Solid Organ Transplantation: Immunology, Indications,Techniques, andEarly Complications

In Italy, in Europe, and in the world, the kidney transplantation from a living donor is the main treatment to satisfy the aspiration for a better quality of life of patients with end-stage renal disease. There are many reasons why the medical physicians (nephrologists, surgeons, etc.) suggest patients and their families taking into consideration the option of kidney donation from living donor instead of applying for the waiting list from deceased donor. The main arguments can be ascribed to two main points: The transplantation from a living donor has better clinical results than the transplantation from deceased donor. This fi rst point is well demonstrated by a recent study [ 1 ] that compares the transplantation results of completely HLAmismatched living and completely HLA-matched deceased. The objective of the study was to evaluate the impact of HLA matching on the outcome of the kidney transplantation. It demonstrated the risk of graft failure increased proportionally with the number of HLA mismatches both in deceased donor and living donor transplantations. At the same time, the relative risk of graft failure for living donor transplantation (even with six mismatches) is the same as for deceased donor transplantation with 0–2 mismatches. The supply of kidneys from donors with brain death is not suffi cient to satisfy the claim of kidney transplantation both in the present and in the future. In developed countries (Europe, USA, etc.), there is a constant reduction of donors with brain death. This is not only in the case of brain traumas, but also in the case with cerebrovascular accidents typical of the old age. In other words, it is no longer possible to consider the category of “marginal” donors, utilized since more than 20 years, as an unlimited source, but this is a progressively reducing source. This is because of the enhanced health of elderly people thanks to a more appropriate lifestyle and to the widespread use of drugs preventing cerebrovascular diseases. In some countries (such as Italy, France, Spain, etc.), we observed an organization delay in the management of transplantation from living donors compared to others countries (USA, the Netherlands, UK, Sweden, etc.). This may be caused by the different attitude of doctors in promoting living donor transplantation in its several forms: direct donations from related donors, unrelated but family donors, and anonymous samaritan donors and indirect donations (such as crossover or domino). In those countries where all these options are activated (such as the Netherlands), the number of living donor transplantations is higher than the number of deceased donor transplantations. Roodnat et al. [ 2 ] illustrated the successful expansion of the pool of living donor by alternative living donation programs. The reason of this success is due to several factors including an effi cient team for the living donor transplantation, the increasing number of potential donors, and the use of alternative programs. It is essential the role of the living donor transplantation since the preliminary base of the chronic kidney disease (CKD). Starting in the third stage of CKD, awareness and health education in the patients and in their family are very important to promote within the family the practice of living donation. The promptness and effectiveness of this phenomenon allow the preemptive transplantation, which represents the best solution in clinical and social terms. It is also of great psychological comfort for the family reaching this goal. How can we ensure the correct understanding of the donation from living donor at the level of the patient and his/her family? It is important to give a simple and exhaustive response to the sources of doubts and concerns coming from all the actors involved: the receiving patient, the potential donors (better if more than one), the nephrologist, the surgeon, the nurse, the psychologist, etc. There are four main arguments in favor of living kidney transplantation: 1. The clinical trend (survival, complications, etc.) in case of living donor transplantation is better than in deceased donor transplantation. 2. The living donor transplantation increases the overall supply of kidney transplant. 3. It is a safe clinical practice for the donor. 4. It gives the opportunity of preemptive transplantation. It is advisable to arrange a presentation to the enlarged family during two or three consecutive meetings. Joint meetings with several family groups with their relatives/ patients at the same stage of the disease are of crucial importance. Thanks to such efforts, the practice of the transplantation from living donor will strengthen in the Southern Europe Countries