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Declining organ donation rates for both living and deceased donors in Greece represent a major current challenge. Organ donation rates are not only influenced by a variety of factors including medical, cultural, legal, ethical but also socioeconomic aspects. Greece has an overall well-established organ transplantation system. However, donation rates have recently seen a historic low.1
Organ Transplantation in Greece
Greece has 5 kidney transplant programs (with 1 unit that has a broad experience of >1000 living-donor renal transplants2): 1 active Liver Transplant program performing deceased-donor liver transplantations3 (2 additional programs that have been approved to perform liver transplants), 4 bone marrow transplant programs (nonautologous), and 1 cardiac transplant program.4 At this time, there is no active small bowel, pancreas, lung, or dedicated pediatric transplant program. Children older than 14 years are registered and get priority on the adult kidney list, whereas children younger than 14 years are referred to centers abroad. All transplant programs are public, and no transplantation license has been issued in private health sector.
The Hellenic Transplant Organization (HTO) has been established in 1999. The HTO is administratively responsible for organ donation and transplantation processes in Greece and provides oversight for the sharing of organs between Greece and other European countries.5 Central coordination is available around the clock facilitated by headquarters in Athens. Hellenic Transplant Organization cooperates with intensive care unit (ICU) coordinators to screen donor eligibility and to coordinate organ evaluation and allocation based on well-established protocols.5
Organ Transplantation Rates in Greece
At the beginning of the millennium, HTO contributed remarkably to the rapid increase of donations and transplantations. In detail, deceased donors increased from 40 per year (3.6 donors/million population) and 116 solid organ transplantations in 2001 (104 kidney, 10 liver and 2 heart transplantations) to 240 in 2006 with 206 kidney, 27 liver, and 7 heart transplantations (donation rate of 7.2 donors/million population).6 Moreover, the conversion of potential donors peaked with 64.5% in 2008.5
In 2008, 182 kidneys, 57 liver, and 16 heart transplantations have been performed5,7; however, in 2011, numbers began to decline (Figure 1). Transplant volumes declined furthermore in 2013 with only 107 kidney, 31 liver, and 9 heart transplantations and a declining donation rate of 4.6/million (from 8.9 in 2008). Renal transplant activities recovered somewhat in 2014; however, liver and cardiac transplants remained stagnant (transplant volume in 2014: 131 kidney, 28 liver, and 12 heart transplantations).5,7 A further decline in deceased donation has been observed during the first 6 months of 2015 with only 30 donors, reflecting a rate of 2.7 million/pp, and the overall volume of solid organ transplants fell below 70.5 Living donor kidney transplants declined in parallel: although 51 living-donor kidney transplants had been performed in 2008, (4.6/million pp), numbers declined to 46 in 2011 (3.5/million pp), with only 39 live donor kidney transplants performed in 2014 (3/million) (Figure 2). Based on the overall transplant numbers, only 10% of waitlisted patients have received a kidney transplant and greater than 1.000 patients are expected to be remaining on dialysis for an average of 5 to 7 years.5,7 A significant transplant tourism has developed and 180 patients travelled abroad between 2010 and 2014, accumulating costs of approximately 50 million Euros.5 Based on law, no 8739/1994, in urgent conditions and with the consent of the Director of the Transplant Center, patients are permitted to travel abroad to receive an organ (mainly liver allografts of which most are performed in Italy) with the understanding that the procedure abroad will be covered by the Greek health care system.
Legislation for Organ Donation in Greece
In 2011, the Greek Parliament approved a presumed consent (opt-out) law for deceased donation. Living donation, previously including only close relatives had been extended to donors with a close and stable emotional relationship. This process includes a confirmation of the donor's motivation by a court decision.8 Of note, only a few living donations have been based on close emotional relationships, potentially reflecting insufficient public information.5 A further legal change had been made to the allocation system in 2014 and a National Transplant Registry had been implemented at the same time. Moreover, an update of waitlist management has been implemented that distinguishes between “active” (medically suitable) and “inactive” (medically unsuitable recipients).5
Although novel allocation rules have been implemented, donor rates have not increased and conversion rates have reached a historic low with only 39% (in 2015).5 Consequences include rising morbidity and mortality rates while awaiting transplantation but also increasing transplant tourism with a substantial economic burden on the Greek National Health System. Reasons for this unsatisfactory situation appear multifactorial and may include an overall insufficient public information on organ donation, an inadequate link of the HTO with donor ICU/hospitals, all potentially exacerbated by the current economic crisis in the country. With the current austerity measures in Greece, more than one third of the HTO's budget has been cut.5 Consequently, the support of local, in-hospital coordinator in ICU has severely suffered, and many donors are potentially lost.
Moreover, the overall economic crisis may have fueled public uncertainty and distrust, thus limiting the registration for donation with a current estimated registry rate of less than 4%9 leading to an unprecedented organ donation tailspin in Greece. A link between economic stability and donation can be assumed. Employment status and financial commitments have been shown to reduce rates of living donation.10 Although altruism and solidarity have traditionally been key elements of the Greek culture, recent legal and administrative changes have unfortunately not been successful in transforming the “will to offer” into an “act to donate.” Budget restrictions for the HTO during the current disastrous economic situation but also an emotional paralysis in the country may have contributed to the downward trend in organ donation and transplantation in Greece.
What is next?
Instituting well trained transplant coordinators linked to the HTO, in addition to a concerted effort in educating the general publication and healthcare professionals will be critical in improving donation rates and transplant numbers to achieve an adequate treatment of patients with end-stage organ failure.
Only well trained personnel will be able to identify and screen potential donors. Clearly, the experience of successful organ donation programs in other countries has shown that the link to ICU coordinators is critical for the identification and treatment of donors. Moreover, the communication of trained personal will be critical in improving conversion rates.
Regaining trust in the overall political and healthcare system will decisive to successfully communicative the priceless value of the life-giving gift of organ donation.
1. Rodrigue JR, Schold JD, Mandelbrot DA. The decline in living kidney donation in the United States: random variation or cause for concern? Transplantation
2. Zavos G, Moris D, Kostakis ID, et al. De novo visceral malignancies in renal transplant recipients: a single center experience of 2054 recipients for more than 30 years. Exp Clin Transplant
3. Tsochatzis E, Koskinas J, Manesis EK, et al. Liver transplantation in Greek patients: epidemiological data, morbidity, and mortality of 71 patients from a single center with 6 years of mean follow-up. Transplant Proc
4. Gkouziouta A, Adamopoulos S, Manginas A, et al. Heart transplantation in a low-organ-donation environment: a single center experience. Transplant Proc
5. EOM. Double Organ Donation from the Venizelos Crete Unprecedented mobilization agencies and health personnel. http://www.eom.gr/
. Published January 16th, 2016. Accessed April 28th, 2016.
6. Karatzas T, Katsani M, Mitropoulou E, et al. Substantial increase in cadaveric organ transplantation in Greece for the period 2001–2005. Transplant Proc
7. Moris D, Zavos G, Menoudakou G, et al. Organ donation during the financial crisis in Greece. Lancet
8. Bottis M. The new Greek statute on organ donation—yet another effort to advance transplants. Eur J Health Law
9. Georgiadou E, Sounidakis N, Mouloudi E, et al. Attitudes and behavior toward organ donation in Greece. Transplant Proc
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10. Cuesta-Briand B, Wray N, Boudville N. The cost of organ donation: potential living kidney donors' perspectives. Health Soc Work