Donor management and extremely high donor lung utilization rate in Japan.

Owing to the extremely short supply of donor lungs in Japan, a unique medical consultant (MC) system was initiated in 2002 to increase the organ availability through intensive management of donors. First, heart transplant surgeons were sent to procurement hospitals as MCs to assess donor organ function and provide intensive care to donors. MCs requested that donor attending doctors perform frequent phlegm aspiration with a bronchoscope, leading to a higher lung availability and better outcomes after lung transplantation. Since 2011, 25 lung transplant surgeons have been registered as lung MCs to assess and manage donor lungs and communicate donor lung conditions to the lung transplantation teams. In 2014, the efficacy of this MC system on lung transplantation opportunities and outcomes was retrospectively reviewed. One hundred and eighty-seven brain-dead lung donor candidates were chronologically divided into three phases: I (May 1998 to November 2006, n=44) and II (December 2006 to January 2011, n=64), before and after MCs requested that local attending doctors perform aggressive bronchial suctioning using a bronchoscope, respectively; and III (February 2011 to January 2013, n=79), after the emergence of lung MCs. The lung utilization rates in phases I, II, and III were 61.4%, 71.9%, and 74.7% (per donor); 51.1%, 64.8%, and 67.7% (per lung, P=0.03). Graft death rates due to primary graft dysfunction in phases I, II, and III were 13.3%, 3.6%, and 3.7%, respectively (per lung, P=0.04). Recently, we analyzed the utilization rate of 63 brain-dead lung donor candidates for a period of one year, from June 2020 to May 2021, which was 83% (per donor). The lung MC system is effective in maintaining an extremely high lung utilization rate and favorable outcomes after lung transplantation in Japan.

[Current Status and Tasks of the Lung Medical Consultant System].

In order to overcome challenges of serious short supply of donor organs, a unique partnership between transplant consultant doctors and local physicians, named medical consultant( MC) system, started in 2002 to maximize the organ utilization rate. As the first step of this system, skillfull heart transplant surgeons were sent to procurement hospitals as MCs to assess donor organ function and provide intensive care to donors. Since 2006, the MC doctors have requested the donors' attending physicians to perform aggressive bronchial suctioning using bronchoscopy, leading to an improved lung utilization rate and better graft survival. Since 2011, more than 25 lung MCs have been registered to assess donor lungs and provide advices on intensive respiratory care to donors. The effects of this system on lung transplantation opportunities and outcomes were retrospectively reviewed in 187 brain-dead lung donor candidates, which were chronologically divided into 3 phases:Ⅰ( May 1998 to November 2006, n=44) and Ⅱ( December 2006 to January 2011, n=64), before and after MCs requested local attending physicians to perform aggressive bronchial suctioning using bronchoscopy, respectively;and phase Ⅲ (February 2011 to January 2013, n=79), after the emergence of lung MCs( Hoshikawa Y, et al. Transplant Proc 47( 3):746-750, 2015). The lung utilization rates in phases Ⅰ, Ⅱ, and Ⅲ, were 61, 72, and 75%( per donor);51, 65, and 68% (per lung, p=0.03). Graft death due to primary graft dysfunction was significantly more frequent in phase Ⅰ (13.3%) than in phases Ⅱ (3.6%) and Ⅲ (3.7%, per lung, p=0.04). The lung utilization rate of 63 brain-dead lung donor candidates for a period of one year from June 2020 to May 2021, which was analyzed anew for this article, was 83%( per donor) and 72%( per lung). We discussed current status and tasks of the lung MC system which has been operated for 10 years.

Interim report of the Japanese original donor evaluation and management system: the medical consultant system.

PURPOSE: Lung transplantation (LTx) is an established therapy for end-stage lung failure. However, in Japan, the donor organ shortage is extremely severe compared with other developed countries, because of the strict Japanese Organ Transplantation Law. To maximize LTx opportunities in Japan, we have established a special donor evaluation and management system termed the medical consultant (MC) system. METHODS: Data from 171 lung donor candidates registered in Japan from May 1998 to May 2012 were obtained and investigated in a retrospective manner. The candidates were separated into the non-MC-intervened and MC-intervened groups, and then data regarding the PaO2/FiO2 ratio, donation rate and organ survival rate were analyzed and compared between the groups. RESULTS: The PaO2/FiO2 ratio of the MC-intervened group was ameliorated from the time of first brain death diagnosis to organ harvest. Although the base condition of the MC-intervened group was significantly worse than that of the non-MC-intervened group, the donation rates showed no significant difference (0.64 and 0.66, respectively; p = 0.89). There was a difference in the organ survival rate between the non-MC and MC-intervened groups (5-year survival rates of 67.2 and 88.3 %, respectively; p = 0.16). CONCLUSION: The MC system used for organ donor evaluation and management in Japan has achieved acceptable interim results.

[The financial status and organization of the organ transplant system in Japan].

The Japan Organ Transplant Network is the only organization in Japan that maintains a waiting list for organ transplants and also functions as a procurement agency recovering organs. The yearly budget of fiscal year 2009 is 692 million Japanese yen, 74% from government funding, and the rest from transplant center membership fees, potential recipient registration fees, transplant recipient coordination fees, and contributions. The registration fee is 30,000 yen for the first year, and 5,000 yen for every following year. The patient is also charged a coordination fee of 100,000 yen when receiving a transplant. As it becomes difficult to rely on government funding, we must discuss about the balance of funding from government and the expenses of the beneficiaries.

[The certification and recruitment of the procurement coordinator].

In Japan, Japan Organ Transplant Network is responsible for the certification and recruitment of the procurement coordinators since April 1995. Individuals that have a medical license or are recognized to have similar knowledge, and who have passed an aptitude test including curriculum vitae, paper test, and practice assessment in an emergency unit, concluding in a recruitment interview are granted certification. As the Revised Organ Transplant Act has been enacted in 2010, we predict the rise in donors, and also the importance of the role of the coordinators. In the future, a governmental certification is desirable, and it is urgent to train procurement coordinators by a professional and systematic training program.