Experience in Organ Donation in Austria and Vienna

1. Experience in Organ Donation in Austria and Vienna Ferdinand Mühlbacher Department of Surgery Visit to Kopenhagen 3.3.2010

2. Basic Structure of Austrian Transplant System Center based System with little national authority • 3 Medical Universities with Transplant Programs for all Organs • 2 Renal Transplant Program in non academic institutions (One City) • 4 Donor Regions • Donor regions and patient service regions match fairly well Vienna Linz Innsbruck Graz

3. # of Tx Centers/ Mill Pop Vs Cadaveric Renal Transplantation

4. Decentralized Donor Procurement

5. Manpower (fte)

6. Budget (Federal Gonvernment)

7. Budget Expences %

8. Potential of Organ Donors Estimation between 20 und 80 Donors / Mio /Year • Schuster et al Öbig 1995: • 85potential d/mio/year realised 21only • Barber K et al Transplant Proc 2005 37:568 • Out of 22668 ICU death: 1387 (6%) brain death (23/mio/year?) • Person N Lak 2005 • Out of 3114 ICU death; 174 (5,6%)brain death

9. Critical Steps in Organ Donation The „Donor Chain of Events“ • 1. Donor detection • 2. Viability / Safety • 3. Donor management • 4. Consent / Authorisation • 5. Organ retrieval / Logistics

10. Donor Age 1998 - 2007

11. Achilles´s Heel of Organ Donation Enthusiasm Information Legislation Infrastructure Kooperation Donor Detection

12. “Singel Person effect”Trauma Unit

13. “Single Person effect”6 month periods

14. Regional Donor distribution

16. UK Autopsy Tradition "Since Henry VIII's time, the sole legal source for corpses for dissection had been the gallows - bodies of murderers handed over to the anatomists as a post-mortem punishment." (Introduction, xv) Ruth Richardson: "Death, Dissection and the Destitute" (London, Routledge & Kegan Paul, 1987)

17. Gerard van Svieten 1700-1772

18. Austrian Autopsy Law KAG § 25(1) and Wr. KAG §40(1) Corpses of patients, who died in public hospitals have to undergo autopsy in case of • Public health concerns • Forensic matters and • Public or scientific interest -

22. Essentials of Austrian TX Law • Removal of organs from deseased persons allowed • For the purpose transplantation • No personal objection (presumed consent) • Death certified by licensed independent doctor • In public hospitals only • No commercial interest allowed • Piety has to be respected

23. What is not regulated in Austrian TX Law • Living Donation • Organ Allocation

24. Long tradition in Austria (Autopsy law) Personal - not family- decision Balances public vs personal interests No written decision by relatives necessary In favour of transplantation Advantages of Presumed Consent Regulation

25. Death Criteria % Agreement 1. Forensic Criteria: 100 Cold, Stiff,Spots, Fermentation 2. Clinical Criteria: Unconscious, No Breathing, No Heart Beat, 3. Brain Death Criteria: 96 / 92 *) No Brainstem Function +Flat EEG *) Wamser et al. Transplant.proc. 1992

26. Controversy About Brain Death Very dangerous!! Brain Death vs Brain Stem Death Pragmatic solution: „Irreversible loss of all intracranial functions“

27. Allocation Basic requirements for Organ allocation Transparency Egalitarian Principle -- Utilitarian Principle Simple Trust

28. ET transplant programs Leiden 66 39 37 25 4 38 Total population: 120 Mill.

30. Allocation:XCOMB (ET)

31. Donor- und Transplant-Frequencies in Austria 1989-2009

32. Deseased Donor Frequencies in Europa*) Transplant Newsletter Vol 9:1 2008 Council of Europe *)Donors per mill population

33. Renal Transplantation in AKH Vienna 1965 - 2009

34. Efficiency of RT in ESRD 51% 52% 52% 51% 50% 50% 51% 52% 52% 54% 55% 54% 55% 54% 55% 56% 55% 56% 60% 63% 65% 49% 48% 48% 49% 50% 50% 49% 48% 48% 46% 45% 46% 45% 46% 45% 44% 45% 44% 40% 37% 35%

35. Ethical Issues in Transplant Legislation - Cadaveric Source for Transplant Organs - Brain Death Criteria /Determination - Safety / Quality Control - Authorisation - Allocation - Live Donation - Non Profit Rule - Logistics

36. „Über Kreuz Transplantation“

37. „Domino“ Transplantation

38. LRD vs LURD vs CAD

39. NHBD Categories (Maastricht) • a) dead upon arrival • b) unsuccessful resuscitation • c) awaiting cardiac arrest • d) circulatory arrest after brain death confirmation

40. Targets of Promotion • >>> ICU Personnel (Communication Courses) • >> Medical staff at large (Lectures, meetings, Courses, „Medical lay journals“ • > Public. (Donation days, „Media culture“-Information)

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