Organ Transplantation in Switzerland

Switzerland is located in central Europe, has an area of 41 285 km2, and a population of 8.5 million. Mainly due to the Alps, only about half of the country is populated, resulting into a density of approximately 400 persons/km2. Switzerland has 3 major official languages: German (spoken by 70%), French (spoken by 25%), and Italian (spoken by 5%). A public healthcare system covers all transplantation-related costs. NUMBERS OF TRANSPLANT PROGRAMS Switzerland has 6 transplant centers (Basel, Bern, Geneva, Lausanne, St. Gallen, and Zürich) (Figure 1). Each transplant center has its affiliated HLA laboratory. All transplant centers perform living and deceased donor kidney transplantations. Other organ transplantations are allocated to specialized centers: heart (Bern, Lausanne, Zürich), lung (Lausanne, Zürich), liver (Bern, Geneva, Zürich), pancreas (Geneva, Zürich), bowel/multivisceral and pancreatic islet (Geneva, Zürich), and allogeneic hematopoietic stem cells (Basel, Geneva, Zürich).FIGURE 1.: Organ transplants in Switzerland are performed in 6 centers with a selection of organs/center.GOVERNMENTAL AND REGULATORY SYSTEMS INVOLVEMENT AND OVERSIGHT All transplant centers use local and national infrastructure (Figure 2). The national infrastructure consists of 3 major parts. Swisstransplant represents the national organ procurement and allocation organization (www.swisstransplant.org). It is mandated by the Federal Office of Public Health (FOPH) and supported by several expert groups. Since 1993, all living organ donors (kidney and liver) are captured in the Swiss Organ Living Donor Health Registry (SOL-DHR; www.sol-dhr.ch), assuring lifelong follow-up.1 Expenses of the SOL-DHR are covered by the healthcare insurance of transplant recipients and the FOPH. Since 2008, the Swiss Transplant Cohort Study collects data of all transplantations performed in Switzerland. While a minimal data set is mandatorily submitted for the FOPH, additional detailed information including biobanked samples support a prolific research platform (www.stcs.ch).2FIGURE 2.: Simplified illustration of local and national infrastructure available for transplant centers in Switzerland. Dashed lines represent data flow between different information technology systems and databases. Currently, there is no electronic data transfer and many redundant data are entered several times manually.OVERALL TRANSPLANT VOLUME Detailed statistics can be found on the homepage of Swisstransplant (www.swisstransplant.org/en/information-material/statistics/). In 2017, Switzerland had 145 deceased donors (17.2 per million population) and 137 living donors (16.3 per million population). In 2017, 360 kidney, 143 liver, 40 heart, 32 lung, 19 pancreas, and 17 multiorgan transplantations have been performed. Switzerland imported 36 and exported 8 organs from/to other European countries. In addition, 262 allogeneic hematopoietic stem cell transplantations were performed in 2017. LIVING AND DECEASED DONATION RATES Living donors contribute with 30%–40% to the overall kidney transplant volume and around 5%–10% of the liver transplant volume. Living kidney donation is strongly supported by all transplant centers. Five of 6 transplant centers have a successful program for ABO-incompatible kidney transplantation. ACHIEVEMENTS Several important national advances have been established or are near completion: A registry for follow-up of all living donors since 1993 (SOL-DHR). A detailed and widely used research platform incorporating all transplantations (Swiss Transplant Cohort Study). Donation after circulatory death in Switzerland, pioneered by the Zürich group, is now performed in all centers.3 Since May 2012, the algorithm for deceased donor kidney allocation uses a calculated panel-reactive antibodies and virtual crossmatch approach, which reduces transplantation across donor-specific HLA antibodies and cold ischemia time (currently around 10 h). A nationwide kidney-paired donation program will soon be operational. Many efforts on different levels have been made to increase donation rates (eg, public awareness programs, improved potential donor detection). Overall, a 42% increase of the donor conversion index has been observed (from 1.9% in 2010 to 2.7% in 2017) (Figure 3).4 The median waiting time for a deceased donor kidney is approximately 3 years.FIGURE 3.: Evolution of the donor conversion index (DCI) from 2010 to 2017. 2010–2015 DCI data4; 2016–2017 DCI values were calculated based on 2015 mortality data. An increase of 1% DCI equals 1 additional actual deceased donor/100 deaths/selected causes of death.4 The DCI increased from 1.9% in 2010 to 2.7% in 2017 (+42%).CHALLENGES We identified 4 key challenges: a successful accomplishment will require a joined effort of all transplant professionals and institutions. First, according to a recent national evaluation, only about half of the potential deceased donors become actual donors. The main reason is a lack of documentation to donate. A national organ donor registry has been implemented on October 1, 2018 to fill this void.5 Furthermore, a national public poll will very likely be performed in the next years asking the question, whether Switzerland should change from an “opting-in”to a presumed consent system. Second, highly sensitized patients with calculated panel-reactive antibody >99%—especially patients with blood groups B and AB—start to accumulate on the waiting list. Besides a kidney-paired donation program, international collaborations providing much larger donor pools are expected to improve transplant options for those patients. Third, organ allocation becomes more challenging as age and comorbidities of recipients and deceased donors are increasing. Ideally, the functional capacity of the donor organ should last for the live expectancy of the recipients, a challenging charge under the current conditions.6,7 In addition, organs from older donors are much less resistant to unspecific injuries linked to ischemia or brain death than organs from younger donors. There is hope that ex vivo organ perfusion can help to preserve, assess, and potentially improve organ function.8 Four, a legal framework and information technology interfaces need to be implemented to enable a smooth data transfer between local and national databases/information systems.