Key words : Deceased donors, Ischemia, Organ transplantation

Introduction

Organ transplant requires the donation of living tissues and grafts from humans, making it a complex process influenced by medical, religious, legal, and social factors. These factors play a crucial role in the success or failure of any national program for organ donation.¹ The gap between the number of patients in need of organ transplants and the number of available organs has been steadily increasing over the past decade. Finding a solution to increase donation rates has proven to be a challenge.²

Participants in the Third World Health Organi-zation Global Consultation on Organ Donation and Transplantation, its member states, and professionals in the field regard organ donation and transplantation as part of every nation’s responsibility to meet the health needs of its population in a comprehensive manner and to address conditions leading to transplantation from prevention to treatment.^3,4 Transplantation is a controversial subject in the health care sector, with advancements in technology leading to improvements in patient lifespan and quality of life through modern immunosuppressive techniques and increased social awareness.⁵

Preoperative factors, such as age, sex, race, and immunologic compatibility, along with postoperative factors like immunosuppressive treatment, play a role in donor and recipient characteristics for transplant. Graft function and rejection can also be influenced by various parameters, including cold and warm ischemia times.⁶

The Middle East Society for Organ Transplantation (MESOT) is represented by more than 20 countries with over 650 million inhabitants.⁷ Iran has developed one of the most successful organ transplant programs in the MESOT region.⁸ Iran ranked 34th in the world in terms of the number of deceased donations per million population in 2022.⁹ Solid-organ transplant in Iran is coordinated by the Organ Procurement Unit (OPU), which is a technical and scientific organization within the Ministry of Health (MOH).¹⁰

Key Insights on Organ Transplantation in Iran

Statistics on organ transplantation in Iran have shown a substantial increase in donor rates but still underperformance in the system. In 2022, kidney transplants were conducted in 32 centers, with 1247 from deceased donors and 1184 from living donors. The number of liver transplants increased to 893 cases in 2022. Heart transplants increased from 15 cases in 2002 to 130 in 2022, with a rate of approximately 8.66 per donor. Overall, there have been 68 660 transplants in Iran, including kidneys, livers, hearts, lungs, pancreases, and small intestines.¹¹

The Iranian Network for Transplant Organ Pro-curement was formed by OPUs and Recognition Centers (RCs). The OPUs and RCs in Iran are responsible for covering all regions of the country due to its large size. Responsibilities of the OPUs include detection of brain deaths, management of donors, and procurement of organs, whereas RCs focus on brain death detection, assessment, donor management, and obtaining consent from families. Once consent is given, RCs transfer the case to OPUs for organ procurement. All OPUs and RCs have hospitals with intensive care units for donor management, and organ procurements are only performed in OPUs.¹⁰

There are a total of 54 transplant centers in Iran where patients with brain death are transferred from their original hospitals to these centers by ambulance or helicopter. Over 95% of transfers are done by ambulances equipped with mobile intensive care units, and 5% of transfers are done by helicopters.

One important factor in successful organ transplant is the minimization of ischemic time. Minimization of ischemic time is crucial to ensure the viability and quality of organs for transplant. Recent studies have shown a clear link between prolonged cold ischemic time and delayed graft function after kidney transplant.^12,13 As shown in a French cohort, for every 1-hour increase in total cold ischemic time, the risks of graft loss and all-cause mortality are increased by at least 1%.^14,15 Some large series have reported acceptable perioperative and long-term survival rates for grafts with ischemic times exceeding 6 hours, but the effects on other important adverse outcomes and indicators of graft function remain unexplored.^16,17 Several studies have shown that long ischemic time is associated with decreased rates in posttransplant survival.^18-20 Improved management of the pretransplant period can help minimize cold ischemia time, which is a key modifiable risk factor before transplant. To enhance outcomes, the optimization of transplant organi-zations to reduce cold ischemia time as much as possible in deceased donor transplants may be preferable.

Organ Donor Transport

With most transplant centers concentrated in provincial centers and the inability to perform transplants in some small cities, as well as the need to reduce ischemic organ time, in Iran, most cases of organ donation from small cities are transferred to transplant centers.

The transfer of a brain dead donor to OPUs can reduce ischemic time of organs to less than 1 hour; in some cases, recipient candidates and brain dead donors are in the same hospital, and the organ transplant can take place immediately after procurement. This new method is presently being implemented in Iran, in which, instead of transferring organs and reducing organ quality due to ischemic time,²¹ the donors are transferred to transplant centers with the help of a trained team after brain death is confirmed and with the consent of the family.

Several changes have been observed when a donor is transported to an OPU. The ischemic times are typically shorter because the procurement team is able to quickly retrieve the organs from the donor and transport them to the recipient. The rate of successful organ transplant also tends to be higher when a donor is transported to an OPU²² because the MOH is able to quickly assess the organ quality, match organs with suitable recipients, and transplant organs to the recipients in a timely manner, reducing the risk of organ damage or rejection.

The process of donor transfer involves confirming brain death at the originating hospital, obtaining consent from the family for organ donation and transfer, dispatching an experienced transplant team, monitoring the brain death cases throughout the transfer, preparing the central hospital for case admission, presenting information on the case to the MOH, having organ allocations and recipient iden-tification done by the MOH, coordinating with the organ procurement team for presence at OPU, preparing transplant candidates, and finally perfor-ming organ procurement and transplant at the same hospital or hospitals located in the same city. After procurement and donation, the deceased donor is transferred by ambulance immediately to the burial site.

After the family provides consent for organ donation, the donor transfer consent form is completed by the family, and the brain death case is transferred to the organ procurement unit by ambulance. If the family wishes, they can accompany their loved one; however, the family is assured that, immediately after organ retrieval, the donor will be returned to their hometown for funeral ceremonies. It is worth mentioning that, if there is no consent for transfer, the transfer operation will be cancelled.

Transportation may present challenges, such as hemodynamic instability, logistical barriers, and regulation of body temperature. A cohesive team of health care professionals is essential to effectively address and resolve any issues that may arise during the transfer. The transfer coordinator, who is often a physician or nurse, is well-equipped with the necessary training and experience to manage the transfer. As mentioned, donor transfer is done by a mobile intensive care unit; a specialist is also present during the transfer, who is constantly monitoring the case.

During the transfer, the transfer coordinator is in constant communication with the team responsible for providing care. In situations where the patient’s condition is critical and urgent, the patient is transferred to the nearest hospital. A successful experience in this context would involve the organ being promptly and safely transported to the OPU without any delays or complications, ensuring that the organ retains its quality and viability for transplantation. This is crucial to maximize the chances of a successful transplantation and ultimately saving the life of the recipient.

Successful experiences in transporting donors to OPUs or Organ Procurement Organizations (OPOs) for organ procurement involve meticulous planning, clear communication, and adherence to protocols and guidelines. In Iran, specialized transport vehicles equipped with the necessary medical equipment, which ensure proper handling and preservation of the donor during transfer, use efficient routes to minimize transport time. This team is knowledgeable about the specific requirements for donor manage-ment and can respond quickly to any unforeseen challenges that may arise during transfer.

Conclusions

Incidences of delayed graft function are associated with longer ischemic time. Consequently, delayed graft function leads to longer hospital stays, a higher incidence of morbidity and mortality in the recipient, and an increased likelihood of late graft loss.²³ The successful transport of donors to OPUs for organ procurement plays a critical role in reducing ischemic time and ultimately increasing the likelihood of a successful organ transplant. Regulation and quality assurance are of utmost importance. Each regional transplant OPO or OPU now undergoes periodic audits with special attention made to safety protocols. A combination of careful planning, effec-tive com-munication, and a dedicated team of health care professionals working together are needed to ensure the timely and safe delivery of the donated organ.

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