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S 04 Masterclass

Programme of the Session

Title: Transplantation

GS: Itziar Martinez Alpuente (Spain)
The Spanish National Transplant Organization (ONT) model and how to raise the number of renal transplants

GS: Lluis Pallardo (Spain)
Increasing access of  patients to renal transplantation

GS: Federico Oppenheimer (Spain)
Living donation: how to increase, (modalities) and results

GS: Julio Pascual (Spain)
Improving the results of renal transplantation


The Spanish National Transplant Organization (ONT) model and how to raise the number of renal transplants

I.M. Alpuente

Abstract is not available



Increasing the access of the patients to renal transplantation
L.M. Pallardo1
1Nephrology Department, Hospital Universitario Dr Peset, Valencia, Spain

The shortage of organs is the main barrier to have access to renal transplanation; but several medical and non-medical conditions can determine the access of the patients to be included in the renal transplantation waiting list and, in the end, receive a transplant.In my presentation I will analyse the different conditionants to be included in the trasplantation waiting list, the way to improve it, and the results.


Living donation: how to increase, (modalities) and results
F. Oppenheimer1
1Clinical Institute of Nephrology and Urology (ICNU), Hospital Clínic de Barcelona, Barcelona, Spain

Living donor kidney transplantation (LKT) is an excellent therapeutic option for patients with chronic renal failure. The two basic premises that justify the use of living donors are the insufficient supply of grafts from deceased donors and the minimal risk of morbidity and mortality for the donor. Having accepted these premises, there are additional benefits: LKT enables preemtive transplantation (or retransplantation) and increases the transplant options for highly immunized patients. Results of LKT are influenced by HLA matching (an HLA-identical siblings is the option with the highest survival rates), previous sensitization, donor age, risk of original disease recurrence and duration of dialysis before the transplant. Genetically unrelated donors and ABO-incompatible transplants offer comparable grafts survival rates to conventional donors. Desensitization therapies in highly immunized patients shows excellent short survival rates, but long-term results are still unsatisfactory due to the early appearance of chronic humoral rejection. The use of altruistic or paired-exchange donors expands the chances of achieving a compatible donor. Combining desensitization and paired exchange donation is a good alternative in very difficult cases. Also, in patients with severe medical or technical conditions, a LKT increases the success rates. Preemtive transplantation minimizes the cost of the procedure, avoids the need of a vascular access for dialysis and improves graft survival. Also, preemtive retransplantation is feasible, reduces the morbidity associated to graft loss and prevents anti-HLA sensitisation that can preclude or difficult further transplants.



Improving the results of renal transplantation



Kidney transplantation (KT) would be theoretically the best treatment for every patient with advanced chronic kidney disease. However, associated comorbidities frequently contraindicate this therapy, and shortage of organs limit the final percentage of patients truly benefiting it. Currently, only around 4500 patients, around 20% of all patients on dialysis, are listed for a KT in Spain. The first principle to improve the overall results in KT is to expand the KT indications and accessibility, and to progress in kidney allocation strategies. We need to extend initiatives to overcome barriers, inequalities, and ethical issues and in general, anything that might prevent more extensive access with the best possible results in KT both from living and deceased donors in all their possible forms. The availability of organs is another crucial point of improvement, as the current donation rates for both living and deceased donor organs are low in many European countries. Vital organ diseases, generalized arteriosclerosis, non-corrected ischemic heart disease, liver disease or neuropathy severely limit successful listing and KT. Efforts should be made in management of important diseases in potential KT recipients currently on dialysis.

The first weeks after surgery, constitute the most important period for KT outcomes. Short-term complications such as delayed graft function, acute rejection, surgical complications or severe infections are very relevant for short and long-term KT success in terms of graft and patient survival and quality of life. Despite the fact that current immunosuppressive regimens have decreased acute rejection to 10%, chronic injury and chronic rejection have not decreased to the same extent. It is therefore mandatory to joint efforts to manage chronic renal allograft injury, with early detection, distinction of causes, monitoring, and correct treatment. In this sense, individualizing the dosing of maintenance immunosuppression, improving adherence to immunosuppressive treatment regimen and continuing developing and testing of new immunosuppressive strategies and novel immunosuppressive agents remain essential for improving outcomes. Continuing research efforts in pioneer fields such as inducing tolerance or engineering of organs is also very important.
Malignancies, cardiac disease, vascular disease and infections are the most important complications and the causes of patient death with a functioning graft. Modifying traditional cardiovascular risk factors with identification, validation and modification of novel risk factors, and appropriate screening, prevention and treatment of viral reactivation and malignancy constitute basic strategies for improvement.
Finally, the best way to progress is promoting activities of high scientific interest in the generation of evidence and value in the area of kidney donation and transplantation, with clinical trials, observational studies, systematic revisions, guidelines and recommendations. In addition, promoting first class training activities that focus on KT learning for renal physicians and nurses, both in the context of the annual congresses and in other meetings, as well as through online platforms appears essential.