Solid organ transplantation: the Italian experience in the international context

The Italian experience in the organization of transplantation procedures could represent a relevant example of an internal development at a national level, combined with a strengthening of international collaborations. These results can be attributed first to the creation of the Italian National Transplant Centre (Centro Nazionale Trapianti [CNT]), and then to an ongoing European process that is leading to a greater awareness of the importance of closer collaboration between the organizations already existing and operating in the field of transplantation. This article summarizes the role and the most significant achievements of the CNT.

Retrospective screening of solid organ donors in Italy, 2009, reveals unpredicted circulation of West Nile virus

Since the occurrence of West Nile virus (WNV) infection in humans in 2008 in Italy, concerns have been raised about the potential risks associated with solid organ transplantation (SOT). A nationwide retrospective survey showed that 1.2% of SOT donors in 2009 were WNV-seropositive and demonstrated that human WNV infection is distributed throughout several Italian regions. Transmission of WNV or other arboviruses through SOT is a possibility and risk assessment should be carried out before SOT to avoid infection through transplantation.

Measures taken to reduce the risk of West Nile virus transmission by transplantation in Italy

For the first time in Italy, two patients with meningoencephalitis were diagnosed with West Nile virus (WNV) infection in September 2008 [1]. The patients live in the Bologna and Ferrara provinces of Emilia Romagna where WNV infections had previously been noted in horses, crows and magpies [2]. The Italian National Transplant Centre (CNT), which is responsible for the procurement, processing and distribution of organs and tissues in Italy, has now reviewed the risks of transmission of WNV by organ, tissue and cell transplantation and, taking into account the advice and recommendations of the relevant authorities in other countries, issued guidance to the transplant community.

Exchange of organs and patients with foreign nations during the first 15 months of activity of the Italian gate to Europe

The Italian Gate to Europe (IGE) was established in April 2005 to supply a single national coordinating center for the exchange of organs and patients with the rest of Europe. When an organ is offered from Italy, the IGE ascribes it to the first foreign organization that accepts it on a first-come, first-served basis. In the case of offers from abroad, the IGE allocates the organ to one of the three Italian Interregional Centres in rotation. On the basis of international agreements, the IGE also manages the transfer of foreign patients to Italian transplant centers. The first 15 months of activity have been compared with the previous period of the same length. The IGE managed 353 contacts. 53 organs were transplanted in Italy versus 19 in the previous period. Seven foreign patients received liver transplantations in Italy. The increase in imported organs could be a function of IGE creation, since it allowed a reduced response time to offers and guaranteed the participation of all Italian centers in the program of international exchanges with a subsequent increase in the pool of recipients and equitable distribution of transplanted organs. The drop in the number of exported organs was a probable a consequence of increased acceptance criteria of Italian centers. The mentioned international agreements have allowed us to better meet the health care needs of foreign citizens who live in countries with low per-million-population donation rates with no detriment to the probability of Italian citizens being transplanted.

Quality Evaluation of Solid Organ Transplant in Italy for the Period 2000 to 2002 Data from the National Transplant Center

BACKGROUND

As part of the increased need for transparency and disclosure of information in health care, the Italian Minister of Health has commissioned the Superior Institute of Health to study health outcomes for several procedures, among which is solid organ transplants. We herein report the results of a quality evaluation of solid organ transplants and on the relationship between hospital volume of activity and outcomes, using the data routinely collected by the National Transplant Center during the period 2000 to 2002.

METHODS

We collected and analyzed all the information on solid organ transplants between 2000 and 2002, along with clinical information before and after transplant. Multivariate survival analysis was performed to adjust the follow-up data for the complexity of the cases. Correlation graphs are presented that assess the association between the number of transplants and the adjusted 1-year survival of both the organ and the patient.

RESULTS

One-year survival was 92.4% for kidney, 77.8% for liver, and 83.9% for heart. Patient survival was 97.0%, 84.1%, and 83.9%, respectively. A negative correlation was observed between the number of transplants performed by each center and 1-year survival of the organ.

CONCLUSIONS

Our study indicated that survival after organ transplants in Italy is good and that hospital quality, indirectly measured through survival, overlaps that observed in other Western countries.

Optimizing the organ procurement process: organizational prerequisites and monitoring strategies in a national network

The current project sought to collect detailed information on the Italian donation system and in particular on the organization and functioning of the local coordinating centers. The final objective was to provide local and regional institutions with the information required to improve the system. While improving the knowledge of current Italian donation system, the project had constructive purposes. Our intention was to analyze how the national system is working, what the coordinating centers are actually doing, how they are organized, to what extent existing rules are obeyed, and what are the main limits of the system. This analysis sought to lead to the development of a set of proposals that can be summarized in two categories: (1) "intrinsic" actions, that is, those established and implemented at the hospital level; and (2) supporting "extrinsic" actions, that is, those identified by the National Transplant Centre and addressed to the regional and interregional coordinating networks. Finally, the analysis of the application of the existing rules should lead to the development of practice guidelines such that each center conforms to the existing regulations established by European directives.

Molecular monitoring of organ recipients from cancer-affected donors by detection of circulating tumor cells

We have initiated regular molecular monitoring based on nested RT-PCR detection of circulating tumor cells for monitoring recipients of organs from cancer-affected donors in Italy (in the context of a "Donation Safety and Donated Organ Quality" project organized by the Centro Nazionale Trapianti). Five patients are being monitored. For two patients who each received a kidney from a single donor with prostate adenocarcinoma, RT-PCR was performed using PSA mRNA. For three recipients of organs (two livers and one kidney) from donors with renal cell carcinoma, RT-PCR was performed using cytokeratine 18 and 19 mRNA. Blood samples from five healthy subjects were used as negative controls. After a median monitoring time of 26 months (range 8 to 32), none of the regular 3-month assays has tested positive. This pilot study suggests that detection of circulating tumor cells by nested RT-PCR may provide a feasible molecular monitoring, which might assist decision making regarding other forms of clinical surveillance.

[Kidney transplantation in Italy: an evolving scenario]

BACKGROUND

Italian transplantation systems have dramatically improved in the last decade. Kidney transplantations are now strictly monitored and excellent results has been achieved in terms of quality and the ability to reduce waiting times for receiving transplantation.

METHODS

The Italian organizational retrieval and transplant system is articulated on four levels: local, regional, inter-regional and national. The Italian Transplant Information System (SIT) was set up in 2000 in accordance with Law 91/99. Patient data on the waiting lists and follow-up of transplanted patients are routinely collected.

RESULTS

A total of 4406 kidney transplants have been carried out in the 40 Italian kidney transplant centers in 2001-2003. The survival analysis was conducted for the 2000-2002 in 4222 cases. Overall 1-yr survival was 92.4% for the graft and 97% for the patients. After adjusting for variables independently associated with the outcome at multivariate analysis (for example, the case-mix), patient and graft survival at 1 yr was 98.1% and 93.8%, respectively. No remarkable differences in 1-yr graft survival were observed between the 40 Italian kidney transplant centers. At multivariate analysis, variables independently associated with graft failure were donor age, degree of HLA mismatch and recipient case-mix. Analysis of the waiting list showed approximately 6500 patients waiting for kidney transplantation. The mean waiting time was 3.04 yrs, with a mortality rate of 1.18% per year.

CONCLUSIONS

Kidney transplantation activity in Italy has produced excellent results in terms of quality and number of transplants per year. However, the number of patients on the waiting list and the waiting time call for further action to increase the number of available organs.