Plenary IV - Latest Advances and Controversies in Transplantation

Cadaveric donor organ transplantation is one of the greatest feats of modern medicine. Transplant recipients enjoy significant improvements in their quality of life and life expectancy. However, the demand for donor organs far out stripe their availability resulting in prolonged waiting times for transplants. 
The number of donation after brain death (DBD) donors has always been very limited. In order to increase the donor pool, multiple strategies have been deployed over the decades. The use of organs from donation after circulatory death (DCD) has proven to be an important strategy in many countries, significantly increasing the number of cadaveric donor organs available for transplantation. In general, the outcomes of DCD transplants are comparable to DBD transplants for most organs.
Most of the advances have been in the area of "controlled" DCD donors. These are patients on life support with very severe neurological injuries or disorders in whom treatment is deemed futile and it would be in the patient's best interest to discontinue life support. The patient or their surrogate had expressed a wish to donate organs after death and consent signed. Life supporting treatment is then withdrawn when eventual circulatory arrest can be anticipated. After mechanical asystole and a mandatory period of observation to confirm no spontaneous return of the circulatory or respiration, death is certified and the donor organs can be retrieved for transplantation. 
Public support for DCD organ donation is remarkably high in many Western countries. However, there is no universal agreement in many aspects of the DCD process. Should interventions that do not directly benefit the patient be permissible before confirmation of death? This can range from non-invasive investigations such as a transthoracic echocardiogram to giving the patient full-dose systemic anticoagulation and the insertion of perfusion cannulae. Where should withdrawal of life supporting treatment (WLST) take place? This could range from the Intensive Care Unit bed space to the operating room. When would the potential donor organs start to become ischaemic? What, if any, "comfort therapy" is appropriate? How long should the mandatory observation period be after circulatory arrest? How long should the retrieval teams wait for circulatory arrest before standing down? Once death has been certified, which retrieval technique is acceptable? These and other controversies remain and will be discussed.

We are aware that worldwide there is lack of organs and today we can only achieve the 10% of the global needs in transplantation, even using living donation from liver and kidney because we have only 38.000 cadaveric donors worldwide per year. 
What are the solutions? Our proposal is that nations should support by regulating, laws and legislation and the regions must implement the health systems including developing of deceased donation and basically, as shown in other countries like Spain, Iran, Portugal, Italy, France, etc , to have an hospital structure with organ procurement units , is the main factor to develop Deceased Donation. And that is the TOP 5 models in the world, including USA with a different model which is a OPO system.
The Transplant Procurement Model is based in the TPM professional who is a medical specialist in ICU supported by nurses , dedicated 24h/7days to organ donation , could be a single person or a professional team and the main issue is that depends from the hospital medical direction , it is a social responsibility for any hospital to perform that, and those professionals do the clinical activity, they do the research, they do the quality , they do the management to analyze the cost, as well as training or education.
From our point of view there is no single demonstration that by only changing legislation, awareness campaigns, donor registries, driving license or other way of promotion, donation has increased. 
We believe that one professional trained by the health system is the same of 2000 citizens aware of organ donation. Thus, the development of programs to professionalized people has shown in many areas in Europe, in Iran, in China in Emirates and worldwide good results: as many professionals trained, more the donation rates increase. 
Also new procedures are useful today like the use of Deceased Donors After Circulatory Death (22% Worldwide, 45% Spain and 54 % in Catalonia). That means the use of NRP and Touraco Abdominal Regional Perfusion as well as ex situ organ perfusion machines to assess viability, improve preservation and restore ischemic damage.
Finally, during more than 25 years, we have been implementing this model in Spain and we have achieved the point of self-sufficiency, that means that our waiting list at the end of the year remains stable of the previous years. So, all the patients in the waiting list have the great opportunity to get transplanted.
In addition, for example in Catalonia (region), the 54% of the patients with chronical kidney disease are transplanted and the other in dialysis, and even the 7% of these patients are preventive transplanted before dialysis.
In conclusion the implementation of the TPM professionals inside the hospitals is the key solution to develop deceased donation Worldwide and can be replicable in any country willing to, included Hong Kong.

China has made significant progress in organ donation and transplantation in recent years. As of 2022, the five major systems have been fully established and developed:
1. Human Organ Donation System: The Red Cross Society of China plays a crucial role in promoting organ donation. More than 6.7 million people have registered in the national organ donation volunteer registration system.
2. Organ Procurement and Allocation System: In 2022, 112 organ procurement organizations (OPOs) completed 5,628 deceased organ donations, with a donation rate of 3.99 per million population (PMP). Each OPO has its own service area assigned by province-level health authorities. The China Organ Transplant Response System (COTRS) ensures fair, just, and transparent allocation of deceased donor organs based on medical needs.
3. Clinical Service System for Human Organ Transplantation: By the end of 2022, 183 medical institutions were qualified to perform organ transplantation. In 2022, 20229 organ transplant surgeries were completed, including 6053 liver, 12712 kidney, 710 heart, 799 lung transplants.
4. Quality Control System for Human Organ Transplantation: Quality control has been strengthened in donor evaluation, organ procurement, preservation, transportation, and transplant outcomes. In 2022, 1-year patient survival rates were 83.9% for liver, 97.6% for kidney, 81.4% for heart, and 59.2% for lung transplantation.
5. Regulatory System for Human Organ Donation and Transplantation: Laws, regulations, and policies have been established by 2007 State Council Regulation and further strengthened by its 2023 update, to prohibit organ trading, ensure transparency and traceability, protect the rights of donors and recipients, and impose severe penalties for violations.
China's organ donation and transplantation systems have entered a stage of steady and high-quality development. Continued efforts are needed to increase donation rates, optimize allocation, improve outcomes, strengthen oversight, and promote voluntary donation.