Donation after circulatory death program in Italy

Donation after cardiac death (DCD) donors may help increase the donor pool for lung transplantation. Here, we briefly describe the Italian organ transplantation system and present the Italian DCD program. Our country adopts a mixed “opting-in” and “opting-out” system. Death declaration is confirmed by neurological or cardiocirculatory criteria; in case of cardiac death, the Italian law requires 20 minutes of documented asystole. Organs are primarily allocated to urgent patients, otherwise they are offered to a centre within the region. Lung transplantation centres in Lombardy, instead, use Lung Allocation Score (LAS). In Italy organ donation activity and transplantation has been growing, but the gap remains between patients on the waiting list and the number of transplantations. DCDs may alleviate donor shortage, but the path towards a DCD Italian program was complicated, and physicians had to face the challenge of organ preservation with a prolonged no-touch period. The first DCD program (Alba protocol) started in 2007 and proved DCD after unexpected cardiac arrest [uncontrolled DCD (uDCD)] possible for kidney transplantation, using post-mortem normothermic regional perfusion (NRP) before recovery. In 2015 the first DCD liver transplantation in Italy was performed at Niguarda Hospital in Milan using innovative strategies based on NRP and ex-situ organ perfusion. The Careggi Teaching Hospital in Florence started a DCD protocol for kidney and liver transplantation. The first lung transplantation from an uDCD donor in Italy was performed at the Policlinico transplant centre in Milan in 2014: our protocol consists of a normothermic open-lung preservation, namely without chest drainages for topical cooling, avoiding lung hypoxia through recruitment manoeuvres, continuous positive airway pressure (CPAP), and protective ventilation. Lungs are assessed using ex-vivo lung perfusion (EVLP). Eventually, we also began including controlled DCDs (cDCDs). A dedicated protocol for thoracic and abdominal organs retrieval was established in 2017, combining NRP with our open lung approach, with good results. Over the last 5 years, transplantation with grafts from DCDs has been increasing: in 2019, they represented 4.5% of such procedures and 8.5% of lung transplantations. Our results showed the feasibility of combined procurement in different settings with no detrimental effects on abdominal organs despite extended ischemia times.