In Poland OrganTransplantation W. Rowiiski, M. Lao, J. Walaszewski,w' Lisik publicopinionsurvey Key words: renaltransplantation, organtnnsplantation, legalregulations,
lntrodu€tion The first cadavericrenal transplantantationin Poland tookplacein Warsawon January26tl\ 1966,andvcrysoon wasfollowedby the first livingrelateddonor kidrey tralsplantation.At that time the World Registryorganizedby ProlessorJosephMurray recordedonly 600 suchproceduresin the wholeworld. ltwas our wish and beliefthat the kidney transplantationin Poland would become a standardprocedrre.I'Iowever,itwasnot the case.Ensting legalregulationswerenot veryhelpful.Cadaverickidneys procurementwasconsidereda part ofposlmortemexamination.Since$e postrnortemwasobligatoryat that time, the families w€re told about, but no1askedlbr, kidney halvesting. Although the brain death conceptwas known, its diagnosiswasnot lcgally pennissiblc.I-Iarvestingof the kidneys was alwaysdone a1the timc or afler cardiac arrest, which resdted in high incidence of ischemic grdt failure atler transplantation.The attitudc of the mcdical societytoward transplantationprocedureswasreluctart, to saythe least. For suchreasons,dudng thes€earlyycars(1966-1976) only 10-12 transplantationswere pedormed annually. Transplantatiom were considered by some medical pro fessionalsto be lhe "personalambitionsand hobby' of a few surgeons,so kidreys were procured only witlin the samehospitalas the transplantationcenter. The challengecame in 1976,when the new Medical School Hospital was opened. Department of Vascular movedto thathospital,and Surgeryand Transplantology an active transplantationsenice was developed.Only duringoneycar(1976)75 cadavericlddneysweresuccessfuIy transplanted. In the sameyear,the InstituteofTrans plantology, which houscd two nedical departments (transplanlationnephrologyand immunotherapy)and a depa ment of erye mental immunology wilh a tissue typingiabofalory,waslbundl3d.The pretransplantassessment and the posttmnsplantationcare includingimmu' nologicalmo torhg and the fbllow up were donein thG institution. In the carly 80{ies kidncy uansplantationprograms werc started in a nurnber of Medical School hospitals acrossthe country. Most of then werc not too active. However, this increasedthe number of transplantsto 200-250lyear.Although the announcemert of the diag nosticcriteriafor the braia stemdeathrecognition,by the Committeenominatedbythe Ministry ofHealth in 1984, had only minimal legal value, it servedto promote the
inqease of renal transplantationsto 300-350/yearand allowedto starttransplantationof odler organs. In 1983,a secondrcnal transplantationprogramwas startedinthe"old' MedicalSchoolHospitalintheDepartmcnt ofGeneral andTmnsplantationSurgeryin Warsaw. Both surgicaltransplantunits have closelycooperated with thc Insrilrte. Sincethattime the WanawTransplantation Center hascorlsistedoftwo surgical teamsfrom th13 tlvo MedicalSchoolllospilals and the medicaltearnftom the TransplantationIfftitu1c. The number of kidney transplantations increasedto 220lyear. For a numbel ofyears in Polandtherewas a practice donorstothe transplan' of transferriDg so-calledpolential tatioDcenterwhichwascausingcertainobviousproblems. To develop a pmper organ procurementprcgram tor three consecutiveyea1s,1985 1987,two of us (JEW, WAR) werelecturingin manyregioDalhospitalsiocatedasfar as 250 km out of Wa$aw. This resultedin aD inoease of rumbcr of transplantationsdone in our Ccnter fiom 15 up to 85/year.At the sametime we stafied,togetherwith cardiacsurgeons,the multiorganprocurementprogram. This aclivity gavedse to the fourdation ol National Organ Procurementand SharingCenter,namedPOLTRANSPLANT, which startedto operatein the aulumn of 1993. The fuIl listory of oryan transplantation in Warsaw and other centreswaspublishedin tl1efirst issucof thisjoumal. OryanLattonofTtsse andotganTnwLt t ttio in Polutut. The National Trdnsplantation Council appointed by the Minister ofHealth and Welfare in 1993,consistirgof 20 members representhg tnnsplant surgeons,nephrolo gists,anaestesiologists, immunologists,neurologistsand publicadmininrltionoFficial'i. re.pon.ibletor: . Elaborationof strategyfor the developmentof tissue and organtransplantation. . Promotionoftheideaoforgandonationandtransplantation amonggereral public,aswell aspreparationof the educationalprogran for the medicalstudentsand hospitalslaffconceminglhe organdonation andtransplantation. . Active participation in crcating legal rcgulations concemingorgan and tissuetmnsplantation. DepanmenbotGeneraandTnispai6tm sursefy&TBroplaibtoi fled.he, TEns plantrdon ni tue, ai d orgai Procurcmnt Coord i ition cenre r Poltons
to asstrrcclTicientuseof all availableorgaDs,promotion of multiorganhaNesting,propcr allocalionof organsaccordiDgtL)thc nationalwailing list priorities,training of coordinators,andthc promolionofeducationalprograms coDceniDgmoslinportanl aspechoftransplantationmedicineamongthc ncdical societyand the lay public. Renal tra splantation On December31st,1995thc Dational\{aitinglistconsisted of 1838rccipientso(1 ofwhom 324had beenwaitingfor more than iive years,237 had beeDpoientialcandidatcs for a sccondtransplanland 9 urgentlyneededtransplantation dtLeto very poor vascularaccessfor hemodi lysis. Unfortunately,only oDethird of ESRF palientstreated with chronichemodialysis havebecn rcgislcrcdlbr lransplantation.Mean waitingtimc lbr transplanlalionin 1994 was28 monthsfor transplantedpaticntsand uchlonger for thosewho had not re{-eneda gralt prcviously.The ean waiting time for the total patient population reached5 years in 1994and is steadilyincrcasing.Thc mean ageof kidney rccipicntsduring last lew yearswas 36 38ycars.Thc chancelbr verygoodor goodHl-A match are very 1ow (due to a hnitcd Dunrberof prospeciive recipients.).In 1995ncarlyhail'ol'lhepatientsreceivedthe kidrcy wilh 3 and 30% with 4 HLA mismatches(Fig. 1). Accordingto thc POLTRANSPLANT Registry,over 4000rcnal lransplantationshavebeenperformedin Po land sincc 1966 till the .3ndof 1995.Eighty live were pelJormedfiom livingdonor(allbutone from genetically related donors).Rcmaininggralls were procured trom cadalcrs.Thckidneysare being transplantedin 10 trans plant centersby 13 surgicalteams (Fig. 2). Oul ot this nunibcr2305l.idneys\\'eretransplanted in 2214recipients WarsawMedicalSchoolTransplantCentcr (WTC). Iri the majoriq,ofcasesthc graftswcrc oblainediiom cadavers (2147)and only in 85 fiom living donors.At prcscrit. ll59recipients(52%)are aliveardwcllwith alunclioning grafl,5Sl patients(277.)went backon chronichemodi.r lysisprogranrand 474patients(21%) died . The pcrccnlagcoL'primary nonfunctionof the graft (PNF) lrasbeen very hieh:'7c/ain 1994and 6o/c1\ 1995. Delayedgraft function (DF) 'vaslbund in 457.,in 199s (49C(,i 1994).Imnediate good lunction (JF) can bc ex?ectedin 50% oftransplantcdkidncys(Fig-3). ODeandfivcycarpaticntsuwnal hasbeen97%and88% respectivcly(Fig. 4,5).Fi\a yearsgraft survivalshowssignilicant differenccsanong difltrcnt cenlen and mngesfrom graftsun ivals 12%to 4'7%(Fig.6).I'Iabtirne(t %)cadaveric in Wa$aw TransplantationCcnler hasbeen8.3years.
Fig, L HlAantiSen maehing, Poland, 995
Fig.2. fidney qan5p ant (€nGE
Liting rclateddonorkidnettransplatatit,l For a vadcl' rcasonsthc nunber oL'livingrelatedkidney lransplanlalions hasbeenenremelylow (0.87,of all lr an splants)so practicnllyall proceduresare cloneusing cadaverickidneys. Fig. 3. Kidney lunct on arter hansp aibl on n Poland
Simrtta eouskidnet-pa crcastransplantations Only 38suchprocedureshavebcanpc blmed,allofthem by two independentteamsftolrl thc WaftawTranansplant
Palients no supedolity of either method could bc estab65%. lished.Threeyealsgraft sunival approaches Heatt ftansphntation The first succesfulheafl transplaDtationwas peformed in Zabrzein 1985aDdshce then a regularprogramofheart activein twocenters(Zabrzeand transplantationhasb€en Krak6w)to reach80 100transplantsperyear(2-2.5/pmp). Till December 1995 350 patients receivedheart lrans_ arevelygood. plants.The resultsof hearttransplantations The three-years suflival is approximately 7574.
3 @ $ro
Poland,995 Fig.4.Oneyearpatientandsrattsuryiv:lsin
3 d
Poland,995 Fig,5.Fiveyearspatentandaraltsuryivalsin
.r
transplanlcente6, Poland
Fig,6. FiveyearsgraltsuNivals in Poland,1995
Ltuet tnnsplsntation Clinioal atlemptsat liver lransplaniationbegan in 1989 and sincethat lime over 40 liver transplantation have beefl performed in several centels, however this program has been succeslulin ChildreD'sMemorial Hospital in Warsaw only. At prcsent 14 children and 3 adull liver gralt q ilh goodgraflfunction. recrpienr\ dresurvrvrng
Legalaspectsof organ transplantation in Poland From 1966till the end of 1995,i.e for nearly 30 years, cadavericorgan pmcurem€ntwas basedon the very old PresidenlialAct(1928)regulatingaspectsof postmortem exarrination, which was obligatory in all casesof palients which had dyingin hospitals.The family ofthe deceased no right io refuse d1l-consent to postmortem was usually told about the organ procurement but not asked for it medi lransplanlaliorr DesDitclhelackoflesd rcsuldrron( \4ini'lr) ol .lo$l):c\c-l,cprng. In lo'5.lhe cinehadbeen Heatth and Social weliare inrroducedthe Decree on cadaveric kidncy procurement, which made this procedure legal, bur severalaspectswere not clear. The announcementof t1lediagnosticditedaforbrainstemdealh recognilion, by the Commiftee nominated by the Ministry of Health in 1984,had oily minimal legal value,but it servedto promotethe increaseof renal transplantations to 300-350/yearand allowed to stafi transplanlation of other organs. As of March 1996the new ParliamentaryAc1 on the Procuremert & Transplantation ol CeIs, Tissues and Organs was signed by the Pr€sident of the Country. This oI cclls. all lcllala.pect.ol tran.planlalron Acr reaulares Lj*ues':rndorean. fiom crdave'ic a. w;ll rs livingdonor'. Cadaverictissuesand organscanbe harr'esledody ifthe d€ceasedduring his or her lifetime had not expressed con.en0.The Acl inLro ol,icdionro donarior(pre\umed ducesrhe conceptol brain .rem dcalh dnd ils cfileria. regulatesthe principlesof organallocation,allowsfor the reldtedlran.planlrlions livinggenericallyandernolionally u r ) dp r o h i b i r \ a na)l l e m p l d l c o m m e r c i a l l i \ s u e a n d o t g transplantationintrcducingseverepenakiesfor suchprocedures. So, finaliy, 30 yeals after the first kidney transplantation,Poland shall have,similarly to a number of European Coulties, a legal act which regulates all aspectsrelated to ce1l,tissueand organ transplantation. The CentratRegistryof Objectionsto donationshallbe operating as of Octoberlst 1996.The widelyspreadinformation availablein all the mediaandeposedinpublicplaces
arecausingccrtainconcernamongthepublic,a factwhich may be partiallyresponsiblefor thc low number of procuredorgans.The first one is Iackofunderstandingof the presumedconsentconcepl. andthe secondinvolvessome hesitatioDs conccrningthe diagnosisofbrain death.This lus beeD coDfirmedin a poll on ihe attitudestoward iraNplantation anong the public arrangedby National TraDsplantation Council(1995). Limitationsto organ transplantationin Poland Overthreethousandpatientsin ourcouDtrydie ofchronic renal failure each ycar (i.e. 80-100/milionpopulatioD). Ncarly 607,olthesepatientshaveto die mainlyduc101oo pcrfotmed.Presently low a mmber of iransplaDtations the numberof kidDeytrzrnsplantations in Polandremains at a low levelof 8-1O/milliorpopulalion.The numberof patientswho wouldbe potentialrccipientsofheartorlrver transplantsin Polandis similarto tlut obse ed in mostof the Europeancorntries (approximately12lmilionofpopulation).The number of hearl transplantsin Polandis srill at a very low lcvel ard approached2.5pmp lasryear. The liver traDsplantationprogrammeis srill at an early stageof development.Thesc data showthat in respectto organ transplaDtationPol nd occupiesone of the last placesamongthe Europeancountries. The number of pcople dying of head injuries,brain tumon ard vascularbrain diseasein Polandis very higl and far excecdsth.3number of organsneededfor lraDs plantation.Reviewof the recordsofover 16 000patients who died in Warsawhospilalsin 1992showedthat in 258 caseskidneyscould have been harvested.OrgaDswerc proclrredfor transplantationfrom only 50 of fiese patienis.Accordingto the hospitalrecords,in all remaining 208 casesthe clinical criteria of brain death had bcen presentfor a few daysbeforecardiac rrestoccured.Only on 4 occasionsbrain death was formally diagnosedbut harvestingdid not takeplace. Wat are the Nasont that so few kidney transplantatio s are beingdonel Among the number of lactors which may possiblybe responsibleare rhe following:lack of accep' bymaiorpart of thc tanccof cadavericorganprocurernent society(due to difficulties in undcrstandinglhe brain deathconcept),the rcluctantatlillLdeofmedicalcommunity andinsufficientcooperaiionbetwccnlransplantation centers,unpreciselegalrcgulations,lack of supporttiom rhehierarclryofPolishRonranCatholicChurcharldother moral authorities,and,lastbut not least,the economical situaiior ofthe NationalI'IealthSystem. Medidil limitations Despitethe long iistory of cadavcrickidneytransplantation inPolandihe legalregulations,includingthoseallowing braiDstcan death recognition,were introducedonly few yearsago.For a varieg'of reasoDs brain dealhin the potentialdono$ isbeingdiagnosed andofficiallydcclared quite la1e,so very often organdonorsare beingletered to transplantcentersat the point whcn severehemodynamic and metabolic disturbancesa1c present. These changesrelatedto brainsteamdeathquite often progress
is bcing pedormedin the abovedescribedsituation.The meaDtimc bclweenbrain stemdeathdiagnosisandorgan rctrieval amounis to morc than 30 hours. In 1992, in W saw,kidneyswerehaNcsledfrom lessihan 207, of all possibledonors.Theperccnlageofutilized donorsis three timcs lower than in Spain, twicelower thaDiD thc Nethcrlandsand in France,and significantlylower than in the USA, Swedenand Brazil. Thc incidenceof the causesof deathofkidney donors in nrmerous cenires is similar to that encounteredin Warsaw.The potcntialdonon are mostlyhospitalizedin: intc sive care units, traumatologywards, neurosurgery, neurologyard intcnsivecardiaccare.Thus,medicalstaff of thesewardsshouldbe especiallywell Lnowledgeablc aboutorganharvestingaDdtransplantationand ought to stayin touchwith neighbou ng transplantcentres.How' ever thc rcsultsa of recentsuNey amongphysicianson their attiiudctowardscadaverickidneyharvesringshowed resistanc€of the medicalcommunily.Surr'eyedanaesthe siologistssaidthat the reasonsfor it werc, amongothers, difficullies in obiaining acceptanceof donor family 1br h r.,'cslingoryans,althoughl€gal regulationsclo not require family consent,and are bascdon donor presuncd Therefore,in PolaDdan educationalprogrammetor mcdicalstaffespeciallyconccrningdonor managementts of prevalentsignificanceand hasbeen aheadyslarted. Social limitations of orgsn transpldntdtionsin Polan.l Inordcr to clariq/certaindoublsthe NationalTransplantation CouncilcommissionedDemoskop(a public opinro conou(l an otrnion sune\ ror surve)orgdnizalionr anong thc public,and the medicalcommunity. Public opinion suney Nine hundred and eighty two respondenls(of different ageand sociri background)were givenseveralquestrons in order to assessthe level of acceplanceof cadaveric organ hanesting,their attitude townrd legal regulations in that respect (prcsuned consent,position of family rights) and undelstandingof the brain deathconcept.A high proportion of respondentsacceptedharvestingof kidncys,hearr and liver from lhe deceased(?47, of respondeDts) and saidtheywould be willirrgto donatetheir own organsafler their dearh(69%). However,only 267, conthe presumedconsent olquestionedpeopleaccepl.3d ccpl (nearly60% of respondcnts were ofthe opinion that the objectionof the family, despitethe abscnceof ihe objectionof the deceascdregisteredduriDghis lifetime, shouldpreclude the possibilityof organ procurement). Answcringthe questionwhethcrdoctorshavethc dgbt to declarc the patient dead bnsing their diagnosison the "yes" criteriaofbrain dedth377,ofrespondentsanswered 'no'. Howeveras many as 417, of respon al'd 22% said dentswerenot ablcto er?resstheir opinionin that matter. theirwilligness o!:pressed Finally,537, of the respondents to doDatcone of their own kidneysfor a closefamily membersuliring of end stagcrcnal disease,23%would choosethc useof a cadavedckidney in such a situalion,
The resultsof this surveyshow tlat despited€clared acceptanceof organ traDsplantatiollamong the society there is lack of knowlcdgeof legalregnlationsand some hesitanceconcerringthe diagnosisofbrain death.
iamily,fear of the responseof localcommunityand relucworkwiurout exlra tanccto undertakeadditionalstr€sstul eJQlained Twentypcrcentof respondsDts compensation. their attitude with lack of preciselegal regulalions(the suNeywasconductedin 1995,beforeintroductionofthe TransplantationAct in 1996). Despitethe presumedconsentbasedon legal regulations in Poland,a maiority of the questionedphysicians (ou ,) e\Tre-ed rh( opinrol lhar one 'hould a(k .\e r e l a r i r e[ o s f l l e i r( o n \ r n r ^ o r g ] nr e m o \ a lH. o $ e \ e r . l h e role ofthc iamily s decisionhasbecn questioned.657, oI plrysiciansand 45l, of medical studentscxprcssedlhe opinion that the negativeattitude of the family of the deceasedshouldnot precludeorganharvestingif no ob' jection of th€ patient had been rcgisteredduring his,&er lifetimc.Tlis attitudecanbe supportedby findingsof an idependentsurueyamoDgthe public (Demoskop,1993) 1()leavethe decision whereonly5T,ofrespondentswished coDcemingorganharvestingto the familyThe suney carried out among medical students showcdinsulTicieniknowledgeofvarious aspectsrclated despite lo cadavericorganhanestingand transplaDtation thc fact that most of theseproblemshad beenlecturcd.
tudidl\onnunN Amadpo|J hrdhds, 'Mn amnngth? In ordcr 1{)clarily rhe attitude toward transplanlalion scntto, amongthc medicalproflssiona questionnairewas (anesthesiologists, nclr andreceivcd1iom,707physicians rologislsand neurosDrgeons.) and 926 Dursesworking in the samedepartments.Similar suwcywascondlrctedamong ov€r 1700studenlsoI all medicalschoolsin the couDtry. The resultsshowedthat the majo tJ of plrysicians, nursesand medicalschoolstudcnts(well over98%) consider transplartationof kidncys and heart an effective methodoftreatmeDt,acceplingcadavericorganprocuremetpatientseither ment (95%).Mostofthe respondenls awaiiingor aftertransplantation oI the kidneyor heart,so the opinionswere basedon pcrsonaler?erience.Over 957o of physicians, nurses and siudents would agree to donation of theil organs aller death, but the attitud€ would be slightly different if the organswere to be tc movedafter the deathofafanilymember (12% of physicia alrdstudentsandnearly207oofnurseswouldobiect to removaland more than 20% ofrespondentscxpressed no opinion on that subject). ResultsoftheknowledgeandattiiudesuNeypresented Majority of the respondents(98% ofphysicians,88% of studcntsand B27aof nurses)acceptthe brain dcalh here indicatethat therc is a need for aD intensebroad concepl,but only 297, ofphysicians(36%ofaDesthesiolo educationalprogramnot only for the publicbul, most of gists,27% of neurosurgconsand 20% of neruologists) Jl, lbi lhc Inedrcrlcommunily.l he re.ulr\lf( in a \\a) would be preparedto swilchoffthe ventilatorofa brain similarto rhosepresentedin similarsuFeyscarricdorl in deadpatientiforgan procuremeniwasDotto take place. otherEuropeancountties.Eurotransplanljniiiaied,three Thirt perceDtof the qucstionedphysicianswould defi- yea^ ago, the activiq, of EDHEP which is aiming at nilelycontinueartificialrcspiraiionin sucha situationand increasingthe Dumberof oryansavailablcfbr iransplan25%werenotpreparedtogivcan answer.Answersof 427, tation. Be11erunderstandirgof the need of coopemtion of medical studentsand 57% of nursessupportedthis betweenlocal communig'hospitalsand transplantation centers,as well as support of the medical community, attitudeof physicians. proseem to be very important factors wbich may help in deciared acceptaDce of cadavcric organ Despite and extensionof cadavericorgantransplan curement,only44%ofphysicians(607dofneurosurgeons, contiDuatioD and 33% ofneurologists)would tation.Only thenthe dialoguewidr the publiccansucceed. 497dol anethesiologists d€finitely notiq7 POLTRANSPLANT (Organ Sharing OrgrnL./rlion) or J tfrnsplanlccnlcrabouth"\ ing " po- Address r.eprint requests to: Wojciech Rowiiiski, MD, tentialorgandonor in lheir care.47% of the respondents PhD, Departmentof General and TransplantationSuransweEdthat the decisionwhethcr to notiti the trans- gerf Warsaw Medical School,Nowogrodzka59, 02 006 plant center or not would dependon the circumstances warsaw,Poland,E-mail
[email protected]. (but the rcal notiticationrate indicalesthat in mosl in-
