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Excerpt
This issue of Transplantation presents the results of a European survey that inquired into center variation in the selection of recipients for renal transplantation.
Geographically the survey was comprehensive in that information was sought from all transplant centers in the Western European countries with active cadaver programs together with those in two countries from Eastern Europe. The questionnaire used was also comprehensive in its breadth in that it included 45 diagnostic procedures and 45 medical conditions that might be considered contraindications to transplantation. It also attempted to characterize the responding centers by seeking information on such points as waiting list size and transplant activity. It did not, however, try to evaluate the process of selection, which was disappointing because it is important to know how the assessment of the patient is organized.
This survey is valuable in that it is the first that has looked in a comprehensive fashion at selection policy for renal transplantation in Europe. It, therefore, complements the study of Ramos et al. (1), which examined U.S. practice. However, one has to be cautious in comparing the two studies because the U.S. survey was reported 6 years ago, and continuing evolution of selection criteria is likely to be taking place. Nonetheless, it is of interest to see whether there are obvious differences between U.S. and European practice. The short answer is that as far as one can tell from studying the two articles there are no major policy differences in either the investigations undertaken or the contraindications to transplantation. As one would expect, both surveys show that close to 100% of centers regard such conditions as HIV infection and advanced cardiac or vascular disease as contraindications. By contrast, viral infections, such as hepatitis B and C, would exclude patients in <10% of European centers whereas the figure for hepatitis B in the U.S. survey was slightly higher at 22%, but that may be a consequence of the time difference between the two surveys. One clear difference that comes out of the comparison between the two surveys is the method of decision making regarding acceptance to the waiting list. In the U.S., the decision was made by a committee in 86% of centers. In Europe the decision was shared by nephrologists and surgeons in 55% of cases, the implication being that in the remainder, that is, almost half of centers, nephrologists or surgeons made the decision without consultation with other colleagues. If this interpretation is correct, it indicates too narrow an approach in Europe to this important decision.
As well as allowing us to make the above comparisons between U.S. and European selection policy, the article by Fritsche et al. also enables us to compare selection procedures and policy in different parts of Europe. This reveals an interesting point with respect to those diagnostic procedures for which there is no consensus throughout Europe. The survey shows that in the U.K. and Scandinavia, these assessment procedures for which there is no consensus are used much less frequently than in the other countries in Western Europe and those in the South of Europe. I suggest that there may not be need for these particular procedures as a routine in all patients. They included such things as ophthalmology and ear-nose-throat consultations, prostate specific antigen assay, and voiding cystourethrography. All of these, of course, have an important role in specific circumstances. Fritsche et al.
