Organ Donation in Croatia: The Importance of a National Champion, a Comprehensive Plan, and International Collaborations

The Republic of Croatia is a global leader in organ donation and transplantation despite having fewer resources and more modest healthcare expenditures than other countries in the European Union. The results of an extensive literature review were combined with expert input in an iterative multi-step data collection and evaluation process designed to assess trends in Croatian organ donation and transplantation and identify key elements, policy changes, and drivers of the system that have contributed to its success. Multiple sources of evidence were used in this study, including primary documents, national and international transplantation reports, and insights from critical informants and content experts. The results highlight several key organizational reforms that have substantially improved the performance of the Croatian transplant program. Our findings emphasize the importance of strong central governance led by an empowered national clinical leader acting under the direct auspices of the Ministry of Health and a comprehensive and progressive national plan. The Croatian transplant system is notable for its integrated approach and efficient manner of managing scarce health resources. Collectively, the results suggest that Croatia has become nearly self-sufficient due to its systematic implementation of the guiding principles for organ donation and transplantation.

A Conceptual Framework for Evaluating National Organ Donation and Transplantation Programs

Conceptual frameworks are valuable resources that can be used to guide the planning, evaluation, and development of healthcare services. However, there are currently no comprehensive frameworks focused on organ donation and transplantation that identify the critical factors underlying a successful national program. To address this knowledge gap, we developed a conceptual framework that takes into account all major domains of influence, including political and societal aspects as well as clinical implementation. The framework was initially constructed based on a targeted review of the relevant medical literature. Feedback provided by a panel of international experts was incorporated into the framework via an iterative process. The final framework features 16 essential domains that are critical for initiating and maintaining a successful program and improving the health of patients with organ failure. Of particular note, these domains are subject to three overarching health system principles: responsiveness, efficiency, and equity. This framework represents a first attempt to develop a whole-system view of the various factors that contribute to the success of a national program. These findings provide a useful tool that can be adapted to any jurisdiction and used to plan, evaluate, and improve organ donation and transplantation programs.

Lessons From the Portuguese Solid Organ Donation and Transplantation System: Achieving Success Despite Challenging Conditions

Over the past two decades, Portugal has become one of the world leaders in organ donation and transplantation despite significant financial constraints. This study highlights how Portugal achieved success in organ donation and transplantation and discusses how this information might be used by other countries that are seeking to reform their national programs. To accomplish this goal, we performed a narrative review of relevant academic and grey literature and revised our results after consultation with two national experts. Our findings were then synthesized according to a conceptual framework for organ donation and transplantation programs. Our results revealed several key strategies used by the Portuguese organ donation and transplantation program, including collaboration with Spain and other European nations, a focus on tertiary prevention, and sustained financial commitment. This report also explores how cooperative efforts were facilitated by geographical, governmental, and cultural proximity to Spain, a world leader in organ donation and transplantation. In conclusion, our review of the Portuguese experience provides insight into the development of organ donation and transplantation systems. However, other countries seeking to reform their national transplant systems will need to adapt these policies and practices to align with their unique cultures and contexts.

Solid Organ Donation and Transplantation in the United Kingdom: Good Governance is Key to Success

The United Kingdom (UK) supports a highly successful organ donation and transplantation program. While the UK originally had one of the lowest organ donation rates in Europe, sustained reforms have resulted in steady improvement. Of note, the UK nearly doubled its rate of deceased donations between 2008 and 2018. In this report, we present a case study of the UK organ donation and transplantation program as an example of a complete system with sound and inclusive governing structures that are strongly integrated with critical programs focused on training and research. This study was based on an initial targeted review of the literature led by a UK expert that included guidelines, national reports, and academic papers. Feedback solicited from other European experts was incorporated into our findings via an iterative process. Overall, the study highlights the stepwise evolution of the UK program that ultimately became successful largely due to ongoing collaborative efforts carried out at all levels. Centralized coordination of all aspects of the program remains a key driver of improved rates of organ donation and transplantation. The designation and empowerment of expert clinical leadership have helped to maintain focus and promote ongoing quality improvement.

How to Structure a Successful Organ Donation and Transplantation System in Eight (Not So Easy) Steps: An Italian Case Study

Valuable information can be obtained from a systematic evaluation of a successful national transplant program. This paper provides an overview of Italy's solid organ transplantation program which is coordinated by the National Transplant Network (Rete Nazionale Trapianti) and The National Transplant Center (Centro Nazionale Trapianti). The analysis is based on a system-level conceptual framework and identifies components of the Italian system that have contributed to improving rates of organ donation and transplantation. A narrative literature review was conducted and the findings were validated iteratively with input from subject matter experts. The results were organized into eight critical steps, including 1) generating legal definitions of living and deceased donation, 2) taking steps to ensure that altruistic donation and transplantation become part of the national culture and a point of pride, 3) seeking out existing examples of successful programs, 4) creating a situation in which it is easy to become a donor, 5) learning from mistakes, 6) working to diminish risk factors that lead to the need for organ donation, 7) increasing the rate of donations and transplantations via innovative strategies and policies, and 8) planning for a system that supports growth.

The National Organ Donation and Transplantation Program in Greece: Gap Analysis and Recommendations for Change

Greece has fallen far behind many comparable European countries in the field of organ donation and transplantation and has made little progress over the past decade. Despite efforts to improve its organ donation and transplantation program, systemic problems persist. In 2019, the Onassis Foundation commissioned a report to be prepared by the London School of Economics and Political Science that focused on the state of the Greek organ donation and transplantation program and proposed recommendations for its improvement. In this paper, we present our analysis of the Greek organ donation and transplantation program together with an overview of our specific recommendations. The analysis of the Greek program was undertaken in an iterative manner using a conceptual framework of best practices developed specifically for this project. Our findings were further developed via an iterative process with information provided by key Greek stakeholders and comparisons with case studies that featured successful donation and transplantation programs in Croatia, Italy, Portugal, Spain, and the United Kingdom. Because of their overall complexity, we used a systems-level approach to generate comprehensive and far-reaching recommendations to address the difficulties currently experienced by the Greek organ donation and transplantation program.

Ten Lessons From the Spanish Model of Organ Donation and Transplantation

The organ donation and transplantation program in Spain has long been considered the gold standard worldwide. An in-depth understanding of the Spanish program may promote the development and reform of transplant programs in other countries. Here, we present a narrative literature review of the Spanish organ donation and transplantation program supplemented by expert feedback and presented according to a conceptual framework of best practices in the field. Core features of the Spanish program include its three-tiered governing structure, close and collaborative relationships with the media, dedicated professional roles, a comprehensive reimbursement strategy, and intensive tailored training programs for all personnel. Several more sophisticated measures have also been implemented, including those focused on advanced donation after circulatory death (DCD) and expanded criteria for organ donation. The overall program is driven by a culture of research, innovation, and continuous commitment and complemented by successful strategies in prevention of end-stage liver and renal disease. Countries seeking ways to reform their current transplant systems might adopt core features and may ultimately aspire to include the aforementioned sophisticated measures. Countries intent on reforming their transplant system should also introduce programs that support living donation, an area of the Spanish program with potential for further improvement.

Renal transplantation in gigantism: A case report

BACKGROUND

Gigantism, characterized by excessive growth and height is due to increased secretion of growth hormone, most commonly from a pituitary adenoma. In addition to the surgical and anesthetic complexity, the extreme stature of these patients presents a unique challenge for kidney transplantation in deciding whether to proceed with a single or dual kidney transplantation. The lack of relevant literature further adds to the dilemma.

CASE SUMMARY

A 45-year-old patient with untreated gigantism and end stage renal failure on renal replacement therapy was waitlisted for a deceased donor dual kidney transplantation due to the extreme physical stature (Height-247 cm and weight-200 kg). He was offered 2 kidneys from a 1-0-1 HLA mismatched 24-year-old DCD donor (Height-179 cm and weight-75 kg), and was planned for a bilateral retroperitoneal implantation into the recipient external iliac vessels. The immunosuppression consisted of alemtuzumab induction (50 mg) and steroid-free maintenance with tacrolimus. The donor’s right kidney was uneventfully implanted extra-peritoneally into the right external iliac vessels. On contralateral exposure, the left common and external iliac arteries were ectatic and frail. A complex vascular reconstruction was not preferred in order to preserve the arterial supply to the left lower limb, to minimise the cold ischemia time and prevent additional warm ischemic insult to the second kidney. Hence, it was decided not to proceed with dual transplantation. Amidst concerns of nephron mass insufficiency, the graft function was remarkable with a serum creatinine of 120 µmol/L within a month from transplantation and 94 µmol/L at 1-year post transplantation, and without proteinuria.

CONCLUSION

To our knowledge, this is the first case report on kidney transplantation in gigantism. Although it is believed that dual kidney transplantation is ideal, a single kidney transplantation from an appropriately selected donor can provide sufficient functioning nephron mass in patients with gigantism.

Impact of COVID-19 on Global Kidney Transplantation Service Delivery: Interim Report

This article gives a personal, historical, account of the impact of the COVID-19 pandemic on transplantation services. The content is based on discussions held at two webinars in November 2020, at which kidney transplantation experts from prestigious institutions in Europe and the United States reflected on how the pandemic affected working practices. The group discussed adaptations to clinical care (i.e., ceasing, maintaining and re-starting kidney transplantations, and cytomegalovirus infection management) across the early course of the pandemic. Discussants were re-contacted in October 2021 and asked to comment on how transplantation services had evolved, given the widespread access to COVID-19 testing and the roll-out of vaccination and booster programs. By October 2021, near-normal life and service delivery was resuming, despite substantial ongoing cases of COVID-19 infection. However, transplant recipients remained at heightened risk of COVID-19 infection despite vaccination, given their limited response to mRNA vaccines and booster dosing: further risk-reduction strategies required exploration. This article provides a contemporaneous account of these different phases of the pandemic from the transplant clinician’s perspective, and provides constructive suggestions for clinical practice and research.

The Impact of Cold Ischaemia Time on Outcomes of Living Donor Kidney Transplantation: A Systematic Review and Meta-Analysis

Studies have been carried out to investigate the effect of a prolonged cold ischaemia time (CIT) on the outcomes of living donor kidney transplantation (LDKT). There is no clear consensus in the literature about the effects of CIT on LDKT outcomes, and therefore, we performed a systematic review and meta-analysis to provide evidence on this subject. Searches were performed in five databases up to 12 July 2021. Articles comparing different CIT in LDKT describing delayed graft function (DGF), graft and patient survival, and acute rejection were considered for inclusion. This study is registered with PROSPERO, CRD42019131438. In total, 1452 articles were found, of which eight were finally eligible, including a total of 164,179 patients. Meta-analyses showed significantly lower incidence of DGF (odds ratio (OR) = 0.61, p < 0.01), and significantly higher 1-year graft survival (OR = 0.72, p < 0.001) and 5-year graft survival (OR = 0.88, p = 0.04), for CIT of less than 4 h. Our results underline the need to keep CIT as short as possible in LDKT (ideally < 4 h), as a shorter CIT in LDKT is associated with a statistically significant lower incidence of DGF and higher graft survival compared to a prolonged CIT. However, clinical impact seems limited, and therefore, in LDKT programmes in which the CIT might be prolonged, such as kidney exchange programmes, the benefits outweigh the risks. To minimize these risks, it is worth considering including CIT in kidney allocation algorithms and in general take precautions to protect high risk donor/recipient combinations.

The Impact of Recipient Demographics on Outcomes from Living Donor Kidneys: Systematic Review and Meta-Analysis

Background and Aims: Recipient demographics affect outcomes after kidney transplantation. The aim of this study was to assess, for kidneys retrieved from living donors, the effect of recipient sex, ethnicity, and body mass index (BMI) on delayed graft function (DGF) and one-year graft function, incidence of acute rejection (AR), and recipient and graft survivals. Methods: A systematic review and meta-analysis was performed. EMBASE and MEDLINE databases were searched using algorithms through Ovid. Web of Science collection, BIOSIS, CABI, Korean Journal database, Russian Science Citation Index, and SciELO were searched through Web of Science. Cochrane database was also searched. Risk of bias was assessed using the NHBLI tools. Data analysis was performed using Revman 5.4. Mean difference (MD) and risk ratio (RR) were used in analysis. Results: A total of 5129 studies were identified; 24 studies met the inclusion criteria and were analysed. Female recipients were found to have a significantly lower serum creatinine 1-year-post renal transplantation (MD: −0.24 mg/dL 95%CI: −0.18 to −0.29 p < 0.01) compared to male recipients. No significant difference in survival between male and female recipients nor between Caucasians and Africans was observed (p = 0.08). However, Caucasian recipients had a higher 1-year graft survival compared to African recipients (95% CI 0.52−0.98) with also a lower incidence of DGF (RR = 0.63 p < 0.01) and AR (RR = 0.55 p < 0.01). Recipient obesity (BMI > 30) was found to have no effect on 1-year recipient (p = 0.28) and graft survival (p = 0.93) compared to non-obese recipients although non-obese recipients had a lower rate of DGF (RR = 0.65 p < 0.01) and AR (RR = 0.81 p < 0.01) compared to obese recipients. Conclusions: Gender mismatch between male recipients and female donors has negative impact on graft survival. African ethnicity and obesity do not to influence recipient and graft survival but negatively affect DGF and AR rates.

New Year's greeting and overview of World Journal of Transplantation in 2021

World Journal of Transplantation (WJT) was launched in December 2011. While we are celebrating WJT’s 10-year anniversary, we are very proud to share with you that since its first issue, WJT has published 312 articles, which have been cited 2786 times (average cites per article of 9.0). Together with an excellent team effort by our authors, Editorial Board members, independent expert referees, and staff of the Editorial Office, WJT advanced in 2020. In this editorial, we summarize the journal’s bibliometrics, including its citation report, published articles in 2020, peer review rate and manuscript invitation metrics, as well as its Editorial Board members and existing problems of WJT. The overall aim of this editorial is to promote the development of WJT in 2021. We appreciate the continuous support and submissions from authors and the dedicated efforts and expertise by our invited reviewers. This collective support will allow us to be even more productive in 2021. In addition, we commit to working with you all to raise the academic influence of WJT over the upcoming year. Finally, on behalf of WJT, we wish you and your families the best for the New Year.

COVID-19 pandemic: Building organisational flexibility to scale transplant programs

The prevailing coronavirus disease 2019 pandemic has challenged our lives in an unprecedented manner. The pandemic has had a significant impact on transplantation worldwide. The logistics of travel restrictions, stretching of available resources, unclear risk of infection in immunosuppressed transplant recipients, and evolving guidelines on testing and transplantation are some of the factors that have unfavourably influenced transplant activity. We must begin to build organisational flexibility in order to restart transplantation so that we can be mindful stewards of organ donation and sincere advocates for our patients. Building a culture of honesty and transparency (with patients, families, colleagues, societies, and authorities), keeping the channels of communication open, working in collaboration with others (at local, regional, national, and international levels), and not restarting without rethinking and appraising all elements of our practice, are the main underlying principles to increase the flexibility.

A Systematic Review of COVID-19 Infection in Kidney Transplant Recipients: A Universal Effort to Preserve Patients' Lives and Allografts

The coronavirus disease 2019 (COVID-19) pandemic has posed a significant challenge to physicians and healthcare systems worldwide. Evidence about kidney transplant (KTx) recipients is still limited. A systematic literature review was performed. We included 63 articles published from 1 January until 7 July 2020, reporting on 420 adult KTx recipients with confirmed COVID-19. The mean age of patients was 55 ± 15 years. There was a male predominance (67%). The majority (74%) were deceased donor recipients, and 23% were recently transplanted (<1 year). Most patients (88%) had at least one comorbidity, 29% had two, and 18% three. Ninety-three percent of cases were hospitalized. Among them, 30% were admitted to the intensive care unit, 45% developed acute respiratory distress syndrome, and 44% had acute kidney injury with 23% needing renal replacement therapy. From the hospitalized patients a total of 22% died, 59% were discharged, and 19% were still in hospital at the time of publication. Immunosuppression was reduced in 27%, discontinued in 31%, and remained unchanged in 5%. Hydroxychloroquine was administered to 78% of patients, antibiotics to 73%, and antivirals to 30% while 25% received corticosteroid boluses, 28% received anti-interleukin agents, and 8% were given immunoglobulin. The main finding of our analysis was that the incidence of COVID-19 among kidney transplant patients is not particularly high, but when they do get infected, this is related to significant morbidity and mortality.

Anticoagulation in simultaneous pancreas kidney transplantation - On what basis?

BACKGROUND

Despite technical refinements, early pancreas graft loss due to thrombosis continues to occur. Conventional coagulation tests (CCT) do not detect hypercoagulability and hence the hypercoagulable state due to diabetes is left untreated. Thromboelastogram (TEG) is an in-vitro diagnostic test which is used in liver transplantation, and in various intensive care settings to guide anticoagulation. TEG is better than CCT because it is dynamic and provides a global hemostatic profile including fibrinolysis.

AIM

To compare the outcomes between TEG and CCT (prothrombin time, activated partial thromboplastin time and international normalized ratio) directed anticoagulation in simultaneous pancreas and kidney (SPK) transplant recipients.

METHODS

A single center retrospective analysis comparing the outcomes between TEG and CCT-directed anticoagulation in SPK recipients, who were matched for donor age and graft type (donors after brainstem death and donors after circulatory death). Anticoagulation consisted of intravenous (IV) heparin titrated up to a maximum of 500 IU/h based on CCT in conjunction with various clinical parameters or directed by TEG results. Graft loss due to thrombosis, anticoagulation related bleeding, radiological incidence of partial thrombi in the pancreas graft, thrombus resolution rate after anticoagulation dose escalation, length of the hospital stays and, 1-year pancreas and kidney graft survival between the two groups were compared.

RESULTS

Seventeen patients who received TEG-directed anticoagulation were compared against 51 contemporaneous SPK recipients (ratio of 1: 3) who were anticoagulated based on CCT. No graft losses occurred in the TEG group, whereas 11 grafts (7 pancreases and 4 kidneys) were lost due to thrombosis in the CCT group (P = 0.06, Fisher’s exact test). The overall incidence of anticoagulation related bleeding (hematoma/ gastrointestinal bleeding/ hematuria/ nose bleeding/ re-exploration for bleeding/ post-operative blood transfusion) was 17.65% in the TEG group and 45.10% in the CCT group (P = 0.05, Fisher’s exact test). The incidence of radiologically confirmed partial thrombus in pancreas allograft was 41.18% in the TEG and 25.50% in the CCT group (P = 0.23, Fisher’s exact test). All recipients with partial thrombi detected in computed tomography (CT) scan had an anticoagulation dose escalation. The thrombus resolution rates in subsequent scan were 85.71% and 63.64% in the TEG group vs the CCT group (P = 0.59, Fisher’s exact test). The TEG group had reduced blood product usage {10 packed red blood cell (PRBC) and 2 fresh frozen plasma (FFP)} compared to the CCT group (71 PRBC/ 10 FFP/ 2 cryoprecipitate and 2 platelets). The proportion of patients requiring transfusion in the TEG group was 17.65% vs 39.25% in the CCT group (P = 0.14, Fisher’s exact test). The median length of hospital stay was 18 days in the TEG group vs 31 days in the CCT group (P = 0.03, Mann Whitney test). The 1-year pancreas graft survival was 100% in the TEG group vs 82.35% in the CCT group (P = 0.07, log rank test) and, the 1-year kidney graft survival was 100% in the TEG group vs 92.15% in the CCT group (P = 0.23, log tank test).

CONCLUSION

TEG is a promising tool in guiding judicious use of anticoagulation with concomitant prevention of graft loss due to thrombosis, and reduces the length of hospital stay.

Machine Perfusion and the Pancreas: Will It Increase the Donor Pool?

PURPOSE OF REVIEW

Pancreas transplantation enables complete patient independence from exogenous insulin administration and increases both patient survival and quality of life. Despite this, there has been a decline in pancreas transplantation for the past 20 years, influenced by changing donor demographics with more high-risk extended criteria (ECD) and donation after cardiac death (DCD) donors. This review discusses whether the advent of machine perfusion (MP), if extended to the pancreas, can increase the pool of suitable donor organs.

RECENT FINDINGS

Hypothermic and normothermic MP, as forms of preservation deemed superior to cold storage for high-risk kidney and liver donor organs, have opened the avenue for translation of this work into the pancreas. Recent experimental models of porcine and human ex-vivo pancreatic MP are promising. Applications of MP to the pancreas however need refinement-focusing on perfusion protocols and viability assessment tools. Emerging research shows pancreatic MP can potentially offer superior preservation capacity, the ability to both resuscitate and manipulate organs, and assess functional and metabolic organ viability. The future of MP will lie in organ assessment and resuscitation after retrieval, where ultimately organs initially considered high risk and unsuitable for transplantation will be optimised and transformed, making them then available for clinical use, thus increasing the pool of suitably viable pancreata for transplantation.

The Effect of Donors' Demographic Characteristics in Renal Function Post-Living Kidney Donation. Analysis of a UK Single Centre Cohort

Introduction: There is a great need to increase the organ donor pool, particularly for living donors. This study analyses the difference in post-living donation kidney function according to pre-donation characteristics of age, genetic relationship with the recipient, sex, ethnicity, and Body Mass Index (BMI). Methods: Retrospective single centre analysis of the trajectory of estimated Glomerular Filtration Rate (eGFR) post-living kidney donation, as a measure of kidney function. Mean eGFR of the different groups was compared at 6 months and during the 60 months follow up. Results: Mean age was 46 ± 13 years, 57% were female, and 60% Caucasian. Mean BMI was 27 ± 5 kg/m², with more than a quarter of the cohort having a BMI > 30 (26%), and the majority of the donors genetically related to their recipients (56%). The higher decline rate in eGFR was at 6 months after donation, with female sex, non-Caucasian ethnicity, and age lower than 60 years being independently associated with higher recovery in kidney function (p < 0.05). In the 60 months follow up, older age, genetic relationship with the recipient, and male sex led to higher percentual difference in eGFR post-donation. Conclusion: In this study, with a high proportion of high BMI living kidney donors, female sex, age lower than 60 years, and non-genetic relationship with recipient were persistently associated with higher increase in post-donation kidney function. Ethnicity and BMI, per se, should not be a barrier to increasing the living donor kidney pool.