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Surgeons perform Germany's first crossover kidney transplantation

BMJ 2005; 331 doi: (Published 06 October 2005) Cite this as: BMJ 2005;331:798
  1. Tuffs Annette
  1. Heidelberg

    German surgeons have carried out the country's first crossover kidney transplantation at transplant centres in Hamburg and Essen, after a court ruling making the procedure legal in certain circumstances.

    Crossover transplants are used in some countries, such as Switzerland and Romania, when a healthy partner in a couple is unable to donate his or her kidney to the spouse, either because of blood group incompatibility or the potential recipient's sensitisation to certain antibodies. In a crossover transplantation a healthy person in one couple donates his or her kidney to the ill person in another couple, in exchange for a kidney from the recipient's healthy spouse.

    In the past crossover transplantation was not done in Germany because it was considered illegal under the German transplantation law of 1997. To prevent trade in human organs the law in Germany allows transplantation only between close relatives or between people who have a close relationship, such as a longstanding friendship. Every arrangement in which one person offers a kidney to another has to be scrutinised by an independent committee to ensure that no economic incentives are offered.

    However, in 2003 the Federal Social Court issued a ruling that laid the way for the recent introduction of crossover transplantation. The ruling related to an earlier incident in 1999, when a couple from Germany and a transplant surgeon from Freiburg, Germany, went to a transplantation centre in Basel, Switzerland, to perform a kidney exchange with a Swiss couple. Switzerland has no legal obstacles to crossover transplantation and a tradition of performing such operations.

    The 1999 transplantation was carried out successfully, but the health insurance company refused to reimburse the cost of the operation for the German couple, on the grounds that crossover transplantation was illegal under German law.

    The German couple took the case to court, and after several defeats in the lower courts the Federal Social Court ruled in their favour. It took the view that the couple had developed a close relationship by the time of the transplantation, which meant that the kidney exchange was legal. The insurance company therefore had to pay the cost of the operation.

    After that ruling the relationship between the two couples in Hamburg and Essen was reviewed by internal and independent experts and was considered sufficiently close. “Trusting relationships between the couples have to be established,” said Professor Uwe Koch-Gromus, director of medical psychology at Hamburg University Hospital.

    A shortage of donor kidneys in Germany has put pressure on doctors and patients to find alternatives to organs from cadavers. Currently about 10 000 patients are awaiting a kidney, but only 2000 patients a year receive a kidney from cadavers. Consequently, living donation has increased to about 20% of the total a year (almost 500 transplantations). In addition, because of the problem of incompatible blood groups between living donor and recipient, some transplantation centres also offer plasmapheresis, which can eliminate antibodies efficiently but produces extra costs.

    Both transplantation centres in Hamburg and Essen are planning to increase their crossover transplantation programmes, following the example of some other European countries which allow the practice, such as Switzerland, Romania, and Holland. Switzerland's first crossover transplantation was in 1991, and more recently Romania has adopted the practice.

    The Netherlands has had a very active programme since 2004 but has slightly different arrangements to those in Germany. All kidneys are offered and taken from a pool. Recipients and donors can stay anonymous, which is generally preferred by the participants. It is organised by the Dutch Kidney Foundation, and all seven Dutch transplantation centres take part under the leadership of the centre in Rotterdam. So far more than 30 couples have successfully participated.

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