A proposal for an algorithm enhancing transparency and achieving harmonization for patient selection in rescue allocation for liver allografts in Germany

Abstract

University Hospital Frankfurt is the first German University Hospital certified in accordance with the ISO 9001:2008 for patient care, clinical education, and patient-oriented clinical science including all administrative fields. It is one of the institute’s major interests to define standard operating procedures for all fields of medicine. Currently, a transplantation scandal in liver transplantation raises different issues with guidelines, allocation, and transparency of organ allocation in Germany. One of the critical discussion points is rescue allocation for livers. When a liver has not been allocated one hour before the planned explantation time as depicted in chapter 3 of the Eurotransplant manual (www.eurotransplant.org), Eurotransplant will allocate the organ as rescue allocation. It gives centers the opportunity to choose a patient from the waiting list and to weigh the potential risks of a marginal organ with the benefits the patient gains being transplanted. Already in 2009, the German Medical Association admonished all German liver transplant centers to perform a lawand guideline-conformed selection of recipients in rescue allocation, especially focusing on urgency and success. General practice is the use of rescue allocation organs for recipients that are not adequately depicted in the Model for End-Stage Liver Disease (MELD) allocation system, e.g., low-MELD patients with significant concomitant disease from cirrhosis. To date, a standardized decision algorithm is not defined for Germany. Here, we propose an algorithm, representing our approved standard operating procedure for the selection of recipients in rescue allocation intending to enhance transparency and to achieve harmonized procedures throughout Germany (Fig. 1). Every center should define a “Center Waiting List” for rescue allocation offers. In principle, every patient from the general waiting list is eligible for the “extra” list and must pass the interdisciplinary liver board respecting the “Six Eyes and Three Disciplines Principle” defined in the guidelines for liver transplantation by the German Medical Association. We recommend placement of not more than three to five patients per blood group (depending upon the size of the whole waiting list) on the Center Waiting List and to respect the following hierarchy principles. First, blood-group-identical recipients should be selected, mainly to avoid disadvantages for blood-group-0 recipients. Next, weight and size matching should outrank medical reasons such as concomitant disease from the underlying liver cirrhosis. This approach has been chosen as most patients will be on the CenterWaiting List with similar concomitant disease A. A. Schnitzbauer (*) : F. Ulrich :W. O. Bechstein Department of General and Visceral Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany e-mail: andreas.schnitzbauer@kgu.de

DOI: 10.1007/s00423-013-1099-9

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Cite this paper

@article{Schnitzbauer2013APF, title={A proposal for an algorithm enhancing transparency and achieving harmonization for patient selection in rescue allocation for liver allografts in Germany}, author={Andreas Anton Schnitzbauer and Martin Walter Welker and Hans Joachim Wilke and Frank Ulrich and Kai Zacharowski and Stefan Zeuzem and Wolf Otto Bechstein}, journal={Langenbeck's Archives of Surgery}, year={2013}, volume={398}, pages={917-918} }