performed in a single national transplant centre attached to the OsloUniversityHospital, localising all transplant expertise under the one roof as opposed to a triplication of support services as applies in Ireland.
This is what we need to strive for.
Transplant Surgeons
No Transplant Surgeons, No Transplants
There is a worldwide shortage of trained and capable transplant surgeons.This is because of the lifestyle, unfriendly nature of the work which involves much night work and weekend work. This crisis is a bigger threat to the management of end organ failure than the lack of donors
If the European Working Time Directive was strictly adhered to in transplantation, we would probably need twenty transplant surgeons to run our currently service. Presently, we have four wholetime equivalents, i.e. funding for four transplant surgeons in our service. The minimum UK requirement as of 1997 is 2 kidney transplant surgeons per million of population (pmp). The unattractive nature of transplant surgery has to be addressed, has to be incentivised and there has to be added compensation for people who take on this difficult lifestyle.
The Future
The future is now. It has to be accepted that we should follow the lines of most serious international programmes and have all intra-abdominal and heart/lung transplant patients under the one roof. This should be part of a UniversityHospital.
The details of what a transplant centre should look like are well established but essentially, everyone should have an acuity adaptable single room with plenty of space, good lighting, proper air conditioning and low sound.
Contemporary hospital design is essential for transplantation. Six patients to a room, men and women mixed, one bathroom is no longer acceptable, if it ever was.
The concept that transplant patients would be happy to be transplanted on the side of the street, whilst probably true, should not be the mantra adopted.
Solution
A model, somewhat similar to Norway, needs to be established. This can be done in any of the three hospitals, incorporating Organ Procurement, liver, kidney, pancreas, heart and lung transplantation. Bone marrow should also consider being part of this centre. This could probably be done very quickly as there are possibilities of empty space in both Vincent’s and the Mater. This would be an incredible advantage to the most important person involved in transplantation, the patient, who has been moved further and further from the centre of all discussions over the last 20 years.
This New National Centre should have separate budget and governance, be independent of the CEO of any hospital it is located in and answerable only to the NODTO, Department of Health and the HSE.
This is essential.