Allocation of Organs Should be Based on the Current Status of Medical Science.

We refer to the recent article in your journal “Transplantation in Germany” by Nashan et al.[1] We would like to respond to the section dealing with audit results of the German Assessment Committee (of the German Medical Association), especially that concerning our Department of Cardiac Surgery at Munich University. It was alleged that manipulation of patient's files and treatment irregularities occurred to make our patients appear sicker and thus ultimately eligible for high urgency (HU) status (equivalent to United Network for Organ Sharing 1A), and that the case was passed to the public prosecutors.

After careful evaluation, the state attorney recently resolved the accusations of a possible 17 homicides, judging that our 17 patients were rightfully on the HU list, and their inclusion did not therefore unfairly impair the chances of patients at other hospitals.

The state attorney also commented that in her view, and this accords with expert opinion, the guidelines for HU listing do not reflect current scientific knowledge. This problem is not unique to Germany, as the recent article of the North American heart transplant surgeon J. G. Rogers demonstrates.[2] The guidelines do not, for example, include recalcitrant tachycardia nor concomitant signs of right ventricle (RV) failure as defined by decreased RV ejection fraction; significant tricuspid incompetence; or additional severe liver and renal failure. All our patients needed continuous intensive care treatment. However continuous inotropic support, 1 of 4 prerequisites for HU listing in Germany, was deemed inappropriate and potentially dangerous due to side effects such as tachycardia, increase of pulmonary vascular resistance, and reduction of regional blood flow within organs; consequently, mortality would have been expected to rise.[3] We therefore provided such treatment only as required on an intermittent basis.[4,5] It may thus be important to review the HU listing criteria in Germany and elsewhere to address modern clinical best practice.

Finally, Figure 3 of the article requires further explanation. As shown, the steady decline of the number of deceased donors commenced in 2010 and lasted until it reached a new low baseline by the end of 2013. However, public accusations of misconduct only began in 2012, by which time, the donation rate was already markedly reduced. The “German transplant scandal” cannot therefore be the sole cause of the observed decline, there must be other causes, as mentioned in the article.

Yours sincerely,

Prof. Dr. B. Reichart Prof. Dr. K.W. Jauch Prof. Dr. U. Schroth