by Mr Nizam Mamode (pictured) – This year’s European Society for Organ Transplantation meeting, held in Vienna, saw a concerted attempt at providing a high quality congress for those who sought an alternative to the long flight west for the American Transplant Congress. It was a huge meeting, with thousands of participants and plenary talks from many of the key names in transplantation- but most noteworthy was the modern, interactive approach. It was a pleasant surprise for many delegates to be handed their congress IPad at the registration desk, and to discover a free Wi-Fi link; an ability to message other participants; a facility to take notes and an entirely electronic abstract book which could be selectively downloaded to personal emails.
There were many excellent presentations, but several innovative approaches were of particular interest.
Gabi Oniscu from Edinburgh presented early data from a multicentre UK trial of in-situ normothermic perfusion in donors after circulatory death (DCD) organ retrieval, showing that the technique appears to result in less delayed graft function, and possibly a greater proportion of transplanted organs. This may be useful when such organs are transplanted into elderly recipients who will not tolerate repeated biopsies, or other complications, and is especially pertinent given the tremendous rise in the number of DCD donors in the UK over the last five years. It remains to be seen whether normothermic perfusion will allow assessment of organ function, and thus assist in donor selection, or will improve graft survival. What is certainly true is the exciting possibility of manipulating the organ with biological treatments prior to transplantation, whilst the organ is safely preserved.
Rajeev Desai from the Cambridge group presented an analysis of data from the UK Transplant registry, which considered the risk of cancer transmission after using organs from donors with known malignancies. There were 202 cases where the donor had cancer and in 61 of these the risk of transmission was considered ‘unacceptable’ according to current guidelines (for example, in patients with recent breast cancer). However, no recorded cases of transmission from any of these donors were found, and the tentative conclusion is that the risk is relatively low, and outweighed by the risks of remaining on dialysis.
Another collaboration with NHSBT resulted in the presentation by Hannah Maple, which described outcomes in the first 148 unspecified (altruistic or non-directed) donors in the UK. Post-operative levels of mental ill-health and regret were equivalent to a comparable cohort of specified donors, suggesting that these donors are not mad, bad or sad, and that the programme should continue- given that 7% of living donor transplants in the UK are from these donors, with the numbers rising, this is important information.
Cell therapy holds many hopes for the future. Details of the ONE Study were presented. This is an ambitious multicentre, international collaboration, involving the use of T regulatory cells to induce a degree of tolerance, or at least reduce rejection, with the first phase of baseline data collection underway. The plan is for the first patients to undergo infusion early next year- results will be awaited with a great deal of interest and expectation.
An exciting development in cell therapy is the use of mesenchymal stem cells (MSCs), pluripotent cells which are relatively easily accessible in adipose tissue. Although clinical trials in transplantation are at an early stage, results from several in vitro studies were presented which suggest that MSCs, for reasons that are still not entirely clear, may exert a regulatory role, and inhibit inflammation and rejection.
Antibody incompatible transplantation continues to develop. A new approach was described by Denis Glotz, who presented early results in 16 patients who underwent deceased donor transplantation despite significant donor specific antibody, or a positive flow cytometric cross-match. The data is from an Alexion-sponsored multicentre study, using a 9 week course of eculizumab as prophylaxis against early humoral rejection. Many of these patients had spent years on dialysis, and early outcomes were excellent, with only one participant experiencing antibody-mediated rejection, and no graft loss. Although later outcomes will be important, this may represent a new option for sensitised patients without a living donor, who would otherwise be unlikely to receive a transplant.
Finally, long term outcome data after blood group incompatible transplantation (ABOi) is beginning to appear. A Japanese study showed that when 263 patients undergoing ABOi were compared with 833 who underwent compatible transplants, graft and patient survival at 20 years showed no significant difference. This supports a growing body of evidence which suggests that ABOi, apart from a small excess of early aggressive rejection, has excellent outcomes and should be an integral part of any transplant programme.
After four days of intensive education, networking, terrific weather and great coffee, conference participants might have been struck by two conclusions. Firstly, a tremendous number of new avenues are being pursued in transplantation- cell therapy, extending our criteria for donors, and transplanting those who have previously been unable to receive a transplant. Secondly, it is clear that the last five years have seen an increasing number of multicentre, and multinational, collaborations, which are starting to pay dividends. Such co-operation means that European research and innovation can clearly match that in North America, with the advantage of high quality national registries which can yield valuable outcome data. Perhaps over the next decade we will witness more of our transatlantic cousins taking the long flight east, eager to hear the latest from us.