Ethical dilemma in organ allocation for lung transplantation John-David Aubert Respiratory Division...
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Ethical dilemma in organ allocation for lung transplantation John-David Aubert Respiratory Division Lausanne-Geneva Lung Tx Centre - Switzerland ERS Vienna
Ethical dilemma in organ allocation for lung transplantation
John-David Aubert Respiratory Division Lausanne-Geneva Lung Tx
Centre - Switzerland ERS Vienna 2012
Slide 3
Disclosure - JD Aubert Financial support for travel from:
Astellas Boehringer Ingelheim
Slide 4
Organ procurement from deceased donors Why is it different from
other therapies ? A treatment strategy with an explicit shortage of
organs Unpredictable waiting time from the therapeutic decision
(listing) to the effective therapy (transplantation)
anticipation
Slide 5
Donor: 36 yr, death through brain injury, non smoker, PaO2 =
410 mmHg Situation # 1 Recipient 1 63 yr COPD Ex-smoker Intubated
in the ICU since 10 days Waiting time : 30 days Recipient 2 35 yr
Cystic Fibrosis At home on Oxygen + nutrition by PEG > 6
exacerbations the last year Waiting time : 230 days
Slide 6
Your choice ? Recipient 1 63 yr COPD ? Recipient 2 35 yr Cystic
Fibrosis ? 12
Slide 7
Analysis of determinant criteria If you choose 1 the 63 yr
COPD: Risk of death for the recipient 1 > Risk for the Recipient
2 Medical efficacy If you choose 2 the 35 yr CF: Younger age Age
match with the donor CF is not a self-inflicted disease such as
smoke-induced COPD Equity
Slide 8
Conflicting Principles in Organ Transplantation Medical
Efficacy Equity
Slide 9
LET US CHANGE JUST TWO ITEMS.
Slide 10
Donor: 64 yr, death through brain injury, ex smoker, PaO2 = 410
mmHg Situation # 1 bis Recipient 1 63 yr COPD Ex-smoker Intubated
in the ICU since 10 days Waiting time : 30 days Recipient 2 35 yr
Cystic Fibrosis At home on Oxygen + nutrition by PEG > 6
exacerbations the last year Waiting time : 230 days
Slide 11
Your choice ? (1bis) 1.Transplant the 63 yr COPD 2.Transplant
the 35 yr CF 3.Do not accept these lungs
Slide 12
WHO statement (GP 9, May 2010) Organ allocation must be Open
Transparent Fair Equitable
Slide 13
Council of Europe: Statute art 15b Organ transplantation should
follow the rules: 1.An allocation system should exist 2.Management
of the official waiting list 3.Organs should be allocated to
officially registered recipients 4.Criteria for registration on the
list should be explicit 5.A patient can be registred on only one
list 6.Transplant centres should be certified 7.The management of
the list and the organ allocation should be controlled at the
national level
Slide 14
The ways to allocate organ from deceased donors Random
selection Through the economic rules of supply and demand
Centre-based through expert opinion of the surgeon By chronological
order +/- established exceptions By a severity score of the
recipients
Slide 15
The ways to allocate organ from deceased donors Random
selection Through the economic rules of supply and demand
Centre-based through expert opinion of the surgeon By chronological
order +/- established exceptions By a severity score of the
recipients
Slide 16
Allocation through the transplant surgeon and/or the transplant
pneumologist Pro Decision in expert hands Flexibility in particular
cases Optimal match donor- recipient Con Criteria are not open
Potential bias Detailed knowledge of each recipients history?
Cognitive performance 24h a day?
Slide 17
Putative criteria used by the transplant surgeon Priority to
the sickest patient Size match between donor and recipient Age
difference between donor and recipient > 30 years Extra caution
when a TX had turned bad in the previous month!...
Slide 18
Allocation through the surgeon
Slide 19
Expert surgeon Back to Situation # 1 Donor: 36 yr, death
through brain injury, non smoker, PaO2 = 410 mmHg Recipient 1 63 yr
COPD Ex-smoker Intubated in the ICU since 10 days Waiting time : 30
days Recipient 2 35 yr Cystic Fibrosis At home on Oxygen +
nutrition by PEG > 6 exacerbations the last year Waiting time :
230 days
Slide 20
Chronological order with priorities First come First served
Priority = urgent cases (ICU) IPF, PAH The allocation is
patient-based and no longer centre-based
Slide 21
Allocation through the surgeon Centralized patient allocation,
with queuing
Slide 22
Donor: 36 yr, death through brain injury, non smoker, PaO2 =
410 mmHg Situation # 2 Recipient 1 53 yr IPF 1st LTX 2007 BOS
Listed for redo Under non-invasive ventilation 16/24h Waiting time
: 230 days Recipient 2 35 yr Cystic Fibrosis At home on Oxygen +
nutrition by PEG > 6 exacerbations the last year Waiting time :
60 days
Slide 23
Your choice ? (2) 1.Re-Transplant the 53 yr recipient
2.Transplant the 35 yr CF 3.Transplant the 35 yr CF and remove the
53 yr recipient from the waiting list
Slide 24
Donor: 36 yr, death through brain injury, non smoker, PaO2 =
410 mmHg Situation # 2 Recipient 1 53 yr IPF 1st LTX 2007 BOS
Listed for redo Under non-invasive ventilation 16/24h Waiting time
: 230 days Recipient 2 35 yr Cystic Fibrosis At home on Oxygen +
nutrition by PEG > 6 exacerbations the last year Waiting time :
60 days
Slide 25
Redo LTX: usual practice Same priority as first LTX Some
programs do not consider urgent status for Redo recipients (e.g.
France)
Slide 26
LAS Calculator The Lung Allocation Score (LAS) is a numerical
calculation used for allocating lungs to candidates who are 12
years of age or older. The LAS is calculated from clinical
diagnostic factors which estimate each candidate's waitlist urgency
and post-transplant survival probability Lung allocation score LAS
- USA
Slide 27
Slide 28
Is it possible to predict, before transplantation, the survival
after LTX?
Slide 29
Predictive ROC curve for specific preTX diagnosis
DiagnosisCOPDIPFCF AUC0.5530.5910.584 AUC = 0.5 Random AUC = 1.0
Perfect prediction
Slide 30
THE LUNG ALLOCATION SCORE IS MORE PREDICTIVE FOR THE WAITING
LIST MORTALITY THAN THE POST TX SURVIVAL An understatement..
Slide 31
Slide 32
Allocation through the surgeon Centralized patient allocation,
with queuing Lung allocation severity score
Slide 33
Expert surgeon Centralized allocation + urgency criteria LAS
Back to Situation # 1 Donor: 36 yr, death through brain injury, non
smoker, PaO2 = 410 mmHg Recipient 1 63 yr COPD Ex-smoker Intubated
in the ICU since 10 days Waiting time : 30 days Recipient 2 35 yr
Cystic Fibrosis At home on Oxygen + nutrition by PEG > 6
exacerbations the last year Waiting time : 230 days
Slide 34
Donor: 36 yr, death through brain injury, non smoker, PaO2 =
410 mmHg Back to situation # 2 Recipient 1 53 yr IPF 1st LTX 2007
BOS Listed for redo Under non-invasive ventilation 16/24h Waiting
time : 230 days Recipient 2 35 yr Cystic Fibrosis At home on Oxygen
+ nutrition by PEG > 6 exacerbations the last year Waiting time
: 60 days LAS= 50.65LAS = 40.20
Slide 35
How to compare different allocation systems ? Number of lung
TX/ Mio habitants ? Median waiting time on the list ? Mortality on
the waiting list ? Acceptance rate of organs ? Survival 1,3, 5
years after lung TX ?
Slide 36
Would you transplant Joe the ugly ? A 49 yr prisoner, with
rapidly progressing IPF. Jailed with life- sentence for numerous
crimes and murders
Slide 37
Your choice case # 3 1.This prisoner should be put on the
waiting list 2.This prisoner should not be offered a lung
transplant 3.Unsure
Slide 38
Slide 39
Shocking: Doctors have given new lungs to Joe the Ugly! If you
answered yes, Have you thought on the impact on organ donation to
this type of recipient in the general population ?
Slide 40
My choice: Do not list Joe the Ugly for lung TX The reason: he
did not quit smoking.
Slide 41
To conclude Organ transplantation = therapy with explicit
shortage of supply Equity and medical efficacy are the two
(sometimes) antagonistic forces that drive the process Different
allocation systems coexist within Europe Comparison of distinct
allocation systems should not be based on a single parameter