Progress in Transplantation

Organ procurement and transplantation have been difficult in Italy for many years. However, recent initiatives at the organizational level led to the establishment of the National Reference Centre, which is working hard to accomplish its tasks. We describe the transplantation activity of the past 2 years, which shows an improved situation that is encouraging. We include a brief history on transplantation in Italy and give some information to enhance understanding of the changes that have occurred and their impact on transplantation.

A limited supply of organs is the main obstacle for organ transplantation. The shortage reflects not only a shortage of donors but also a failure to make use of existing donors. The Basque Country Transplant Coordination Team is an organ procurement organization that operates in the Basque country, an area of 7260 km² with 2.1 million inhabitants. From January 1, 1990, to December 31, 1995, the number of potential cadaveric organ donors found by the team increased, to 70 donors per million inhabitants in 1995. Since 1993, the organization has had more than 30 donors per million persons and has procured more than 90 cadaveric organs, including more than 60 cadaveric kidneys, per million persons. Because of these rates, the team coordinated 61.7 cadaveric kidney transplants per million persons during 1995. This paper describes some characteristics of the Basque organ procurement organization that might explain these results.

Answers to the question about consent for organ donation on the Queensland Transport Driver's Licence Database were reviewed to determine if age is an indicator of willingness to donate. As of November 1994, the database contained records on 1,969,382 persons (54% male, 46% female), accounting for 86.7% of the population 17 years of age or older. Fifty-four percent had answered yes to the question; 46% had indicated no or had not answered. The data were divided into three groups, males only, females only, and males plus females, and then sub-grouped by age. The number of subjects who had not answered the question was included in the number who had answered no. In the males-plus-females group, the percentage of yes answers by age remained relatively constant (56%–62%) for persons 17 to 49 years old but decreased to 39% for persons 70 years old. The data for males only and females only showed a similar decrease. Slightly more females than males had answered yes among persons 17 to 49 years old (mean difference, 5%; range, 1%–8%). This difference decreased with age. A higher willingness to donate in the younger age groups may augur well for the future. The data indicate that more attention must be given to persons 50 years of age and older to increase their awareness of their ability to donate.

A country's organ donation rate and hence the availability of thoracic organs can be increased by organizational measures, by legislative incentives, and by increasing awareness among the public and healthcare professionals. We analyzed the relative impact of organ procurement legislation or policy on heart and lung donation rates per million population per year in the four countries participating in the Eurotransplant organization (population, 112.7 million) between January 1992 and December 1994. Within this organization, Austria and Belgium have presumed-consent legislation, whereas Germany and the Netherlands have an opting-in (explicit-consent) policy. Although practices vary even among countries with similar policies (eg, in Belgium, relatives of the donor retain the right to object to procurement of organs in the absence of an explicit consent from the deceased before death), rates of heart and lung donation were at least twice as high in the two countries with presumed-consent legislation as in the two countries that rely on a policy of explicit consent from the donor's next of kin.

As solid-organ transplantation has evolved into a highly effective treatment for end-stage organ disease, the long-term health implications of chronic exposure of recipients to immunosuppressants and other pharmacological agents are becoming more apparent. Coronary heart disease has long been known to plague kidney transplant recipients and more recently has been found to affect heart transplant recipients disproportionately. Coronary heart disease after liver transplantation, however, is less well known. The purpose of this study was to examine risk factors for premature coronary heart disease in asymptomatic adult recipients of liver transplants. Nutrition-related risk factors for coronary heart disease (obesity and hyperlipidemia) were measured in 29 patients before and after liver transplantation. Changes with respect to primary immunosuppression protocol (cyclosporine plus corticosteroid vs tacrolimus plus corticosteroid) were compared. Risk factors that had not been present before transplantation were apparent in both groups by 6 months after transplantation. Although obesity and hyperlipidemia were not found to be independent risk factors for coronary heart disease, they were clinically important when considered in combination. Cyclosporine was associated with significantly higher serum lipid concentrations than was tacrolimus.

This study of seminary students, religious leaders, and hospital chaplains illustrates the importance of educating clergy about organ donation. Religious objections are often cited as a reason for refusal to give consent for donation. Results of this study show that most clergy are supportive of organ donation. However, the survey pointed out some misunderstanding of the concept of brain death. Thus, although the clergy are supportive and influential, they tend not to receive medical information that is key to the donation process. Further education specifically focused on religious leaders is needed.

An exploratory descriptive study of donor families and recipients of cadaveric organs was done to determine their feelings about direct contact with each other. Direct contact was desired by 70% of donor families and 75% of recipients. Donor families wanted to see firsthand the benefit of the transplant to another person. Recipients primarily wanted to express gratitude. Both groups think they have a right to meet. Although both think these interactions should be professionally regulated and facilitated, they do not think the transplant center or the organ procurement organization is responsible for the outcome of a meeting. Donor families and recipients think the process should be gradual with prior correspondence. On the basis of our findings, we have developed a list of suggested guidelines to use when facilitating an interaction.

From 1983 to August 1995, the University of Miami Organ Procurement Organization evaluated 41 candidates for non–heart-beating cadaveric donation and determined that 34 patients met the criteria. All patients had irreversible brain injury incompatible with survival. All families gave permission for withdrawal of life support and for tissue and organ donation after cardiac arrest. Thirteen donors died in the operating room, and 9 died in the ICU or emergency department. Four of the 9 patients who died in the ICU had undergone femoral cannulation. The remaining 12 donors were brain-dead but had an unpredicted cardiac arrest before laparotomy. All kidneys were preserved by using machine pulsatile perfusion, and 21 kidneys were transported to other centers. Of the 35 transplanted kidneys, 26 (74%) had immediate function, 6 (17%) had delayed graft function, and 3 (9%) were not used for other reasons. Five of the six transplanted livers had immediate function.

The organ procurement community has always considered public education a primary challenge. According to conventional wisdom, greater awareness generated by public education will lead to more donated organs. This notion may be based on faulty assumptions about public education and about the relationship between awareness and behavior. Public education, as the primary focus for the organ procurement community, should be abandoned. Increased efforts in professional education and basic research are more appropriate endeavors for organ procurement organizations.

This article is the first in a series of three focused on the steps in the development of a research proposal. This first article presents the beginning steps of identification of a problem, statement of the research question and hypotheses, and review of the literature. The series of articles is meant to provide an overview of how to accomplish each of the steps. The discussion of the steps focuses the reader on helpful hints pertinent to each step. Additional references are provided for a more in-depth discussion of the process.

Voluntary certification of transplant coordinators has taken place in the United States since 1988 and has operated under the auspices of the American Board of Transplant Coordinators since its formation in 1987. This article reviews the rationale for development of a certification process, how the examinations were developed and are updated, eligibility to take the examination, and relationship with standards of practice for transplant coordinators.

The purpose of this study was to determine whether use of vasopressors in cadaveric donors of renal transplants was associated with an increased prevalence of acute tubular necrosis after kidney transplantation. We compared immediate allograft function in 26 consecutive renal allograft recipients whose donors had been given vasopressors with that in 26 recipients whose donors had not. The donors treated with vasopressors had been given more than 10 μg/kg per minute of dopamine, norepinephrine, or epinephrine, alone or in combination. The groups were matched with respect to donors' age, recipients' disease, and cold ischemic time. The prevalence of immediate allograft function was significantly lower in recipients whose donors had required use of vasopressors (38.5%) than in recipients whose donors had not required vasopressors (65.4%). We conclude that use of vasopressors in kidney donors leads to an increased prevalence of acute tubular necrosis.