It has been five years since the revised Organ Transplant Act went into effect, but the number of organ transplants has not increased; indeed, there has been a decreasing trend in the number of cases. Because of that, we have decided to respond by establishing a Parliamentarians' League for Consideration of Organ Transplants in the parliament. Although various measures have been undertaken up to now, we express our renewed determination to execute stronger measures, in cooperation with medical societies, the Japan Organ Transplant Network, and other groups, with the aim of increasing the number of transplants to over 200 cases within five years.

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Since a revised Organ Transplantation Act was issued in 2010, brain organ donations in Japan increased to 40 cases a year, from 10. Some loads on organ procurement hospitals have reduced, but others remain or have increased. Therefore the Japan Council of Organ Transplantation Related Academic Societies (J COTRAS) has continually worked to reduce the load on organ procurement hospitals in collaboration with members of the National Diet, such as Dr. Tsutomu Tomioka and the Ministry of Health, Labour and Welfare. In 2015, five rules were revised to reduce the burden as follows.
1. Confirmation of recipient's intent can be carried out after the first step of determination of the potential donor's brain death. 2. The potential donor can be transferred to another hospital to perform organ procurement if the hospital is directly connected physically to the donor hospital. 3. The legal determination of the potential donor's brain death can be helped by a physician who belongs to the other hospital. 4. The regulation of determination method of a so-called brain-dead condition is relaxed. 5. The amount of papers required for submission to the government's Verification Committee can be reduced if the donor hospital has experienced a brain-dead organ donation within the preceding five years and the donor is more than 18 years of age.

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Although the Japanese Organ Transplantation Act was revised in 2010 and brain-dead organ donations then increased to 4.1 cases monthly, from 0.6, only 164 institutions experienced brain-dead organ donations among a total 897 institutions in Japan that are allowed to procure organs under brain-dead conditions. Under these circumstances, in-hospital procurement coordinators (In-Hp PTCs) may play important roles in increasing organ donations and making procurement procedures progress smoothly. Therefore an education system for In-Hp PTCs should be established by the national government.
In this review, three special educational seminars for In-Hp PTCs are introduced. The first is In-Hp PTC educational programs by prefectural PTCs. The second is a seminar corresponding to brain-dead organ donations in emergency hospitals. The third is an extension seminar for In-Hp PTCs organized by Osaka University.

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In Japan, the ignorance and indifference of almost all medical doctors with respect to organ donations hampers the development of transplantation medicines. The author is a neurosurgeon and has been devoting substantial work to improve adequate edification and education about transplantation medicines. In lectures to medical students in medical faculties, the following issues were discussed. 1. Insufficiency of the comprehension or acceptation of a patient's death. 2. Conflicts between personal unwillingness and professional participation. 3. Shortage of information about the rules or data concerning donations and transplantations. 4. Hesitation of inquiries about donations to families of the donation candidates. 5. Confusions about the concepts of brain death in terms of philosophy, law, and medical science. In his lectures, the author has corrected student misunderstandings to clarify the needs and provide guidance to proper recognition. As a result, the students had improved interests and more-positive feelings in regards to transplantation medicines. For a wide diffusion of the appropriate education in all medical faculties in Japan, the participation of doctors in donor activities and decisions is essential. However, it is extremely difficult to accomplish. The author mainly aims at the local success of future organ donations as an initial goal by educating students in several medical universities.

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With the support of the government, Nagasaki Prefecture has improved the system of organ donation. The number of organ donors per capita is the second highest among all prefectures in Japan. Since amendment of the organ transplant law in 2010, organ donations in Japan after brain death has increased, but those after cardiac arrest have decreased. As a result, until 2014 the total number of organ donations has decreased. Before the law was amended, there were several donations after cardiac arrest from hospitals in Nagasaki Prefecture other than tertiary medical facilities, but none since the amendment. As part of the prefecture's support of the project financed by the Japan Organ Transplant Network for the implementation of organ donation, we performed retrospective research on 166 cases of death with emergency admission to two tertiary medical facilities in Nagasaki. Among these patients who were admitted to the hospitals during 2014, eleven patients with brain death and 25 with cardiac arrest were considered to be candidates for organ donation. Among these 36 candidates, only four patients' families were asked if they were interested in organ donation. Our study found that we might have been able to confirm the willingness of five more families to allow organ donation. Although we must take patients' satisfactory end of life into consideration, we also should present organ donation as one option when it occurs.

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【Background】The organ-donation rate in Japan is extremely lower than in other developed countries. Several reasons are responsible for such an unfavorable donation rate, but advanced education for in-hospital procurement coordinators is a possible solution to favorably lessen these influences. Thus we introduced the transplant procurement management (TPM) educational project to Hyogo Prefecture, Japan.
【Method】From 2009 to 2015, ten health-care professionals in Hyogo Prefecture participated in an Advanced International TPM course to learn about TPM educational methods and held TPM-model Organ Procurement Training Workshops in Hyogo Prefecture for in-hospital procurement coordinators. We also conducted a preworkshop questionnaire survey to grasp their abilities and motivations for organ donations. To evaluate our workshops, we also held a postworkshop and 3-months later conducted a workshop questionnaire survey.
【Results】Preworkshop survey revealed that in-hospital procurement coordinators lacked knowledge of the entire organ donation process, the Japanese current status of organ donation, and also of brain death definition. Moreover, they seemed to hardly understand the meaning of organ donation and the lives of organ-failure patients. A questionnaire survey after the workshop showed that our educational project effectively improved the knowledge and skills of these coordinators in regard to organ donation, leading them to more-positive motivation and favorable behavioral changes.
【Conclusion】This survey revealed that our TPM-model educational program offers proper knowledge and skills to increase organ donations in Hyogo Prefecture. We will continue this educational project and make efforts to further contribute to Japanese organ donation activities.

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【Objective】Good long-term kidney graft function and graft survival depend on multiple factors. This study aimed to assess the impact of donor and recipient clinical factors on 20-year graft survival after kidney transplantation (KT).
【Material and Methods】From 1987-1994, twenty-five KTs (14 living and 11 deceased donors) were performed at Ryukyu University Hospital, and 24 of these cases were followed for more than 20 years after the KTs and reviewed. Ten patients had 20 years of graft survival, and 14 experienced graft failure for some reason within 20 years after KTs. Retrospective analyses were performed to elucidate the difference in donor and recipient factors among these patients.
【Results】The death censored graft survival rates at 5, 10, 15, and 20 years were 92.0%, 83.0%, 67.0%, and 67.0% in living-donor KTs and 73.0%, 62.0%, 62.0%, and 31.0% in deceased-donor KTs, respectively. The overall graft survival rates at 5, 10, 15, and 20 years were 85.0%, 77.0%, 62.0%, and 54.0% in living-donor KTs and 63.0%, 55.0%, 45.0%, and 27.0% in deceased-donor KTs, respectively. Comparison of clinical factors between the ≥ 20-year graft survivor group (10 cases) and <20-year graft survivor group (14 cases) revealed no differences in, for example, recipient age, duration of dialysis, donor age, donor type, number of human leukocyte antigen mismatches, and occurrence of acute rejections within 1 year of KTs. However, among 13 cases of living-donor KTs, the overall graft survivals after KTs from donors older than 50 years were worse than those after KTs from donors younger than 50 years. Also, the death-censored graft survivals after KTs from donors older than 60 years were worse than those after KTs from donors younger than 60 years. Moreover, graft survivals after KTs from maternal donors were worse than those after KTs from nonmaternal living donors, and there were no 20-year graft survivors after KTs from maternal donors.
【Conclusion】Our results suggest that the principal risk factors associated with <20-year graft survival after living-donor KTs are the presence of donors older than 50 or 60 years and a maternal donor.

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To realize the tendency of judgments for legal actions about kidney transplantation in Japan, we analyzed trials that were recovered from published journals and digital databases of adjudications over the past 25 years. Six civil lawsuits were found. The first case is about a patient who refused the reintroduction of hemodialysis and died. The second explores the troubles derived from disbelievers of a family in the harvest of a cadaver kidney. The third is a case that involves death by over-hydration that occurred during the immediate period after operation, and the fourth is a case of postoperative pneumonia. The others are two death cases by posttransplant lymphoproliferative disorder (PTLD). Two judgments were found guilty, and payments were ¥68,850,000 and ¥200,000. Decisions for two cases of PTLD emphasize the significance of accountabilities for the risk of PTLD on preoperative presentations; PTLD has a lower incidence, but it will occasionally produce fatal results. Recent judgments have tendencies to demand good results from kidney-transplantation procedures because they are performed under less urgent situations for the purpose of providing better everyday health to patients.

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【Objective】The sensitivities of antibody testing using single antigen beads on the Luminex platform and flow cytometry crossmatch (FCXM) testing are higher than the sensitivity of the traditional estimation of complement-dependent cytotoxicity (CDC) for the detection of anti-human leukocyte antigen (HLA) antibodies. Therefore, these novel techniques are considered important for the prediction of graft survival before kidney transplantation. Here, we examined the usefulness of FCXM and immunocomplex capture fluorescence analysis (ICFA) in 188 kidney transplant candidates.
【Results】The results showed that permeabilization with a solvent was required in FCXM for immunostaining, but not in ICFA. On comparison of the results of FCXM with those of ICFA in terms of the presence of HLA antibodies and histopathological characteristics, we found that the results of FCXM showed a correlation of 100% to those of ICFA for HLA class I antibody and of 95% for HLA class II antibody.
【Conclusion】The results of the present study showed that FCXM and ICFA were useful in clinical practice because they required only a small amount of blood sample from the donor and did not necessitate the extraction of lymphocytes. Furthermore, the results of ICFA showed a good correlation with those of FCXM. These findings suggest that ICFA and FCXM can be useful tools for the preoperative evaluation and postoperative monitoring of HLA antibodies.

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【Objective】Therapeutic drug monitoring (TDM) of tacrolimus and cyclosporine A is essential to maintain the safety and efficacy in personalized immunosuppressive therapy. This study was to evaluate the recently developed electro chemiluminescence immunoassay (ECLIA) method for measuring tacrolimus and cyclosporine A blood concentrations in clinical practice.
【Methods】Spiked whole-blood samples were used to evaluate the performance of ECLIA. Whole-blood tacrolimus (n=160) or cyclosporine A (n=140) concentrations of transplanted patients were measured by ECLIA, chemiluminescence immunoassay (CLIA), affinity column mediated immune assay (ACMIA), and liquid chromatography with tandem mass spectrometry (LC-MS/MS).
【Results】The ECLIA measurements of tacrolimus and cyclosporine A showed good performance in terms of sensitivity, repeatability, and specificity. Values obtained with the ECLIA were highly correlated with the CLIA for tacrolimus （ECLIA= 1.013×CLIA - 0.055; r=0.996）, with the LC-MS/MS for tacrolimus （ECLIA=0.945×LC-MS/MS ＋ 0.630; r=0.983）, with the ACMIA for cyclosporine A （ECLIA = 1.099×ACMIA - 18.999; r= 0.989） and with the LC-MS/MS for cyclosporine A （ECLIA = 0.890×LC-MS/MS ＋ 27.099; r= 0.977）.
【Conclusion】The ECLIA is a sensitive and useful method to routinely monitor tacrolimus and cyclosporine A concentration in whole blood.

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It is reported that in the United States 1 living liver-transplant donor may die out of every 200 such transplants. Although the incidence is low in Japan, only 1 living liver donor died in more than 7,000 living liver transplants, and the death of a living kidney-transplant donor reported in 2013 remains vivid in our memory. It is advisable for medical transplant personnel to recognize that the death of a living organ-or tissue-transplant donor can occur and that a risk-management program medical facilities should be developed because of this possibility. Nagasaki University Hospital has established and implemented a Donor Advocacy Team (DAT), which is a risk-management program, in the event of a serious, persistent, or fatal impairment that a living donor may experience in a living-organ, tissue, or cell transplant. The purposes of the program are (1) to disclose official information immediately, (2) to provide physical care and psychiatric care for the patient experiencing impairment and the family, (3) to provide psychological care for the medical staff in charge of the transplant, (4) to standardize the responses of the diagnosis and treatment department staff and other hospital staffs, and (5) to minimize the damage the whole medical transplantation system may suffer and leverage it for improvement. The workflow for (1) and (5), such as reporting and responses to the government, mass media, transplant-related societies, and organ-transplant networks, has been established to assure implementation. Because the DAT plays a wide variety of roles, including provision of care not only for relevant donors and families, but also for hospital staff (doctors, nurses, and paramedical personnel), and immediate transmission of information, a risk-management team consisting of professionals from different fields, including a doctor, risk manager, psychological counselor, spokesperson, legal professional, bioethicist, and social worker, should be assembled for smooth operation.

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