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Cardiac preload is traditionally considered to be represented by its filling pressures, but more recently, estimations of end diastolic volume of the left or right ventricle have been shown to better reflect preload. One method of determining volumes is the evaluation of the continuous right ventricular end diastolic volume index (cRVEDVI) on the basis of the cardiac output thermodilution technique. Because preload and myocardial contractility are the main factors determining cardiac output during liver transplantation (LTx), accurate determination of preload is important. Thus, monitoring of cRVEDVI and cRVEF should help with fluid management and with the assessment of the need for inotropic and vasoactive agents. In this multicenter study, we looked for possible relationships between the stroke volume index (SVI) and cRVEDVI, cRVEF, and filling pressures at 4 predefined steps in 244 patients undergoing LTx. Univariate and multivariate autoregression models (across phases of the surgical procedure) were fitted to assess the possible association between SVI and cRVEDVI, pulmonary artery occlusion pressure (PAOP), and central venous pressure (CVP) after adjustment for cRVEF (categorized as 40%). SVI was strongly associated with both cRVEDVI and cRVEF. The model showing the best fit to the data was that including cRVEDVI. Even after adjustment for cRVEF, there was a statistically significant (P < 0.05) relationship between SVI and cRVEDVI with a regression coefficient (slope of the regression line) of 0.25; this meant that an increase in cRVEDVI of 1 mL m(-2) resulted in an increase in SVI of 0.25 mL m(-2). The correlations between SVI and CVP and PAOP were less strong. We conclude that cRVEDVI reflected preload better than CVP and PAOP.

The reliability of abdominal ultrasound in screening liver and kidney donors was assessed by correlating ultrasound findings with the suitability of organs for transplantation as determined by direct examination of the organs. We evaluated 100 multiorgan donors (100 livers, 200 kidneys) during a 15-month period. Abdominal ultrasound showed the following results for liver and kidney, respectively: specificity, 95.6% and 98.9%; sensitivity, 62.5% and 66.6%; and accuracy, 93% and 97%. These results show that abdominal ultrasound is a valuable tool for determining suitability of organs for transplantation when the ultrasound findings are normal. When ultrasound findings are abnormal, further studies are necessary to determine the suitability of the organs for transplantation.

Organ and tissue donation and transplantation have a role in public health programs as organizational projects designed by public health departments to increase the quality and number of donations and transplantations. These programs serve as communication projects to inform public opinion on cerebral death, organ and tissue shortages, procurement and allocation rules, and the quality of life of transplanted patients. The health department of Emilia-Romagna created a regional law and a multimedia communication program for these purposes, resulting in a 95% increase of cadaver donor in 4 years. In 1995, regional activity reached the European mean level and afterwards surpassed it. In 1997, the bone bank was activated, followed in 1998 by the heart valve and vascular segment bank. The regional health department now considers transplant activities a primary goal; human and professional relations between intensive care units and the transplant reference center are considered crucial; cooperation among health departments, medical teams involved in organ procurement and transplant activities has been fostered, and the local coordination network has been active and efficient. The public information campaign has proven important in providing information both to professionals and citizens.

The number of donations per million population (pmp) per year and the number of transplants pmp/year enables one to compare donation or transplant programs made in different years in the same area or made the same year in different areas. These pmp indexes may be integrated with an evaluation system by which each organ is evaluated separately in terms of the efficiency of its procurement and transplant systems using the procurement index (percentage in terms of number of organs utilized/number of organs procurable from donors utilized in a single area during 1 year) and the transplant index (percentage in terms of number of transplants performed/number of organs harvested in a single area during 1 year). We have called them Caldes I (procurement) and Caldes II (transplant) indexes. The harvest index evaluates the efficiency of utilization of organs retrieved from suitable donors. It usually ranges between 80–90 % for the kidney, 70–95 % for the liver, 40–50 % for the heart, and 5–15 % for the lungs. The transplant index evaluates for each organ the transplant team capacity to use available organs which can be harvested locally or in different areas. It usually ranges between 60–120 %. Index determination did not require information different from the standard data available. Both the harvest and transplant indexes could be used to compare the efficiency of donation and transplant programs and policies in the same area during different years or at the same time in different areas. They can be critical in evaluating: (a) marginal donor utilization, (b) marginal organ utilization, and (c) dishomogeneity of organ retrieval and organ transplantation in different regions belonging to the same area. They also enable to evaluate if organs considered not available in a single area are offered to other areas or are not retrieved at all from available donors.

The main organizational features of AIRT are outlined The InterRegional Transplant Association (AIRT) was founded in Turin in 1989 by experts in transplantain Table 2. They pre-suppose a network among regional centres with equal responsibilities, involvement of tion from the region of Piedmont, Valle d’Aosta, Emilia-Romagna and Tuscany. regional offices with co-responsibility, appropriate separation of operative from organizational functions, In February 1994, the Health Offices of the regions involved drew up a working agreement on quick dissemination of knowledge and information [1], direct connection by computer links, co-responsibility co-ordination of organ procurement and transplantation activities in the whole area (11.8 million inhabitamong operative units (intensive care, immunogenetics, transplant units) and transparency of waiting list ants). The contents (Table 1) chiefly regarded the direct engagement of Health Offices in these activities, the admission criteria and organ allocation [2], as reported by other transplant organizations [3–6 ]. interregional co-ordination of autonomous regional centres, the standardization of outside relationships According to the agreement, the Interregional Co-ordination centre shall be run by one Regional with other national interregional transplant centres and the autonomous creation of area transplant centres Reference Centre, on a 3-year rotation basis. In the 1994–1997 term, it came under the Piedmont region remain responsible for including and running waiting lists within a framework of unified co-ordination and with headquarters at the Transplant Immunogenetics Service at Turin’s Molinette Hospital. Since June 15, controls. An interregional centre was set up, operating 1997 management of the Centre has passed to the Transplant Reference Centre of the Emilia-Romagna through technical and scientific co-operation by AIRT experts. In 1994, it was officially recognized by the region [7]. By regional law 53/1995 ‘Norms for enhancing, rationalizing and co-ordinating organ and tissue Health Ministry as the Interregional Co-ordination Centre and included in the National Health Plan. In procurement and transplant activities’ [8], the EmiliaRomagna region resolved to further the interregional 1997, the autonomous Province of Bolzano (the bilingual Italian–German speaking region of North Italy) agreement by building up its own Transplant Reference Centre. To this end, specific staff have been appointed joined AIRT. On March 1998, AIRT included 12.2 million inhabitants, four Regional Centres (Bologna, and independent headquarters set up with their own logistic arrangements. The functions of this centre are Bolzano, Florence and Turin) and one Interregional Centre situated in Bologna. purely organizational, with co-ordination and verification of the whole organ and tissue procurement and Table 1. AIRT agreements on co-ordination of organ and tissues transplant sector; all operative processes, regarding procurement and transplant activities: main points

The high demand for organs for transplantation has made it necessary to consider using even the oldest and youngest of potential donors in order to increase the organ supply. In this retrospective study, the outcome of kidney transplantation using cadaveric pediatric donors was compared with that of an adult control series. Graft procurement took place in two regions of Italy (Emilia-Romagna and Piemonte) over an 11-year period. A group of pediatric donors ( < 15 years old, n = 30) was compared with an adult donor group (n = 67). All recipients were adults who received cyclosporin as immunosuppression. Actuarial patient and graft survival rates did not differ significantly between the two groups (patient survival 96 % and 96 % for pediatric donors versus 98 % and 92 % for adult donors at 1 and 5 years post-transplantation; graft survival 76 % and 68 % for pediatric donors versus 88 % and 74 % for adult donors 1 and 5 y post-transplantation). Complications were also evaluated, but no difference was found (the only exception being the creatinine level in the 5th year). Renal transplantation with cadaveric donors starting at 4 years of age gave results comparable to kidneys coming from adults. These data show that cadaveric pediatric donor kidneys may be used in adult recipients with good results. The ethical implications of the subject are extensively reviewed.