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Esot presidential address by Prof. Jan Lerut ? 19 October 2005

2006; Springer Science+Business Media; Volume: 19; Issue: 10 Linguagem: Inglês

10.1111/j.1432-2277.2006.00342.x

1432-2277

Jan Lerut,

Organ Donation and Transplantation

Dear Members, Guests, Friends, Ladies and Gentlemen, Sir Roy Calne and a group of ten transplant colleagues founded this society in Zurich in 1982. When studying this small- and well-selected population, I found out that the 23-year actual survival is 91.3%, apparently having been or being a transplant doctor has a beneficial on effect long-term outcome. When founded, the following major goals were set forward: promote and encourage education and research, foster contacts and interactions within the European transplant community and encourage the training of future transplant professionals. Almost one-quarter of a century has passed since…. So, what is ESOT nowadays, what does our society stands for? Several major changes have taken place over the last years. The creation of different autonomous sections and committees, aimed to make ESOT strong, has been created during recent years. You have been presented in Geneva with a first class scientific program, put together by the local Organizing Committee and by an active ESOT Council (Fig. 1), and it's newly created very efficient, Basic Science and Educational Committees. The various plenary sessions with an excellent balance of highly ranked oral abstracts, first class state of the art lectures, and the different plenary sessions were outstanding. ESOT-congress attendance during the last 12 years. The number of attendees at the last few meetings indicates that we are moving in the right direction. We come from 200 participants in 1982 to 3300 in 2005…all records have been beaten in Switzerland! A compliment must be given to Philippe Morel and his local organizing committee (Fig. 2). ESOT-council 2003–2005. The prestige of the society has been raised by the new profile of our journal Transplant International, under the guidance of Ferdinand Muhlbacher and Thomas Weckerle, and by the creation of honorary memberships, presented to the outstanding leaders in transplantation Prof. Rene Kuss, Roy Calne and Thomas Starzl. The efforts of ESOT to provide the best possible care to our transplant recipients have been translated into the ESOT-educational program, which is especially of value in view of the recent political changes in Europe and in view of the rising erosion in enthusiasm for this medical field. The EC-Program – better known as the ESOT-Pyramid – already includes eight highly regarded courses, as well by the students as by the lecturers and teachers (Fig. 3). ESOT educational pyramid. Over the last 10 years, almost 800000 euro have been spent in order to allow researchers, transplant physicians, and surgeons from 25 different countries to improve their knowledge in this field of medicine. About 1000 individuals have been able to attend the different courses organized under the auspices of ESOT. Further initiatives to extend these projects are being undertaken by the ESOT-council and the Basic Science and Grant Committees. All these initiatives represent outstanding opportunities for continuing education in clinical and basic science research. This educational package will surely be of value in our commitment to the Global alliance for Transplantation initiative from the Transplantation Society. It is worthwhile mentioning the official collaboration with the American Society of Transplantation (AST), which has resulted in the implementation of major transcontinental – bilateral – research grants and with the Latin-American and Caribbean Transplant Society. Both collaborations, which were achieved under the guidance of the International Relationship Committee, correspond to the desire of these different transplantation societies to promote transplantation medicine worldwide. All these projects should stimulate young transplant physicians, surgeons, and researchers to become new members of our society, allowing them to have full access to all these educational and professional opportunities necessary to secure the future of transplantation medicine. Much information about transplantation in Europe has been collected on our website (http://www.esot.org) during the last 2 years. In view of the continuously changing European political – and thus also medical – landscape, exchange of information between professionals is of utmost importance. Our website should become the pivotal point for information and exchange of knowledge for the European transplant community. The ESOT-transplant center directory is worthwhile visiting and…using. Communication between transplant professionals is essential for progress. I would like to leave you with some personal thoughts about transplantation. We all know that transplantation has become victim of its own success…because of the inequality between supply and demand. The words ‘too few’ are dominating our daily professional life and practice more and more. …are available for too many patients. We should however ask ourselves if the lack of organs is indeed as fixed or as important as we claim. Do we do everything possible to increase the – maybe already available – organ pool, to reduce the gap between available donors and listed recipients? The differences between organ procurement rates between different countries are really important and this has of course a consequence on the number of recipients transplanted. Even in neighboring countries within a same allocation system such as Eurotransplant, the donor rates may vary considerably. Donor family refusal rates still are responsible for a fair amount of graft losses. What can be carried out for this? A very good tool would be to intensify sensitization of adolescents (such as those organized since more than five years in Belgium by the Euroliver Foundation) toward transplantation and organ donation. It has indeed been shown repeatedly that 17–18-year-old adolescents have a great lack of information in this matter, and we should convince authorities to introduce officially 1-h teaching about organ transplantation and donation in the last year of middle school. Another way to improve the situation relies directly on our continuous motivation ‘to go ahead’. In my personal practice, which is during the last two decades mainly related to liver transplantation, I have been impressed by the fact how easily donor offers are declined by a center, often for reasons that are not clear or even unjustified. Fortunately, a certain number, but not all of them, of these declined allografts are finally transplanted successfully in another center. This situation, already highlighted 10-year ago by the Birmingham group, still exists. At almost every congress or meeting, we state that marginal or compromised, aged, high-risk, nonheart-beating and split liver organs should be used; however, the reality is different. This is exemplified by the fact that the audited ELTR data show that in 2004 more European centers were performing live donor liver transplantation than split liver transplantation, this despite the fact that split liver transplantation was developed in Europe. The explanation for this aberrant situation lies in the fact that personal and center interests and results often prevail over those of the recipients. To improve this situation, concentrated efforts should be developed and transplant center logistics should be optimized. We must organize ourselves better. A very good example of this has been set up recently by the creation of the national split liver transplant program in Italy, endorsed, also financially, by the national authorities, and they should be congratulated for such an initiative. Information technology should help streamline the logistics…it is the example to follow! In the US, the number of living donors has equaled or even exceeded the number of cadaveric donors in recent years. In Europe, considerable differences exist in relation to the use of such grafts…again an untapped potential is open to our reflection. In Norway, live donation is almost the standard, in other countries it is inexisting. This relates to considerable differences in organization of transplant centers and even more in perception of ethics. What is normal in one country is forbidden in a neighboring country…see also the example of NHB or donation and kidney living donor swap programs in the Netherlands and in Germany; what is forbidden in one country is almost rule in the other one…a more general reflection on this is thus necessary! I am pleased to see that eastern countries have recently taken up the challenge to expand carefully their experience in this delicate matter. The discrepancies in different fields of deceased and live donor transplantation show that there is an urgent need to move toward a global-European ethical philosophy. We can hardly speak every day about common European guidelines and rules for almost everything such as in – and export of tomatoes…except for the delicate, but of utmost important field of transplantation. A society such as ESOT can probably play an important part in the streamlining of these processes. The problem of care for the live donor – on the short-term and maybe even more important on the long-term – is a major one, facing many different aspects of daily life…clear regulations are badly needed. This problem has been recently taken up by the Transplantation Society. It should be stressed that Gil Thiel already established in 1993 a very well-structured exemplary SOLDHR (Solid Organ Living Donor Healthy registry) live donor registry in Switzerland. It is the example to follow! That such initiatives are mandatory is very well stressed by the most recent developments coming from China. Read the http://www.bek.transplant.com carefully in order to believe the message of this website. If you follow carefully the arrow, you can be successfully transplanted within a well-defined time schedule. It is surely time that the moral and ethical leaders of this and other sister societies take up the challenge to communicate with these professionals in order to progressively regularize this situation. The Munchen group already showed a great interest in the ethical and legal framework of transplantation. I am pleased to see that the Rotterdam group, with the full endorsement of this society, will analyze in depth these ethical, legal, and economical problems during an upcoming spring symposium in 2007. Two decades ago, transplant physicians and surgeons only had a few immunosuppressive drugs at their disposal; nowadays, they are overwhelmed not only by a multitude of drugs, but also, even more, by a multitude of industry-driven studies. Recently, a very famous transplant physician told me that he could not tell which immunosuppressive therapy his patients had…because all patients are included in various studies combining different drugs in different combinations and dosages…all imposed by industry. Nowadays even the results of such studies are written up by professional writers! We should ask ourselves where the place of academic research in transplantation stands! This listing about peer reviewed papers in relation with steroid-free IS in LT exemplifies this statement. There are so many studies with so many different study protocols. So, it becomes really difficult to make secure conclusions out of it. Moreover, results often are overruled; showing e.g. that quadruple and double IS schemes give similar results in LT in a period were mono- or bi-therapy are already standard therapies will not advance the patient care. The conclusions of many studies are often also made too rapidly. The recent guidelines published in the AJT in relation to this matter are a clear warning signal. The clinician and researcher must keep at least some autonomy in order to guarantee progress. During my presidency, I have been asked very frequently if I knew of some transplant surgeon to keep an ongoing, sometimes even major, transplant program upright. Such requests go along with inquiries performed by the AST revealing that there is a shortage of qualified transplant surgeons, a major problem fed by a very high rate of burn-out syndrome. An inquiry, I performed within the European transplant community, confirms this discomforting situation. The replies of many top European transplant surgeons confirm that recruitment of young and most important, enthusiastic, transplant surgeons is too low even if the best selection criteria are put forward. There is indeed a recruitment crisis in transplantation (Fig. 4). ESOT questionnaire in relation to the profession of transplant surgery. Reasons to change. The main explanations for this low inflow and important outflow are unfavorable familial or personal conditions, poor quality of life, inadequate career planning, and insufficient financial reward for a very demanding, both physically and mentally, job. The competition with financially more attractive fields of surgery, such as laparoscopic surgery, does not deserve much of an explanation. Adequate measures should be taken to make the transplant profession more attractive. Financial upgrading of the job as well as the creation of first class fellowships in accredited centers seems to play a major role in this context (Fig. 5). ESOT questionnaire in relation to the profession of transplant surgery. Making the profession more attractive again. ESOT is therefore becoming an active player in collaborating with UEMS (Union Européenne des Médecins Spécialistes), in order to establish standards for a European surgical transplant board and for accreditation of transplant centers and programs (Fig. 6). ESOT questionnaire in relation to the profession of transplant surgery. Role of ESOT in the upgrading process of the transplant surgical profession. All discussed ‘too fews’ will increasingly dominate the transplant community in the near future. I dare to hope that ESOT will major its influence in resolving at least some of these problems, and rapid solutions will be necessary in order to keep transplantation well and alive. Further professionalization will be required to reach these goals. As my term as President of ESOT comes to an end, I realize that the time has gone quickly but I also realize that ESOT has made a major step forwards in the development of transplantation not only in Europe, but also worldwide. My presidency has not only been very demanding, but also a rewarding period in my medical and professional career. I would like to express my sincere gratitude to all council members for their active and dynamic participation in the different projects we have put forward during the last 2 years. We achieved nearly all of them. We were a real European team. A special word of thanks goes to Analisa Ponchia, our newly appointed administrator, for her critical follow-up of many projects and a more than special thanks to our secretary (and my friend) Rutger Ploeg. Working with all of them was a personal enrichment! A special thanks also to Jannie Uildriks, who allows ESOT to function optimally. She is our ever present secretary keeping an overview of all ESOT-activities. My gratitude goes to all friends from the industry and all corporate sponsors of ESOT for their invaluable contribution that made it possible not only to make this meeting a success, but also to allow ESOT and especially its educational and grant activities to continue to grow. I take the opportunity of this floor to express my gratitude to all my former mentors in surgery; a particular word goes to four of them, Prof. Jacques Gruwez, my first chief of surgery, always had a particular eye for ‘the new things’ in surgery and thus for organ transplantation; Prof. Wilhelm Sandmann who taught me that surgery needs to be highly performant and efficacious in order to be justified; Prof. Henri Bismuth who taught me the art of ‘intellectual surgery’; and finally Prof. Thomas Starzl, a great personality in medicine, who taught me that surgery and medicine can only succeed if one approaches the patient in his totality as an human being. A thank to all my close collaborators in Brussels who did the work when ESOT absorbed my time: my closest collaborator Olga Ciccarelli, my two dedicated transplant coordinators Francine Roggen and Chantal De Reyck, the data manager Dominique Gonse, the secretary Catherine Dochez, the social worker Caroline Compere and the head nurse of the transplant unit Anne-Sophie Buseyne and her dedicated and highly professional nursing team. You may see I was not able to find a close male collaborator! Maybe, my ESOT-absences in the hospital were a good means to survive in this exclusively female biotope. Lastly, but not least, I want to thank another female crew at home. My three daughters and my charming and always present wife BEA, an exemplary mother and spouse. Their support was an invaluable help keep me upright in the often very demanding and unforgivable transplant world; their support also helped me pursue the fulfillment of many of my ongoing personal and ESOT-projects. I hope some of my thoughts will give you – my dear members, guests, and friends – inspiration for the future. I hope you had a very fruitful Geneva-meeting giving you more insight about best practices in transplantation medicine and research. I dare to hope that this event will further stimulate your interests to become an active partner in the future development of ESOT, a condition that will finally translate into better care of our patients, and, also, we should not forget their living or deceased donor families. The future directions for ESOT have to be determined. In my mind, they are very clear. The recent restructuring and the European alliance for transplantation, the basis of which was created two days ago, must be consolidated. ESOT must become and remain a major player, recognized by the authorities, in the development of the European view of transplantation. These conditions will be necessary in order to build up a new generation of motivated and enthusiastic transplanters. I hope to see you all at the next ESOT-meeting in Prague in order to celebrate the 25th anniversary of ESOT.