Update on living-donor lobar lung transplantation:

Living Donor Lung Transplantation After Hematopoietic Stem Cell Transplantation From the Same Donor: A Risk Worth Taking

Living donor (LD) lung transplantation (LT) represents an exceptional procedure in Western countries. However, in selected situations, it could be a source of unique advantages, besides addressing organ shortage. We report a successful case of father-to-child single-lobe LT, because of the complications of hematopoietic stem cell transplantation from the same donor, with initial low-dose immunosuppressive therapy and subsequent early discontinuation. Full donor chimerism was hypothesized to be a mechanism of transplant tolerance, and this postulated immunological benefit was deemed to outweigh the risks of living donation and the possible drawbacks of single compared with bilateral LT. Favorable size matching and donor's anatomy, accurate surgical planning, and specific expertise in pediatric transplantation also contributed to the optimal recipient and donor outcomes. Ten months after LD LT, the patient's steadily good lung function after withdrawal of immunosuppressive therapy seems to confirm the original hypothesis.

[Lung transplantation: current situation and developments]

Lung transplantation is currently the gold standard treatment for end-stage lung diseases. Advances in the preservation of donor lungs, the surgical technique and immunosuppressive therapy have led to lung transplantation now being a routine procedure. Nevertheless, the shortage of donor organs, the acute and particularly chronic lung allograft dysfunction (CLAD) still represent major challenges even in experienced centers. Research in this area is still necessary to improve the long-term survival of lung recipients.

Donation after circulatory death and lung transplantation

Lung transplantation is the most effective modality for the treatment of patients with end-stage lung diseases. Unfortunately, many people cannot benefit from this therapy due to insufficient donor availability. In this review and update article, we discuss donation after circulatory death (DCD), which is undoubtedly essential among the strategies developed to increase the donor pool. However, there are ethical and legislative considerations in the DCD process that are different from those of donation after brain death (DBD). Among others, the critical aspects of DCD are the concept of the end of life, cessation of futile treatments, and withdrawal of life-sustaining therapy. In addition, this review describes a rationale for using lungs from DCD donors and provides some important definitions, highlighting the key differences between DCD and DBD, including physiological aspects pertinent to each category. The unique ability of lungs to maintain cell viability without circulation, assuming that oxygen is supplied to the alveoli-an essential aspect of DCD-is also discussed. Furthermore, an updated review of the clinical experience with DCD for lung transplantation across international centers, recent advances in DCD, and some ethical dilemmas that deserve attention are also reported.

Join the Lone Kidney Club: incentivising live organ donation

Given the dramatic shortage of transplantable organs, demand cannot be met by established and envisioned organ procurement policies targeting postmortem donation. Live organ donation (LOD) is a medically attractive option, and ethically permissible if informed consent is given and donor beneficence balances recipient non-maleficence. Only a few legal and regulatory frameworks incentivise LOD, with the key exception of Israel's Organ Transplant Law, which has produced significant improvements in organ donation rates. Therefore, I propose an organ procurement system that incentivises LOD by allocating additional priority points to the living donor on any transplant waiting list. I outline benefits and challenges for potential recipients, donors and society at large, and suggest measures to ensure medical protection of marginalised patient groups.

Bilateral Lobar Transplants Using One Donor for Two Small-Sized Recipients

Cadaveric lobar lung transplantation is an alternative for patients whose chest cavities have small dimensions. We present here a case where 1 donor was used for bilateral lobar transplantations in 2 high-risk patients. Coordination between the graft preparation at the back table and the 2 concomitant lung transplant teams was necessary to minimize the ischemic injury of the grafts and to plan for adequate vascular and bronchial cuffs for both implantations.

Pediatric lung transplantation

Pediatric lung transplantation is a highly specialized clinical endeavor. Since the late 1980's, there have only been slightly more than 2200 implants reported to the International Society for Heart and Lung transplantation registry. This review will discuss the historical aspects of pediatric lung transplantation. It will familiarize the reader with the current indications for transplant and the referral and listing process. The current state of lung assist devices as a bridge to pediatric lung transplantation is discussed in addition to the technical aspects of the transplant procedure. Finally, posttransplant outcomes, including anticipated morbidity and the role of retransplantation, are clarified.

Cytokine filtration modulates pulmonary metabolism and edema formation during ex vivo lung perfusion

BACKGROUND

Ex vivo lung perfusion (EVLP) has improved the process of donor lung management. Cytokine accumulation during EVLP has been shown to correlate with worse outcome after lung transplantation. Our objective in this study was to test the safety and efficacy of cytokine filtration during EVLP in a large animal model.

METHODS

Pig donor lungs were preserved for 24 hours at 4°C, followed by 12 hours of EVLP, according to the Toronto protocol. The perfusate was continuously run through an absorbent device (CytoSorb) via a veno-venous shunt from the reservoir in the filter group. EVLP was performed according to the standard protocol in the control group (n = 5 each). EVLP physiology, lung X-ray, perfusate biochemistry, inflammatory response and microscopic injury were assessed.

RESULTS

Cytokine filtration significantly improved airway pressure and dynamic compliance during the 12-hour perfusion period. Lung X-rays acquired at the end of perfusion showed increased consolidation in the control group. Electrolyte imbalance, determined by increased hydrogen, potassium and calcium ion concentrations in the perfusate, was markedly worsened in the control group. Glucose consumption and lactate production were markedly reduced, along with the lactate/pyruvate ratio in the filter group. Cytokine expression profile, tissue myeloperoxidase activity and microscopic lung injury were significantly reduced in the filter group.

CONCLUSIONS

Continuous perfusate filtration through sorbent beads is effective and safe during prolonged EVLP. Cytokine removal decreased the development of pulmonary edema and electrolyte imbalance through the suppression of anaerobic glycolysis and neutrophil activation in this setting. Further studies are needed to test the beneficial effect of cytokine filtration on post-transplant lung function.

Current status and problems of lung transplantation in Japan

Lung transplantation has been performed worldwide and recognized as an effective treatment for patients with various end-stage lung diseases. Shortage of lung donors is one of the main obstacles in most of the countries, especially in Japan. Every effort has been made to promote organ donation during the past 20 years. In 2010, Japanese transplant low was revised so that the family of the brain dead donors can make a decision for organ donation. Since then, the number of cadaveric lung donor has increased by 5-fold. However, the average waiting time is still more than 800 days resulting in considerable number of deaths on the waiting list. Lung transplantation in the use of donation after cardiac death (DCD) has now been increasingly performed in Europe, Australia and North America with promising results. However, controlled death is not permitted in Japan making it difficult to accept this strategy. Use of marginal donors is one of the strategies for organ shortage. In Japan, the rate of lung usage is now well over 60% because of careful donor management by medical consultants and aggressive use of marginal donors. Living-donor lobar lung transplantation (LDLLT) has been developed to offset the mismatch between supply and demand for those patients awaiting cadaveric lung transplantation (CLT) and it is often the most realistic option for very ill patients. Between 1998 and 2015, lung transplantation has been performed in 464 patients (55 children, 419 adults) at 9 lung transplant centers in Japan. CLT was performed in 283 patients (61%) and LDLLT was performed in 181 patients (39%). The 5-year survival was 72.3% and 71.6%, respectively. Of note, only seven children received CLT. In conclusion, lung transplantation in Japan has grown significantly with excellent results but the shortage of cadaveric lung donor remains to be an important unsolved problem. LDLLT is often the only realistic option for very ill patients especially for children.

Expanding the lung donor pool: advancements and emerging pathways

PURPOSE OF REVIEW

The number of patients listed for lung transplantation largely exceeds the number of available transplantable organs because of a shortage of organ donors and a low utilization rate of lungs from those donors who are available. In recent years, novel strategies have been developed to increase the donor lung pool: improved donor management, the use of lungs from donations after cardiac death (DCD), the use of lobar lung living-donors (LLLD) and the use of ex-vivo lung perfusion (EVLP) to assess and repair injured donor lungs.

RECENT FINDINGS

An adapted donor management strategy could expand the donor pool up to 20%. DCD lung transplant is an increasing part of the donor pool expansion. Outcomes after controlled DCD seem to be similar to donation after brain death. LLLD transplantation has excellent results for small and critically ill patients. EVLP treatment allows for a significant increase in the rate of suitable lungs and represents an optimal platform for lung reconditioning and specific lung therapies.

SUMMARY

A significant increase in the number of available lungs for transplantation is expected in the future because of the wider use of lungs from controlled or uncontrolled DCD and LLLD lungs, and with organ-specific EVLP treatment strategies.

Lobar lung transplantation from deceased donors: a valid option for small-sized patients with cystic fibrosis

BACKGROUND

Small-sized patients with cystic fibrosis usually face long waiting times for a suitable lung donor. Reduced-size lung transplantation (LTx) was promoted to shorten waiting times. We compared donor and recipient characteristics and outcome in lobar ([L]) versus full-size ([FS]) lung recipients.

METHODS

Between July 1, 1991, and February 28, 2011, 535 isolated LTx were performed, including 74 in cystic fibrosis patients (8 L, 66 FS). Patients were followed up until September 2012.

RESULTS

[L] recipients were younger, smaller, and lighter. Sex, waiting times, and donor data (age, sex, height, weight, PaO2/FiO2, and ventilation time) were comparable. Cardiopulmonary bypass was used more often in [L]; cold ischemia was comparable for first lung but longer in [L] for second lung; implantation times were comparable. In-hospital mortality rate was 0% in [L] versus 3% in [FS]. Both intensive care unit and hospital stay were longer in [L]. Grade 3 primary graft dysfunction was more pronounced in [L] at T0 and at T48. FEV1 increased significantly in both groups from preoperative value. Bronchiolitis obliterans syndrome was absent in [L] and diagnosed in 18 patients in [FS], accounting for 6 of 15 late deaths. All [L] are still alive. No differences in survival were found between the groups.

CONCLUSIONS

Although hindered by a higher incidence of primary graft dysfunction, L-LTx is a viable option with excellent survival and pulmonary function comparable to FS-LTx.

Lung transplantation: a treatment option in end-stage lung disease

BACKGROUND

Lung transplantation is the final treatment option in the end stage of certain lung diseases, once all possible conservative treatments have been exhausted. Depending on the indication for which lung transplantation is performed, it can improve the patient's quality of life (e.g., in emphysema) and/ or prolong life expectancy (e.g., in cystic fibrosis, pulmonary fibrosis, and pulmonary arterial hypertension). The main selection criteria for transplant candidates, aside from the underlying pulmonary or cardiopulmonary disease, are age, degree of mobility, nutritional and muscular condition, and concurrent extrapulmonary disease. The pool of willing organ donors is shrinking, and every sixth candidate for lung transplantation now dies while on the waiting list.

METHOD

We reviewed pertinent articles (up to October 2013) retrieved by a selective search in Medline and other German and international databases, including those of the International Society for Heart and Lung Transplantation (ISHLT), Eurotransplant, the German Institute for Applied Quality Promotion and Research in Health-Care (Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen, AQUA-Institut), and the German Foundation for Organ Transplantation (Deutsche Stiftung Organtransplantation, DSO).

RESULTS

The short- and long-term results have markedly improved in recent years: the 1-year survival rate has risen from 70.9% to 82.9%, and the 5-year survival rate from 46.9% to 59.6%. The 90-day mortality is 10.0%. The postoperative complications include acute (3.4%) and chronic (29.0%) transplant rejection, infections (38.0%), transplant failure (24.7%), airway complications (15.0%), malignant tumors (15.0%), cardiovascular events (10.9%), and other secondary extrapulmonary diseases (29.8%). Bilateral lung transplantation is superior to unilateral transplantation (5-year survival rate 57.3% versus 47.4%).

CONCLUSION

Seamless integration of the various components of treatment will be essential for further improvements in outcome. In particular, the follow-up care of transplant recipients should always be provided in close cooperation with the transplant center.

Interim report of the Japanese original donor evaluation and management system: the medical consultant system

PURPOSE

Lung transplantation (LTx) is an established therapy for end-stage lung failure. However, in Japan, the donor organ shortage is extremely severe compared with other developed countries, because of the strict Japanese Organ Transplantation Law. To maximize LTx opportunities in Japan, we have established a special donor evaluation and management system termed the medical consultant (MC) system.

METHODS

Data from 171 lung donor candidates registered in Japan from May 1998 to May 2012 were obtained and investigated in a retrospective manner. The candidates were separated into the non-MC-intervened and MC-intervened groups, and then data regarding the PaO2/FiO2 ratio, donation rate and organ survival rate were analyzed and compared between the groups.

RESULTS

The PaO2/FiO2 ratio of the MC-intervened group was ameliorated from the time of first brain death diagnosis to organ harvest. Although the base condition of the MC-intervened group was significantly worse than that of the non-MC-intervened group, the donation rates showed no significant difference (0.64 and 0.66, respectively; p = 0.89). There was a difference in the organ survival rate between the non-MC and MC-intervened groups (5-year survival rates of 67.2 and 88.3 %, respectively; p = 0.16).

CONCLUSION

The MC system used for organ donor evaluation and management in Japan has achieved acceptable interim results.

Morbidity and mortality of live lung donation: results from the RELIVE study

The Renal and Lung Living Donors Evaluation Study assesses outcomes of live lung (lobectomy) donors. This is a retrospective cohort study at University of Southern California (USC) and Washington University (WASHU) Medical Centers (1993–2006), using medical records to assess morbidity and national databases to ascertain postdonation survival and lung transplantation. Serious complications were defined as those that required significant treatment, were potentially life-threatening or led to prolonged hospitalization. The 369 live lung donors (287 USC, 82 WASHU) were predominantly white, non-Hispanic and male; 72% had a biological relationship to the recipient, and 30% were recipient parents. Serious complications occurred in 18% of donors; 2.2% underwent reoperation and 6.5% had an early rehospitalization. The two centers had significantly different incidences of serious complications (p < 0.001). No deaths occurred and no donors underwent lung transplantation during 4000+ person-years of follow-up (death: minimum 4, maximum 17 years; transplant: minimum 5, maximum 19). Live lung donation remains a potential option for recipients when using deceased donor lungs lacks feasibility. However, the use of two live donors for each recipient and the risk of morbidity associated with live lung donation do not justify this approach when deceased lung donors remain available. Center effects and long-term live donor outcomes require further evaluation.

Live related donor lobar lung transplantation recipients surviving well over a decade: still an option in times of advanced donor management

As waiting lists for lung transplantation are ever increasing, the number of organ donors is not able to keep pace with it. Living donor lobar lung transplantation is a source of organs which could be lifesaving in end-stage lung disease patients who cannot wait for cadaveric organs due to deteriorating lung function and clinical condition. Two young women with end stage cystic fibrosis received lobes from their relatives and an altruistic friend. They are surviving for more than 12 and 14 years with good lung functions.

First global forum on education on organ donation and transplantation for schools

The Transplantation Society, in collaboration with the Canadian Society of Transplantation, organized a forum on education on ODT for schools. The forum included participants from around the world, school boards, and representatives from different religions. Participants presented on their countries' experience in the area of education on ODT. Working groups discussed about technologies for education, principles for sharing of resources globally, and relationships between education, and health authorities and non-governmental organizations. The forum concluded with a discussion about how to best help existing programs and those wishing to start educational programs on ODT.