Why Did it Take so Long to Start a Non-Heart-Beating Donor Program in Belgium ?

Abstract

The first cadaver kidney transplant, performed in June 1963 in Belgium, was from a heart beating donor (HBD). It was the first ever in the world. Since that period, almost all cadaver organs were procured from brain death donors. When the Belgian law on organ donation and transplantation was published on February 1987, with its opting-out principle, no emphasis was placed on procuring organs after cardiac death. Based on the Maastricht experience, in the early nineties, the transplant community interpellated the National Belgian Council of Physicians to facilitate organ procurement in Non-Heart-Beating Donors (NHBD) following the law. But, the transplant community had to wait for the impulse of the first International Congress on NHBD in 1995,where the 4 categories of Maastricht NHBD were defined. It also published 12 Statements and Recommendations which were eventually approved by the European Council. Then all local Ethical Committees received queries for approving local NHBD programs. Almost all centres requested viability testing assessment of the NHBD organ prior to implantation, and proposed the introduction of machine perfusion technology. Finally, all centres joined their efforts and made a collaborative agreement with Organ Recovery Systems for a 24/7 machine perfusion service from a central laboratory. During a three year period (2003-2005), 46 NHBD kidneys were recovered. Among these kidneys, 32 were perfused in the Organ Recovery Systems central laboratory. The Delayed Graft Function (DGF) rate for these perfused kidneys was 25%. Only one graft was lost in this subgroup. Livers, pancreases (for islet preparation) and lungs (for experimental ex-vivo evaluation) were also recovered from these non-heart-beating donors.

Organ Procurement and Transplantation in Belgium

“…Over the past 10 years, the percentage of controlled DCD to the DD pool has substantially increased to reach 29% in 2016 (Figure 1). 10,11 In contrast, uncontrolled DCD is rarely performed in Belgium. A working group within the Belgian Transplantation Council has established national guidelines on DCD donations that have been approved by the government and the national ethical committee.…”

The History of Kidney Transplantation: Past, Present and Future (with Special References to the Belgian History)

“…Like in Austria and Spain which have a huge activity in DBD organ procurement, in Belgium it took almost 40 years to start with DCD organ procurement (Squifflet, 2006) 25 . The main reasons are multiple.…”

“…Despite her nephrologist's "disapprobation" she gave birth to a second baby boy in December 1990. 24 . It consists in implanting the whole pancreas with a duodenal segment, with portal drainage (into the superior mesenteric vein) of the venous effluent of the pancreatic graft and exocrine diversion to the recipient duodenum.…”

Kidney donation after cardiac death

“…The complexity and profound implications of death are recognised and should be respected, along with differing personal, ethnic, cultural and religious perspectives on death and donation. Decisions around withdrawal of life-sustaining therapies, management of the dying process and the determination of death by cardio-circulatory criteria should be separate from and independent of donation and transplant processes [14] . Ongoing controversies relate to whether the DCD donor is dead after 5 min of absent circulation [42] .…”

“…But it was only in 1987 that the Belgian law on organ donation and transplantation was published, with its opting-out principle but with no emphasis placed on recovering organs after cardiac death. The development of DCD kidney transplantation hinged on: (1) an enabling law; (2) the first International Congress on non heart beating donation (now referred to as DCD) in 1995, where the four categories of Maastricht were defined [13] ; (3) ethical approval; and (4) the desire for viability testing assessment (looking for some indicative measure of the likelihood of kidney function post transplantation) of the DCD organ prior to implantation, and hence the introduction of machine perfusion technology [14] .…”