Slide 1

Thank you. Ok, early Sunday morning, Mother’s day today. Glad you are here. Let’s start and kick off with the problem we Are facing in Europe.

Slide 2

These are Eurotransplant data in which you can see the enormous wait list of patients on dialysis all waiting for a transplant and the number of kidney transplants that is lacking behind enormously.

Slide 3

What is the problem and the scope for the Europeans? These are EU numbers, 120.000 patients on dialysis. 65.000 waiting for a transplant. But unfortunately, only 25.000 transplanted each year with a wait time of 3-5 years and between 5.000-6.000 die on the wait list but there is another similar number that is removed from the wait list because their clinical situation is deteriorating and another unknown cohort of patients that don’t even go to the wait list because the doctors judge that a wait time of 3-5 years Is unrealistic.

Slide 4

So what can we do? Well, intensify our efforts for more deceased donation, expand deceased donor criteria, try and persuade your politicians and law makers to go for an opt out legal system for donation because those countries who have an opt out system, presumed consent that is, have better donation rates like Spain, Belgium and Austria.

I’m going to talk about the active promotion of live donation not only living related but living unrelated, cross-over kidney exchange, altruistic donor programmes, domino-paired programmes and even maybe a little bit about paid donation.

Slide 5

An example, this is for Europe but also for the Netherlands you see a stable number of kidney donations, deceased donations in the last 20-30 years, despite all our efforts nothing happened, remained stable and we did expand in the Netherlands our criteria for donation.

Slide 6

We have now 40-45% non-heart beating donors but nevertheless, the number did not increase and you have rather the impression there is a substitution rather than an elevation of the numbers.

Slide 7

On the other hand, living donation has boomed dramatically during the last 5-6 years as you can see from this slide and this was not only due to living related but for the biggest part from living unrelated, as you can see here.

Slide 8

And now approximately half, slightly less, 45% is living unrelated donations. Not only partners but also friends like others, crossover donors and even altruistic donors.

Slide 9

It’s not always possible, as you know, that you can give directly to the intended recipient because of ABO incompatibility or positive deceased cross matches and the solution in that case is a kidney exchange.

Slide 10

This is crossover, donor A gives to recipient B and donor B gives to recipient A, this is a duplet, you can make a triplet, you can make a quartet, you can make anything to – or whatever up to 17 changes.

Slide 11

But before you embark on such a programme there are ethical and psychological considerations. The first one is that it is donation via strangers. The recipient in a normal directed donation knows who the donor is, he knows that he is a good man or woman, he has all the best for him but in case of a donation via strangers he is not really sure, he could be a good man but he could also be an evil man. It could be the magic law of contagion, he could bring his evilness upon you.
Then there’s the case of anonymity, there are countries in the world where anonymous donation is prohibited. There are countries in the world where for logistic reasons anonymity is not there. There are ideas that anonymity should be good we didn’t know in the Netherlands, we thought let’s ask our patients themselves and it happened that almost all patients wanted to have a crossover programme in an anonymous way.
The third consideration is that there is a loss of medical excuses. In the old days before we went through the ABO barrier and before crossover transplantations were possible, it has been a relief for many donors to hear that they were not suited for donation because of their wrong blood type or because of a positive cross match. A great sigh of relief, not anymore now. They can still be a donor in a crossover programme and that may give them problems.
The fourth is that it is maybe a next step to organ trade, it is an exchange but it is still trade, it is barter. You give something and you receive something and barter as a trade can be due to economic forces. Therefore, we thought that it was not wise to let the allocation be directed by a certain doctor or a certain hospital or a certain patient, or a donor but we went for an independent organisation so that it could not be a next step to organ trade.

Slide 12

We set up a national programme in the Netherlands and the allocation of those kidneys is performed by the Dutch Transplant Foundation.

Slide 13

We do a computerised matching 4 times a year and the allocation criteria are blood type, first identical than the others, match probability that the most difficult to match patients has his kidney first, wait time and donor age.

Slide 14

The other important thing is that there is also an independent organisation that says whether their cross match is positive or negative so we don’t have troubles between the 7 laboratories in the Netherlands, who is right and who is wrong, there is only one answer, one organisation who can say that the cross match is positive or negative.

Slide 15

The donor travels not the kidney. The donor travels to the recipient centre for final acceptance. The surgical procedures are performed at the same time and we keep strict anonymity as was the wish of our patients.

Slide 16

We started in 2004. We have done 17 match procedures, 256 donor-recipient pairs. Approximately half of them blood type incompatible, the other half have a positive cross match and the PRA of the last group because these are desensitised patients, the median PRA is 52%, so they are rather highly desensitised.

Slide 17

Out of the 256 we could match 142, so we have a success rate of 55%. The majority having the positive cross match but also blood type incompatibles. Not only the easy to match A-B and B-A combinations but also those couples with AO recipients in a non-O donor. That means that approximately half of our patients can be matched in a crossover programme but the other half cannot.

Slide 18

So we need another solution and there comes in the Samaritan donors. Samaritan donors are people who care about or help other people even though this brings no apparent advantage to them.

Slide 19

It’s a concept of Auguste Comte in 1851 who was talking about care for wellbeing or the fitness of another person. More or less a lifestyle of a person acting in the interest not of himself but of others.

Slide 20

Motivations of Samaritan donors are religion; they are active in church organisations, third world. They can be triggered by a bereavement or by media attention. They know kidney patients in their immediate environment for the large part of them and they are almost all also blood and bone marrow donors.

Slide 21

They can give their kidney for free to someone they know vaguely, someone with whom they have no emotional or blood related ties.

Slide 22

But it can also be that an altruistic donor gives a kidney away to an unlucky couple of the crossover programme provided that the donor of that programme who already intended to give his kidney away now gives his kidney away to someone on the wait list.

Slide 23

With this programme with one altruistic donor you can make two kidney transplants possible. These are the results of our programme in Rotterdam we have performed in the last 2-3 years. 5 directed donations, 8 non-directed donations to the wait list but also 16 domino paired with results in 32 kidney transplants, so it’s 29 altruistic donors, we performed 45 transplants.

Slide 24

So we think that it is good to have these Samaritan donors in our programme when it’s in a regulated country like in Western Europe. But you can have your doubts about other altruistic donors that seem to be somewhere in the world.

Slide 25

Maybe they are not so altruistic. And there are people in Europe who go on the Internet, for instance, to China and I know it’s legally forbidden in China for civilian hospitals to sell kidneys but it’s not forbidden for the military hospitals at the moment. So there is still organ trade in China. You can wonder what type of donors they will use.

Slide 26

These are the donors they use.

Slide 27

And if you are not willing to do that, you can always look on the Internet and go for www.matchingdonors.com and this is what they say a non-profit organisation. But they give you free airfares for all patients and donors and kidneys can be transplanted, even pancreases can be transplanted. It’s a non-profit organisation and you wonder what this altruistic stranger coming from Nairobi, Africa has to do in Illinois of the USA to give his kidney away.

Slide 28

Then you better go to www.liver4you.org which sells also kidneys.

Slide 29

This is in the Philippines, in the Philippines between 700 and 1000 kidneys are sold each year and all medical insurances are there. Veterinarian administration will provide for the money. You can even buy by PayPal. You see here the languages they have over there Spanish, French, even Danish and even Dutch. There must be a reason why they have these languages on their site. Some prices and some numbers. The estimate is that there are 66.000 kidneys transplanted worldwide and approximately 5.000-8.000 are sold or trafficked.
The prices are there, Philippines $1500, Brazil/Turkey $6.000, also for Colombia which is the biggest at the moment. India/Pakistan slightly less and the USA, the highest price. All trafficked organs.

Slide 30

So people go shopping in the world also from Europe to obtain organs for money and selling organs is legally allowed in some countries and in more countries even tolerated. Buying these organs for us is not forbidden by most national transplant laws in Europe and the United States. Even Health Insurances reimburse the costs.

Slide 31

Trafficking which is exploitation of human beings for sexual exploitation, forced labour, slavery, servitude or for the removal of organs is a crime. It can occur within borders or transnationally.

Slide 32

In Europe it is linked to criminal organisations. Illegal immigration, prostitution, illegal adoption, weapons smuggling, money laundering not through a regulated market such as in Iran or transacted sales with donor consent as in Colombia, Brazil, Philippines but mostly from coercively fraudulent sales.

Slide 33

These are the donor countries in Europe. The recipient countries, the well-to-do countries, the well off countries with money and the transplant countries. The unofficial estimate is between 150-250 each year but last week Europol said that it was probably double this amount.

Slide 34

The fate of the donors is no good. They are jobless poor young men hunted by kidney hunters, desperate. They give false affidavits, promise of jobs that they won’t get, coercion and force and they are paid less than they are promised.

Slide 35

Therefore, last week in Istanbul 75 countries came together in the International Summit on Organ Trafficking and Transplant Tourism.

Slide 36

You will see it in the press next week but the end point is that we think transplant tourism and organ trafficking must stop.
Thank you.