A Multistep, Consensus-Based Approach to Organ Allocation in Liver Transplantation: Toward a "Blended Principle Model".

Since Italian liver allocation policy was last revised (in 2012), relevant critical issues and conceptual advances have emerged, calling for significant improvements. We report the results of a national consensus conference process, promoted by the Italian College of Liver Transplant Surgeons (for the Italian Society for Organ Transplantation) and the Italian Association for the Study of the Liver, to review the best indicators for orienting organ allocation policies based on principles of urgency, utility, and transplant benefit in the light of current scientific evidence. MELD exceptions and hepatocellular carcinoma were analyzed to construct a transplantation priority algorithm, given the inequity of a purely MELD-based system for governing organ allocation. Working groups of transplant surgeons and hepatologists prepared a list of statements for each topic, scoring their quality of evidence and strength of recommendation using the Centers for Disease Control grading system. A jury of Italian transplant surgeons, hepatologists, intensivists, infectious disease specialists, epidemiologists, representatives of patients' associations and organ-sharing organizations, transplant coordinators, and ethicists voted on and validated the proposed statements. After carefully reviewing the statements, a critical proposal for revising Italy's current liver allocation policy was prepared jointly by transplant surgeons and hepatologists.

Physical performance in kidney transplanted patients: a study on desert trekking.

Physical performance of kidney transplanted patients in challenging environments, such as deserts, has been poorly studied. Six kidney transplanted (T: 5 males, 1 female; 45±6 yrs) and 8 control (C: 5 males, 3 females; 49±13 yrs) subjects participated in a 5-day desert trek. Blood pressure, hydration status (Height2/Rz by bioimpedance), heart rate, energy expenditure (by SenseWear Pro Armband) and walking velocities were recorded during each daily trekking stage (GPS-assisted wearable devices). Systo-diastolic blood pressure did not differ between C (119/77±12/8 mmHg) and T (121/77±10/6 mmHg) groups throughout the study. The hydration status was stable from day 1 (Ht2/Rz: 64±13 cm2/Ohm in T and 59±12 cm2/Ohm in C subjects) to day 5 (66±11 cm2/Ohm in T and 61±13 cm2/Ohm in C subjects) in both groups. Two patients on steroid treatment showed a relative hyperhydration. Mean heart rate did not differ between T (135±10 bpm) and C (136±5 bpm) subjects throughout the study, although a reduction from day 1 to day 5 was observed in T subjects only (p<0.05 vs C group). No differences were found between T and C group in walking velocity (1.7±0.6 km/h in T and 1.7±0.5 km/h in C group); mean intensity of physical activity was 3.4±0.5 METs in T and 3.3±0.6 METs in C group during each trekking stage. Negligible differences were observed in cardiovascular, metabolic and hydration status adaptations to desert trekking between selected T and C individuals. T subjects with creatinine clearance > 55 ml/min showed acceptable physical performance and acclimatization to desert environment, suggesting a good long-term outcome of transplantation.

Successful lung transplantation in an HIV- and HBV-positive patient with cystic fibrosis.

Prior to the advent of highly active antiretroviral therapy (HAART), HIV-infected patients were usually not considered as transplant candidates because of the poor prognosis of their underlying disease and concerns regarding the potential detrimental effects of immunosuppression on viral load and immune status. However, with the significant HAART-associated improvements in morbidity and mortality, good short-term outcomes after liver and kidney transplantation for patients with HIV infection have been reported. Nevertheless, HIV infection is currently considered a contraindication to lung transplantation in most transplant centers worldwide. The results of a double lung transplant performed in an HIV and HBV co-infected patient with cystic fibrosis (CF) and end-stage respiratory failure (ESRF) are presented after a 2-year follow-up. Approval of and recommendations for the management of this patient were obtained from the Italian National Center for Transplantation as an extension of the ongoing Italian protocol for liver and kidney transplantation in HIV-infected individuals. The operation was successful and the patient recovered rapidly after surgery. A cautious infectious and immunosuppressive management allowed so far the avoidance of major infectious complications and rejection. To the best of our knowledge, this is the first report of lung transplantation in an HIV and HBV co-infected patient.

Network Model for Optimal Aircraft Location for Human Organ Transportation Activities.

BACKGROUND: The efficiency of transport phases is a key factor in successful organ transplant operations. Reliability, safety, and punctuality must be in compliance with the European Union and national frameworks and be consistent with economic, quantitative, and level-of-service parameters. In this study we investigated the optimal numbers and locations of aircraft in the Italian territory by comparing performance indexes related to different time intervals and service design scenarios. METHODS: An integer linear programming model is described as an optimal service solution for covering the demand for extraregional organ transport by air between June 2015 and May 2016. Restrictions on aircraft utilization and actual length of the missions in cases of incompatible activities are the relevant input data of the model. RESULTS: Based on mission durations and their origin and destination, the model returns the optimal number and location of aircraft in various scenarios. The performance parameters required by law and the need to guarantee the service from/to the whole territory, together with the transplant figures performed and transplant center locations, have been taken into account to determine the most efficient spatial and numerical allocation. CONCLUSION: The efficient design of an urgency-based service such as the transportation of organs for transplant purposes is not an easy task. Nevertheless, knowledge of the logistic chain and continuous monitoring and update of data and performance parameters can allow for collection of useful information to guarantee a high-performing service.

Analysis of the Trend Over Time of High-Urgency Liver Transplantation Requests in Italy in the 4-Year Period 2014-2017.

BACKGROUND: The national protocol for the handling of high-urgency (HU) liver organ procurement for transplant is administered by the Italian National Transplant Center. In recent years, we have witnessed a change in requests to access the program. We have therefore evaluated their temporal trend, the need to change the access criteria, the percentage of transplants performed, the time of request satisfaction, and the follow-up. METHODS: We analyzed all the liver requests for the HU program received during the 4-year period of 2014 to 2017 for adult recipients (≥18 years of age): all the variables linked to the recipient or to the donor and the organ transplants are registered in the Informative Transplant System as established by the law 91/99. In addition, intention to treat (ITT) survival rates were compared among 4 different groups: (1) patients on standard waiting lists vs (2) patients on urgency waiting lists, and (3) patients with a history of transplant in urgency vs (4) patients with a history of transplant not in urgency. RESULTS: Out of the 370 requests included in the study, 291 (78.7%) were satisfied with liver transplantation. Seventy-nine requests (21.3%) have not been processed, but if we consider only the real failures, this percentage falls to 13.1% and the percentage of satisfied requests rises to 86.9%. The average waiting period for liver transplantation (LT) is 1.7 days and most requests (74%) are met in less than 24 hours, if we consider the hours between the registration of the request and the donor reporting . The percentage of late retransplantations is 2.1%. The clinical indication for HU-LT that appears to improve over time is hepatic artery thrombosis (82.5%). The overall 1-year patient survival is 68.3%. The overall 1-year graft survival, performed on all the patients, is 89% and all the indications for HU-LT appear to go well over time with an average survival rate greater than 85%. CONCLUSIONS: The indications for HU-LT are changing according to the changes in the hepatologic field in recent years. The centralized management of requests has proven to be successful in optimizing responses. Urgent LT is confirmed to be lifesaving in its timeliness.

Colonization and infection due to carbapenemase-producing Enterobacteriaceae in liver and lung transplant recipients and donor-derived transmission: a prospective cohort study conducted in Italy.

OBJECTIVES: A prospective cohort study was conducted in Italy in order to describe the microbiologic aspects of colonization/infection by carbapenemase-producing Enterobacteriaceae (CPE) in donors and recipients of lung and liver transplants and the possible CPE transmission from donors to recipients. METHODS: Between 15 January 2014 and 14 January 2015, all recipients of solid organ transplants (SOT) at ten lung and eight liver transplantation centres and the corresponding donors were enrolled. Screening cultures to detect CPE were performed in donors, and screening and clinical cultures in recipients with a 28-day microbiologic follow-up after receipt of SOT. Detection of carbapenemase genes by PCR, genotyping by multilocus sequence typing, and pulsed-field gel electrophoresis and whole-genome sequencing were performed. RESULTS: Of 588 screened donors, 3.4% were colonized with CPE. Of the liver first transplant recipients (n = 521), 2.5% were colonized before receipt of SOT and 5% acquired CPE during follow-up. CPE colonization was higher in lung first transplant recipients (n = 111, 2.7% before SOT and 14.4% after SOT). CPE infections occurred in 1.9% and 5.3% of liver or lung recipients, respectively. CPE isolates were mostly Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae belonging to CG258. Three events of donor-recipient CPE transmission, confirmed by whole-genome sequencing and/or pulsed-field gel electrophoresis, occurred in lung recipients: two involving K. pneumoniae sequence type 512 and one Verona integron-encoded metallo-ß-lactamase (VIM)-producing Enterobacter aerogenes. CONCLUSIONS: This study showed a low risk of donor-recipient CPE transmission, indicating that donor CPE colonization does not necessarily represent a contraindication for donation unless colonization regards the organ to be transplanted. Donor and recipient screening remains essential to prevent CPE transmission and cross-infection in transplantation centres.

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.

Ethical Issues in Uterine Transplantation: Psychological Implications and Informed Consent.

Since 2000, 13 uterine transplantations (UTxs) have been performed in women with absolute uterine infertility factor (AUIF), from both living and deceased donors, in different transplantation centers worldwide. At present the birth of 4 children following UTx is documented by the literature, and a woman was having a second pregnancy in October 2015. Following these successes it is likely that the procedure will become part of normal healthcare practice, even though at the moment it is still experimental and, as such, requires careful attention. Because the emotional aspects that are tied to UTx may foster the "therapeutic misconception" of participants, which consists in an overestimation of the benefits and an underestimation of the risks, careful attention should be paid also to informed consent (IC), which must include the following: describing techniques, pointing out risks and possibility of failure, and informing about the treatments required after the intervention. Because the final aim of UTx is the birth of a healthy child, the IC document must include details not only of the transplantation itself, but also of the very particular pregnancy deriving from it, and the need to remove the uterus following delivery(ies) to avoid these risks. Here we suggest that the IC process includes counselling techniques, possibly involving the psychologist that is part of the transplantation team, to target the information and decision-making process to the specific situation of each couple.

Analysis of the Organ Offers Received From European Union Countries Before and After the Introduction of a Dedicated Information Technology Portal: The COORENOR/FOEDUS Portal.

INTRODUCTION: To optimize the use of nontransplantable organs in their own territory, the European Commission, as part of a project led by Italy, has promoted the use of an information technology (IT) portal, the COORENOR portal, developed by the Czech Republic in 2012, which evolved to become FOEDUS in 2015. METHODS: To evaluate the impact of the portal on our reality, we analyzed the number and type of offers received and organs imported in the previous 48 months (period A) as well as the 48 months after the introduction of the portal (period B). We also examined the origin and the offer mode. RESULTS: The offers received were 404 and 753, respectively, in the two periods, with 315 (41.8%) organs received through the portal. The organs transplanted were 53 and 64, respectively, in the two periods; 20 (31.2%) were sent through the portal. The most commonly offered organs are lungs (36.7% and 29.3% of offers in periods A and B, respectively). The most transplanted organ is the liver (59.4% and 45% of transplants in periods A and B, respectively). The use of the portal has gradually increased, growing from 16.4% of the offer mode in 2012 to 84.7% in 2016. CONCLUSIONS: The increase of offers related to the increase of donations and the attitude to the sharing of resources has determined an increase of 19.2% of total transplants, especially for certain types such as pediatric transplants. The portal, ensuring speed and simultaneity of offer, real time sharing of information and transparency of allocation, is also used for trade in the International Partnership Agreements. Therefore, transplants have been conditioned by the existing agreements with Greece, Malta, and the countries of the South Transplant Alliance.

Transport of Human Organs in Italy: Location, Time, and Performances.

INTRODUCTION: The outcome of transplantation activities depends on a variety of unpredictable factors. Up-to-date criteria on organ allocation foresee an efficient transport chain along with compliant performance parameters. METHODS AND OBJECTIVES: The Centro Nazionale Trapianti and the Department of Civil, Chemical, Environmental, and Materials Engineering of the University of Bologna (respectively, CNT and DICAM) have been updating a national database of organ transplantation activities to investigate performance parameters and the main causes of disruption. RESULTS: Between June 2015 and July 2016, 617 of 1061 organs have been shipped by air (making for 486 flight events), of which 407 were accompanied by medical equipment. Origin/destination and distance matrixes have been drawn for both road and air transport. Each airport node is ranked based on the n° of organs ingoing/outgoing and each route link on its frequency. Performance parameters such as average speed, distance covered, and time have been computed and compared with each organ's cold ischemia time (CIT). Average distance frontiers are rather homogeneous, but much effort is necessary to reduce the number of events performed with approximately 90% or more of CIT spent. CONCLUSIONS: The monitoring of organ transplantation activities' performance is a standalone action within Europe to support strategic policies to optimize the system. Thus, a clearer awareness on performances and issues related to organ transport has been made possible: analyses show that the higher uncertainty associated with total time of displacement by air is due to the steps which take place by road (length and paths must be optimized) and lung transports generally perform weaker than heart transports due to longer average distances travelled and smaller average speeds, often resulting in a total displacement time greater than 90% of CIT.

Hepatitis C Virus Positive Patients on the Waiting List for Liver Transplantation: Turnover and Characteristics of the Population on the Eve of the Therapeutic Revolution With Direct-Acting Antivirals.

INTRODUCTION: Antivirals direct acting (DAA) for hepatitis C virus (HCV) have brought a revolution in the field of transplantation. It is likely to think that in the future patients on the waiting list for liver transplantation (LT) will no longer be registered for HCV-related cirrhosis but for liver disease from other causes. On the eve of this change, we show a snapshot of the Italian waiting list for LT. METHODS: From October 1, 2012 to September 30, 2013, we estimated the total number of patients on the liver waiting list as intention to treat (ITT), the number of incident cases, and the delistings, particularly in the HCV positive (HCV+) population. Gender, median age, etiology and prognosis of liver disease, presence of hepatocellular carcinoma (HCC), reason for delisting, mean waiting time for LT, and rate of death on waiting list were evaluated. RESULTS: In the time period, there were 517 new patients who were HCV+ (median age, 53 years): 255 (49.3%) mono-infected with HCV, 236 (45.7%) co-infected with HCV and hepatitis B virus (HBV), 11 (2.1%) co-infected with HCV and human immunodeficiency virus (HIV), and 15 (2.9%) co-infected with HCV, HBV, and HIV. The median model for end-stage liver disease (MELD) score at listing was 17 and HCC was present in 206 (39.8%) cases. HCV+ patients delisted were 442 (61.9%), 355 (80.3%) for LT. The mean waiting time to transplantation was 1.9 months; the percentage of death was 7.6%. CONCLUSIONS: This snapshot of the waiting list for LT in the year before the advent of DAA drugs will allow us to assess whether and how they will change the waiting list for LT when we start to look at the impact of new therapies on the waiting list.

Optimizing the Use of Available Lungs.

BACKGROUND: Organ transplantation, the treatment of choice in organ failure, is penalized by the lack of organs. Because the increase in the number of donors is not proportional throughout the different age groups, there is no increase in lung transplantations. The aim of this work was to analyze the use of available lungs and evaluate strategies that may help increase transplantations. METHODS: We analyzed the activity of lung transplantation in 2015, divided into various allocation programs. We also examined the surplus organs, in particular, their origin, their destination, their offer's outcome, the characteristics of the donor and the proposed organ, and the reasons for rejection. RESULTS: In 2015, 112 lung transplantations were performed: 66 (68.9%) with regional organs, 46 (41.1%) with extraregional organs; 21 (45.6%) of these were allocated as emergencies/return, and 25 (54.4%) as surplus (19 in the North macroarea, 6 in the South macroarea). The number of surplus lungs was 148: 67 from the North macroarea, 71 from the South macroarea, and 10 from abroad. No organ procured in the North macroarea was transplanted in the South macroarea, whereas 6 lungs coming from the South macroarea were transplanted in the North. CONCLUSIONS: The acceptance criteria are not the same in different transplant centers and they include not only clinical parameters, but also ischemia time and composition of the waiting list at the time of the offer, quality and accessibility of the intensive care units where the donor is located, and organizational reasons. Offering organs which can not be transplanted within the region to other centers, without clinical foreclosures is a system that increases transplant activities by maximizing the available resources.

Liver Allocation in Urgent MELD Score ≥30: The Italian Experience.

INTRODUCTION: Patients with an urgent MELD score ≥30 are managed by the Italian Operative National Transplant Center on the basis of a division of Italy into 2 main areas, the northern macro area (NMA) and the southern macro area (SMA). The object of this study was to evaluate the possibility and the need to transform the MELD score ≥30 macro area-based program into a nationwide one. PATIENTS AND METHODS: When a region reports the presence of a patient with a MELD score ≥30, the same macro area-compatible donors, in the absence of urgent national and 1B status, are offered primarily to this recipient. RESULTS: From August 2014 to August 2015, 132 requests for patients with urgent MELD score ≥30, 98 from the NMA and 34 from the SMA, were handled. The average waiting list in the NMA was significantly different from that of the SMA (2.74 ± 2.29 vs 4.5 ± 3.98, P < .05). A total of 73.7% of the received requests (n = 97) were satisfied: the NMA met 80.4% of the requests (n = 77), whereas the SMA met 55.5% (n = 20). A total of 35 requests (26.5%), 21 from the NMA (60%) and 14 (40%) from the SMA, were not met. The average waiting time of these recipients for a liver was significantly different between the NMA and the SMA (3.14 ± 3.21 vs 5.78 ± 4.59; P < .05). CONCLUSIONS: The MELD score is a priority allocation, and the longer the waiting time to transplantation for these recipients, the more their mortality increases. Given the differences in waiting times between the NMA and SMA, we should start thinking about transforming the macro area program into a national one.

Transportation of Organs by Air: Safety, Quality, and Sustainability Criteria.

INTRODUCTION: The outcomes of organ transplantation activities are greatly affected by the ability to haul organs and medical teams quickly and safely. Organ allocation and usage criteria have greatly improved over time, whereas the same result has not been achieved so far from the transport point of view. Safety and the highest level of service and efficiency must be reached to grant transplant recipients the healthiest outcome. OBJECTIVES: The Italian National Transplant Centre (CNT), in partnership with the regions and the University of Bologna, has promoted a thorough analysis of all stages of organ transportation logistics chains to produce homogeneous and shared guidelines throughout the national territory, capable of ensuring safety, reliability, and sustainability at the highest levels. METHODS: The mapping of all 44 transplant centers and the pertaining airport network has been implemented. An analysis of technical requirements among organ shipping agents at both national and international level has been promoted. A national campaign of real-time monitoring of organ transport activities at all stages of the supply chain has been implemented. Parameters investigated have been hospital and region of both origin and destination, number and type of organs involved, transport type (with or without medical team), stations of arrival and departure, and shipping agents, as well as actual times of activities involved. RESULTS: National guidelines have been issued to select organ storage units and shipping agents on the basis of evaluation of efficiency, reliability, and equipment with reference to organ type and ischemia time. Guidelines provide EU-level standards on technical equipment of aircrafts, professional requirements of shipping agencies and cabin crew, and requirements on service provision, including pricing criteria. CONCLUSIONS: The introduction in the Italian legislation of guidelines issuing minimum requirements on topics such as the medical team, packaging, labeling, safety and integrity, identification, real-time monitoring of temperature, and traceability of the organ during the logistics chain is deemed a valid response to the necessity of improving safety, reliability, and sustainability of organ transplantation activities in Italy.

Inflammatory and Adipose Response in Solid Organ Transplant Recipients After a Marathon Cycling Race.

BACKGROUND: Organ transplant recipients frequently have chronic inflammation, with a weighty impact on cardiovascular risk. These patients can benefit from exercise, although the role of intense training is unclear. We evaluated the effect of a 130-km cycling race on inflammatory cytokines and adiponectin levels in transplant recipients. METHODS: Circulating interleukin (IL)-6, tumor necrosis factor (TNF)-α, interferon (IFN)-γ, and adiponectin were assayed in 35 healthy subjects vs 19 transplant recipients (10 kidney, 8 liver, 1 heart), matched for sex, age, body mass index, and preparation workout. The determinations were performed before the race, at the end, and after 18 to 24 hours. Baseline values of 32 sedentary transplant recipients also were evaluated to explore the possible chronic impact of lifestyle. RESULTS: All cyclists had 6- to 8-fold increased IL-6 levels after the race that decreased, without returning to baseline, the day after. Conversely, serum TNF-α and IFN-γ showed a progressive increase starting during physical performance and enduring for the next 18 to 24 hours in healthy subjects, whereas they were unchanged over time in cyclists with transplants. In transplant recipients who did not perform exercise, all of the analytes were significantly higher in comparison to basal levels of physically active subjects. CONCLUSIONS: Our data suggest that clinically stable and properly trained transplant recipients can safely perform and progressively benefit from exercise, even at a competitive level. The changes in inflammation parameters were temporary and parallel with those of the healthy subjects. The comparison with sedentary transplant recipients revealed an overall amelioration of inflammatory indexes as a possible effect of regular physical activity on systemic inflammation.

Solid Organ Transplantation in HIV+ Recipients: Italian Experience.

INTRODUCTION: According to current estimates, there are about 540,000 patients who are infected with HIV in Western Europe, of which about 3100 are potential candidates for organ transplantation. In Italy, there are currently 85 HIV patients on the transplant list. METHODS: Organ transplantation activity in HIV recipients from 2002 to December 2014 was assessed from the database provided by the Transplant Center of Modena until the year 2011. For the years 2012 to 2014, data are from the Transplant Information System (SIT). The follow-up data have been extracted from the function "Quality" of the SIT. RESULTS: The transplant centers on Italian territory that meet the requirements according to national protocol are in total 29: 11 for the liver, 9 for the kidney including 1 pediatric, 3 for the heart, 3 for the lungs, and for 3 for the combined kidney-pancreas. Since 2002, 257 organ transplantations were carried out, including 185 liver, 59 kidney, 5 combined liver-kidney, 5 combined kidney-pancreas, 2 heart, and 1 double lung. The first cause of death is represented by co-hepatitis C virus infection, in particular in 26 liver recipients (37%) and in 3 kidney recipients (20%). CONCLUSIONS: The analysis showed that transplantation activity in HIV is on the rise, especially in the last 2 years, with an outcome similar to that reported in the literature.

[Kidney transplantation in Italy: an evolving scenario]. / Il trapianto di rene in Italia: una realtà in evoluzione.

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.

Deaths with acute cerebral lesions in ICU: does the number of potential organ donors depend on predictable factors?

BACKGROUND: As the potentiality of deceased organ donation mostly depends on the number of brain deaths (BDs), the aim of this study is to quantify rates and probabilities of BD declaration in Italy. METHODS: Deaths with acute cerebral lesion (ACLDs) in the Italian ICUs have been prospectively collected. A total of 27,490 ACDLs occurred in 5 years. Age, gender, etiology, timing of death and ICU Region have been utilized for multivariate analysis. RESULTS: The global ratio of BD declarations to ACLDs was 39.9%. The rates of ACLDs, BD declarations and actual donors were 93.5, 37.3 and 19.7 pmp respectively. Wide variability resulted among Regions, with 148.2 ACLDs, 77.8 BD declarations and 42 donors pmp as benchmark. The probability of being BD declared was significantly higher in stroke compared with head injury (OR 1.6, P<0.001) and in females (OR 1.5, P<0.001), with half the Regions missing around 50% of BD declarations compared with the benchmark, particularly in elderly patients. CONCLUSION: Predictable factors associated with BD declaration can be identified in ACLD management. Positive factors leading to the identification of potential organ donors, i.e., the capacity of declaring BD in all the patients fulfilling BD criteria irrespective of age and etiology, could be captured in the best performing regions and reproduced throughout the Country. The implementation of simple indicators based on prospective ACLD monitoring, i.e. the declared BDs to ACLDs in ICU ratio, may be helpful in achieving efficiency targets and reliable comparisons of outcomes in the identification of BD potential organ donors.

Short-term thoracic duct drainage in drug resistant immunologically mediated glomerulonephritis. Evaluation of lymph and blood lymphocyte characteristics during drainage.

Thoracic duct drainage has so far been employed in clinical nephrology mainly in renal transplantation and in immunologically mediated glomerulonephritis. The effectiveness of duct drainage in producing immunosuppression has been widely demonstrated, and several authors have used long-term, and others short-term drainage. 12 patients suffering from drug resistant immunologically mediated glomerulonephritis were treated with short-term (mean 10 days) thoracic duct drainage. In order to define the time, type and evolution of changes in immunological status, humoral and cellular immunity were studied daily in all patients. Marked changes (mainly in the number of lymphocytes drained and in their nucleic acid content and E-rosette forming capacity) take place in the first (4-5) days of drainage. These findings, together with positive clinical and laboratory results obtained in our patients, suggest that satisfactory immunosuppression may be achieved by short-term drainage, which is simpler and safer than long-term drainage. The procedure might thus be extended to a wider number of immunological diseases where drug therapy fails to take effect.