Time trends in preemptive kidney transplantation in Europe: an era registry study.

BACKGROUND: Preemptive kidney transplantation has better outcomes when compared to transplantation after dialysis. We aimed to examine trends in preemptive kidney transplantation between 2000 and 2019 in Europe and to provide an overview of associated policies, barriers and initiatives. METHODS: Adult patients from 12 European countries who received a preemptive kidney transplant were included. The representatives of the registries providing these data were questioned on the policies, barriers and initiatives around preemptive kidney transplantation. RESULTS: Between 2000 and 2019, 20 251 adults underwent preemptive kidney transplantation (11 169 from living donors, 8937 from deceased donors). The proportion of first kidney transplantations that were preemptive more than doubled from 7% in 2000 to 18% in 2019, reflecting a similar relative increase for living donor kidney recipients (from 21% to 43%) and deceased donor kidney recipients (from 4% to 11%). Large international differences were found. The increase in preemptive kidney transplantation was observed across all age, sex and primary renal disease groups. Countries had similar criteria for preemptive waitlisting. Barriers mentioned included donor shortage, late referral to the transplant center and long donor or recipient work-up. Suggested initiatives included raising awareness on the possibility of preemptive kidney transplantation, earlier start and shorter work-up time for recipient and living donor. CONCLUSIONS: Over the last two decades the proportion of patients receiving a first kidney transplant preemptively has more than doubled, reflecting a similar relative increase for living and deceased donor kidney recipients.

Improving the Access of Highly Sensitized Patients to Kidney Transplantation From Deceased Donors: The Spanish PATHI Program With Allocation Based on the Virtual Crossmatch.

BACKGROUND: In 2015, the Spanish National Transplant Organization developed a prioritization system (Program for Access to Transplantation for Highly Sensitized Patients [PATHI]) to increase transplant options for patients with calculated panel-reactive antibodies (cPRAs) ≥98%, based on virtual crossmatch. We describe the experience with the implementation of PATHI and assess its efficacy. METHODS: PATHI registry was used to collect characteristics of donors and patients between June 15, 2015, and March 1, 2018. One-year graft and patient survival and acute rejection were also measured. A Cox model was used to identify factors related to patient death and graft loss and logistical regression for those associated with rejection. RESULTS: One thousand eighty-nine patients were included, and 272 (25%) were transplanted. Transplant rate by cPRA was 54.9%, 40.5%, and 12.8% in patients with cPRA98%, cPRA99%, and cPRA100%, respectively. One-year patient survival was 92.5%. Recipient age ≥60, time under dialysis >7 y, and delayed graft function were mortality risk factors. One-year graft survival was 88.7%. The factor related to graft loss was delayed graft function. The rejection rate was 22%. Factors related to rejection were sex, older recipients, and posttransplant donor-specific antibodies. CONCLUSIONS: A prioritization approach increases transplant options for highly sensitized patients with appropriate short-term postransplant outcomes. Along with other programs, PATHI may inspire other countries to adopt strategies to meet transplant needs of these patients.

Low-risk delisting strategy in highly sensitized patients without donor offers included in exchange donation programs. One single-center experience.

Donor exchange programs were designed to allocate organs for highly sensitized (HS) patients. The allocation algorithm differs slightly among countries and includes different strategies to improve access to transplants in HS patients. However, many HS patients with a calculated panel reactive of antibodies (cPRA) of 100 % remain on the waiting list for a long time. Some allocation algorithms assume immunological risk, including Imlifidase treatment, to increase the chance of transplantation in very HS patients. Here, we describe our unicenter experience of low-risk delisting strategy in 15 HS patients included in the Spanish donor exchange program without donor offers. After delisting, 7 out of 15 HS patients reduced the cPRA below 99.95 % and impacted the reduction of time on the waiting list (p = 0.01), where 5 out of 7 achieved transplantation. Within those HS that remained above 99.95 %, 1 out of 8 was transplanted. All the HS were transplanted with delisted DSA, and only one with DSA level rebounded early after transplantation. All HS transplanted after delisting maintain graft function. The transplant immunology laboratories are challenged to search intermediate risk assessment methods for delisting high HS patients.

Factors related to attitudes toward organ donation after death in the immigrant population in Spain.

Considering the relevance of the migratory processes in Western societies, the attitudes toward organ donation after death are analyzed by means of a survey applied to a representative random sample of the resident immigrant population in Spain, comprising 1202 subjects (estimated margin of error of ± 2.88%, p = q, p < 0.05). Considered variables were disposition toward own organ donation, disposition toward deceased relatives' donation in different situations, arguments against donation, socio-demographic indicators, religious beliefs, social integration, and information about organ donation and transplantation. Predisposition to donate varies strongly across geographical origin and religious beliefs and also shows relationships with additional socio-demographic, social integration, and informative variables. In turn, the relationship between religious beliefs and attitude toward donation varies as a function of the degree of social integration. In Spain, the immigrant population is a heterogeneous collective that requires differential strategies to promote donation. Such strategies should be aimed at reinforcing the existing positive attitudes of citizens from West Europe and Latin America, and at familiarizing and informing about donation in citizens from the East, and at making specific efforts to break down the cultural and religious barriers toward donation in African citizens, with special emphasis on people of the Muslim faith.

Analysis of the attitudes and motivations of the Spanish population towards organ donation after death.

Starting with the relevance of the Spanish experience, this study analyses the population's disposition towards organ donation after death by means of a representative survey of the adult Spanish population (N = 1206, estimated error ±2.87%, P < 0.05). Of the participants, 8.1% were declared donors, 59.3% were likely to donate, 14.5% were against donating and 18.1% did not know or did not respond; 87.3% would donate relative's organs if the deceased favoured donation, 50.2% if the deceased's wishes were unknown and 13.1% even if the deceased opposed donation. Among people who were favourable towards donation, the main motives expressed were the will to save other people's lives, solidarity and knowing they might someday need a donation. The most important motives for not donating among participants who were against it were the fear of premature organ extraction, of premature pronouncement of death and of mutilation. Reticence to donate is associated with low socio-economic and cultural level, advanced age and high religious commitment; it is also associated with a low perception of transplant efficacy, not directly knowing any transplanted people and the lack of qualified information. The results support diverse potentially effective strategies for promoting donation in the general population.

[Legislaction, ethics and kidney transplantation.] / Legislación, ética y trasplante renal.

Kidney transplantation (KT) is the best therapeutic option for patients with end-stage renal disease in terms of survival, quality of life and cost-effectiveness. The fundamental difference of KT with respect to other therapies is that the process depends on the availability of organs for clinical use, availability that is insufficient to cover the increasing transplantation needs of the population. Another relevant feature of transplantation is that it entails a risk of transmission of diseases from donor to recipient, a risk that can be minimized, but not completely eliminated. Due to its characteristics and its unique nature (the human being), KT requires a specific regulation that guarantees the protection of all those who participate in the process: donors and their families, patients in need of a transplant, recipients of organs and healthcareprofessionals involved. In this article, we reviewthe ethical-legal standards that regulate the practice of kidney donation and transplantation at the international level and analyze the ethical-legal framework that is applicable in Spain.

El trasplante renal (TR) es la mejor opción terapéutica para los pacientes con insuficiencia renal crónica en términos de supervivencia, calidad de vida y relación coste-efectividad. La diferencia fundamental del TR con respecto a otras terapias es que su realización depende de la disponibilidad de órganos para uso clínico, disponibilidad que resulta insuficiente para cubrir las crecientes necesidades de trasplante de la población. Otro aspecto relevante del trasplante es que conlleva el riesgo de transmisión de enfermedades de donante a receptor, riesgo que puede minimizarse, pero no eliminarse por completo. Por sus características y su naturaleza única (el ser humano), el TR exige una regulación específica que garantice la protección detodos los participantes en el proceso: los donantes y sus familias, los pacientes con necesidad de un trasplante, los receptores de órganos y los profesionales sanitariosimplicados. En este artículo se revisan los estándares ético-legales que regulan la práctica de la donación y el TR a nivel internacional y se analiza el marco ético-legal que resulta de aplicación en España.

Organ donation and transplantation: a multi-stakeholder call to action.

Although overall donation and transplantation activity is higher in Europe than on other continents, differences between European countries in almost every aspect of transplantation activity (for example, in the number of transplantations, the number of people with a functioning graft, in rates of living versus deceased donation, and in the use of expanded criteria donors) suggest that there is ample room for improvement. Herein we review the policy and clinical measures that should be considered to increase access to transplantation and improve post-transplantation outcomes. This Roadmap, generated by a group of major European stakeholders collaborating within a Thematic Network, presents an outline of the challenges to increasing transplantation rates and proposes 12 key areas along with specific measures that should be considered to promote transplantation. This framework can be adopted by countries and institutions that are interested in advancing transplantation, both within and outside the European Union. Within this framework, a priority ranking of initiatives is suggested that could serve as the basis for a new European Union Action Plan on Organ Donation and Transplantation.

Data and optimisation requirements for Kidney Exchange Programs.

Kidney Exchange Programs (KEP) are valuable tools to increase the options of living donor kidney transplantation for patients with end-stage kidney disease with an immunologically incompatible live donor. Maximising the benefits of a KEP requires an information system to manage data and to optimise transplants. The data input specifications of the systems that relate to key information on blood group and Human Leukocyte Antigen (HLA) types and HLA antibodies are crucial in order to maximise the number of identified matched pairs while minimising the risk of match failures due to unanticipated positive crossmatches. Based on a survey of eight national and one transnational kidney exchange program, we discuss data requirements for running a KEP. We note large variations in the data recorded by different KEPs, reflecting varying medical practices. Furthermore, we describe how the information system supports decision making throughout these kidney exchange programs.