Donor Action: an international initiative to alleviate organ shortage.

CONTEXT: Donor Action, an international initiative to alleviate organ shortage, provides a comprehensive state-of-the-art methodology that helps critical care units develop a tailor-made approach to optimize donation practices and performance. OBJECTIVE: To report the impact of the Donor Action methodology on organ donation rates in 8 countries (70 critical care units) in North America and Europe. DESIGN: Baseline data on the clinical potential for donation, staff attitudes, knowledge toward donation, self-reported confidence in performing a range of donation roles, and educational requirements were gathered. These data were analyzed using the Donor Action database and improvement measures were introduced to address identified weaknesses. RESULTS: Following introduction of the program's improvement measures, which addressed identified weaknesses, donations increased on average by 53% (P = .0017) per country at 1 year. Sustained improvements settled at 70% to 160% increases at 3 years. Although Donor Action is at various stages of implementation in different countries, the number of centers and countries demonstrating an immediate awareness effect is increasing and sustained effects in centers with the longest follow-up promise a significant impact on donation rates as more countries implement this methodology.

Inferior outcome of cadaveric kidneys preserved for more than 24 hr in histidine-tryptophan-ketoglutarate solution. Leuven Collaborative Group for Transplantation.

BACKGROUND: During recent years, an increasing number of transplant centers within the Eurotransplant organization have used histidine-tryptophan-ketoglutarate (HTK) solution instead of University of Wisconsin (UW) solution as their preferred cold storage solution for abdominal organ preservation. We report on our single-center experience on the outcome of imported kidneys preserved with either HTK or UW solution in relation to the duration of cold ischemia time (CIT). METHODS: Between July 1989 and July 1997, 323 cadaveric kidneys preserved with UW or HTK and imported as a result of an exchange within the Eurotransplant organization were transplanted at our institution. CIT was <24 hr in 216 kidneys (UW: n=174, HTK: n=42) and > or =24 hr in 107 kidneys (UW: n=67, HTK: n=40). Renal functional outcome was evaluated by comparing delayed graft function and initial non-function rates, daily urinary output, the evolution of serum creatinine, and creatinine clearance at 1, 3, 5, 7, and 14 days and at 1, 3, 6 and 12 months, and graft survival at 1 year after transplantation in relation to the type of cold storage solution and CIT < or > or =24 hr. RESULTS: Whereas the incidence of delayed graft function did not differ significantly between kidneys preserved for less than 24 hr in UW (18.6%) or HTK (26.2%), this rate increased to 50% in HTK kidneys compared to 23.9% in UW kidneys when CIT exceeded 24 hr (P=0.006). Mean serum creatinine and creatinine clearance values were better at 1 and 5 days postoperatively in kidneys preserved <24 hr with UW as compared to HTK (P<0.05). After 24 hr of CIT, HTK-preserved kidneys showed an impaired renal function, not only in the immediate postoperative phase but also at 1, 3, 6, and 12 months after transplantation (P<0.05). Graft survival at 1 year was 92.9% in UW vs. 87.5% in HTK kidneys preserved for <24 hr (NS), and 91% vs. 77.4% when CIT exceeded 24 hr (P=0.059). CONCLUSIONS: From these single-center findings, it can be concluded that UW is superior to HTK in kidney preservation, particularly when CIT exceeds 24 hr.

The relative impact of presumed-consent legislation on thoracic organ donation in the Eurotransplant area.

A country's organ donation rate and hence the availability of thoracic organs can be increased by organizational measures, by legislative incentives, and by increasing awareness among the public and healthcare professionals. We analyzed the relative impact of organ procurement legislation or policy on heart and lung donation rates per million population per year in the four countries participating in the Eurotransplant organization (population, 112.7 million) between January 1992 and December 1994. Within this organization, Austria and Belgium have presumed-consent legislation, whereas Germany and the Netherlands have an opting-in (explicit-consent) policy. Although practices vary even among countries with similar policies (eg. in Belgium, relatives of the donor retain the right to object to procurement of organs in the absence of an explicit consent from the deceased before death), rates of heart and lung donation were at least twice as high in the two countries with presumed-consent legislation as in the two countries that rely on a policy of explicit consent from the donor's next of kin.

Chronic renal allograft failure: clinical overview. The Leuven Collaborative Group for Transplantation.

The factors that have led to a steady improvement of one-year renal allograft survival, have not resulted in better long-term outcome. Main causes of chronic renal allograft failure are patient death with a functioning transplant, chronic rejection and non-compliance with immunosuppressive therapy. The role of hyperfiltration as a cause of graft failure is at present unclear. Among the risk factors associated with allograft outcome are donor- and recipient characteristics, HLA matching, delayed graft function and acute rejection episodes. As with short-term results there are considerable differences between transplant centers. The effect of cyclosporine-based immunosuppression on late graft outcome is still controversial. Possibly, the potential benefit of cyclosporine is obscured due to suboptimal dosing in the fear of chronic nephrotoxicity.

A single-center multiple regression analysis of covariates associated with long-term cadaveric renal allograft survival: further improvement of long-term results with CsA.

This single center analysis shows further improvement in the already excellent long-term, cadaveric renal allograft survival with Aza since the introduction of CsA. In contrast to the findings from the UCLA/UNOS multicenter registries, these results support other observations that the type of maintenance immunosuppression does indeed influence the long-term attrition rate of cadaveric, renal allografts.

A prospective, randomized trial of pretransplant blood transfusions in cadaver kidney transplant candidates. Leuven Collaborative Group for Transplantation.

To assess the effect of pretransplant blood transfusions on the outcome of cadaveric kidney transplantation, a single-centre analysis was performed of 171 patients randomly assigned to receive no pretransplant transfusion (n = 85) or to receive at least three random blood transfusions (n = 86). After transfusion 18 of the latter patients developed circulating lymphocytotoxic T-cell antibodies, but the sensitization was only transient. At the time of transplantation, none was still sensitized. In both groups 60 patients have been transplanted. Patient and graft survival rates were significantly higher in the transfused group than in the non-transfused group. In the non-transfused patients the higher mortality was due to complications related to repeated anti-rejection therapy. Non-transfused patients had more repeated acute rejection episodes than the transfused patients. The present study indicates that pretransplant blood transfusions still facilitate graft acceptance even in the setting of good HLA matching and with cyclosporine as the basic immunosuppressant. The risk of sensitization is very low.

The influence of donor age on initial and long-term renal allograft outcome. Leuven Collaborative Group for Transplantation.

To investigate the impact of donor age on the immediate and long-term graft outcome, 808 primary cadaveric renal allograft recipients, transplanted between January 1983 and December 1992, were divided into six groups according to donor age: 10-19 years (n = 142), 20-29 years (n = 214), 30-39 years (n = 136), 40-49 years (n = 146), 50-59 years (n = 142), 60-69 years (n = 28). The six groups were comparable with regard to donor origin (local/distant), serum creatinine, cold ischemia and reanastomosis time, recipient sex, degree of presensitization, number of pretransplant blood transfusions, number of HLA-B and B/DR mismatches. The incidence of delayed graft function was linearly correlated with increasing donor age, from 11.9% (donors 10-19 years) to 39.3% (donors 60-69 years) (P<0.0001). Graft survival at 3 years was not influenced by donor age (from 89.3% for the youngest donors to 84.4% for donors 60-69 years). After the 3rd decade, the creatinine clearance linearly decreased with donor age (6.2 ml/min, P < 0.01). This progressive decline could not be attributed to the recipient age (-7 ml/decade for 485 recipients < 50 years, and -6.1 ml/decade for 323 patients > or = 50 years). Despite the decreased function in older kidneys, recipient renal function remained remarkably stable between 1 and 3 years after transplantation within each donor age group.