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The Comparable Efficacy of Lung Donation After Circulatory Death and Brain Death: A Systematic Review and Meta-analysis. Transplantation 2019; 103:2624-2633. [DOI: 10.1097/tp.0000000000002888] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Zhang ZL, van Suylen V, van Zanden JE, Van De Wauwer C, Verschuuren EAM, van der Bij W, Erasmus ME. First experience with ex vivo lung perfusion for initially discarded donor lungs in the Netherlands: a single-centre study. Eur J Cardiothorac Surg 2018; 55:920-926. [DOI: 10.1093/ejcts/ezy373] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 10/01/2018] [Accepted: 10/12/2018] [Indexed: 12/20/2022] Open
Affiliation(s)
- Zhang L Zhang
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Vincent van Suylen
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Judith E van Zanden
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Caroline Van De Wauwer
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Erik A M Verschuuren
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Wim van der Bij
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Michiel E Erasmus
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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Ex Vivo Assessment of Porcine Donation After Circulatory Death Lungs That Undergo Increasing Warm Ischemia Times. Transplant Direct 2018; 4:e405. [PMID: 30584586 PMCID: PMC6283086 DOI: 10.1097/txd.0000000000000845] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 10/07/2018] [Indexed: 01/11/2023] Open
Abstract
Background Increased utilization of donation after circulatory death (DCD) lungs may help alleviate the supply/demand mismatch between available donor organs and lung transplant candidates. Using an established porcine DCD model, we sought to determine the effect of increasing warm ischemia time (WIT) after circulatory arrest on lung function during ex vivo lung perfusion (EVLP). Methods Porcine donors (n = 15) underwent hypoxic cardiac arrest, followed by 60, 90, or 120 minutes of WIT before procurement and 4 hours of normothermic EVLP. Oxygenation, pulmonary artery pressure, airway pressure, and compliance were measured hourly. Lung injury scores were assessed histologically after 4 hours of EVLP. Results After EVLP, all 3 groups met all the criteria for transplantation, except for 90-minute WIT lungs, which had a mean pulmonary artery pressure increase greater than 15%. There were no significant differences between groups as assessed by final oxygenation capacity, as well as changes in pulmonary artery pressure, airway pressure, or lung compliance. Histologic lung injury scores as well as lung wet-to-dry weight ratios did not significantly differ between groups. Conclusions These results suggest that longer WIT alone (up to 120 minutes) does not predict worse lung function at the conclusion of EVLP. Expanding acceptable WIT after circulatory death may eventually allow for increased utilization of DCD lungs in procurement protocols.
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Inci I, Hillinger S, Schneiter D, Opitz I, Schuurmans M, Benden C, Weder W. Lung Transplantation with Controlled Donation after Circulatory Death Donors. Ann Thorac Cardiovasc Surg 2018; 24:296-302. [PMID: 29962390 PMCID: PMC6300426 DOI: 10.5761/atcs.oa.18-00098] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Purpose: Utilization of donation after circulatory death (DCD) donors has the potential to decrease donor shortage in lung transplantation (LTx). This study reviews the long-term outcome of LTx from DCD donors. Methods: We included all consecutive DCD (Maastricht Category III) and all donations after brain death (DBD) donor lung transplants at our Center performed between January 2012 and February 2017. Data were analyzed comparing the two groups in regard of survival after LTx as primary outcome. Results: Median withdrawal to cardiac arrest time was 17 min (interquartile range [IQR]: 11.5–20.5). Median cardiac arrest to cold perfusion was 32 min (IQR: 24.5–36.5). Primary graft dysfunction (PGD) grade 3 at T72 occurred in three recipients. Chronic lung allograft dysfunction (CLAD) led to death in two cases. In DCD group, there was no 90-day mortality. In DCD, group 1- and 3-year survival rates were 100% and 80%. In DBD group, 1- and 3-year survival rates were 85% and 69% (p = 0.4). Conclusions: Our report confirmed the comparable outcome from DCD donors compared with DBD donors. Utility of DCD donors is a safe option to overcome donor shortage.
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Affiliation(s)
- Ilhan Inci
- Department of Thoracic Surgery, Zurich University Hospital, Switzerland
| | - Sven Hillinger
- Department of Thoracic Surgery, Zurich University Hospital, Switzerland
| | - Didier Schneiter
- Department of Thoracic Surgery, Zurich University Hospital, Switzerland
| | - Isabelle Opitz
- Department of Thoracic Surgery, Zurich University Hospital, Switzerland
| | - Macé Schuurmans
- Division of Pulmonary Medicine, Zurich University Hospital, Switzerland
| | - Christian Benden
- Division of Pulmonary Medicine, Zurich University Hospital, Switzerland
| | - Walter Weder
- Department of Thoracic Surgery, Zurich University Hospital, Switzerland
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Costa J, Shah L, Robbins H, Raza K, Sreekandth S, Arcasoy S, Sonett JR, D'Ovidio F. Use of Lung Allografts From Donation After Cardiac Death Donors: A Single-Center Experience. Ann Thorac Surg 2017; 105:271-278. [PMID: 29128047 DOI: 10.1016/j.athoracsur.2017.07.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 06/26/2017] [Accepted: 07/17/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Lung transplantation remains the only treatment for end-stage lung disease. Availability of suitable lungs does not parallel this growing trend. Centers using donation after cardiac death (DCD) donor lungs report comparable outcomes with those from brain-dead donors. Donor assessment protocols and consistent surgical teams have been advocated when considering using the use of DCD donors. We present our experience using lungs from Maastricht category III DCD donors. METHODS Starting 2007 to July 2016, 73 DCD donors were assessed, 44 provided suitable lungs that resulted in 46 transplants. A 2012 to October 2016 comparative cohort of 379 brain-dead donors were assessed. Recipient and donor characteristics and primary graft dysfunction (PGD) and survival were monitored. RESULTS Seventy-three DCD (40% dry run rate) donors assessed yielded 46 transplants (23 double, 6 right, and 17 left). Comparative cohort of 379 brain-dead donors yielded 237 transplants (112 double, 43 right, and 82 left). One- and 3-year recipient survival was 91% and 78% for recipients of DCD lungs and 91% and 75% for recipients of lungs from brain-dead donors, respectively. PGD 2 and 3 in DCD recipients at 72 hours was 4 of 46 (9%) and 6 of 46 (13%), respectively. Comparatively, brain-dead donor recipient cohort at 72 hours with PGD 2 and 3 was 23 of 237 (10%) and 41 of 237 (17%), respectively. CONCLUSIONS Our experience reaffirms the use of lungs from DCD donors as a viable source with favorable outcomes. Recipients from DCD donors showed equivalent PGD rate at 72 hours and survival compared with recipients from brain-dead donors.
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Affiliation(s)
- Joseph Costa
- Department of Surgery, General Thoracic Surgery Section, Columbia University Medical Center, New York
| | - Lori Shah
- Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center, New York, New York
| | - Hilary Robbins
- Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center, New York, New York
| | - Kashif Raza
- Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center, New York, New York
| | - Sowmya Sreekandth
- Department of Surgery, General Thoracic Surgery Section, Columbia University Medical Center, New York
| | - Selim Arcasoy
- Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center, New York, New York
| | - Joshua R Sonett
- Department of Surgery, General Thoracic Surgery Section, Columbia University Medical Center, New York
| | - Frank D'Ovidio
- Department of Surgery, General Thoracic Surgery Section, Columbia University Medical Center, New York.
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van Suylen V, Luijk B, Hoek RAS, van de Graaf EA, Verschuuren EA, Van De Wauwer C, Bekkers JA, Meijer RCA, van der Bij W, Erasmus ME. A Multicenter Study on Long-Term Outcomes After Lung Transplantation Comparing Donation After Circulatory Death and Donation After Brain Death. Am J Transplant 2017; 17:2679-2686. [PMID: 28470870 DOI: 10.1111/ajt.14339] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 04/13/2017] [Accepted: 04/21/2017] [Indexed: 01/25/2023]
Abstract
The implementation of donation after circulatory death category 3 (DCD3) was one of the attempts to reduce the gap between supply and demand of donor lungs. In the Netherlands, the total number of potential lung donors was greatly increased by the availability of DCD3 lungs in addition to the initial standard use of donation after brain death (DBD) lungs. From the three lung transplant centers in the Netherlands, 130 DCD3 recipients were one-to-one nearest neighbor propensity score matched with 130 DBD recipients. The primary end points were primary graft dysfunction (PGD), posttransplant lung function, freedom from chronic lung allograft dysfunction (CLAD), and overall survival. PGD did not differ between the groups. Posttransplant lung function was comparable after bilateral lung transplantation, but seemed worse after DCD3 single lung transplantation. The incidence of CLAD (p = 0.17) nor the freedom from CLAD (p = 0.36) nor the overall survival (p = 0.40) were significantly different between both groups. The presented multicenter results are derived from a national context where one third of the lung transplantations are performed with DCD3 lungs. We conclude that the long-term outcome after lung transplantation with DCD3 donors is similar to that of DBD donors and that DCD3 donation can substantially enlarge the donor pool.
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Affiliation(s)
- V van Suylen
- Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - B Luijk
- Department of Respiratory Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - R A S Hoek
- Department of Respiratory Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - E A van de Graaf
- Department of Respiratory Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - E A Verschuuren
- Department of Pulmonary Medicine and Tuberculosis, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - C Van De Wauwer
- Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - J A Bekkers
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - R C A Meijer
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - W van der Bij
- Department of Pulmonary Medicine and Tuberculosis, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - M E Erasmus
- Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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7
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Abstract
The number of patients actively awaiting lung transplantation (LTx) is more than the number of suitable donor lungs. The percentage of lung retrieval rate is lower when compared to other solid organs. The use of lungs from donation after cardiocirculatory death (DCD) donors is one of the options to avoid organ shortage in LTx. After extensive experimental research, clinical application of DCD donation is becoming wider. The results from most of the centers show at least equal survival rate compared to donors from brain death. This review paper will summarize experimental background and clinical experience from DCD donors.
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Affiliation(s)
- Ilhan Inci
- Department of Thoracic Surgery, University Hospital, University of Zurich, Zurich, Switzerland
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van Loo ES, Krikke C, Hofker HS, Berger SP, Leuvenink HGD, Pol RA. Outcome of pancreas transplantation from donation after circulatory death compared to donation after brain death. Pancreatology 2016; 17:13-18. [PMID: 27838258 DOI: 10.1016/j.pan.2016.11.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 11/01/2016] [Accepted: 11/05/2016] [Indexed: 12/11/2022]
Abstract
INTRODUCTION To overcome the gap of organ shortage grafts from donation after circulatory death (DCD) can be used. This review evaluates the outcomes after DCD pancreas donation compared to donation after brain death (DBD). MATERIALS AND METHODS A literature search was performed using Medline, Embase, and PubMed databases. All comparative cohort studies reporting the outcome after DCD and DBD pancreas transplantation were included. All data were assessed according to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. To evaluate the event rates, pooled odds ratios (ORs) as well as the 95% confidence intervals (CI) were calculated. Since the number of studies is small we used the random-effects model only to overcome heterogeneity. RESULTS There is no difference in 1-year pancreas graft survival (OR 1.092, CI 95% 0.649-1.837, P = 0.741) or patient survival (OR 0.699, CI 95% 0.246-1.985, P = 0.502). Simultaneous pancreas-kidney (SPK) transplantation showed significantly higher graft survival rates compared to pancreas transplantation alone (87.2% vs. 76.6%, P < 0.001 in DBD and 86.5% vs. 74.9%, P < 0.001 in DCD). DCD SPK grafts show a higher delayed kidney graft function rate compared to DBD SPK-grafts (OR 0.209, CI 95% 0.104-0.421, P < 0.001). There is significantly less pancreas graft thrombosis after DBD-donation (OR 0.567, CI 95% 0.340-0.946, P = 0.030). We found no difference in the HbA1c level at 1-year follow-up with a median of 5.4% in both groups and a mean of 5.63% (DCD) vs 5.43% (DBD). DISCUSSION DCD pancreas transplantation has comparable patient and 1-year graft survival rates and should be considered a safe alternative for DBD pancreas transplantation.
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Affiliation(s)
- Ellen S van Loo
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
| | - Christina Krikke
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
| | - Hendrik S Hofker
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
| | - Stefan P Berger
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
| | - Henri G D Leuvenink
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
| | - Robert A Pol
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
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Luc JGY, Nagendran J. The evolving potential for pediatric ex vivo lung perfusion. Pediatr Transplant 2016; 20:13-22. [PMID: 26694514 DOI: 10.1111/petr.12653] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2015] [Indexed: 11/28/2022]
Abstract
Despite the rise in the number of adult lung transplantations performed, rates of pediatric lung transplantation remain low. Lung transplantation is an accepted therapy for pediatric end-stage lung disease; however, it is limited by a shortage of donor organs. EVLP has emerged as a platform for assessment and preservation of donor lung function. EVLP has been adopted in adult lung transplantation and has successfully led to increased adult lung transplantations and donor lung utilization. We discuss the future implications of EVLP utilization, specifically, its potential evolving role in overcoming donor shortages in smaller children and adolescents to improve the quality and outcomes of lung transplantation in pediatric patients.
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Affiliation(s)
- Jessica G Y Luc
- Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.,Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
| | - Jayan Nagendran
- Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.,Mazankowski Alberta Heart Institute, Edmonton, AB, Canada.,Alberta Transplant Institute, Edmonton, AB, Canada.,Canadian National Transplant Research Program, Edmonton, AB, Canada
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Erasmus ME, van Raemdonck D, Akhtar MZ, Neyrinck A, de Antonio DG, Varela A, Dark J. DCD lung donation: donor criteria, procedural criteria, pulmonary graft function validation, and preservation. Transpl Int 2016; 29:790-7. [DOI: 10.1111/tri.12738] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 08/02/2015] [Accepted: 12/21/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Michiel E. Erasmus
- Department of Cardiothoracic Surgery; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Dirk van Raemdonck
- Department of Thoracic Surgery; University Hospitals Leuven; Leuven Belgium
| | - Mohammed Zeeshan Akhtar
- Nuffield Department of Surgical Sciences; Oxford Transplant Centre; University of Oxford; Oxford UK
| | - Arne Neyrinck
- Department of Thoracic Surgery; University Hospitals Leuven; Leuven Belgium
| | | | - Andreas Varela
- Thoracic Department; Hospital Universitario Puerta de Hierro Majadahonda; Madrid Spain
| | - John Dark
- Institute of Cellular Medicine; Newcastle University; Newcastle upon Tyne UK
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11
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Cypel M, Levvey B, Van Raemdonck D, Erasmus M, Dark J, Mason D, Glanville AR, Chambers D, Edwards L, Stehlik J, Hertz M, Whitson BA, Yusen RD, Hopkins P, Snell G, Keshavjee S. Lung transplantation using controlled donation after circulatory death donors: Trials and tribulations. J Heart Lung Transplant 2015; 35:146-147. [PMID: 26552615 DOI: 10.1016/j.healun.2015.10.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 10/02/2015] [Indexed: 01/16/2023] Open
Affiliation(s)
- Marcelo Cypel
- International Society for Heart and Lung Transplantation Donation after Circulatory Death Registry, Dallas, Texas
| | - Bronwyn Levvey
- International Society for Heart and Lung Transplantation Donation after Circulatory Death Registry, Dallas, Texas
| | - Dirk Van Raemdonck
- International Society for Heart and Lung Transplantation Donation after Circulatory Death Registry, Dallas, Texas
| | - Michiel Erasmus
- International Society for Heart and Lung Transplantation Donation after Circulatory Death Registry, Dallas, Texas
| | - John Dark
- International Society for Heart and Lung Transplantation Donation after Circulatory Death Registry, Dallas, Texas
| | - David Mason
- International Society for Heart and Lung Transplantation Donation after Circulatory Death Registry, Dallas, Texas
| | - Allan R Glanville
- International Society for Heart and Lung Transplantation Donation after Circulatory Death Registry, Dallas, Texas
| | - Daniel Chambers
- International Society for Heart and Lung Transplantation Donation after Circulatory Death Registry, Dallas, Texas
| | - Leah Edwards
- International Society for Heart and Lung Transplantation Donation after Circulatory Death Registry, Dallas, Texas
| | - Josef Stehlik
- International Society for Heart and Lung Transplantation Donation after Circulatory Death Registry, Dallas, Texas
| | - Marshall Hertz
- International Society for Heart and Lung Transplantation Donation after Circulatory Death Registry, Dallas, Texas
| | - Brian A Whitson
- International Society for Heart and Lung Transplantation Donation after Circulatory Death Registry, Dallas, Texas
| | - Roger D Yusen
- International Society for Heart and Lung Transplantation Donation after Circulatory Death Registry, Dallas, Texas
| | - Peter Hopkins
- International Society for Heart and Lung Transplantation Donation after Circulatory Death Registry, Dallas, Texas
| | - Greg Snell
- International Society for Heart and Lung Transplantation Donation after Circulatory Death Registry, Dallas, Texas
| | - Shaf Keshavjee
- International Society for Heart and Lung Transplantation Donation after Circulatory Death Registry, Dallas, Texas
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Cypel M, Levvey B, Van Raemdonck D, Erasmus M, Dark J, Love R, Mason D, Glanville AR, Chambers D, Edwards LB, Stehlik J, Hertz M, Whitson BA, Yusen RD, Puri V, Hopkins P, Snell G, Keshavjee S. International Society for Heart and Lung Transplantation Donation After Circulatory Death Registry Report. J Heart Lung Transplant 2015; 34:1278-82. [DOI: 10.1016/j.healun.2015.08.015] [Citation(s) in RCA: 140] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 07/20/2015] [Accepted: 08/31/2015] [Indexed: 01/21/2023] Open
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Strategies for safe donor expansion: donor management, donations after cardiac death, ex-vivo lung perfusion. Curr Opin Organ Transplant 2015; 18:513-7. [PMID: 23995370 DOI: 10.1097/mot.0b013e328365191b] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The number of patients listed for lung transplantation largely exceeds the number of available transplantable organs because of both a shortage of organ donors and a low utilization rate of lungs from those donors. Two major innovations in recent years include the use of lungs from donations after cardiac death (DCD) and the use of ex-vivo lung perfusion (EVLP) to assess and improve injured donor lungs. RECENT FINDINGS DCD lung transplants now account for about 20% of lung transplants in many centres and outcomes after transplantation have been excellent with this source of donation. Clinical experience using EVLP has shown the method to be well tolerated and allow for reassessment and improvement in function from high-risk donor lungs. When these lungs were transplanted, low rates of primary graft dysfunction were achieved and long-term survival was comparable with standard transplantation. Preclinical studies have shown a great potential of EVLP as a platform for the delivery of novel therapies to repair injured donor lungs. SUMMARY A significant increase on the number of available lungs for transplantation is expected in the coming years with the wider use of DCD lungs and with organ-specific ex-vivo treatment strategies.
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15
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Abstract
Lung transplantation (LTx) is an established treatment option for eligible patients with end-stage lung disease. Nevertheless, the imbalance between suitable donor lungs available and the increasing number of patients considered for LTx reflects in considerable waitlist mortality. Among potential alternatives to address this issue, ex vivo lung perfusion (EVLP) has emerged as a modern preservation technique that allows for more accurate lung assessment and also improvement of lung function. Its application in high-risk donor lungs has been successful and resulted in safe expansion of the donor pool. This article will: (I) review the technical details of EVLP; (II) the rationale behind the method; (III) report the worldwide clinical experience with the EVLP, including the Toronto technique and others; (IV) finally, discuss the growing literature on EVLP application for donation after cardiac death (DCD) lungs.
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Affiliation(s)
- Tiago N Machuca
- Toronto Lung Transplant Program, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, University of Toronto, University Health Network, Toronto, Ontario, Canada
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Abstract
PURPOSE OF REVIEW Donor shortage has forced transplant teams to explore new methods to increase the potential donor pool. Donation after circulatory death (DCD) has opened new perspectives and could be a valuable option to expand the brain-dead donors. The purpose of this review is to provide an overview of current practice and to identify remaining questions related to ethical and medical issues that should be further addressed in the future. RECENT FINDINGS Recent findings demonstrate acceptable outcomes after DCD kidney and lung transplantation but inferior graft survival for liver transplantation. The impact and importance of the agonal phase following withdrawal of treatment in controlled DCD is increasingly recognized. Premortem interventions are currently under debate related to preservation strategies or comfort therapy. New preservation strategies using in-situ/in-vivo extracorporeal membrane oxygenation or ex-vivo machine perfusion have large potential in the future. Finally, organizations and institutions are reporting more uniform guidelines related to declaration of death and DCD organ procurement. SUMMARY DCD donation has regained much attention during the last decade and is now part of standard clinical practice albeit this type of donation should not be regarded as an equally acceptable alternative for donation after brain death. It will be important to further explore the potential of DCD, to monitor the long-term outcomes and to further optimize the quality of these grafts. Development and implementation of uniform guidelines will be necessary to guarantee the clinical use of these donor pools.
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Incidence and distribution of transplantable organs from donors after circulatory determination of death in U.S. intensive care units. Ann Am Thorac Soc 2013; 10:73-80. [PMID: 23607834 DOI: 10.1513/annalsats.201211-109oc] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE All U.S. acute care hospitals must maintain protocols for recovering organs from donors after circulatory determination of death (DCDD), but the numbers, types, and whereabouts of available organs are unknown. OBJECTIVES To assess the maximal potential supply and distribution of DCDD organs in U.S. intensive care units. METHODS We conducted a population-based cohort study among a randomly selected sample of 50 acute care hospitals in the highest-volume donor service area in the United States. We identified all potentially eligible donors dying within 90 minutes of the withdrawal of life-sustaining therapy from July 1, 2008 to June 30, 2009. MEASUREMENTS AND MAIN RESULTS Using prespecified criteria, potential donors were categorized as optimal, suboptimal, or ineligible to donate their lungs, kidneys, pancreas, or liver. If only optimal DCDD organs were used, the deceased donor supplies of these organs could increase by up to 22.7, 8.9, 7.4, and 3.3%, respectively. If optimal and suboptimal DCDD organs were used, the corresponding supply increases could be up to 50.0, 19.7, 18.5, and 10.9%. Three-quarters of DCDD organs could be recovered from the 17.2% of hospitals with the highest annual donor volumes-typically those with trauma centers and more than 20 intensive care unit beds. CONCLUSIONS Universal identification and referral of DCDD could increase the supply of transplantable lungs by up to one-half, and would not increase any other organ supply by more than one-fifth. The marked clustering of DCDD among a small number of identifiable hospitals could guide targeted interventions to improve DCDD identification, referral, and management.
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18
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Abstract
After a brief review of conventional lung preservation, this article discusses the rationale behind ex vivo lung perfusion and how it has shifted the paradigm of organ preservation from conventional static cold ischemia to the utilization of functional normothermia, restoring the lung's own metabolism and its reparative processes. Technical aspects and previous clinical experience as well as opportunities to address specific donor organ injuries in a personalized medicine approach are also reviewed.
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Wind J, Faut M, van Smaalen TC, van Heurn ELW. Variability in protocols on donation after circulatory death in Europe. Crit Care 2013; 17:R217. [PMID: 24090229 PMCID: PMC4057469 DOI: 10.1186/cc13034] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 07/31/2013] [Indexed: 12/02/2022] Open
Abstract
Introduction Organ donation after circulatory death (DCD) has become an accepted strategy to reduce the shortage of organs for transplantation in many European countries. The use and number of DCD donors varies between countries. The purpose of this study was to evaluate the available protocols for DCD in Europe. Methods We contacted national transplant societies and responsible transplant co-ordinators in the countries that perform DCD to obtain DCD protocols. We compared information on the protocols and additional data including: inclusion and exclusion criteria for donation, legislation, determination of death and preservation methods. Results In ten European countries DCD is performed, eight of which describe the methods in protocols. There are large differences in used DCD categories, legislation and the way death is determined. Protocols differ in the detail in which DCD procedures are described and the way methods are supported by additional consensus statements and ethical frameworks. Conclusions Although DCD is an established strategy to enlarge the donor pool and to contribute to the reduction of the waiting list for transplantation, its potential has not been fully utilized yet. To further promote DCD transplantation, it is important to share expertise and obtain consensus, so that this can be translated into more uniform and solid protocols supported by the competent authorities, transplant and intensive care professionals, which may eventually result in a further promotion of DCD transplantation in Europe.
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Lindstedt S, Pierre L, Hlebowicz J, Ingemansson R. Heparin does not seem to improve the function of pulmonary grafts for lung transplantation. SCAND CARDIOVASC J 2013; 47:307-13. [DOI: 10.3109/14017431.2013.825734] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Protective effect of surfactant inhalation against warm ischemic injury in an isolated rat lung ventilation model. PLoS One 2013; 8:e72574. [PMID: 24009692 PMCID: PMC3757025 DOI: 10.1371/journal.pone.0072574] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 07/09/2013] [Indexed: 12/29/2022] Open
Abstract
Warm ischemia-reperfusion injury remains a crucial issue in transplantation following the cardiac death of donors. Previously, we showed that surfactant inhalation during warm ischemia mitigated ischemia-reperfusion injury. This study investigated the mechanisms of surfactant inhalation protection of the warm ischemic lung after reoxygenation with ventilation alone. In an isolated rat lung ventilation model, cardiac arrest was induced in the CTRL (control) and SURF (surfactant treatment) groups by ventricular fibrillation. Ventilation was restarted 110 min later; the lungs were flushed, and a heart and lung block was procured. In the SURF group, a natural bovine surfactant (Surfacten®) was inhaled for 3 min at the end of warm ischemia. In the Sham (no ischemia) group, lungs were flushed, procured, and ventilated in the same way. Afterwards, the lungs were ventilated with room air without reperfusion for 60 min. Surfactant inhalation significantly improved dynamic compliance and airway resistance. Moreover, surfactant inhalation significantly decreased inducible nitric oxide synthase and caspase-3 transcript levels, and increased those of Bcl-2 and surfactant protein-C. Immunohistochemically, lungs in the SURF group showed weaker staining for 8-hydroxy-2′-deoxyguanosine, inducible nitric oxide synthase, and apoptosis, and stronger staining for Bcl-2 and surfactant protein-C. Our results indicate that surfactant inhalation in the last phase of warm ischemia mitigated the injury resulting from reoxygenation after warm ischemia. The reduction in oxidative damage and the inhibition of apoptosis might contribute to the protection of the warm ischemic lungs.
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Cypel M, Keshavjee S. Expanding lung donation: the use of uncontrolled non-heart beating donors. Eur J Cardiothorac Surg 2013; 43:419-20. [PMID: 23319489 DOI: 10.1093/ejcts/ezs461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Marcelo Cypel
- Toronto Lung Transplant Program, University of Toronto, Toronto, ON, Canada
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Abstract
OBJECTIVE To evaluate the effects of prearrest heparin administration on lung quality in a model of donation after cardiac death (DCD), and to assess the potential application of ex vivo lung perfusion (EVLP) in the identification of better grafts from the DCD donor pool. METHODS Cardiac death was induced by electric shock in 10 pigs. One group received a prearrest heparin dose of 300 units/kg (H group, n = 5) and the other did not (NH group, n = 5). Animals remained at room temperature for 1 hour without ventilation, defining the warm ischemic time. After harvest, the lungs underwent 6 hours of cold ischemia before being evaluated with EVLP for 4 hours. RESULTS Static compliance 28 ± 3 versus 29 ± 2 (Cstat-cm H2O), pulmonary vascular resistance (PVR) 593 ± 127 versus 495 ± 70 (PVR-dyn·s/cm), and oxygenation 327 ± 32 versus 330 ± 28 (ΔPO2-mm Hg) remained stable from the beginning until the end of EVLP in the H group. In the NH group, Cstat started to decline after the first hour (25 ± 2 vs 21 ± 2), ΔPO2 after hour 2 (265 ± 44 vs 207 ± 44), and PVR started to increase after hour 3 (765 ± 132 vs 916 ± 168). Significant differences between the groups were observed at the end of EVLP (P < 0.001). Parameters of lung quality after EVLP also showed significant differences between the groups: wet weight-to-dry weight ratio (P < 0.001), protein in the bronchial lavage (P < 0.01), Na + K-ATPase activity (P < 0.001), and E-selectin (P < 0.001) in the perfusate. CONCLUSIONS Prearrest heparin administration improved organ function by preserving endothelial homeostasis. EVLP proved to be a useful platform for assessing DCD lungs, providing reliable means of discriminating injured grafts.
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Piazza O, Romano R, Cotena S, Santaniello W, De Robertis E. Maximum tolerable warm ischaemia time in transplantation from non-heart-beating-donors. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2013. [DOI: 10.1016/j.tacc.2013.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Motoyama H, Chen F, Ohsumi A, Hijiya K, Okita K, Nakajima D, Sakamoto J, Yamada T, Sato M, Aoyama A, Bando T, Date H. Protective effect of plasmin in marginal donor lungs in an ex vivo lung perfusion model. J Heart Lung Transplant 2013; 32:505-10. [PMID: 23499355 DOI: 10.1016/j.healun.2013.02.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 01/25/2013] [Accepted: 02/15/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Donor lung thrombi are considered an important etiology for primary graft dysfunction in lung transplantation. We hypothesized that thrombolysis before lung transplantation could alleviate ischemia-reperfusion injury. This study was designed to evaluate the effect of the fibrinolytic agent plasmin on lungs damaged by thrombi in an ex vivo lung perfusion (EVLP) system. METHODS Rats were divided into control, non-plasmin, and plasmin groups (n = 7 each). In the control and plasmin groups, cardiac arrest was induced by withdrawal of mechanical ventilation without heparinization. Ventilation was restarted 150 minutes after cardiac arrest. The lungs were flushed, and the heart and lungs were excised en bloc. The lungs were perfused in the EVLP system for 60 minutes, and plasmin or placebo was administered upon EVLP initiation. RESULTS Fibrin/fibrinogen degradation products in the perfusate were significantly higher in the plasmin group than in the control and non-control groups (p < 0.001 for both). Plasmin administration significantly decreased pulmonary vascular resistance (plasmin vs non-plasmin, p = 0.011) and inhibited the exacerbation of dynamic compliance (plasmin vs non-plasmin, p = 0.003). Lung weight gain was less in the plasmin group than in the non-plasmin group (p = 0.04). CONCLUSIONS Our results confirmed that plasmin administration in an EVLP model dissolved thrombi in the lungs, resulting in reconditioning of the lungs as assessed by various physiologic parameters.
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Affiliation(s)
- Hideki Motoyama
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Sakyo-ku, Kyoto, Japan
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Ohsumi A, Chen F, Sakamoto J, Nakajima D, Hijiya K, Motoyama H, Okita K, Horita K, Kikuchi R, Yamada T, Bando T, Date H. Protective effect of pre-recovery surfactant inhalation on lungs donated after cardiac death in a canine lung transplantation model. J Heart Lung Transplant 2012; 31:1136-42. [DOI: 10.1016/j.healun.2012.07.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Revised: 05/28/2012] [Accepted: 07/28/2012] [Indexed: 11/16/2022] Open
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Cypel M, Yeung JC, Machuca T, Chen M, Singer LG, Yasufuku K, de Perrot M, Pierre A, Waddell TK, Keshavjee S. Experience with the first 50 ex vivo lung perfusions in clinical transplantation. J Thorac Cardiovasc Surg 2012; 144:1200-6. [PMID: 22944089 DOI: 10.1016/j.jtcvs.2012.08.009] [Citation(s) in RCA: 210] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Revised: 07/08/2012] [Accepted: 08/01/2012] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Normothermic ex vivo lung perfusion is a novel method to evaluate and improve the function of injured donor lungs. We reviewed our experience with 50 consecutive transplants after ex vivo lung perfusion. METHODS A retrospective study using prospectively collected data was performed. High-risk brain death donor lungs (defined as Pao(2)/Fio(2) <300 mm Hg or lungs with radiographic or clinical findings of pulmonary edema) and lungs from cardiac death donors were subjected to 4 to 6 hours of ex vivo lung perfusion. Lungs that achieved stable airway and vascular pressures and Pao(2)/Fio(2) greater than 400 mm Hg during ex vivo lung perfusion were transplanted. The primary end point was the incidence of primary graft dysfunction grade 3 at 72 hours after transplantation. End points were compared with lung transplants not treated with ex vivo lung perfusion (controls). RESULTS A total of 317 lung transplants were performed during the study period (39 months). Fifty-eight ex vivo lung perfusion procedures were performed, resulting in 50 transplants (86% use). Of these, 22 were from cardiac death donors and 28 were from brain death donors. The mean donor Pao(2)/Fio(2) was 334 mm Hg in the ex vivo lung perfusion group and 452 mm Hg in the control group (P = .0001). The incidence of primary graft dysfunction grade 3 at 72 hours was 2% in the ex vivo lung perfusion group and 8.5% in the control group (P = .14). One patient (2%) in the ex vivo lung perfusion group and 7 patients (2.7%) in the control group required extracorporeal lung support for primary graft dysfunction (P = 1.00). The median time to extubation, intensive care unit stay, and hospital length of stay were 2, 4, and 20 days, respectively, in the ex vivo lung perfusion group and 2, 4, and 23 days, respectively, in the control group (P > .05). Thirty-day mortality (4% in the ex vivo lung perfusion group and 3.5% in the control group, P = 1.00) and 1-year survival (87% in the ex vivo lung perfusion group and 86% in the control group, P = 1.00) were similar in both groups. CONCLUSIONS Transplantation of high-risk donor lungs after 4 to 6 hours of ex vivo lung perfusion is safe, and outcomes are similar to those of conventional transplants. Ex vivo lung perfusion improved our center use of donor lungs, accounting for 20% of our current lung transplant activity.
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Affiliation(s)
- Marcelo Cypel
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Wallinder A, Steen S, Liden H, Hansson C, Hussein AA, Sjöberg T, Dellgren G. Heparin does not improve graft function in uncontrolled non-heart-beating lung donation: an experimental study in pigs. Eur J Cardiothorac Surg 2012; 43:413-9. [DOI: 10.1093/ejcts/ezs364] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Whose Consent Matters? Controlled Donation After Cardiac Death and Premortem Organ-Preserving Measures. Transplantation 2012; 93:965-9. [PMID: 22576161 DOI: 10.1097/tp.0b013e31824836fa] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nakajima D, Chen F, Yamada T, Sakamoto J, Ohsumi A, Bando T, Date H. Reconditioning of lungs donated after circulatory death with normothermic ex vivo lung perfusion. J Heart Lung Transplant 2012; 31:187-93. [PMID: 22305381 DOI: 10.1016/j.healun.2011.11.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Revised: 10/22/2011] [Accepted: 11/25/2011] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The use of donation-after-circulatory-death (DCD) donors for lung transplantation has come into practice. In this study we investigated whether DCD lungs can be resuscitated after warm ischemia with normothermic ex vivo lung perfusion (EVLP). METHODS Four hours after cardiac arrest, beagle dogs were divided into two groups (n = 6 each): those with static cold storage (SCS group) and those with normothermic EVLP (EVLP group), for 3.5 hours. Physiologic lung functions were evaluated during EVLP. In both groups, the left lungs were then transplanted and reperfused for 4 hours to evaluate post-transplant lung functions. Lung tissue adenosine triphosphate (ATP) levels were measured at given time-points. RESULTS Lung oxygenation was significantly improved with EVLP (p < 0.01), and lung oxygenation at the end of EVLP significantly reflected post-transplant lung oxygenation (r = 0.99, p < 0.01). Post-transplant lung oxygenation was significantly better in the EVLP group than in the SCS group (p < 0.05). Both dynamic pulmonary compliance and wet-to-dry lung weight ratio 4 hours after transplantation were also significantly better in the EVLP group than in the SCS group (p < 0.05). Microthrombi in the donor lungs before transplantation were microscopically detected more often in the SCS group. The lung tissue ATP levels 4 hours after transplantation were significantly higher in the EVLP group compared with the SCS group (p = 0.03). CONCLUSIONS Normothermic ex vivo lung perfusion could resuscitate DCD lungs injured by warm ischemia, and may ameliorate ischemia-reperfusion injury.
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Affiliation(s)
- Daisuke Nakajima
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Sakyo-ku, Kyoto, Japan
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Gomez-de-Antonio D, Campo-Cañaveral JL, Crowley S, Valdivia D, Cordoba M, Moradiellos J, Naranjo JM, Ussetti P, Varela A. Clinical lung transplantation from uncontrolled non–heart-beating donors revisited. J Heart Lung Transplant 2012; 31:349-53. [DOI: 10.1016/j.healun.2011.12.007] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Revised: 11/22/2011] [Accepted: 12/14/2011] [Indexed: 10/14/2022] Open
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Abstract
PURPOSE OF REVIEW Lung transplantation is now a well established treatment option for several end-stage respiratory diseases. Survival after lung transplantation has significantly improved over the last decade. The primary limitation to increased utilization of lung transplantation remains donor scarcity. Suitable allografts have been procured from donors after determination of neurologic death and from donors after determination of cardiac death (DDCD or DCD). Historically, the first human lung transplantation performed, utilized an allograft procured after cardiovascular death, also referred to as nonheart-beating donor.The experience at University of Wisconsin in 1993 reintroduced DCD lung transplantation with the first successful clinical case. RECENT FINDINGS A potential additional lung allograft source, DCD lung transplantation has been established with very acceptable outcomes observed by several centers. We provide the relevant background for the rationale of donor allograft expansion to include DCD lungs from controlled (Maastricht category III donors). SUMMARY This review considers the available evidence for DCD lung transplantation and compares reported primary graft dysfunction rates and current survival data available.
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Munson JC, Christie JD, Halpern SD. The societal impact of single versus bilateral lung transplantation for chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2011; 184:1282-8. [PMID: 21868502 PMCID: PMC3262042 DOI: 10.1164/rccm.201104-0695oc] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Accepted: 08/15/2011] [Indexed: 02/06/2023] Open
Abstract
RATIONALE Bilateral lung transplantation (BLT) improves survival compared with single lung transplantation (SLT) for some individuals with chronic obstructive pulmonary disease (COPD). However, it is unclear which strategy optimally uses this scarce societal resource. OBJECTIVES To compare the effect of SLT versus BLT strategies for COPD on waitlist outcomes among the broader population of patients listed for lung transplantation. METHODS We developed a Markov model to simulate the transplant waitlist using transplant registry data to define waitlist size, donor frequency, the risk of death awaiting transplant, and disease- and procedure-specific post-transplant survival. We then applied this model to 1,000 simulated patients and compared the number of patients under each strategy who received a transplant, the number who died before transplantation, and total post-transplant survival. MEASUREMENTS AND MAIN RESULTS Under baseline assumptions, the SLT strategy resulted in more patients transplanted (809 vs. 758) and fewer waitlist deaths (157 vs. 199). The strategies produced similar total post-transplant survival (SLT = 4,586 yr vs. BLT = 4,577 yr). In sensitivity analyses, SLT always maximized the number of patients transplanted. The strategy that maximized post-transplant survival depended on the relative survival benefit of BLT versus SLT among patients with COPD, donor interval, and waitlist size. CONCLUSIONS In most circumstances, a policy of SLT for COPD improves access to organs for other potential recipients without significant reductions in total post-transplant survival. However, there may be substantial geographic variations in the effect of such a policy on the balance between these outcomes.
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Affiliation(s)
- Jeffrey C Munson
- Section of Pulmonary and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Dartmouth Medical School, Lebanon, NH 03756, USA.
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Nakajima D, Chen F, Yamada T, Sakamoto J, Osumi A, Fujinaga T, Shoji T, Sakai H, Bando T, Date H. Hypothermic machine perfusion ameliorates ischemia-reperfusion injury in rat lungs from non-heart-beating donors. Transplantation 2011; 92:858-63. [PMID: 21832959 DOI: 10.1097/tp.0b013e31822d8778] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The use of non-heart-beating donors (NHBD) has come into practice to resolve the shortage of donor lungs. This study investigated whether hypothermic machine perfusion (HMP) can improve the quality of NHBD lungs. METHODS An uncontrolled NHBD model was achieved in male Lewis rats. Ninety minutes after cardiac arrest, HMP was performed for 60 min at 6°C to 10°C. The first study investigated the physiological lung functions during HMP and the lung tissue energy levels before and after HMP. The second study divided the rats into three groups (n=6 each): no ischemia group; 90-min warm ischemia+60-min HMP+120-min static cold storage (SCS) (HMP group); and 90-min warm ischemia+180-min SCS group. All lungs were reperfused for 60 min at 37°C. Lung functions were evaluated at given timings throughout the experiments. Oxidative damage during reperfusion was evaluated immunohistochemically with a monoclonal antibody against 8-hydroxy-2'-deoxyguanosine. RESULTS The first study revealed that lung functions were stable during HMP. Lung tissue energy levels decreased during warm ischemia but were significantly increased by HMP (P<0.05). The second study confirmed that HMP significantly decreased pulmonary vascular resistance, increased pulmonary compliance, and improved pulmonary oxygenation. The ratio of 8-hydroxy-2'-deoxyguanosine positive cells to total cells significantly increased in the SCS group (P<0.01). CONCLUSIONS Short-term HMP improved lung tissue energy levels that decreased during warm ischemia and ameliorated ischemia-reperfusion injury with decreased production of reactive oxygen species.
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Affiliation(s)
- Daisuke Nakajima
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Adenosine A₂A agonist improves lung function during ex vivo lung perfusion. Ann Thorac Surg 2011; 92:1840-6. [PMID: 22051279 DOI: 10.1016/j.athoracsur.2011.06.062] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2011] [Revised: 06/16/2011] [Accepted: 06/21/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND Ex vivo lung perfusion (EVLP) is a novel technique than can be used to assess and potentially repair marginal lungs that may otherwise be rejected for transplantation. Adenosine has been shown to protect against pulmonary ischemia-reperfusion (IR) injury through its A(2A) receptor. We hypothesized that combining EVLP with adenosine A(2A) receptor agonist treatment would enhance lung functional quality and increase donor lung use. METHODS Eight bilateral pig lungs were harvested and flushed with cold Perfadex (Vitrolife, Englewood, CO). After 14 hours of storage at 4°C, EVLP was performed for 5 hours on 2 explanted lung groups: (1) control group lungs (n = 4) were perfused with Steen Solution (Vitrolife) and dimethyl sulfoxide and (2) treated group lungs (n = 4) received 10 μM CGS21680, a selective A(2A) receptor agonist, in a Steen solution-primed circuit. Lung histologic features, tissue cytokines, gas analysis, and pulmonary function were compared between groups. RESULTS Treated lungs demonstrated significantly less edema as reflected by wet-dry weight ratio (6.6 versus 5.2; p < 0.03) and confirmed by histologic examination. In addition, treated lung demonstrated significantly lower levels of interferon-γ (IFN- γ) (45.1 versus 88.5; p < 0.05). Other measured tissue cytokine levels (interleukin [IL]-1β, IL-6, and IL-8) were lower in the treatment group, but values failed to reach statistical significance. The oxygenation index was improved in the treated group (1.5 versus 2.3; p < 0.01) as was mean airway pressure (10.3 versus 13; p < 0.009). CONCLUSIONS Combined use of adenosine A(2A) agonist and EVLP significantly attenuates the inflammatory response in acutely injured lungs after IR and enhances pulmonary function. This combination may improve donor lung quality and could increase the donor lung pool for transplantation.
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Targeted endothelial delivery of nanosized catalase immunoconjugates protects lung grafts donated after cardiac death. Transplantation 2011; 92:380-7. [PMID: 21778930 DOI: 10.1097/tp.0b013e318226bc6b] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Donor organ shortage represents a major problem in lung transplantation. Donation after cardiac death could help to expand the pool of organs, but the additional period of warm ischemia after cardiac arrest aggravates primary graft dysfunction. The pulmonary endothelium of the graft constitutes an important source and target of reactive oxygen species generated during ischemia and reperfusion. Targeted protection of graft pulmonary endothelial cells by the antioxidant enzyme catalase, conjugated with a platelet/endothelial cell adhesion molecule-1 (PECAM-1) antibody to nanosized particles (anti-PECAM/catalase conjugates), might improve outcome in lung transplantation using donors after cardiac death and prolonged hypothermic preservation. METHODS Left lung transplantation was performed in 18 pigs. Before cardiac arrest, donors received anti-PECAM/catalase, unconjugated component mixture or vehicle solution. After 90-min warm and 18-hr hypothermic ischemia, lungs were transplanted, and function was assessed during 6 hr after reperfusion. Samples of bronchoalveolar lavage fluid and lung tissue were taken thereafter. Six sham-operated animals served as controls. RESULTS During 6-hr reperfusion, anti-PECAM/catalase significantly ameliorated graft function, evidenced by major improvements of gas exchange and reduced intrapulmonary shunt fraction. Furthermore, lipid peroxidation, alveolar leakage, and edema formation were reduced in protected grafts. Similarly moderate lung pathology was seen after transplantation. CONCLUSIONS Augmentation of the antioxidant capacity of graft pulmonary endothelial cells with anti-PECAM/catalase nanoparticles represents a straightforward approach to enable a safe transplantation of prolonged preserved donation after cardiac death lungs. Anti-PECAM/catalase protection alleviated oxidative stress and allowed immediate reconstitution of normal gas exchange and pulmonary microcirculation, a prerequisite for improved graft and patient outcome.
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A Model of Ex Vivo Perfusion of Porcine Donor Lungs Injured by Gastric Aspiration: A Step Towards Pretransplant Reconditioning. J Surg Res 2011; 170:e159-67. [DOI: 10.1016/j.jss.2011.05.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Revised: 04/04/2011] [Accepted: 05/10/2011] [Indexed: 11/23/2022]
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Van De Wauwer C, Verschuuren EA, van der Bij W, Nossent GD, Erasmus ME. The use of non-heart-beating lung donors category III can increase the donor pool. Eur J Cardiothorac Surg 2011; 39:e175-80; discussion e180. [DOI: 10.1016/j.ejcts.2011.01.035] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Revised: 12/23/2010] [Accepted: 01/12/2011] [Indexed: 10/18/2022] Open
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Domínguez-Gil B, Haase-Kromwijk B, Van Leiden H, Neuberger J, Coene L, Morel P, Corinne A, Muehlbacher F, Brezovsky P, Costa AN, Rozental R, Matesanz R. Current situation of donation after circulatory death in European countries. Transpl Int 2011; 24:676-86. [PMID: 21504489 DOI: 10.1111/j.1432-2277.2011.01257.x] [Citation(s) in RCA: 181] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The aim of the present study was to describe the current situation of donation after circulatory death (DCD) in the Council of Europe, through a dedicated survey. Of 27 participating countries, only 10 confirmed any DCD activity, the highest one being described in Belgium, the Netherlands and the United Kingdom (mainly controlled) and France and Spain (mainly uncontrolled). During 2000-2009, as DCD increased, donation after brain death (DBD) decreased about 20% in the three countries with a predominant controlled DCD activity, while DBD had increased in the majority of European countries. The number of organs recovered and transplanted per DCD increased along time, although it remained substantially lower compared with DBD. During 2000-2008, 5004 organs were transplanted from DCD (4261 kidneys, 505 livers, 157 lungs and 81 pancreas). Short-term outcomes of 2343 kidney recipients from controlled versus 649 from uncontrolled DCD were analyzed: primary non function occurred in 5% vs. 6.4% (P = NS) and delayed graft function in 50.2% vs. 75.7% (P < 0.001). In spite of this, 1 year graft survival was 85.9% vs. 88.9% (P = 0.04), respectively. DCD is increasingly accepted in Europe but still limited to a few countries. Controlled DCD might negatively impact DBD activity. The degree of utilization of DCD is lower compared with DBD. Short-term results of DCD are promising with differences between kidney recipients transplanted from controlled versus uncontrolled DCD, an observation to be further analyzed.
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Cypel M, Yeung JC, Liu M, Anraku M, Chen F, Karolak W, Sato M, Laratta J, Azad S, Madonik M, Chow CW, Chaparro C, Hutcheon M, Singer LG, Slutsky AS, Yasufuku K, de Perrot M, Pierre AF, Waddell TK, Keshavjee S. Normothermic ex vivo lung perfusion in clinical lung transplantation. N Engl J Med 2011; 364:1431-40. [PMID: 21488765 DOI: 10.1056/nejmoa1014597] [Citation(s) in RCA: 742] [Impact Index Per Article: 57.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND More than 80% of donor lungs are potentially injured and therefore not considered suitable for transplantation. With the use of normothermic ex vivo lung perfusion (EVLP), the retrieved donor lung can be perfused in an ex vivo circuit, providing an opportunity to reassess its function before transplantation. In this study, we examined the feasibility of transplanting high-risk donor lungs that have undergone EVLP. METHODS In this prospective, nonrandomized clinical trial, we subjected lungs considered to be high risk for transplantation to 4 hours of EVLP. High-risk donor lungs were defined by specific criteria, including pulmonary edema and a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (PO(2):FIO(2)) less than 300 mm Hg. Lungs with acceptable function were subsequently transplanted. Lungs that were transplanted without EVLP during the same period were used as controls. The primary end point was primary graft dysfunction 72 hours after transplantation. Secondary end points were 30-day mortality, bronchial complications, duration of mechanical ventilation, and length of stay in the intensive care unit and hospital. RESULTS During the study period, 136 lungs were transplanted. Lungs from 23 donors met the inclusion criteria for EVLP; in 20 of these lungs, physiological function remained stable during EVLP and the median PO(2):FIO(2) ratio increased from 335 mm Hg in the donor lung to 414 and 443 mm Hg at 1 hour and 4 hours of perfusion, respectively (P<0.001). These 20 lungs were transplanted; the other 116 lungs constituted the control group. The incidence of primary graft dysfunction 72 hours after transplantation was 15% in the EVLP group and 30% in the control group (P=0.11). No significant differences were observed for any secondary end points, and no severe adverse events were directly attributable to EVLP. CONCLUSIONS Transplantation of high-risk donor lungs that were physiologically stable during 4 hours of ex vivo perfusion led to results similar to those obtained with conventionally selected lungs. (Funded by Vitrolife; ClinicalTrials.gov number, NCT01190059.).
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Affiliation(s)
- Marcelo Cypel
- Toronto Lung Transplant Program, University of Toronto, ON, Canada
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Cypel M, Yeung JC, Keshavjee S. Novel approaches to expanding the lung donor pool: donation after cardiac death and ex vivo conditioning. Clin Chest Med 2011; 32:233-44. [PMID: 21511086 DOI: 10.1016/j.ccm.2011.02.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Two novel approaches have been developed to potentially increase the availability of donor lungs for lung transplantation. In the first approach, lungs from donation after cardiac death (DCD) donors are used to increase the quantity of organ donors. In the second approach, a newly developed normothermic ex vivo lung perfusion (EVLP) technique is used as a means of reassessing the adequacy of lung function from DCD and from high-risk brain death donors prior to transplantation. This EVLP technique can also act as a platform for the delivery of novel therapies to repair injured organs ex vivo.
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Affiliation(s)
- Marcelo Cypel
- Division Thoracic Surgery, Toronto Lung Transplant Program, Toronto General Hospital, University of Toronto, Toronto, M5G 2C4, Canada
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Short- and long-term outcomes of 1000 adult lung transplant recipients at a single center. J Thorac Cardiovasc Surg 2011; 141:215-22. [DOI: 10.1016/j.jtcvs.2010.09.009] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2010] [Revised: 08/23/2010] [Accepted: 09/02/2010] [Indexed: 01/08/2023]
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Inci I, Arni S, Acevedo C, Jungraithmayr W, Inci D, Vogt P, Weder W. Surfactant alterations following donation after cardiac death donor lungs. Transpl Int 2010; 24:78-84. [PMID: 20723176 DOI: 10.1111/j.1432-2277.2010.01154.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The use of lungs from donation after cardiac death (DCD) donors is one of the strategies to increase the donor pool. The aim of this study was to assess the surfactant alterations in DCD donor lungs. Pigs were sacrificed and left untouched for 1 (DCD1), 2 (DCD2) and 3 (DCD3) h. Lungs were then topically cooled with saline for 1, 2 or 3 h to reach a total ischemic time of 4 h. Heart-beating donors (HBD) served as control group. Bronchoalveolar lavage (BAL) samples were assessed for protein levels and surfactant function. Left lungs were prepared for ex-vivo evaluation. Pulmonary vascular resistance (PVR), oxygenation, airway pressure (AWP) and wet-to-dry weight ratio were significantly different between HBD and DCD3 groups (P < 0.05). BAL protein levels were statistically higher in DCD3 compared with HBD group (P < 0.05). Surface tension and surface tension measured at minimal bubble diameter (adsorption) were lower in HBD compared with DCD groups (P < 0.05). Adsorption was also lower in DCD1 compared with DCD2 (P < 0.05). Adsorption and surface tension were correlated with oxygenation and AWP (P < 0.05). This study has shown that lung function deteriorates with increasing warm ischemic time intervals. BAL protein, surface tension, adsorption, peak AWP and PVR increase significantly after 2 h of warm ischemia together with a significant reduction of the ratio PaO(2)/FiO(2).
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Affiliation(s)
- Ilhan Inci
- Division of Thoracic Surgery, University Hospital, Zurich, Switzerland.
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