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Networking and Shared Quality Standards
Over National Borders:
A European Roadmap to Improve Organ Retrieval
** Interview with Alessandro Nanni Costa **

ISHLT Links International Correspondents Board Member
University of Bologna
Bologna, Italy

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Dr. Alessandro Nanni Costa, President of the European Committee on Organ Transplantation

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Luciano Potena, MD, PhD, ISHLT Links Associate Editor

Numbers of heart transplantations worldwide are suffering from an important epidemiological shift in donors' and recipients' characteristics. More and more often the standard hearts offered for allocation are far from what used to be considered optimal donations, with ICU management of borderline donors sometimes further decreasing the organ performance and quality, raising concerns for their allocation in highly deteriorated transplant candidates as well as in stable VAD patients. Two categories of candidates now include the vast majority of waiting list patients.

In this scenario, the development of international standards for the quality and safety of donations and of large scale networks for organ sharing and urgency management is still an unmet need that scientific societies, organ procurement agencies, and health authorities should face with joint policies and activities.

Aiming to paint a picture of what is changing in the European stage on the side of organ procurement and international standards, I met with Dr Alessandro Nanni Costa, current director of the CNT (the Italian organ procurement agency) and president of the European Committee on Organ Transplantation. I asked him to share his view and plans with ISHLT members.

L: Dr Nanni Costa, you've recently been elected President of the European Committee on Organ Transplantation (CDTPO). Could you explain to us the role of this organization?

ANC: This committee depends from the Committee of Prime Ministers of the Council of Europe. This organization should not be confounded with European Union. The Council of Europe covers the entire European continent, with 47 member countries, and is aimed to create a common democratic and legal area, developing and promoting human rights, democracy and the rule of law throughout the continent. In this context CDTPO provides guidance and recommendations on the processes of organ donations and related healthcare organizational issues. Its mission is to ensure quality and safety over organ donation procedures, and in absence of specific EU or national laws CDTPO's recommendations represent a very strong reference point for the member countries. In addition it develops and support emerging European countries in creating a donation and transplant system, as for example is happening with the Black Sea project in which we are providing direct organizational support to the Black Sea countries in setting up an efficient transplant system.

You are also among the promoters of a novel supranational transplant organization: the South Transplant Alliance. What is it? A sort of Mediterranean Eurotransplant?

Well ... not exactly. In Europe there are now three supranational transplant organizations which aggregate countries with common cultural backgrounds: Eurotransplant includes central Europe and balcanian countries, and manages organ allocation; Scandiatransplant, in Northern Europe, mainly re-allocates not used organs, and the newborn South Transplant Alliance (STA) includes Spain, France and Italy. These three countries, beyond the common cultural background, have very similar healthcare systems and share common ethical principles in the management of health issues. STA has been conceived as a strategic choice in improving transplant network and the specific weight of Southern Europe in EU transplant policies. The first steps of this alliance will be to set up a shared living donor program, pediatric urgencies and auditing systems. In the future I hope we will be able to create shared standards in the three countries for the quality of the donations, and for the allocations systems, also in thoracic transplantation.

In the European setting, the Italian National Transplant Center is viewed as a model for the other organ procurement agencies; which are its exportable strengths and which are the weak points the international cooperation may improve?

The strength of the Italian system is the network. We have a shared network of high quality controls on the donor safety, with the possibility of 24hrs on-call service for a second opinion regarding the infectious and neoplastic risk related to the donor. Regional transplant coordinators are the knots that hold this network. In addition, a systematic auditing program and a crystal clear system of high urgency management made our transplant surgeons and physicians very confident on being an active part of transplant and donation network: everyone is fighting the battle on the same side, the patient's. The system is so much integrated in the way transplant professionals are working that heart transplant centers have asked the CNT to promote a similar network of quality controls and auditing system on VAD implant. On the other hand, our system needs to improve the mechanism of donations and donor management in the ICUs, which is currently working very well in Spain and France. In addition, Italy's regional healthcare systems do not provide uniform standards across the country, and this sometimes impairs the donation system, creating discrepancies in the number and quality of donors between different areas of the country.

Despite the fact that the overall number of donors in Europe is stable, the number of acceptable hearts is steadily declining, in particular in Italy, UK and Germany. By the side of the organ procurement, which strategy do you think may be put into practice to change this epidemiological trend?

This is an epidemiological problem directly linked to the aging of the population in western countries. Kidney and liver surgeon may extend almost indefinitely their donors' age, cardiac surgeons can't. The point is accepting or not the risk of worse results by increasing the numbers (for example in France surgeon accept older donors than in Italy, and perform many more transplants, but their first year survival rate is about 15% less than in Italy, - n.d.r.). This depends on the feasibility and results of VAD programs, which can make unacceptable allocating a high-risk graft. I think that this is a trend difficult to revert, even though setting up older donor rescue programs may help to scratch the barrel. The other side that needs effort is the standardization of ICUs care. I think that in the future there is room to identify large referral ICUs with high donor numbers to set up shared and standardized donor management protocols, to reduce the possibility of loosing potential grafts for the donor deterioration.

Disclosure Statements: The author and interviewee have no conflicts of interest to report.