Spain and Italy take the lead in the first international cross kidney transplant in southern Europe

The kidney extractions and transplants were carried out on the same day, 19 July, at the Fundació Puigvert in Barcelona, a leading centre for cross kidney transplantation, and the Ospedale Cisanello in Pisa.

The cross kidney transplantation programme is based on swapping live kidney donors between two or more couples. The aim is to offer patients with chronic kidney failure the possibility of receiving a kidney from a living donor, even though the patient's partner or family member who wishes to donate the organ is incompatible.

Transplants of this type involve a complicated logistical process. It becomes even more complex with its internationalisation, requiring full collaboration between the head offices of the national transplant organisations of Spain and Italy, the regional transplant coordinators and the medical teams from the two hospitals participating in the process. The period between the National Transplant Organisation (Spanish acronym: ONT) carrying out the cross examination that detected a possible compatibility between these two couples and the actual transplants taking place was barely 8 weeks.

A total of 14 hospitals were involved in this first successful cross transplant in the international Cross Kidney Transplant Programme: 10 Spanish, 3 Italian and 1 Portuguese. There were 113 donor-recipient couples: 79 Spanish, 19 Portuguese and 15 Italian (see attached tables).

The cross kidney transplant programme is one of the forms of kidney transplantation from a living donor that the ONT implemented in Spain nearly a decade ago, after developing a joint work protocol together with a multidisciplinary working group. The first cross kidney transplant took place in Spain in July 2009. Since then, there have been 194 transplants of this kind in the country.

Cross kidney transplants are a highly developed therapeutic model in some countries with a high rate of kidney transplants from live donors. This is the case in Australia, Canada, South Korea, the United States, Holland and the United Kingdom, which have been carrying out these kinds of operations for some time with excellent results.

The use of increasingly less invasive surgical techniques and the study and care of donors (before, during and after the operation) have boosted the use of these kinds of transplants, given that the possible complications for donors have been reduced considerably. Currently kidney extraction from live donors is considered a low-risk procedure.

Registration of donor-recipient couples

A basic aspect of the programme is the registration of donor-recipient couples, involving the use of a computer application to carry out cross examinations and discover the results quickly.

In fact, it was Spain, through the ONT, which fostered the creation of the International Cross Kidney Transplant Programme between the countries making up the South Transplant Alliance (Spain, France, Italy, Portugal, the Czech Republic and Switzerland). The first cross transplantation process involved the joint participation of Spain, Italy and Portugal. However, the rest of the countries will probably become involved in the future as they see the results.

The programme must be supervised by the head of national cross-donation programs in each participating country, in this case Italy, Portugal and Spain.

The internationalisation of this programme aims to increase the chance of couples finding a compatible donor and being able to exchange the donors' kidneys. The more couples that participate and the greater its genetic variety, the greater the chance of a successful kidney donation and exchange.

Other countries in northern and central Europe are working in the same direction.

The ONT's pilot process

The ONT, which has coordinated this procedure end-to-end, has contributed its experience in transplants of this type and the computer platform that allows an analysis of the possibilities of exchange between the couples in the International Registry.

The ONT will also be in charge of managing the matching of couples, providing sufficient information for the participating countries on the possible combinations detected after each cross examination, and drafting an annual report on the results. To achieve this objective, the ONT has adapted its web platform for the cross kidney donation programme, which contains information on all incompatible donor-recipient couples. This platform is located at the ONT and is maintained and administered by ONT staff.

Table 1 Couples participating in the international registry

Table 2 Hospitals participating by country

The stages of the transplant process

• 24/05/2018: The ONT carries out a cross-examination that detects the possible compatibility between some of the couples included in the International Registry and informs the countries that form part of the programme. Finally, the decision is made for a transplant between a Spanish and an Italian couple.
• 04/06/2018: The national organisers of transplants in Italy and Spain give the go-ahead for the cross-transplant.
• 18/06/2018: Dr Lluís Guirado, head of the Nephrology service at Fundació Puigvert in Barcelona, and Dr Emanuele Cozzi, Immunologist coordinating a working group at the National Transplant Centre (CNT) in Italy, confirm the immunological compatibility of the donors in Barcelona and Pisa. Histocompatibility analyses are carried out at laboratories in Pisa and Florence in Italy and at the HistoCat of Hospital Clinic in Spain.
• 29/06/2018: The transplantation centres in Barcelona and Pisa notify the ONT and the CNT of the clinical suitability of the two couples involved in the cross transplant.
• 04/07/2018: Clinical and instrumental data on the two couples involved in the cross transplant are exchanged between the Spanish and Italian centres.
• 11/07/2018: The medical teams from both countries set the date for the nephrectomies and transplants.
• 19/07/2018: The kidneys are extracted between 9 a.m. and 7 p.m. in Barcelona and Pisa. The organs are transported and exchanged at El Prat Airport and the transplant procedures are completed.
• A few days later, the donors and recipients leave hospital.

Non official translation