Pulmonary Retransplantation in the Nordic Countries

Selection Criteria for Lung Transplantation: Controversies and New Developments

Lung transplantation is an accepted therapeutic option for end-stage lung diseases. The imbalance between limited availability and vast need of donor organs necessitates careful selection of recipient candidates, ensuring the best possible utilization of the scarce resource of organs. Nonetheless, possible lung transplant candidates who could experience a meaningful improvement in survival and quality of life should not be excluded solely based on the complexity of their case. In this review, controversial issues or difficult limitations for lung transplantation, and new developments in recipient selection criteria, are discussed, which may help broaden recipient eligibility for lung transplantation without compromising long-term outcomes.

Lung retransplant. Experience of a referral centre

BACKGROUND

Lung retransplantation (LR) is a valid choice with a significant risk of perioperative morbidity and mortality in selected patients with graft dysfunction after lung transplantation. Our goal is to analyse our experience in LR in terms of survival and lung function.

METHODS

Retrospective study of patients undergoing LR (1990-2019).

VARIABLES

recipients and procedure, early mortality, survival and lung function in patients with CLAD. Quantitative variables (mean±SD); qualitative (%). Student's t test or χ2 was used. Survival was estimated using Kaplan-Meier, compared with Log Rank. A p < 0.05 was established as significant.

RESULTS

Of 784 transplanted patients, 25 patients (mean age 38.41-16.3 years, 12 men and 13 women) were LR; (CLAD (n = 19), pulmonary infarction (n = 2), airway complications (n = 2), graft dysfunction (n = 1), hyperacute rejection (n = 1), mean time to retransplantation: 5.41 ± 3.87 years in CLAD and 21.2 ± 21.4 days in non-CLAD. The 90-day mortality was 52% and 36.8% in the second period (p = 0.007), being higher in patients who required preoperative ECMO (80 vs. 20%, p = 0.04). The 1- and 5-year survival was 53.9% and 37.7%, respectively (p = 0.016). Survival of the CLAD group was greater (p = 0.08). Pre LR ECMO decreased survival (p = 0.032). After LR, FEV₁ improved an average of 0.98 ± 0.13L (25.6 ± 18.8%) (p = 0.001).

CONCLUSIONS

LR is a high mortality procedure that requires careful selection of patients with better results in patients with CLAD. The lung function of patients with CLAD improved significantly.

The impact of alteplase on pulmonary graft function in donation after circulatory death - An experimental study

Objective

Lung transplantation is hampered by the lack of organs resulting in deaths on the waiting list. The usage of donation after circulatory death (DCD) lungs would dramatically increase donor availability. The most optimal organ preservation method, and the need for antithrombotic and fibrinolytic treatment to prevent thrombosis in the donor lungs is currently on debate. The present study investigated, in a simulated clinical DCD situation, whether the addition of alteplase in the flush-perfusion solution at the time of pulmonary graft harvesting could prevent thrombosis in the donor lung and thereby improve pulmonary graft function.

Methods

Twelve Swedish domestic pigs were randomized into two groups. All animals underwent ventricular fibrillation and were then left untouched for 1 h after declaration of death. None of the animals received heparin. The lungs were then harvested and flush-perfused with Perfadex^® solution and the organs were then stored at 8 °C for 4 h. In one group alteplase was added to the Perfadex^® solution (donation after cardiac death with alteplase (DCD-A)) and in the other, it was not (DCD). Lung function was evaluated, using ex vivo lung perfusion (EVLP), with blood gases at different oxygen levels, pulmonary vascular resistance (PVR), lung weight, and macroscopic appearance.

Results

During EVLP, there were no significant differences between groups in PaO₂ at any investigated FiO₂ level (1.0, 0.5, or 0.21). At FiO₂ 1.0, the PaO₂ in the DCD and DCD-A was 51.7 ± 2.05 kPa and 60.3 ± 3.67 kPa, respectively (p = 0.1320). There were no significant differences between groups PVR levels, in the DCD (372 ± 31 dyne x s/cm⁵) and in the DCD-A (297 ± 37 dyne x s/cm⁵) groups (p = 0.1720). There was no significant difference between groups in macroscopic appearance.

Conclusions

All the lungs showed excellent blood gases after EVLP, and they all meet the criteria's for clinical lung transplantation. The use of alteplase did not seem to have any obvious benefit to the donor lungs in a DCD situation. The donor lungs treated with alteplas showed slightly better blood gases and slightly lower PVR compared to the group without alteplas, however the difference was not significant. DCD appears to be a safe and effective method to expand the donor pool.

Experiences of supportive care when waiting for a lung re-transplantation

Objectives:

Lung transplant patients and their next of kin share the experiences of illness but little is known in the face of a lung re-transplantation. To describe patients’ and next of kin’s experiences of supportive care while awaiting lung re-transplantation and the objective was to highlight a small group with special circumstances and needs.

Methods:

Using qualitative content analysis, seven adult patients and seven next of kin were consecutively selected from a regional lung transplantation centre and individually interviewed shortly after decision about lung re-transplantation.

Results:

The experiences of supportive care were captured in one main category: ‘once again haunted by death’ and three sub-categories: ‘when life turns and death once again snorts down your neck’, ‘the importance of information’, and ‘perceptions of support’. A complex interaction between the experience of waiting, and communication patterns, emotional states, and social support was shown.

Conclusion:

This study provides insights into the complex interaction between the experience of waiting for a second lung transplant and communication patterns, emotional states, social support and social roles between patients, next of kin, healthcare professionals, and the health and social welfare system. There is a need for developing supportive care programme to achieve the best possible care.