Nota Técnica N. 3/2021 - GERTRAN/CCM - 19813 - fluxo regulatório da Central Estadual de Transplantes de Goiás / Technical Note N. 3/2021 - GERTRAN/CCM - 19813 - regulatory flow of the Goiás State Transplant Center

Em Goiás, desde a publicação do Decreto N.º 4.930/98, que criou o Programa Goiás Transplantes, as ações relacionadas aos transplantes, tem evoluído constantemente, atingindo um maior número de doadores, os órgãos e tecidos captados são enviados para outras unidades federativas. Diante disso, todo esse processo complexo é monitorado pelo Sistema Nacional de Transplantes ­ SNT do Ministério da Saúde ­ MS e para padronizar e organizar essas atividades a Portaria MS/SAS N.º 2600/2009, determina que a coordenação, promoção, controle e fiscalização das ações relacionadas aos transplantes, são incumbências das Centrais Estaduais de Transplantes ­ CETs. Tendo em vista que no âmbito dos receptores, as ações iniciam-se com a inclusão em lista de espera para o transplante, desse modo, é intrínseco que entre as responsabilidades da CET/GO há o compromisso com as atividades de regulação do acesso, para este fim. De modo a atender a demanda existente em Goiás, a CET/GO apresenta o fluxo regulatório para as solicitações do agendamento de consultas destinadas à avaliação especializada em transplantes em todas as modalidades disponibilizadas, via SUS no Estado

In Goiás, since the publication of Decree N.º 4.930/98, which created the Goiás Transplants Program, actions related to transplants have constantly evolved, reaching a greater number of donors, the organs and tissues collected are sent to other federative units. . Therefore, this entire complex process is monitored by the National Transplant System - SNT of the Ministry of Health - MS and to standardize and organize these activities, Ordinance MS/SAS N.º 2600/2009 determines that the coordination, promotion, control and supervision of actions related to transplants, are the responsibility of the State Transplant Centers ­ CETs. Considering that, in the scope of the recipients, the actions begin with the inclusion in the waiting list for the transplant, in this way, it is intrinsic that among the responsibilities of the CET/GO there is the commitment to the activities of access regulation, to this end. In order to meet the existing demand in Goiás, CET/GO presents the regulatory flow for requests for scheduling appointments for specialized evaluation in transplants in all available modalities, via SUS in the State

Local versus distant lung donor procurement does not influence short-term clinical outcomes.

OBJECTIVE: The purpose of this study was to recognize clinically meaningful differences in lung transplant outcomes based on local or distant lung procurement. This could identify if the lung allocation policy change would influence patient outcomes. METHODS: This single-center retrospective cohort study analyzed adult patients who underwent lung transplant from 2006 to 2017. Donor and recipient data were abstracted from a collaborative, prospective registry shared by our local organ procurement organization, and tertiary medical center. Short-term outcomes, 1-year survival, and hospitalization costs were compared between local and distant lung transplants defined by donor service area. RESULTS: Of the 722 lung transplants performed, 392 (54%) had local donors and 330 (46%) had distant donors. Donors were similar in age and cause of death. Recipients were significantly different in diagnosis and local recipients had lower median lung allocation scores (local, 37.3 and distant, 44.9; P < .01). Distant lung transplants had longer total ischemic times (local, 231 ± 52 minutes and distant, 313 ± 48 minutes; P < .01). The rate of major complications, length of hospital stay, and 1-year survival were similar between groups. Distant lung transplants were associated with higher median overall cost (local, $183,542 and distant, $229,871; P < .01). Local lung transplants were more likely to be performed during daytime (local, 333 out of 392 [85%] and distant, 291 out of 330 [61%]; P < .01). CONCLUSIONS: Local lung transplants are associated with shorter ischemic times, lower cost, and greater likelihood of daytime surgery. Short- and intermediate-term outcomes are similar for lung transplants from local and distant donors. The new lung allocation policy, with higher proportion of distant lung transplants, is likely to incur greater costs but provide similar outcomes.

Hypothermic preservation of rat hearts using antifreeze glycoprotein.

Antifreeze proteins are an effective additive for low-temperature preservation of solid organs. Here, we compared static hypothermic preservation with and without antifreeze glycoprotein (AFGP), followed by nonfreezing cryopreservation of rat hearts. The heart was surgically extracted and immersed in one of the cardioplegia solutions after cardiac arrest. Control rat hearts (n=6) were immersed in University of Wisconsin (UW) solution whereas AFGP-treated hearts (AFGP group) (n=6) were immersed in UW solution containing 500 ?g/ml AFGP. After static hypothermic preservation, a Langendorff apparatus was used to reperfuse the coronary arteries with oxygenated Krebs-Henseleit solution. After 30, 60, 90, and 120 min, the heart rate (HR), coronary flow (CF), cardiac contractile force (max dP/dt), and cardiac diastolic force (min dP/dt) were measured. Tissue water content (TWC) and tissue adenosine triphosphate (ATP) levels in the reperfused preserved hearts were also assessed. All the parameters were compared between the control and AFGP groups. Compared with the control group, the AFGP group had significantly (p<0.05) higher values of the following parameters: HR at 60, 90, and 120 min; CF at all four time points; max dP/dt at 90 min; min dP/dt at 90 and 120 min; and tissue ATP levels at 120 min. TWC did not differ significantly between the groups. The higher HR, CF, max dP/dt, min dP/dt, and tissue ATP levels in the AFGP compared with those in control hearts suggested that AFGP conferred superior hemodynamic and metabolic functions. Thus, AFGP might be a useful additive for the static/nonfreezing hypothermic preservation of hearts.

Drástico impacto de la epidemia de COVID-19 sobre la actividad de donación y trasplante en España / Dramatic impact of the COVID-19 outbreak on donation and transplantation activities in Spain

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Why NOTTO? The National Organ and Tissue Transplant Organisation and Why It Is Crucial to Regulate Organ Donation and Transplantation in India.

OBJECTIVES: This study addresses the establishment of the National Organ and Tissue Transplant Organisation (NOTTO) and its impact on organ donation and transplantation in India. METHODS: Yearly data, 2013 to 2018, from all the states and union territories of India as per the World Health Organization-Global Observatory on Donation and Transplantation (WHO-GODT) format, were analyzed and tabulated. The various national and international legislation, advisories, and reports that mandated establishment of national regulatory bodies were studied. Comparisons were drawn, noting points of similarity and contrast between analogous organizations. RESULTS: In the WHO Madrid Report 2004, the international advisory highlighted the need for a national transplantation agency for effective integrated development of donation and transplantation. Its parallel in India was the 2011 Amendment of the Transplantation of Human Organs Act 1994 to set NOTTO up with its first director in 2014, and also with a national donor and recipient registry to achieve transparent allocation. A challenging task for NOTTO was to collect from all transplant and/or retrieval centers their real-time data of donors, recipients, and transplants in the National Organ and Tissue Transplant Registry (NOTTR). However, NOTTO succeeded in collecting data offline from all 29 states and 7 union territories and submitted to GODT in 2019. There was a greater than 2-fold increase of deceased organ donors from 340 in 2013 (pre-NOTTO) to 875 in 2018 (post-NOTTO). The deceased organ donation rate went up from 0.27 to 0.65, and the total number of transplants went up from 4990 to 10,340 in the same period. All the outcome measures doubled or tripled, establishing the role of NOTTO. Albeit having differences, NOTTO is analogous to the National Transplant Organization of Spain and United Network of Organ Sharing of the United States. CONCLUSION: The 2011 Amendment of THOA 1994 provided the basis for the establishment of NOTTO, which has been crucial in regulating organ donation and transplantation in India with the setting up of the NOTTR in 2015. NOTTO has been instrumental in augmenting all outcomes.

São Paulo State Liver Transplantation Supply Chain Study.

BACKGROUND: The number of liver transplantations is increasing worldwide, and Brazil ranks in the second position. It has one of the biggest public health care systems, which is responsible for the coordination and financial funding of transplantation procedures. Meeting the demands of such a large system of transplantation has become a challenge, particularly when attempting to minimize costs of scarce and expensive resources. The aim of this study was to investigate the process of donation, the retrieval of organs, and the transplantation itself using engineering methods based on logistics analyses. METHODS: Three steps were used: study planning, data gathering, and data analysis. Researchers surveyed professionals to acquire raw information based on their observations, experience, and knowledge. Then, a data analysis was conducted, putting together all the information gathered during the previous steps. Bias was removed, and conflicting perceptions were resolved in order to have a standard view on the transplantation process. RESULTS: Data was gathered between 2014 and 2018 and included 5502 liver donors and 2678 (48.7%) patients who received liver transplants organs. A total of 2824 organs were refused because of logistics issues (transport and handling). Interviews of health care professionals enabled the design of a process map in which 4 stakeholders were identified: patient, physician, organ, and information. CONCLUSIONS: The liver transplantation process is analyzed based on a supply chain methodology applying this knowledge and putting together medical and engineering sciences to promote better efficiency and outcomes for the transplantation program. Future studies should focus on the implementation of these ideas aiming to promote optimization gains in any step of the process.

Suboptimal Donors Do Not Mean Worse Results: A Single-Center Study of Extending Donor Criteria for Lung Transplant.

BACKGROUND: Lung transplant remains the only viable treatment for most of the end-stage lung diseases. It is believed that extending criteria for donor lungs would increase the number of lung transplants. The aim of the study was to compare the graft function by means of oxygenation index among recipients who received the lungs from donors of extended criteria with those whose received lungs from donors who met the standard criteria. METHODS: This retrospective study analyzed 71 donors whose lungs where transplanted into 71 first-time double lung recipients of 2 groups: patients who received transplants before and after 2018. The objective was to assess whether there is a significant difference in quality of the donor pool after applying extended criteria. The second objective was to compare results of recipients with lungs from donors of oxygenation index > 400 mm Hg with those obtained among recipients with this parameter < 400 mm Hg. RESULTS: In the case of transplants performed in 2018 to 2019, oxygenation indices were significantly lower in donors but significantly higher in recipients on the first day than those observed in 2015 to 2017. The number of transplants increased from 9 per year to 22 per year. Irrespective of whether the donor had PaO2/fraction of inspired oxygen above or below 400 mm Hg, recipients showed similar oxygenation index values after transplant (mean oxygenation index, 462 vs 412 mm Hg, respectively). Short-term mortality did not differ either. CONCLUSIONS: Extended criteria of lungs suitability as a potential grafts not only increases the donor pool but also proves that suboptimal donors are not associated with producing inferior results of the recipients.

Donation after circulatory death liver transplantation: What are the limits for an acceptable DCD graft?

The utilization of donation after circulatory death (DCD) livers has been growing over the last decade. In large-volume centers, survival outcomes have improved and are comparable to outcomes with brain death donor (DBD) liver transplantation (LT). The relatively concentrated success with DCD LT demonstrated by high-volume transplant centers has rekindled international enthusiasm. The combination of increasing expertise in DCD LT and ongoing shortage in transplantable organs has promoted expansion of the DCD donor pool with regards to donor age, body mass index and donor warm ischemia time. In this review, we focused on the practice patterns in DCD liver graft utilization in the last decade, along with the possibilities for further expansion of DCD liver graft utilization and new technologies, such as machine perfusion.

Expanded Criteria Donor Kidneys With Kidney Donor Profile Index ≤ 85%: Are We Doing Enough to Counsel Our Patients?

BACKGROUND: Kidneys at higher risk for allograft failure are defined by the Kidney Donor Profile Index (KDPI) > 85% in the current kidney allocation system (KAS), replacing the historical concept of expanded criteria donor (ECD) kidneys in the previous KAS. Discrepancies exist in the classification of "high-risk kidneys" between the 2 KAS. In the current KAS, only recipients of KDPI > 85% kidneys are counseled about the high risk of allograft failure and are required to sign a consent. In this study, we evaluated the outcomes and allocation of kidneys with discordant classification. METHODS: Using the Scientific Registry of Transplant Recipients, kidneys transplanted between 01/2002 and 09/2016 were classified according to the old (standard criteria donor [SCD]/ECD) and current (KDPI) KAS. We then grouped them as concordant (KDPI ≤ 85% + SCD or KDPI > 85% + ECD) and discordant (KDPI ≤ 85% + ECD or KDPI > 85% + SCD) kidneys. RESULTS: Approximately 11% of transplanted kidneys were discordant in classification. Among kidneys with KDPI ≤ 85%, ECD status conferred a 64% (95% CI: 56%-73%) higher risk of allograft failure compared to SCD status. However, SCD/ECD status was not associated with differential outcomes in KDPI > 85% kidneys. These ECD kidneys have KDPIs > 50% and have been transplanted across all estimated post-transplant survival (EPTS) deciles. CONCLUSION: Adequate counseling about the risk and benefit of accepting ECD kidneys with KDPI ≤ 85% versus waiting on dialysis should be explored with the patients, especially those with lower EPTS.

Cadaveric Organ Donation in Lebanon: Proposed Suggestions for Improvement.

Organ transplantation is the treatment of choice for most end-stage diseases, despite the continuous advancements in the medical and surgical field. The dilemma of the shortage between supply and demand of organs for transplantation has been an ongoing debate and concern. The well-known "Spanish Model" was established in 1989 and adopted by the National Transplant Organization. The main commitment of the National Transplant Organization is to increase organ donation and transplantation rates. The program was also successfully adopted in countries such as Australia and Great Britain as well as Latin-American countries. The system is based on recruitment of cadaveric organs by a specialized team in hospitals at the regional and national level. Lebanon hopes to initialize a model similar to the Spanish Model but faces several obstacles. Adopting such a model could help increase cadaveric organ donation in Lebanon.

Hypothermic Machine Perfusion as an Alternative to Biopsy Assessment in Transplantation of Kidneys Donated After Cardiocirculatory Death: A Pilot Study.

BACKGROUND: Transplantation of kidneys from donation after cardiocirculatory death (DCD) donors is becoming an ever-increasing reality. So far, biopsy histologic assessment is the main parameter for evaluation of graft suitability, but it has several drawbacks and has poor reliability. The aim of this study is to verify if real-time renal resistance (RR) measurement during hypothermic machine perfusion (HMP) can be used as a reliable parameter to evaluate the quality of grafts from DCD and extracorporeal membrane oxygenation (ECMO) donors. METHODS: From January 2015 to September 2018, HMP has been systematically applied to all organs from DCD and ECMO donors. All grafts underwent preimplantation biopsy histologic assessment with Karpinski's score. Single kidney transplants (SKTs) or double kidney transplants (DKTs) were performed according to biopsy score results. Kidneys were considered suitable for transplant if RR reached ≤ 1.0 within 3 hours of perfusion. RR trend and postoperative outcome were analyzed considering biopsy score and donor type. RESULTS: A total of 30 kidneys (15 from DCD and 15 from ECMO donors) were used to perform 26 transplants (22 SKTs and 4 DKTs). Considering RR trend, all grafts were considered suitable for transplant within 1 hour of perfusion. Biopsy confirmed this result in all cases, and median score was 3 (range, 0-7). SKT score kidneys had lower starting RR than DKT ones (1.88 vs 2.88; P = .04) but identical final RR (0.58 vs 0.57; P = .76). DKT recipients had faster postoperative creatinine reduction than SKT recipients but similar postoperative day 30 value (1.42 vs 1.15 mg/dL; P = .20). No differences were found between DCD and ECMO grafts in terms of RR trend and postoperative outcome. CONCLUSIONS: HMP can be an alternative to histologic biopsy assessment for evaluation of transplant suitability of DCD and ECMO kidneys. If acceptability threshold is reached, SKT can be performed in all cases. ECMO donors should be considered like DCD donors.

Organ Transplantation From Nonstandard Risk Donors: Midway Between Rigid and Flexible Rules.

In order to bridge the gap between available organs and patients needing transplants, donor selection criteria for donors are increasingly being extended; the possibility of using organs from nonstandard risk donors has been introduced in many countries. This clearly poses considerable ethical issues that should be analyzed and taken into consideration by the competent bodies and institutions. In this article, we illustrate the Italian situation regarding the possibility of using organs from anti-hepatitis C virus (HCV) and HCV RNA-positive donors (anti-HCV+ve) in negative recipients (healthy subjects who have never come into contact with the hepatitis C virus) in light of the availability of new direct-acting antiviral drugs (DAAs) for hepatitis C treatment. We discuss the motivations behind the both favorable opinions of the Ethics Committee of the Italian National Institute of Health (Istituto Superiore di Sanità) and the Italian National Bioethics Committee (Comitato Nazionale per la Bioetica) discussing the main implications from an ethical point of view.

Can We Improve the Effectiveness of the Spanish Nondirected Donation Program?

BACKGROUND: A nondirected altruistic living kidney donor is a person who wants to donate a kidney to anyone in need. In 2010, the Spanish National Transplant Organization developed a national protocol to make the assessment of every potential nondirected living kidney donor. The aim of this study was to describe the potential donor pool and its characteristics and the overall effect of the program. MATERIAL AND METHODS: A retrospective analysis was performed using data from the Spanish National Registry of Transplant Activity, and the Nondirected Donors National Database, between 2010 and 2017. Data related to sociodemographic characteristics, main motivations toward donation, and causes of dismissal were collected from all potential donors. The assessment of each candidate was carried out in a step-by-step process based on the national protocol. RESULTS: Two hundred seventy-two people contacted us, showing interest in the nondirected kidney donation, only 203 people underwent the early triage, and 16 of them successfully completed the assessment proces s, representing 8% of the total. The main motivation toward anonymous donation (n = 161) was: social awareness (22%) and to improve the quality of life of other people (9%). One hundred eighty-two candidates did not proceed, due to medical and psychological contraindications (42%) or donor refusal after specific information about the donation process (33%). The number of utilized nondirected altruistic living donors was 13 out of 203 (6%) of the candidates who began the early triage. Twelve transplant chains and a direct donation were performed, which made 38 kidney transplants possible (2.9 transplants per nondirected donor). CONCLUSIONS: We have to continue working to optimize our program. Our next steps will be to review the evaluation process, to detect areas for improvement, to understand why we lost many possible donors, and to ascertain if any of the reasons could be avoided.

False-Positive Tumor During Organ Retrieval: All Cats Are Gray in the Dark.

OBJECTIVE: Efforts to expand the organ donor pool to meet growing transplant demands remains a top priority, as does maintaining the quality and safety standards of potential recipients. There is a short window of time from organ retrieval to decision making on organ acceptance, based on the available data. Furthermore, the limitations of intraoperative biopsy can often lead to donor or organ refusal due to a suspected tumor, which, if not confirmed in the final biopsy, results in the loss of a transplant opportunity. METHODS: Donor characteristics and organs discarded on suspicion of neoplastic disease at the time of extraction were analyzed in Andalusia between January 2014 and July 2018. The variable analysis included sociodemographic data, type of donor, location of the potential malignancy, histopathologic examination, and discarded organs. RESULTS: A total of 43 cases were identified. The organs of 33 donors (76.7%) were discarded. Kidneys were the most frequent location for a suspected tumor (44%), followed by the liver (21%). In 18 of the 43 cases (42%), the suspected malignancy was not confirmed, and of these, only 3 livers and 1 kidney were implanted. Sixty potentially transplantable organs were discarded, including those that would have been extracted and/or implanted in the absence of a suspected tumor. CONCLUSIONS: These results highlight the need not only to improve the accuracy of intraoperative biopsies but to seek new decision-making strategies for the short interval after organ retrieval. This involves avoiding both extremes of donation contraindications, while maintaining quality and safety standards.

Current Status of Discarded Grafts in Korean Organ Transplantation.

OBJECTIVES: Despite the severe shortage of available organs, many are discarded after procurement. This study aims to analyze the current status of discarded organs (retrieved, but not transplanted organs) from deceased donors in Korea. METHODS: Deceased donor organ and procurement data were collected from the Korean Network for Organ Sharing and Korea Organ Donation Agency database from 2013 to 2016. RESULTS: Between 2013 and 2016, a total of 6315 deceased donor organ transplants were performed nationwide. A total of 63 organs were discarded. The most commonly discarded organs were kidney (n = 24), followed by islet cell (n = 23), lung (n = 9), liver (n = 6), and pancreas (n = 1). The most common cause for discarding solid organs was poor organ condition (n = 24). Other reasons included aggravation of donor condition, incidental cancer detection of the donor, and the abscence of matching recipient. Islet cells (n = 23) were not used because of inadequate separation and purification. CONCLUSIONS: To reduce unnecessary graft discard in Korea, systems-based improvements in preprocurement organ evaluation and postprocurement preservation are imperative.

Liver Donations and Transplants in the State of Paraná, Brazil.

BACKGROUND: The increase in the waiting list for a liver and the high mortality rate of patients with terminal liver disease represent serious public health problems in Brazil. OBJECTIVE: To analyze donations and liver transplants in the State of Paraná, Brazil. METHOD: A cross-sectional study was carried out with data from 3931 reports of deaths due to brain death and 8146 solid organ transplants made available by the State Transplant System of Paraná between 2011 and 2016. The data related to donation and liver transplantation were analyzed using descriptive statistics and inference. RESULTS: A total of 751 (28.9%) liver donations were carried out. Of these, the greatest chance of effectiveness occurred in patients younger than 50 years OR: 1.94 (CI: 1.60-2.34; P < .01) and male OR: 1.27 (CI: 1.06-1.52; P < .01). A total of 720 (8.8%) liver transplants were performed, most of which were funded by the Unified Health System. There was a significant increase in donations and liver transplants over the years. CONCLUSION: Donor numbers and liver transplants increased in the State but did not meet the need for the waiting list within the analyzed period.

Simultaneous Pancreas-Kidney Transplant From Donors After Brain Death vs Donors After Circulatory Death: A Single-Center Follow-up Study Over 3 Decades.

BACKGROUND: Despite an increase in the number of pancreas transplants in the Scandiatransplant region in the last decade, there continues to be a gap between demand and supply of transplantable organs. This imbalance has encouraged the transplant community to consider new sources of grafts, such as the reintroduction of donors after circulatory death (DCD) who were the standard donors in our center before 1988. MATERIAL AND METHODS: In this long-term follow-up study, we compare 44 consecutive, simultaneous pancreas kidney transplants performed at Karolinska University Hospital between 1986 and 1991: 21 patients received DCD grafts and 23 received grafts from donors after brain death. RESULTS: Both groups had similar donor and recipient characteristics, but cold ischemia times were significantly shorter in the DCD group. Warm ischemia times were very short compared with other studies on DCDs. Patient and graft survival rates were similar in both groups. CONCLUSION: This study suggests that controlled DCD pancreas and kidney grafts transplanted simultaneously can be a feasible option for reducing organ shortage without any negative impact on the long-term results.

Expanding the Donor Pool With the Use of Extended Criteria Donation After Circulatory Death Livers.

Use of donation after circulatory death (DCD) donor livers for transplantation has remained cautious in the United States. The aim of this study was to demonstrate the expansion of a DCD liver transplantation (LT) program with the use of extended criteria donor (ECD) DCD livers. After institutional review board approval, 135 consecutive DCD LTs were retrospectively studied. ECD DCD livers were defined as those with 1 of the following factors: donor age >50 years, donor body mass index >35 kg/m2 , donor functional warm ischemia time >30 minutes, and donor liver macrosteatosis >30%. An optimization protocol was introduced in July 2011 to improve outcomes of DCD LT, which included thrombolytic donor flush and efforts to minimize ischemia times. The impact of this protocol on outcomes was evaluated in terms of graft loss, ischemic cholangiopathy (IC), and change in DCD LT volume. Of 135 consecutive DCD LTs, 62 were ECD DCDs. In total, 24 ECD DCD LTs were performed before (era 1) and 38 after the institution of optimization protocol (era 2), accounting for an increase in the use of ECD DCD livers from 39% to 52%. Overall outcomes of ECD DCD LT improved in era 2, with a significantly lower incidence of IC (5% versus 17% in era 1; P = 0.03) and better 1-year graft survival (93% versus 75% in era 1; P = 0.07). Survival outcomes for ECD DCD LT in era 2 were comparable to matched deceased donor LT. With the expansion of the DCD donor pool, the number of DCD LTs performed at our center gradually increased in era 2 to account for >20% of the center's LT volume. In conclusion, with the optimization of perioperative conditions, ECD DCD livers can be successfully transplanted to expand the donor pool for LT.

Lung Allocation Score System: First Italian Experience.

BACKGROUND: Lung transplantation is an established therapeutic option for patients with end-stage pulmonary disease. In May 2005, the lung allocation score (LAS) was introduced in the United States to maximize the benefit to the recipient population and reduce waiting list mortality. The LAS has been applied in a region of Italy since March 2016 on a provisional basis. The aims of the study were describing waiting list characteristics and short-term outcomes after lung transplantation before and after LAS introduction. METHODS: All the patients who received transplants between January 1, 2011, and March 15, 2017, were included in our retrospective study. The study population was divided into 2 cohorts (historical cohort and post-LAS cohort) and a comparison among the main perioperative data was performed. RESULTS: The historical cohort consisted of 415 patients on the waiting list with 91 deaths and 199 lung transplants; the post-LAS cohort consisted of 134 patients with 10 deaths on the waiting list and 51 transplants. Median waiting time and mortality on the list decreased from 223 to 106 days (P = .03) and from 11.2% to 7.5% (P > .05), respectively. The transplantation rate increased from 25% to 38% (P = .001) and the probability to receive a transplant in the first year in the post-LAS era increased significantly (P = .004). CONCLUSIONS: The results of the introduction of the LAS system in our region are encouraging and have not shown any adverse short-term effects. The regional coordination decided to prolong the experimental application of LAS in order to accumulate more data and to evaluate medium-term outcomes.

Ethical Issues in the Use of Suboptimal Kidneys for Transplants: An Italian Point of View.

The shortage of organs leads to the need for utilizing suboptimal kidneys for transplantation. The distinction between optimal, marginal, and suboptimal kidneys leads surgeons to face not only technical problems but also ethical and legal issues related to clinical advantages offered by the transplant of a nonstandard kidney and the acquisition of consent. Between 1999 and 2015, we performed 658 transplants, 49 (7.5%) using suboptimal kidneys. All patients were alive and with vital graft throughout follow-up. We did not encounter any major surgical complications. From a technical point of view, our experience and literature review confirm that transplant of suboptimal kidney leads to good clinical results but exposes patients to a increased risks of surgical complications. Therefore, these interventions must take place in hospitals fully prepared for this type of surgery and performed by experienced transplant surgeons with proper matching between organ and recipient. Considering the insufficient resources available, from an ethical and legal point of view, doctors play an essential role in optimizing the use of these kidneys by avoiding wastage of organs, ensuring that transplants are done in suitable patients, and that patients are fully informed and aware of the risks and benefits associated with the specific suboptimal kidney being transplanted. We believe that, in highly specialized centers, the number of suboptimal kidney transplants should be increased, as their use has shown good clinical results and carries fewer ethical issues compared with marginal kidneys. Further, suboptimal kidneys may also be proposed for use in young patients with end-stage renal disease.