tpm: the spanish modeltpm: the spanish model martí manyalich, md, phd, assoc. prof. ... del mar,...
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TPM: The Spanish Model
Martí Manyalich, MD, PhD, Assoc. Prof.
Hospital Clínic – University of Barcelona - Spain
Del Mar, California 21st May 2012
The New Vital Cycle
Society
Follow-up Social Attitude
Procurement Sharing
Donation
Retrieval
Transplantation
Global Activity in Organ Transplantation 2010 Estimates
Deceased Donors pmp versus Human Development Index 2010
32
30
,4
28
,66
25
,9
25
,6
25
,2
23
,4
21
,6
20
,9
20
,5
19
,6
17
,1
15
,9
15
,8
15
,7
15
,1
14
,8
14
,5
14
,54
13
,8
13
,7
13
,3
13
12
,92
12
,6
12
,6
12
,5
10
,9
9,9
9,7
9,6
9,4
9,4
6,7
6,0
5,1
4,1
4,0
3,9
3,5
3,5
3,4
3,2
3,1
8
2,8
5
2,5
2,4
2,0
1,9
1,4
0,9
0,7
0,5
0,0
0
0
5
10
15
20
25
30
35
Sp
ain
Po
rtu
ga
l
Cro
ati
a
Pu
ert
o R
ico
US
A
Be
lgiu
mA
ust
ria
Ita
ly
No
rwa
yS
love
nia
Cze
ch R
ep
Fin
lan
d
Ge
rma
ny
Hu
ng
ary
Est
on
ia UK
Latv
ia
Uru
gu
ay
Arg
en
tin
aA
ust
rali
a
* C
an
ad
aP
ola
nd
Ne
the
rla
nd
s
De
nm
ark
Sw
ed
en
Sw
itze
rla
nd
Co
lom
bia
Lith
ua
nia
* C
ub
aIr
ela
nd
Bra
zil
Ice
lan
d
Ne
w Z
ea
lan
d
Ho
ng
Ko
ng
Luxe
mb
ou
rg
Sin
ga
po
reIr
an
Gre
ece
Sa
ud
i A
rab
iaT
urk
ey
Ve
ne
zue
laR
uss
ia
* P
eru
Ro
ma
nia
Bu
lga
ria
Ecu
ad
or
**
Qa
tar
Me
xico
Pa
rag
ua
y*
Bo
livi
a
Jap
an
Ma
lays
ia
* L
eb
an
on
Tri
nid
ad
To
bN
ica
rag
ua
2010
Organ Deceased Donors 2010 pmp DBD + DCD
IRODaT International Registry of
Organ Donation
and Transplantation
Organ Deceased Donors . Numbers in pmp (per million of population) *New reports: Bolivia, Canada, Cuba, Perú and Lebanon.
www.tpm.org
51
,8
50
,5
41
,7
41
,7
40
,0
37
,3
36
,7
33
,0
30
,5
30
,4
29
,9
27
,8
27
,6
27
,4
26
,9
26
,5
26
,1
25
,5
25
,1
24
,6
23
,7
23
,6
23
,2
22
,9
21
,5
19
,2
19
,1
15
,7
12
,1
12
,0
10
,4
9,9
8,4
8,0
7,6
6,2
6,2
6,2
6,0
5,9
5,2
4,8
4,4
3,7
3,6
3,6
3,1
2,4
1,6
1,3
0,9
0,2
0,0
10,0
20,0
30,0
40,0
50,0
60,0
70,0
Cro
ati
a
Po
rtu
ga
l S
pa
in
Au
stri
a
Fra
nce
US
AN
orw
ay
Cze
ch R
ep
Slo
ven
iaF
inla
nd
Ge
rma
ny
Latv
ia
Hu
ng
ary U
K
Est
on
ia
Uru
gu
ay
Ita
lyP
ola
nd
Sw
itze
rla
nd
Au
stra
lia
Ne
the
rla
nd
s
Ca
na
da
De
nm
ark
Arg
en
tin
aS
we
de
n
Co
lom
bia
Lith
ua
nia
Bra
zil
Ne
w Z
ea
lan
d
Luxe
mb
ou
rg
Ho
ng
Ko
ng
Cu
ba
Pu
ert
o R
ico
Sin
ga
po
re
Ira
nR
uss
ia
Sa
ud
i A
rab
ia
Ve
ne
zue
la
Gre
ece
Ro
ma
nia
Tu
rke
y
Bu
lga
ria
Me
xico
Bo
livi
a
Be
lgiu
m
Qa
tar
Nic
ara
gu
a
Ecu
ad
or
Jap
an
Ma
lays
iaLe
ba
no
n
Pa
rag
ua
y
Kidney Transplantation Including single, double and combined transplants. Numbers in pmp (per million of population).
Kidney Transplantation 2010 pmp
www.tpm.org
IRODaT International Registry of
Organ Donation
and Transplantation
Liver Transplantation . Including combined transplants. Numbers in pmp (per million of population).
Liver Transplantation 2010 pmp
www.tpm.org
20
,7
20
,1
19
,8
19
,3
18
,2
17
,2
16
,4
16
,0
14
,9
13
,2
13
,1
13
,0
11
,5
11
,0
9,7
9,3
9,1
8,4
8,3
7,9
7,8
7,1
6,7
6,2
5,7
4,8
4,5
3,9
3,5
3,3
3,0
2,8
2,4
2,4
2,3
2,2
2,0
1,7
0,9
0,7
0,5
0,2
0,2
0,1
23
,9
0,0
5,0
10,0
15,0
20,0
25,0
30,0
Cro
ati
a
Sp
ain
US
AP
ort
ug
al
Be
lgiu
mN
orw
ay
Ita
ly
Au
stri
aF
ran
ce
Ge
rma
ny
Ca
na
da
Sw
itze
rla
nd
Sw
ed
en
Slo
ve
nia UK
Cze
ch R
ep
Fin
lan
d
Au
stra
liaD
en
ma
rkIr
ela
nd
Ne
wN
eth
erl
an
ds
Arg
en
tin
aB
razi
lH
on
g K
on
g
Po
lan
dC
olo
mb
iaH
un
ga
ry
Lith
ua
nia
Uru
gu
ay
Ira
nS
ing
ap
ore
Tu
rke
y
Ro
ma
nia
Sa
ud
i Ara
bia
Est
on
ia
Gre
ece
Cu
ba
Bu
lga
ria
Ru
ssia
Me
xic
o
Leb
an
on
Jap
an
Ma
lay
sia
Ecu
ad
or
IRODaT International Registry of
Organ Donation
and Transplantation
Pancreas Transplantation 2010 (pmp)
Pancreas Transplantation from Deceased Donors, including combined transplants. Number in pmp (per million of
population)
www.tpm.org
3,7
3,7
3,2
3,1
2,8
2,1
2,0
1
2,0
2,0
1,9
1,8
1,5
4
1,5
1,5
1,4
1,3
5
1,2
1,2
0,8
0,7
0,5
0,5
0,4
0,2
0,2
0,2
0,1
8
0,1
0,1
0,0
0,5
1,0
1,5
2,0
2,5
3,0
3,5
4,0
4,5
5,0
USA
Austria UK
Norway
Sweden
Canad
a
Belgium
Germany
Spain
Czech
Rep
Switz
erland
Argentin
a
France
Australia
Portugal
Croat
ia
Uruguay
Netherla
ndsIta
ly
Brazil
Slove
nia
Poland
Turkey
Finla
nd
New Zeala
nd
Colom
biaIra
n
Russia
Saudi A
rabia
IRODaT International Registry of
Organ Donation
and Transplantation
Thoracic Transplantation 2010 pmp Lung + Heart
Thoracic Transplantation: Heart and Lung (including Heart-Lung). Numbers in pmp (per million of population)
www.tpm.org
IRODaT International Registry of
Organ Donation
and Transplantation
32
16.4
23.8
21.6
30.4
13.3
6.5
12.6
9.7
15.7
12.9
20.8
12.6
17.1
25.2
13
14.5
15.8
14.7
3.18
17.4
ORGAN DONORS p.m.p. 2010
6.4
6.2
3.5
18.7
2.85
10.9
30 DONORS PMP
20 DONORS PMP 10 DONORS PMP
<10 DONORS PMP
0
0.0 20.5
35.3 (2011)
23.4
20
IRODaT
Donor Procurement
55 47 52 36 60 59 4979 75 71 77 78 73 87 78 92
58 52 61 536 2
24 8 20
22 36 32
86
177 211229
279 228264
304 297366
0
50
100
150
200
250
300
350
400
450
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Organs Tissues
55
4752 36 60
59
4979
75 71
77
7873 87
7892
5852 61
53
2 2 48 362220
632 86 177 211 229 279 228 264 304 297
366
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Organs Tissues
Donor Procurement
Tissue Procurement
269 282 315 300 306356 339
403
118 122104 150 133
155133
11645
74 4554 74
5890
89
79
105 100134 110
138 145151
24
91
140
15
35
1
3
72
1
3
271
10 142
1
11
6
10
0
100
200
300
400
500
600
700
800
900
1000
2002 2003 2004 2005 2006 2007 2008 2009
T.Ocular Cor HV Vascular Hueso Piel Condrocitos M.Amniótica
539 597 595 655 649 744 809 908
Corporate Social Responsability
Hospital Vision
Health
Profesionals
Mision
Hospital
Vision
Prevention
Treatment
Education
Deceased Donation
Death referals for
Organ & Tissues
Donation
Evolution of Donors in Spain
550
687
778832
869
9601037 1032
1155
1250
1334 1345 1335
15461509
1550 1577 1605
1502
1667
144814101494
32
35,3
14,3
17,8
20,2
21,722,6
25
27 26,829
31,5
33,6 33,932,5
33,7 33,9 34,635,1
33,8 34 34,234,3
0
200
400
600
800
1000
1200
1400
1600
1800
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
0
5
10
15
20
25
30
35
40
Number Rate pmp
Organ Donors pmp 2011-CCAA-SPAIN
Characteristics of Spain (2009)
17 Autonomous Communities
Population of 46.74 million inhabitants
505,957 km2
167 hospitals authorised for donation
45 hospitals authorised for transplantation
Refusals to donate in family interviews
27.6% 16.9%
N
16,515,2
16,817,8
16,418
15
17,8
2020
23,421,8 2221,321,7
24,823,625
27,6
24,8
0
5
10
15
20
25
30
92 93 94 95 96 97 98 99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11
Family organ donor refusal in Spain (%)
Donor Pool
Non heart beating donors
Living donors
Encephalic death optimization
Organs for transplantation different sources
Expanded criteria donors
Living Donation: TPM Procedure
Medical evaluation, ethical and legal
Biological Risk
Altruistic Donation
Social and Economic Evaluation
Informed Consent
Civil Registry
Living Donation – Civil Registry
BRAIN DEATH
Cerebral Gammagraphy
Brain Death
DCD Procedures Classification & Consideration
I
Pre-Hosp.
Perfusion
Family
Consent
II
Emergency
Perfusion
Family
consent
III
ICU
Family consent
Perfusion
IV
ICU
Family consent
DCD-NHBD Procedure
Catheter of a unique balon
Vein Catheter
Arterial Catheter
1.Prolonged CPR 2. Canulation 3. Thoracic Fogarty
4.Arterial & Vein Catheter 5.NTR
Normothermic Recirculation
Am.J.Transpl. 2005; 5:2385-2392
Transplantation 2000; 70:730-737
31
Spain. Age groups
Spain: mean age of deceased donor
Spain: deceased donor’s cause of death
Principles of the Spanish Model of organ donation
Legal framework
Qualified professionals/
technical proficiency
Mass media attention
Audits on brain deaths
ONT network
Hospital expenses
reimbursement
Training & continuing education
In-house Transplant
Procurement
Managers
All the ingredients together
Principles of the Spanish Model of organ donation
Legal framework
Qualified professionals/
technical proficiency
Mass media awareness
Audits on brain deaths
ONT network
Hospital expenses
reimbursement
Training & continuing education
In-house Transplant
Procurement
Managers
Legal Framework
• Solidarity/ Non profit / Anonymity
• Death Certification
• Presumed consent, but in practice, informed or opting-in model
• Criteria for living and deceased donation
• Criteria for organ procurement and transplant centers accreditation
• Traceability
• Organization of the Coordination system
• Publicity
LEY 27-10-1979, Nº 30/1979
SOBRE EXTRACCIÓN Y TRASPLANTE DE ÓRGANOS
Principles of the Spanish Model of organ donation
Legal framework
Qualified professionals/
technical proficiency
Mass media awareness
Audits on brain deaths
ONT network
Hospital expenses
reimbursement
Training & continuing education
In-house Transplant
Procurement
Managers
NATIONAL
R
R R
R
REGIONAL
H
H
H
H
HOSPITAL
Transplant coordination network
LIVING BRAIN-DEATH CARDIAC-DEATH EXITUS
D.C.D
TISSUES
ORGANS AND TISSUES
KIDNEY
+
LIVER
+
TISSUES
TRANSPLANTATION RESEARCH EDUCATION
Clinical activities
OCATT Organització Catalana de Trasplantaments
ABROAD
H
CITY
A.R.
ZONE
H2
H1
H3
H5
H2
H4
H1
H5
H4
H6
H2
STATE
H2
H3
H4
H6
H8
Criteria for organ distribution
Geographic: Procurement center
Clinical: Emergency 0 & pediatrics
Principles of the Spanish Model of organ donation
Legal framework
Qualified professionals/
technical proficiency
Mass media awareness
Audits on brain deaths
ONT network
Hospital expenses
reimbursement
Training & continuing education
In-house Transplant
Procurement
Managers
3-5% Hospital dead
1 Donor / ICU Bed
Tissue Donors – 20% Hospital dead
Donors Potentiality
HOSPITAL DONOR DETECTION
Treure bos 4 ucies afegir passadis clinic
Hospital Donor Detection
Hospital Development
Principles of the Spanish Model of organ donation
Legal framework
Qualified professionals/
technical proficiency
Mass media awareness
Audits on brain deaths
ONT network
Hospital expenses
reimbursement
Training & continuing education
In-house Transplant
Procurement Managers
TPM location
Hospital
HOSPITAL
Tx.
Teams
HOSPITAL
TPM Tx.
Teams
HOSPITAL
OPO
Tx.
Teams
PAST USA SPAIN
PAST
Good to began
Problems to grow
Hospital
PAST
HOSPITAL
Tx.
Teams
TPM
CADAVER DONOR RECIPIENT
Transplant Procurement Management
TPM Professional Profile
• Professionally trained • Recognized • Supported • Paid
Suggestions
Background
• Male or Female • 30 years old • Physician • Senior Nurse • Full/part time dedication • ICU +/- Anesthesiology • Dependency: medical director • Main objective: organ and tissue donation
Skills
• Experience in critical care • Independent thinker • Mature professional • Empathy • Enthusiasm toward donation • Flexibility • Tenacity • High motivation
Specialization Degree
Academic Situation
0
10
20
30
40
50
60
Nurse Doctor
12,1 % 87,9 %
Anaesthesiology and Reanimation
Intensive Medicine
General and Digestive Surgery
Nefrology
Non specialization
9,1 % 1,5 %
69,7 %
6,1% 13,6%
Professional Situation
0
10
20
30
40
50
Full time Part time NA
Dedication
0
5
10
15
20
25
30
35
0 - 5
6 -
10
11 - 1
5
16 -
20>
20 NA
Experience (years)
50 %
21,2 %
27,3 % 69,7 % 3 %
13,6 %
7,6 % 4,5 % 3 %
118 < 20 56 179
1988 1990 1992 2011
Number of TPM TEAMS in Spain
Principles of the Spanish Model of organ donation
Legal framework
Qualified professionals/
technical proficiency
Mass media awareness
Audits on brain deaths
ONT network
Hospital expenses
reimbursement
Training & continuing education
In-house Transplant
Procurement
Managers
DONATION PROCESS: RESULTS
Internal evaluation (1999-2009)
Medical Contraindications : 5.846 (25%)
No Legal Diagnosis : 34 (0,1%)
Coroner Refusals in judicial cases : 61 (0,3%)
Management problems : 650 (2,8%)
Family Refusals : 3.123 (13,4%)
Lack of adequate Receptor : 167 (0,7%)
Non Referred ED : 699 (3%)
Logistic Problems : 123 (0,5%)
UCI DEATHS: 185.350
ENCEPHALIC DEATHS (E.D.): 23.354 (12,3%)
ACTUAL DONORS : 12.641 (54,17% of E.D.)
2,6% inappropriate
0,3% avoidables
0,2% avoidables
0,8% avoidables
Principles of the Spanish Model of organ donation
Legal framework
Qualified professionals/
technical proficiency
Mass media awareness
Audits on brain deaths
ONT network
Hospital expenses
reimbursement
Training & continuing education
In-house Transplant
Procurement
Managers
Medical
Services Surgical
Services
Central Services
Laboratory
Maternity Ward
Extra
Activities
Rx
Scans
Critical Care
Donation, among others, is a medical activity in the hospital
Hospital Reimbursement
Economic Evaluation
Cost 2005: Hospital Clínic
Donor B.D. between 7.000 € (K & P)
and 9.000 € (L & H)
Donor NHBD Preservation, extraction
and renal perfusion: 14.000 €
Principles of the Spanish Model of organ donation
Legal framework
Qualified professionals/
technical proficiency
Mass media awareness
Audits on brain deaths
ONT network
Hospital expenses
reimbursement
Training & continuing education
In-house Transplant
Procurement
Managers
The transplant community has the
responsability to accurately inform the
public about the medical, legal and ethical
issues of donation
Effective use of the mass media
can help provide the education
needed by society to increase
donation
Principles of the Spanish Model of organ donation
Legal framework
Qualified professionals/
technical proficiency
Mass media awareness
Audits on brain deaths
ONT network
Hospital expenses
reimbursement
Training & continuing education
In-house Transplant
Procurement
Managers
TPM is an international training program offering comprehensive interdisciplinary skill based learning,
continuing education and consulting services for donation professionals
Transplant Procurement Management
Training & continuing education
DO ACTION
SHOW HOW SIMULATION
KNOW HOW COMPETENCE
KNOW KNOWLEDGE
TPM Pyramid Training Methodology
1st TPM Course 1991
1991 - 2012
TPM participants: 12434 from 100 countries (1991-2011)
Canada USA
Egypt
La Reunion
Morocco
South Africa
Tunisia
Costa Rica Honduras
Cuba Mexico
Dominican Rep. Panama
El Salvador Puerto Rico
Guatemala Nicaragua
Argentina Paraguay
Bolivia Peru
Brazil Trinidad & Tobago
Chile Uruguay
Colombia Venezuela
Ecuador
Albania Denmark Latvia Slovak Rep.
Andorra Estonia Lithuania Slovenia
Austria Finland Malta Spain
Belarus France Moldova Sweden
Belgium FYROM Netherlands Switzerland
Bosnia Germany Norway UK
Bulgaria Greece Poland Ukraine
Croatia Hungary Portugal
Czech Rep. Ireland Romania
Cyprus Italy Russia
Bahrain Oman
Iran Qatar
Israel Saudi Arabia
Jordan Syria
Kuwait Turkey
Lebanon UAE
Bangladesh
Brunei
China
India
Japan
Malaysia
Pakistan
Philippines
Singapore
South Korea
Sri Lanka
Taiwan
Thailand
Vietnam
Australia
New Caledonia
New Zealand
Tahiti FACE-TO-FACE LEARNING MODALITY
E-LEARNING MODALITY
7321
947
1357 160
75 99
5118 625
702 18
69 45
4166
2500
1666
ETPOD (EOD SEMINARS – TRAINING x TRAINERS)
TPM Effect Over Donation 2010
8589 89 86,5
95,49290,5 90
92,590,6 909489 90,589,591,7
0
20
40
60
80
100
Kidney Liver Heart Pancreas
2001-2002 2002-2003 2003-2004 2004-2005
89
89
89 82,4
80,4
82,2
85,3
86,3
85,7
86,2
86,8 85,8
Results efficiency: survival / year
UNOS – OPTN / Annual Report
Donors & Transplants per area (pmp) 2011 Donors Transplant
Iran* 3.3 9.9
Greece* 4 12
Hong Kong* 6.7 20.1
Qatar 7 21
Germany 14.7 44.1
Australia 14.9 44.7
Italy 21.6 63.9
USA 23.9 71.7
Portugal 28.5 85.5
Croatia 33.5 100.5
Spain 35.3 105.9
*2010 Data
Kidney waiting list and transplants Eurotransplant 1969 - 2010
0
2000
4000
6000
8000
10000
12000
14000
196
9197
1197
3197
5197
7197
9198
1198
3198
5198
7198
9199
1199
3199
5199
7199
8199
9200
0200
1200
2200
3200
4200
5200
6200
7200
8200
9201
0
Living donor trpl. Kidney waiting list Deceased donor trpl.
10768
3705
1262
160616911793
82 98 138
126212641136
944103210971071113211691112
136414361625
1061331291241166725 22 41 38
121 116 101
0
500
1000
1500
2000
2500
3000
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Liver waiting list Deceased donor transplants Living donor transplants
Liver waiting list and transplants Eurotransplant 1995 - 2010
2695
Demanarli a Hawart Nattan x filadelfia
Source: Registre de Malalts Renals de Catalunya, Organització Catalana de Trasplantaments
Number of Patients Percentage
In waiting list
Excluded for age
Pending of studies
Excluded per clinical reasons
Voluntarily excluded
Transplant
Evolution of liver waiting list 1990-2010: Patients aged 15 years or over
Source: Donation and transplantatio activity 2010 in Catalonia. OCATT
Waiting list Transplants
Waiting list in Spain
Dr. JV Torregrosa. Hospital Clinic. Barcelona
Evolution of the waiting list:
Conclusions
Procurement Model
Hospital Vision
Health Professionals Mission
Professionalized TPM
DBD, DCD and LD
Organs and Tissues
Quality, Research and Education
Spanish background
It’s a matter of
Knowledge
& Passion
Experience
T
H
A
N
K
Y
O
U
!
Qualified professionals & technical proficiency
Up to date more than 65.000 Transplants done in Spain
Conclusions Spanish donation model
• Central office supporting the entire process
• Favourable health system for universal coverage
• Legal framework
• In-house transplant Procurement Managers and paid job
• Procurement hospitals and reimbursed expenses
• Mass media awareness
• Quality and safety control systems
• Training and education for especialist and health professionals
• Development of: DCD and living programs
FIFA Club World Cup Football
December 18th, 2011
SEUSA
REFERAL +
CONVERSION rate
+
STRUCTURE
SEUSA
Hospital +
Region +
Country
Conclusions Spanish donation model
• central office supporting the entire process
• Favourable health system for universal coverage
• Legal framework
• In-house transplant coordinators and paid job
• Procurement hospitals and reimbursed expenses
• Mass media awareness
• Quality and safety control systems
• Training and education for especialist and health professionals
• Development of: DCD and living programs
Cadaveric Organ Donors (pmp) 2009 preliminary numbers
34,4
31
25,4 24,6 24
21,3 21,120 19,4 19,1 18,8
17,6 17,416,5
15,5 14,9 14,8 14,7 13,9 13,8 13,311,5 11,4 11,3 11
108,7
4,63,3 2,9
1,4 0,8 0,5
0
5
10
15
20
25
30
35
40
Spai
nPo
rtug
alAu
stri
aEs
toni
a
USA
Italy
Nor
way
Mal
taU
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ayCz
ech
Rep
Icel
and
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and
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Ger
man
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Swed
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ralia
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ew Z
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apor
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udi A
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pan
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aine
IRODaT
www.tpm.org Figure 1: Organ Deceased Donors: DBD + DCD, 2009. Numbers in pmp (per million of population)
Kidney Transplant (pmp) 2009 preliminary numbers
50
45,2
39,6 39 39
35,432,7 32,6
30,328,6 27,8 27,7 26,7 25,6 24,7 24,3 23,9
22,120,7 20,6
17,815
13,3 13
8,45,3 4,5
2,81,4 1,3 0,5
0
5
10
15
20
25
30
35
40
45
50
55
Cyp
rus
Spai
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sto
nia
Au
stri
aN
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rain
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IRODaT
www.tpm.org
Figure 3: Liver Transplantation 2009. Including combined transplants. Numbers in pmp (per million of population).
Liver Transplant (pmp) 2009 preliminary numbers
22,9
17 16,9 16,6 16,514,9 14,7
13,312,4 11,7
10,69,4 9
7,6 7,1 7,16,3 5,6 5,1
3,4 3 2,4 2,2 2,1 2,1
0,2 0,2 0,1 0,10
5
10
15
20
25
30
Sp
ain
No
rway
Au
stri
a
USA
Italy
Irela
nd
Sw
ed
en
Cro
ati
aG
erm
an
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itze
rlan
d
UK
Cze
ch
Re
pFin
lan
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ew
Ze
ala
nd
Au
stra
lia
De
nm
ark
Bra
zil
Po
lan
dC
olo
mb
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gap
ore
Est
on
iaU
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ay
Iran
Lith
uan
iaSau
di A
rab
iaM
ala
ysia
Ukr
ain
eJa
pan
Ecu
ad
or
IRODaT
Refusals to donate in family interviews
27.6% 16.9%
N
EUROS (€)
Multi-organ procurement 6.000
Renal procurement 4.500
Multi-organ + tissue procurement 7.500
1 hour of operating room: 1.500 €
Hospital reimbursement (estimated mean values)
The Spanish National Healthcare system
• Funded by taxes
• Decentralized to autonomic regions
• Universal coverage
• Free access
• Wide range of public services
• Co-payment in pharmaceutical products
• Services provided mainly in public facilities
