We can and must improve. Even if Italy in 2023 was at second place for number of donors in Europe, with a rate of 28.2 per million inhabitants, in Europe only behind Spain. This is stated by the numbers of the annual activity of the National Transplant Network present in the Report of the National Transplant Center. In short, we are behind Spain (at the top of the planet with 48.9), but ahead of France (26.3), the United Kingdom (21.3) and Germany (11.4).
But, as mentioned, there is still room for improvement. And not just on donations. To use more and more organs and therefore allow you to further reduce waiting lists. In any case, the growth in activity was followed by a decline in the number of patients waiting to receive an organ: as of 31 December 2023 there were 7,941, of which 76% were waiting for a kidney, compared to 8,112 at the end of 2022.
Can transportation be improved?
There is technology, developed by Transmedics, that can promote the availability of organs. Is called Organ Care System (OCS)is CE certified in Europe and is FDA approved in the USA. It is currently used for the heart, liver and lung. In practice, by allowing the donated organs to be kept in a para-physiological condition, i.e. warm, perfused and functioning, it allows their viability to be validated in advance and, consequently, to significantly increase the number of transplantable organs.
The innovation was presented in Rome. OCS (for heart, lung and liver) is a portable monitoring systemcharacterized by being normothermic with a functioning organ (the heart beats, the lung breathes, the liver produces bile). The system is therefore designed to maintain the donated organ itself in a metabolically active state, similar to the physiological one. Thus doctors can monitor key parameters of the functioning organ, evaluating its general condition, vitality and potential suitability. Thanks to this innovation, the aim is to achieve a percentage of organ use, after cardiac or brain death, above 80 percent. Studies show that for the liver the percentage of use would be even higher.
Reduce the risks of “cold” ischemia
“Too frequently it happens that a large part of donated organs are not used for transplantation due to the limitations resulting from their cold storage, i.e. in thermal containers with ice – comments Waleed Hassanein, founder and CEO of TransMedics. This prolonged ischemic statewithout blood supply, can cause permanent damage to the organs furthermore, since the organs themselves are placed in such containers, it is not possible to evaluate their condition and vitality, nor is it possible to intervene on them in order to optimize them. Problems that can be overcome with the use of OCS technology which allows the key parameters of the organs to be monitored even during their transport, placing them in clinical conditions more suitable for transplantation”.
The case of the heart and lung
Igor Vendramin, director of the complex cardiac surgery operational structure of the University Health Authority of Friuli Centrale in Udine, comments on the situation in this way. “The shortage of organs remains strong and the percentage of patients who die on the waiting list is high – recalls the expert. It is well known that the heart represents the most delicate organ due to the reduced tolerance to the period of ischemia which requires very careful selection, severely limiting the number of hearts available. The technological innovation offered by the OCS system and the new organ management method has opened new scenarios in the use of hearts defined as “marginal”, which would not be used with conventional techniques, expanding the number of transplantable patients and thus offering new hope to the numerous people waiting for an organ”.
In Italy it is imbalance between available organs and waiting list it also has a notable impact on lung transplantation. “This situation requires resorting to donors in cardiac death (CDC) or even to those whose organs have a marginal suitability – says Marco Schiavon, of the Thoracic Surgery and Lung Transplant Center division of the University Polyclinic of Padua – In these cases the technology comes to the rescue by allowing the treatment and evaluation of organ function and at the same time reducing the pulmonary ischemia time. The implementation of this system in clinical practice has allowed an increase in the number of transplants in our center (54 procedures in 2023), reducing recipients’ waiting time and, consequently, mortality on the waiting list.”
Why we talk about “marginal” organs for the heart (and not only)
When the potential availability of a heart is verified, the hospital in which the death occurred communicates the availability of the organ to the Regional Transplant Center (CRT). The CRT, in turn, communicates this availability to the National Transplant Center (CNT) which, in turn, takes action to identify a possible recipient, on the basis of strict precedence rules on the list e precise physiological compatibility criteria.
Unfortunately, not all hearts donated and made available for transplant are then used; actually, only 30% of them is actually transplanted. In the remaining 70% of cases, obstacles of various kinds arise which can compromise the transplant; some of these obstacles are absolute contraindications and cannot be overcome, such as a pathology of the coronary arteries or valves.
But there are cases where the organs are called “marginal”. And it is on these that we need to work to increase their availability. This situation can occur, for example, if the organ has been stopped for more than 20 minutes, if the heart to be transplanted has a limited capacity to pump an adequate quantity of blood into the circulatory system, if the tissues are thickened, if the organ , being far from the transplant center, suffers from too long a cold ischemia time. Today, in some cases, the transport of organs still takes place using a thermal container with ice and this method has the major limitation of not allowing the evaluation of “marginal” organs.
