(Vol.6 No.4 --- June 2001)

Organ Transplantation in Hong Kong

Transplantation programs for the kidney, liver, heart, and lung have been established in Hong Kong since 1969, 1991, 1992, and 1995 respectively. At present there are 4 centres for kidney transplantation, 2 centres for liver transplantation, and 1 centre for heart, lung, or heart-lung transplantation. Transplant operations performed locally in the year 2000 included 60 kidneys, 54 livers, 6 hearts, 166 corneas, 45 skin recipients, and 6 bone recipients.

Advances in immunosuppressive therapy, the management of complications, and the overall delivery of healthcare, have resulted in significant improvements in the outcome after solid organ transplantation. The local 1-year graft and patient survival rates for cadaveric kidney transplantation approach 90% and 95% respectively. The respective survival rates for liver transplantation are around 80-85%. These figures compare favourably with major overseas transplant centres. While there has been considerable success in the prevention and treatment of acute rejection, much clinical research is still ongoing to define optimal therapeutic strategies for the long-term preservation of graft function. The latter may entail selective combinations from the increasingly diverse immunosuppressive armament and better definition of individualized indications. Concomitant with prolonged patient survival, the prevention of chronic complications such as cardio-vascular diseases, diabetes mellitus, and hyperlipidaemia has assumed pivotal importance in optimizing long-term outcome.

Yet organ transplantation is hardly a purely clinical issue. The problem of organ shortage has been escalating. Only 5% of more than 1100 patients on the kidney transplantation waiting list were transplanted locally last year. The justifications and criteria for the prioritization of organ allocation have been under thorough review on a regular basis. The relative importance of histocompatibility, age, and waiting time remains controversial, and needs to take into account local circumstances. Public education and continuous efforts in upkeeping public awareness are essential in sustaining cadaveric organ transplantation programs. We have active living-donor programs for kidney and liver transplantation, and these accounted for 32% and 67% of total transplants in the past year respectively. Other attempts to partially alleviate the problem of organ shortage include the use of marginal cadaveric kidneys or kidneys from "elderly" subjects, and split liver transplantation. Territory-wide sharing of cadaveric kidneys with the aid of computerized registry data is in place, and sharing of split liver grafts across countries has been accomplished successfully. In recent years there has been an increase in transplantation involving living unrelated donors. Legal and administrative procedures are necessary to guard against coercion and organ trading, while taking into consideration the dire clinical circumstances. The Human Organ Transplant Board has been timely established for these purposes. Organ transplantation exemplifies the importance of coordination between different specialties and personnels. In this regard, the Transplant Coordinating Service is instrumental to ensure seamless comprehensive patient care.

The increasing costs of clinical and pharmaceutical innovations have imposed great stress on health financing. In view of the limited budget and the increasing patient number, clinicians in public institutes have found it difficult to implement new effective but expensive immunosuppressive medications for organ transplantation, irrespective of the growing expectations of the public. These factors have contributed to misunderstanding and conflict both between patients and front-line clinical personnel, as well as between clinical staff and the administration. Long-term resolution of these problems entails major restructuring of the health financing system at a macroscopic level, which is indisputably not an easy task. It calls for not only the government but also a responsible community to face up to these challenges.

Prof. T. M. Chan