European ACCORD Programme, headed up by ONT, shows crucial role played by Intensive Care Units (ICUs) in improving donations, one of the keys to Spanish transplant model

This is one of the main conclusions of the European ACCORD Programme, headed up by the Spanish National Transplant Organisation (Spanish acronym: ONT), which once again stressed the effectiveness of the Spanish transplant model. The programme shows the need for intensivists to systematically incorporate donations, with prior authorisation from the family, as part of end-of-life care, as takes place in Spain.

The results from the ACCORD programme were presented on Tuesday in Madrid at the headquarters of the Mutua Madrileña Foundation, at an international event organised by the ONT and the European Commission, which met with experts from all around Europe, representatives from the European Commission and patients' associations.

Donor Day

This meeting coincides with the events for National Donor Day to be held on Wednesday under the slogan "Great news for everyone". For Rafael Matesanz, the results of the ACCORD programme and, above all, the significant increase in donations recorded in Spain, constitute the finest tribute that can be made to organ donors and transplant patients. "The good news is that the number of donors has increased by 14% in the first four months of this year, resulting in a 12.9% increase in the number of transplants. Transplants of all organs are on the rise, although particularly noteworthy are the increases in pancreas and kidney transplants", stressed the Director of the ONT.

Rafael Matesanz, who appeared at a press briefing, was accompanied by Eduardo Miñambres, the transplant coordinator in Cantabria and Jesús Molinuevo, President of the National Federation ALCER, on behalf of all the associations of transplant patients.

For his part, the President of the National Federation ALCER, Jesús Molinuevo, asked all people to take note of the importance of donation, to speak with their families and to continue contributing to saving lives. "We want this year's campaign to help so that the number of donations continues along the same upward curve as to date. It is vitally important for this message to reach all of society".

Improve availability of organs

In this regard, Rafael Matesanz underlined the importance of the ACCORD programme, which ratifies the benefits of the 'Spanish Transplant Model'. "This programme has shown that decisions taken by intensivists in end-of-life patient care can preserve or, in contrast, completely eliminate the possibility of organ donation", he underlined.

ACCORD (Achieving Comprehensive Coordination in Organ Donation throughout the European Union) is the most important programme run by the European Commission in this field in recent years. Headed up by the ONT, upon a decision from the European Commission in recognition of its international leadership and experience, this programme comes within the framework of the Action Plan on Donations and Transplantation that accompanies the European Directive on Quality and Security, approved in 2010. 23 European countries and 10 institutions as collaborating partners took part in drawing this up. With an allocation of close on 2.5 million euros, this was set in motion three years ago with the aim of increasing the availability of organs in the European Union and boosting collaboration between countries.

Since the approval of the European Directive, headed up by Spain, donation in the EU have slowly but surely increased (up 7.5%), from 9,206 donors (18.3 pmp) in 2010 to close on 10,000 (19.5 pmp) in 2013. According to the World Transplant Registry, run by the ONT, 31,165 transplants were performed in 2013 in Europe, 50% of its needs.

"In this period, the donation rate has improved in 21 countries in the EU. In seven of them, the increase was by more than four points (Belgium, Croatia, Spain, Finland, Malta, Norway and the United Kingdom)", added Rafael Matesanz, who stressed the importance of programmes like ACCORD which contribute to increasing donations.

The ACCORD programme has mainly focused on analysing the role of ICUs in the donation process, following the Spanish model (task force led by the United Kingdom) and in studying safety in live kidney donations (task force led by Holland). It has also fostered twinning programmes between EU countries to facilitate the implementation of the European Directive and the Action Plan in countries with support needs (task force led by France).

67 hospitals in 15 countries took part in the survey on the role of ICUs, (Germany, Spain, Slovenia, Estonia, France, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Holland, Portugal and the United Kingdom). 17 of these hospitals are Spanish. The format was a multi-centre "prospective review" study of the clinical records of 1,670 deceased patients in a period of six months, due to brain damage (and hence potential donors), below the age of 80.

The results have shown the enormous differences that exist in Europe in attending to neurocritical patients at the end of their lives. "The possibilities of improving the donation process in Europe are significant: only 23% of potential donors were actual donors in the end", underlined Rafael Matesanz.

Spanish participation

Together with the United Kingdom, Spain was the country that contributed the most cases to this study, with a total of 413 potential donors. The results in our country have clearly shown the excellent development of the donation process in brain dead patients: 30% of potential donors were effective brain dead donors compared with the European average (including Spain) of 19%. "The detection of brain dead donors is clearly optimised in our country", claimed Rafael Matesanz.

Moreover, in Spain 8% of potential donors were patients in an ICU, with the aim of incorporating donation as part of end-of-life care, with prior family consent, an option that is uncommon in the majority of the countries that took part in the study. In Spain, the involvement of intensivists in organ donation is a key feature, as seen with the SEMYCIUC Ethical Code

The study ratifies the effectiveness of the Spanish model, which has been successfully copied in other areas such as Australia, Canada, Ibero-America, Croatia and Portugal. This is also the case in the United Kingdom, which, after having incorporated many elements of the Spanish model, such as the involvement of intensivists, has managed to increase organ donation by 63% over the last six years.

Despite that, Spanish hospitals taking part in the European ACCORD programme detected two areas for improvement in our country: firstly, the need to further improve collaboration between coordinators, intensivists and professionals that attend neurocritical patients in ICUs (emergency physicians, neurosurgeons and neurologists). According to this programme, 8% of potential donors never became ICU patients, although they had no medical grounds for not donating.

Secondly, the study showed the importance of extending asystole donation to smaller hospitals. 25% of potential donors that pass away following limitations on vital support treatment could have become asystole donors, but the donation could not take place due to the absence of specific programmes. 42 Spanish hospitals now have programmes for this type of donation in 13 autonomous regions, but the ONT considers that this should be extended throughout the country.

ACCORD Spain

The ONT has already adopted measures to optimise donations in these two areas. In fact, this forms the basis of the 2015 Strategy implemented at the start of this year with the aim of increasing donations by 10% and transplants by 20% in the next five years.

The 2015 Strategy includes the ACCORD Spain programme, in which 71 hospitals are taking part with the aim of implementing the improvements necessary to increase organ donation. These measures have already started to bear fruit, when taking into account that as from 1 May, the ONT recorded a significant increase in both the number of donors (up 14%) and in the number of transplants (up 12.9%), exceeding the figures obtained in the same period last year, a year in which Spain recorded its best figures ever in terms of donations.

As Rafael Matesanz explained, the increase in the number of donors is both due to asystole donation (up 68%), and brain dead donation (up 7%). The increase in cardiac arrest donation (asystole) is made at the expense of type III donations (controlled asystole). Asystole donation now represents 18% of the total.

Live donor safety

ACCORD has also ratified safety in short-term kidney donor safety, after analysing 2,909 European donors, by a task force led by Holland, in which 15 countries have taken part, including Spain. The figures show the inexistence of major adverse effects one year after donation. No donor needed renal replacement therapy following donation. They all returned to their previous level of activity within a maximum period of three months.