Burgos to Host XXXVII National Congress of Transplant Coordinators: Current Issues in Donation and Transplantation to Be Discussed

Burgos will host the XXXVII National Congress of Transplant Coordinators from May 16 to 18, which will bring together more than 150 attendees, and during which some of the most current issues in transplant coordination will be reviewed, such as donation in asystole, the donation after the process of helping to die, and the contraindications for the donation. During the three days that the Congress lasts, professionals from all over Spain will review the fundamental activities of donation and transplantation, and will influence the “most current or recent” issues. The regional coordinator of Transplants in Castilla y León and president of the Organizing Committee for the Congress, Dr. Pablo Ucio reviews the current situation of the Community in this area, the work of a transplant coordinator and how the donor profile has evolved.

Burgos will host a new edition of the National Congress of Transplant Coordinators, in which they will deal with some of the most current issues in terms of donation and transplants. What are these themes?

The most current is donation after aid in dying, euthanasia donation, which has also come to be called Asystole type 5. The recently expanding route of organ donation in Spain is asystole donation, of which , in some aspects we are very leaders, such as cardiac donation, after asystole. One of the tables is about this, and another about donation after euthanasia. It is a law that was approved recently and there are more and more donors after this practice, and we are interested in disseminating the centers and speakers that we have the most experience for all the rest of the coordinators of other hospitals.

What is the job of a transplant coordinator?

It is what has made Spain number one for many years in transplants in the world, and even more in donation. There is a doctor and one or more nurses, who are specifically dedicated to this, but they are also involved in the hospital itself. They carry out the entire donation process, from the detection of the possible donor, they control and establish a relationship with all the units from which these donors can come, and they establish control over these possible donors so that the system works. Once the donor is obtained, they assess which organs are useful, establish the donation with the National Transplant Organization (ONT) and the regional coordination to distribute those organs to the most suitable recipient, following established criteria. That would be clinical action. They also carry out quality control of the entire process and also coordinate the implantation with the teams after the distribution of organs and the teams that implant it.

What is the current situation of donations in Castilla y León? Do you face any difficulties being an aging population?

Indeed, our population is aged and dispersed, with hospitals with different degrees of complexity and these are things that make organ donation difficult. However, we are at a good level. We can boast of this, with a level of family refusals lower than the average for Spain and a level of donors that is practically in the Spanish average. We have a problem that is donation in asystole. In Spain there are thirty-something percent of donors in asystole, while in Castilla y León we are at 20 percent. We try to encourage it. We have already had asystolic donors in all the hospitals, but it is a practice that we want to promote and it is possibly the most possible way to increase donors.

Are there difficulties?

Donors in asystole are accepted younger, that hurts us. Then, donors in asystole come from limiting the therapeutic effort in patients and these are the two added difficulties. Often we can boast of being healthy, our patients, who are left untreated, are older patients who have associated pathology and that often makes them unable to be donors. We have a transplant donation system that works very well, both in donation and in transplantation, it can always be improved and we are working on it, but we must realize that a population like ours, in Castilla y León, with all these difficulties exposed, we doubled in donors and transplants to Germany. Improvement capabilities are difficult because we are at a very high level.

What data is shuffled in the last year?

This year is quite similar to the previous one. In 2019 we had 48.9 donors per million inhabitants and in 2022, 46 donors per million inhabitants. Very little difference, while in the year of Covid we dropped to 36 donors per million inhabitants.

Has precovid activity picked up?

Yes, clearly. We have not reached the 2019 data in 2022, but they are very similar.

How did the pandemic affect donation?

It fundamentally affected the fact that the sick were often not taken to the hospital. They were afraid, the scheduled activities were paralyzed and the critical units, which is where those who can be donors can be generated, were absolutely blocked due to the pandemic. It influenced both donors and transplants, which also fell because patients were not subjected to transplants due to the risk that they would catch Covid and the remedy would be worse than the disease. All this came together and it was a year that in Castilla y León, perhaps for the high level of impact we had from Covid, it was not particularly serious. For example, Spain also fell, practically the same as Castilla y León, but some communities much more.

Is there a profile change in the donor?

It depends where we go back. If we go back to the 90s, the change is radical. The majority of traffic accidents were young people from trauma, this has practically disappeared. The young donor with his organs all perfect, who died in a traffic accident, right now is 4 percent or a little less of the donors. It is very irrelevant.

And the current donor?

The current donor is a person with an average age of 60 years, who has suffered a cerebrovascular accident, a cerebral hemorrhage or an ischemic cerebrovascular accident (cerebral thrombosis). That is the majority donor profile. There are now donors who die of brain death, their brain dies, and being in an intensive treatment unit, their heart does not stop and serves as donors. The one that is growing are those coming from this same pathology to which is added post-arrest or post-ischemic encephalopathy, that in which the heart has been stopped for a while, which causes very significant brain damage. This, even if they do not become brain dead, are the ones who will end up as asystole donors because this treatment is appreciated, since they are in a situation of very little response, and it is considered that treating them in this state does not lead to anything. And they are the ones who are limited to intensive treatment, have a cardiac arrest, are diagnosed with death and from there, with a series of maneuvers, we manage to prevent these organs from being damaged and being transplanted again. This is the profile of the donor in asystole that is increasing a lot in Spain, because the brain death profile is stabilized, because we have such good results that it is very difficult. You can always improve, because there is always a donor who escapes or gets lost in a performance, but there we are going to go up very little.

Aren’t there as many young people as before?

Donors under 50 years of age do not even reach 20 percent in 2022, and in 2021 the same. If we talk about 10 to 29 years old, we had zero percent in 2021, and 4 or 5 percent in 2022. Donors are between 50 and 80 years old, the vast majority, and there are even many donors, 15 percent last year, over 80 years. Chronological age in itself is not a contraindication to be a donor. Logically, you have to carefully evaluate the organs so that they are okay, but if they are, they can be donors at those ages.

Do you think there is more awareness than before?

The data says it all. We only have 10 percent of refusals, it is clear that social awareness is very high and reaches almost all sectors of the population, in addition to the work of the coordinators who do the family interview and have specific training and action protocols. There is a sector of very old people who tell their family that they would not want to donate, but I think it is increasing. Young people are very aware, and let’s see if we manage, in a few years, to have zero percent refusals. Although 10 percent is considered marginal, there are many organs and many lives, and you have to fight for it.

Have new techniques been implemented?

The fundamental new technique, already several years old, but recent, is normothermic perfusion. It is a device called ECMO, the acronym for Extracorporeal Membrane Oxygenation. To asystolic donors, when their heart stops, and the criteria established by law are met, death is declared and this device begins to function, which allows us to somewhat replace the function of that heart that does not work and those organs are useful. They are oxygenated, they are kept for between one and two hours in these conditions, they are seen to recover and then they are extracted. It is the newest technique, which in our country has allowed quite a few cardiac extractions with this technique in asystole, with which we are pioneers. The first intestinal extraction has also been done, in a girl from Castilla y León, although the procedure was in Madrid, in this type of donor in asystole, something that had not been done in the world because the intestine is an organ that suffers extremely cardiac arrest and it is the first time that it has been done successfully in the world.

What are the great challenges facing the Community in the field of donation and transplants?

The challenge is to improve, to maintain the systems that are already very good as they are or better. One pending issue that we have is living donation, which has perhaps had little impact on our population and is possibly the best kidney transplant technique. A transplant from a living donor has better results than from a dead donor. Last year we only did eight in Spain, this is a problem we have throughout the country. Just as we transplant much more than in any country in the world, there are quite a few countries that surpass us in donation and live transplantation and that is something that must be promoted.