Transplantology Challenges for Today

Authors: Maria Boratyńska Dariusz Patrzałek

Publish Date: 2017/01/12

Volume: 64, Issue: 1, Pages: 37-45

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Abstract

Clinical transplantology in Poland had its 50th anniversary this year With the early and long results comparable to the best achieved in the world leading centers we face old and completely new challenges for this medical speciality Main and growing challenge is insufficient number of available organs With less than 15 donors/mln population/year Poland stay in the lower row of European countries in this measurement of transplant activity Donation system is not efficient enough and we lose a big number of potential donors still Living donation with the exception for the fragments of the liver remains low despite of different initiatives made so far on the national and local levels Donation after cardiac death is possible from the point of Polish juridical regulations but since last 3 years had not showed real impact on country donation rates only three procedures done Methods of tissue typing remain slow and cause relatively long times of cold ischemia for kidney programs Second main challenge is chronic rejection causing loss of organs in the longterm followup and no efficient treatment employed The emerging possibility of tolerance induction despite of plenty of new protocols proposition in the publications does not show up a clinical everyday practice in work The same is with xenotransplantation promises even we were informed recently that till 2030 such genetically modified porcine organs will be available The next challenge is production of organs and tissues from own recipients cells installed on the different scaffolds or 3D printed Other challenge is the personnel working in this field We observe like in the other European countries lack of new candidates for work in this field together with serious problems of nursing staff being a catastrophic perspective in country medical service in general not only in transplant centers The last but not least challenge is financial side of transplant programsClinical transplantology in Poland had its 50th anniversary this year With the early and long results comparable to the best achieved in the world leading centers we face old and completely new challenges for this medical speciality In this paper we wanted to present the most important problems of clinical transplantology as they are seen from Polish perspective Our aim was to show the new area for scientific research for people involved in basic sciences in immunology and immunogenetics during EWIC conference held in Wroclaw in April 2016The main challenges in today’s transplantology are insufficient number of available organs chronic rejection clinical implementation of tolerance induction practical application of xenotransplantation regenerative medicine using organs produced with own recipient cells human resources in transplantation staff and finances involved in transplantation programs on the country levelDespite many efforts Poland rate in donation measured traditional as number of donors per million population per year is not exceeding 15 Malanowski and Czerwiński 2016 The recent tendency is showing further decrease The reasons for such situation are multifactorial The first source of organs is brain dead donors The number of such patients is decreasing everywhere in the world less cranial trauma better medical care for cerebrovascular accident but still the main problem in Poland is small percent of potential donors identification and less than 40 of hospitals show any donation activity The weak position of transplant coordinator in most of Polish hospitals is added to the above mention problemsThe second source of organs is donors after cardiac death DCD It is allowed by law in Poland but the whole procedure is “transplant effective” in less than 40 and consumes a huge number of trained staff additional equipment and materials Polish governmental refundation system is not ready for such high expenses yet As a result there were only three DCD procedures done in Poland during last 3 years when the law for such procedure was introduced The third source of organs only kidneys and liver fragments comes from living related donors Kidneys from living donation in Poland represent less than 2 of kidney transplantations This small number comes from high rate of potentials living donors discard ratio and social reluctance for living donation—both from recipients their families and medical staff in dialysis centers It seems that for all above mentioned problems we need a complex and continuous work to better adapt whole system to better serve the still growing needsChronic allograft rejection referred as injury or dysfunction is a multifactorial process which leads to allograft fibrosis and failure After death of a patient with a functional graft it is the second most common cause of graft loss except liver transplantation Renal allograft failure is a main cause of return of patients to dialysis treatment and requirement for another transplant On the poltransplant waiting list 30 of patients await a second or third kidney transplant Currently the immunosuppressive regimens unselectively inhibit the activity of T and B cells by interfering with their effector and immunoregulatory functions and they do not fully control the chronic rejection reactionChronic allograft rejection may develop months or years after transplantation but the incidence increases with time after transplantation Our study found that chronic renal allograft dysfunction occurred in 43 of recipients within 10 years after transplantation Boratynska et al 2014 The studies from other transplant centers showed chronic allograft nephropathy in 55–62 of patients after about 8 years from renal transplantation Grinyo et al 2011 Marcén et al 2010 High incidence of chronic rejection defined as cardiac allograft vasculopathy occurs in 25–60 of heart recipients and as obliterative bronchiolitis in 28–80 of lung transplant patients within 5 years after transplantation However chronic rejection affects only about 4–6 of liver transplant patients

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