Transplants and organ donations: it's booming. But 3 out of 10 Italians still say no (to saving more lives)

If the good morning was already seen in 2022, last year donations and transplants of organs, tissues and hematopoietic stem cells in Italy set an all-time record. We can say this with a certain satisfaction and a bit of pride – comments Massimo Cardillo, director of the National transplant center — , because they are truly important results: it is the best result ever, but also the largest increase in recent years.

Let's talk about 4,462 organ transplants, 15% more than in 2022 (3,876 transplants) with a consistent increase for heart (+46.2%), lung (+33.8%), liver (+14.7%), kidney (+10, 4%, with that from a living donor decreasing by 0.3%) and pancreas (5.3%). Donations (14,912, +21%) and transplants (24,949, +16.7%) of tissues are also increasing. The data were presented today by the Minister of Health Orazio Schillaci and the director of the National Transplant Center Massimo Cardillo at the opening of the General status of the transplant networkwhich brings together over 400 operators from all over Italy in Rome until Friday.

Thus we have also reached the historical record of 28, 2 donors per million population. Still far from Spain, firmly at the top of the rankings not only in Europe but in the world with 48.9 donors per million population. Certain. But Spain has managed to build an extraordinary organizational model since the 1980s, which has become a global benchmark.

The reasons for success

What were the most important factors that contributed not only to the stabilization of a result that was already good last year, but to an improvement?

The main one is an organizational element and the numbers tell us this: the most significant data the increase in referrals from potential donors, therefore it means that hospitals are increasingly improving their ability to identify deceased subjects who can be potential donors – replies Cardillo -. This is essentially the result of the work of hospital donation coordinators and intensive care professionals, but let us remember that many healthcare professionals from other disciplines also collaborate around organ donation and must be trained, motivated and coordinated. I like to think that this is also the fruit of the work done in recent years with the National organ donation program which the CNT had already developed in 2018. The Plan contained many aimed at supporting hospital coordination and over time many regions have adapted, proceeding with the implementation of the Plan and the implementation in the field of the measures contained therein, he adds.

2020 was the year of the Covid pandemic which slowed down the process of growth of donations, because the intensive care staff had been largely dedicated to supporting the impact of the pandemic emergency. Once this delicate phase has been overcome, the process is back in motion, thanks also to the great work of the healthcare workers.

The different types of donation: the leap forward of DCDs

A big step forward also regarding the type of donation: how did it go? The increase occurred above all, or rather I would say exclusively, in the donation from a deceased person, because living donors have not increased significantly. As regards the former, there are two types of donation (HERE explains how the death of a person is ascertained): that which occurs after death ascertained with a neurological criterion (due to brain damage) and that ascertained with a cardiovascular criterion (for prolonged cardiac arrest) . The different methods of assessment involve different technical complexities, so in Italy the donation program from a deceased person with cardiovascular assessment (or DCD, ed.) started later than in other countries, because in our country there is a very guarantee criterion in the assessment of death, and the period of cardiac arrest needed to certify death is longer, underlines the director of the CNT.

THE 20 minutes which are required by law to define death, ascertained by cardiac arrest, are a time which in the past was considered too long to maintain good organ function as the arrest of the heart also causes damage to the organs which then must be transplanted. In recent years, our centers have developed techniques that allow us to overcome these critical issues, such as organ perfusion systems: with these technologies, the organs are oxygenated and “nourished” in such a way that they do not suffer damage related to the lack of blood circulation; in this way, it is possible to evaluate the function of the organs before the transplant, but in some cases also improve it.

The development of these techniques allowed the development of the program heartfelt donation, which instead for many years had not been significant and this year we have arrived at transplant more than 400 organs from this type of donor, therefore almost 10% of the transplant activity was obtained thanks to organs from heart-stopped donors. With this procedure it is therefore possible to use organs that in the past were considered non-transplantable, with results that are completely comparable to those we obtain with transplantation from a deceased donor with neurological assessment.

Transplants derived from this type of donor have increased exponentially: we went from 100 in 2018 to 221 in 2022 to reach 438 transplants in 2023 thanks to organs taken from DCD. Starting last May the DCD heart sampling program has also started, an activity that has been present until now only in Great Britain and Spain where for (as in the rest of the world) the cardiac arrest time necessary to confirm death is 5 minutes versus the 20 required by Italian law.

As many as 6 centers nationwide (starting from Padua, the first) have so far carried out 13 DCD heart sampling and transplants. The successful use of cardiac organs which overall also address over 40 minutes of “warm ischemia” currently a world record. Such a significant result is due to the increased ability of professionals in the use of organ perfusion technologies (a sector that is experiencing important development) and to the training and organizational work carried out in the area to structure healthcare teams capable of efficiently managing this type of highly complex withdrawals.

Regional data: Central-South (still) follows

Returning to organ donation, if you look at the activity divided into the 21 Regions and Provinces, Italy confirms itself for the umpteenth time at two speeds: why? true, unfortunately this is one of the sore points – admits Cardillo -. In general terms, the donation-transplant system continues to grow but this growth is not uniform great inhomogeneities remain among the Italian regions, although this year in some regions of Central and South there have been significant signs of recovery. And this bodes well for the future. These inhomogeneities are not mainly linked to a problem of sensitivity of the population, but rather to organizational problems which we talked about previously, linked to the implementation of the National Donations Plan.

The hard core of those who oppose donation and transplantation

Despite the exciting numbers and great steps forward, in our country there remains a hard core of people who really don't want to know about organ donation and transplantation. As we always say, the donation and transplant system stands on two legs: one is the organization of hospitals; the second, communication with citizens. Because transplantation is a treatment that can only be provided if at its core there is a citizen's willingness to donate. And unfortunately, compared to the increase in reports which was really important, we have not had a corresponding improvement in oppositions which they are stable around 30%. This cannot be influenced.

We have now collected almost 18 million declarations from living citizens, so today we can say that one Italian in three has already declared his will, which therefore must be respected. The development of declarations in life, desired by the law 91/99compared to the past, it has changed the paradigm of communication on donation: if once the conversation in intensive care between healthcare professionals and the potential donor's family was the key to gathering consent, today the manifestation of will released in life to be of greater importance, given the 18 million declarations recorded. This means that, alongside training programs aimed at healthcare professionals and aimed at improving the relationship of assistance to the family members of the potential donor, it is also necessary to develop communication programs aimed at the population general, so that people make an informed and conscious choice when they are alive.

The reasons for saying no to donation and transplantation

Why then do over 5 million Italians oppose a gesture, that of donation, capable of changing the fate of a person who could even die without a transplant? We have analyzed the data on this. Meanwhile, there is an important one, which tells us that oppositions increase with age – says Cardillo -. Opposition percentages are higher in the older segments of the population; young people are more attentive, more generous, perhaps even more informed. We have not launched specific investigations into this specific aspect, but we can believe that in many cases the “no” is based on the mistaken belief of many that the elderly cannot be donors, as after a certain age the organs are no longer suitable for transplantation. Nothing could be further from the truth.

Therefore, also informing on this aspect, that there are no age limits for donation, could already contribute to reducing opposition among those over 70 and 80. And then, in more general terms, among the main reasons for opposition there are mistrust towards the healthcare system as a whole, the fear that organs may be removed when a person is not yet deceased, or that doctors do not treat a person appropriately and adequately if he or she has declared his or her consent to donation: these are all false mythsoften also powered by distorted communications that come from unreliable sourcesas often happens with other types of hoaxes that cannot be dismantled.

Tissues and marrow, best result ever here too

The record increase in donations has also had a huge impact on the textile business: we have 14,912 blood samples (+21%) and 24,949 transplants (+16.7%), with strong increases both on the corneas and on the musculoskeletal tissue. Record year also for hematopoietic stem cells: in 2023 in Italy there were 399 bone marrow donations (+21.3%) and 1,023 transplants (+6.5%). The tendency to prefer the sampling of cells from peripheral blooda very minimally invasive method (very similar to a blood donation) which now concerns over 90% of donations.

Very good too registrations to the IBMDR donor registry: 29,396 18-25 year olds were newly recruited, which brought the list of possible active donors to almost half a million (496,754).

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