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Gouchoe DA, Sanchez PG, D'Cunha J, Bermudez CA, Daneshmand MA, Davis RD, Hartwig MG, Wozniak TC, Kon ZN, Griffith BP, Lynch WR, Machuca TN, Weyant MJ, Jessen ME, Mulligan MS, D'Ovidio F, Camp PC, Cantu E, Whitson BA. Ex vivo lung perfusion in donation after circulatory death: A post hoc analysis of the Normothermic Ex Vivo Lung Perfusion as an Assessment of Extended/Marginal Donors Lungs trial. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00212-5. [PMID: 38508486 DOI: 10.1016/j.jtcvs.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 03/22/2024]
Abstract
OBJECTIVE Donation after circulatory death (DCD) donors offer the ability to expand the lung donor pool and ex vivo lung perfusion (EVLP) further contributes to this ability by allowing for additional evaluation and resuscitation of these extended criteria donors. We sought to determine the outcomes of recipients receiving organs from DCD EVLP donors in a multicenter setting. METHODS This was an unplanned post hoc analysis of a multicenter, prospective, nonrandomized trial that took place during 2011 to 2017 with 3 years of follow-up. Patients were placed into 3 groups based off procurement strategy: brain-dead donor (control), brain-dead donor evaluated by EVLP, and DCD donors evaluated by EVLP. The primary outcomes were severe primary graft dysfunction at 72 hours and survival. Secondary outcomes included select perioperative outcomes, and 1-year and 3-years allograft function and quality of life measures. RESULTS The DCD EVLP group had significantly higher incidence of severe primary graft dysfunction at 72 hours (P = .03), longer days on mechanical ventilation (P < .001) and in-hospital length of stay (P = .045). Survival at 3 years was 76.5% (95% CI, 69.2%-84.7%) for the control group, 68.3% (95% CI, 58.9%-79.1%) for the brain-dead donor group, and 60.7% (95% CI, 45.1%-81.8%) for the DCD group (P = .36). At 3-year follow-up, presence observed bronchiolitis obliterans syndrome or quality of life metrics did not differ among the groups. CONCLUSIONS Although DCD EVLP allografts might not be appropriate to transplant in every candidate recipient, the expansion of their use might afford recipients stagnant on the waitlist a viable therapy.
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Affiliation(s)
- Doug A Gouchoe
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Center, College of Medicine, Columbus, Ohio; 88th Surgical Operations Squadron, Wright-Patterson Medical Center, Wright-Patterson Air Force Base, Ohio
| | - Pablo G Sanchez
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Jonathan D'Cunha
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, Ariz
| | | | - Mani A Daneshmand
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Robert D Davis
- Department of Cardiovascular and Thoracic Surgery, Florida Hospital Transplant Center, Orlando, Fla
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, NC
| | - Thomas C Wozniak
- Division of Cardiothoracic Surgery, ProHealth Care, Waukesha, Wis
| | - Zachary N Kon
- Division of Cardiothoracic Surgery, Department of Surgery, Northwell Health, Manhasset, NY
| | - Bartley P Griffith
- Department of Cardiac Surgery, University of Maryland Medical Center, Baltimore, Md
| | - William R Lynch
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Tiago N Machuca
- Division of Lung Transplantation, Department of Surgery, University of Miami Miller School of Medicine, Miami, Fla
| | | | - Michael E Jessen
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern, Dallas, Tex
| | - Michael S Mulligan
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, Wash
| | - Frank D'Ovidio
- Section of General Thoracic Surgery, Lung Transplant Program, Columbia University Medical Center, New York, NY
| | - Phillip C Camp
- Department of Cardiothoracic Surgery, Corewell Health-East, Dearborn, Mich
| | - Edward Cantu
- Division of Cardiac Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Bryan A Whitson
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Center, College of Medicine, Columbus, Ohio; Collaboration for Organ Perfusion, Protection, Engineering, and Regeneration Laboratory, The Ohio State University, Columbus, Ohio; The Davis Heart and Lung Research Institute, The Ohio State University Wexner Center, College of Medicine, Columbus, Ohio.
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2
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Noda K, Furukawa M, Chan EG, Sanchez PG. Expanding Donor Options for Lung Transplant: Extended Criteria, Donation After Circulatory Death, ABO Incompatibility, and Evolution of Ex Vivo Lung Perfusion. Transplantation 2023; 107:1440-1451. [PMID: 36584375 DOI: 10.1097/tp.0000000000004480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Only using brain-dead donors with standard criteria, the existing donor shortage has never improved in lung transplantation. Currently, clinical efforts have sought the means to use cohorts of untapped donors, such as extended criteria donors, donation after circulatory death, and donors that are ABO blood group incompatible, and establish the evidence for their potential contribution to the lung transplant needs. Also, technical maturation for using those lungs may eliminate immediate concerns about the early posttransplant course, such as primary graft dysfunction or hyperacute rejection. In addition, recent clinical and preclinical advances in ex vivo lung perfusion techniques have allowed the safer use of lungs from high-risk donors and graft modification to match grafts to recipients and may improve posttransplant outcomes. This review summarizes recent trends and accomplishments and future applications for expanding the donor pool in lung transplantation.
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Affiliation(s)
- Kentaro Noda
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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3
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Furukawa M, Noda K, Chan EG, Ryan JP, Coster JN, Sanchez PG. Lung transplantation from donation after circulatory death, evolution, and current status in the United States. Clin Transplant 2023; 37:e14884. [PMID: 36542414 DOI: 10.1111/ctr.14884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/05/2022] [Accepted: 12/11/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The number of lung transplants from donors after circulatory death has increased over the last decade. This study aimed to describe the evolution and outcomes following lung transplantation donation after circulatory death (DCD) and report the practices and outcomes of ex vivo lung perfusion (EVLP) in this donor population. METHODS This was a retrospective study using a prospectively collected national registry. The United Network for Organ Sharing (UNOS) database was queried to identify adult patients who underwent lung transplantation between May 1, 2005, and December 31, 2021. Kaplan-Meier analysis and Weibull regression were used to compare survival in four cohorts (donation after brain death [DBD] with or without EVLP, and DCD with or without EVLP). The primary outcome of interest was patient survival. RESULTS Of the 21 356 recipients who underwent lung transplantation, 20 380 (95.4%) were from brain death donors and 976 (4.6%) from donors after circulatory death. Kaplan-Meier analysis showed no difference in the survival time between the two groups. In a multivariable analysis that controlled for baseline differences in donor and recipient characteristics, recipients who received lungs from cardiac death donors after EVLP had 28% shorter survival time relative to donor lungs after brain death without EVLP (hazard ratio [HR] 1.53, 95% confidence interval [CI] 1.10-2.15, p = .01). CONCLUSIONS The early survival differences observed after lung transplants from donors after circulatory death in lungs evaluated with EVLP deserves further investigation.
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Affiliation(s)
- Masashi Furukawa
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kentaro Noda
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ernest G Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - John P Ryan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jenalee N Coster
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Pablo G Sanchez
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Abstract
OBJECTIVE To define textbook outcome (TO) for lung transplantation (LTx) using a contemporary cohort from a high-volume institution. SUMMARY BACKGROUND DATA TO is a standardized, composite quality measure based on multiple postoperative endpoints representing the ideal "textbook" hospitalization. METHODS Adult patients who underwent LTx at our institution between 2016 and 2019 were included. TO was defined as freedom from intraoperative complication, postoperative reintervention, 30-day intensive care unit or hospital readmission, length of stay >75th percentile of LTx patients, 90 day mortality, 30-day acute rejection, grade 3 primary graft dysfunction at 48 or 72 hours, postoperative extracorporeal membrane oxygenation, tracheostomy within 7 days, inpatient dialysis, reintubation, and extubation >48 hours post-transplant. Recipient, operative, financial characteristics, and post-transplant outcomes were recorded from institutional data and compared between TO and non-TO groups. RESULTS Of 401 LTx recipients, 97 (24.2%) achieved TO. The most common reason for TO failure was extubation >48 hours post-transplant (N = 119, 39.1%); the least common was mortality (N = 15, 4.9%). Patient and graft survival were improved among patients who achieved versus failed TO (patient survival: log-rank P < 0.01; graft survival: log-rank P < 0.01). Rejection-free and chronic lung allograft dysfunction-free survival were similar between TO and non-TO groups (rejection-free survival: log-rank P = 0.07; chronic lung allograft dysfunction-free survival: log-rank P = 0.3). On average, patients who achieved TO incurred approximately $638,000 less in total inpatient charges compared to those who failed TO. CONCLUSIONS TO in LTx was associated with favorable post-transplant outcomes and significant cost-savings. TO may offer providers and patients new insight into transplant center quality of care and highlight areas for improvement.
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5
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Lung transplantation following donation after circulatory death. TRANSPLANTATION REPORTS 2022. [DOI: 10.1016/j.tpr.2022.100110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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6
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Halpern SE, Wright MC, Madsen G, Chow B, Harris CS, Haney JC, Klapper JA, Bottiger BA, Hartwig MG. Textbook outcome in lung transplantation: Planned venoarterial extracorporeal membrane oxygenation versus off-pump support for patients without pulmonary hypertension. J Heart Lung Transplant 2022; 41:1628-1637. [PMID: 35961827 PMCID: PMC10403788 DOI: 10.1016/j.healun.2022.07.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 06/22/2022] [Accepted: 07/13/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Planned venoarterial extracorporeal membrane oxygenation (VA ECMO) is increasingly used during bilateral orthotopic lung transplantation (BOLT) and may be superior to off-pump support for patients without pulmonary hypertension. In this single-institution study, we compared rates of textbook outcome between BOLTs performed with planned VA ECMO or off-pump support for recipients with no or mild pulmonary hypertension. METHODS Patients with no or mild pulmonary hypertension who underwent isolated BOLT between 1/2017 and 2/2021 with planned off-pump or VA ECMO support were included. Textbook outcome was defined as freedom from intraoperative complication, 30-day reintervention, 30-day readmission, post-transplant length of stay >30 days, 90-day mortality, 30-day acute rejection, grade 3 primary graft dysfunction at 48 or 72 hours, post-transplant ECMO, tracheostomy within 7 days, inpatient dialysis, reintubation, and extubation >48 hours post-transplant. Textbook outcome achievement was compared between groups using multivariable logistic regression. RESULTS Two hundred thirty-seven BOLTs were included: 68 planned VA ECMO and 169 planned off-pump. 14 (20.6%) planned VA ECMO and 27 (16.0%) planned off-pump patients achieved textbook outcome. After adjustment for prior BOLT, lung allocation score, ischemic time, and intraoperative transfusions, planned VA ECMO was associated with higher odds of textbook outcome than planned off-pump support (odds ratio 3.89, 95% confidence interval 1.58-9.90, p = 0.004). CONCLUSIONS At our institution, planned VA ECMO for isolated BOLT was associated with higher odds of textbook outcome than planned off-pump support among patients without pulmonary hypertension. Further investigation in a multi-institutional cohort is warranted to better elucidate the utility of this strategy.
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Affiliation(s)
| | - Mary C Wright
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Gabrielle Madsen
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Bryan Chow
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | | | - John C Haney
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jacob A Klapper
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Brandi A Bottiger
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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7
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Mora V, Ballesteros MA, Naranjo S, Sánchez L, Suberviola B, Iturbe D, Cimadevilla B, Tello S, Alvarez C, Miñambres E. Lung transplantation from controlled donation after circulatory death using simultaneous abdominal normothermic regional perfusion: A single center experience. Am J Transplant 2022; 22:1852-1860. [PMID: 35390225 DOI: 10.1111/ajt.17057] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/04/2022] [Accepted: 04/04/2022] [Indexed: 01/25/2023]
Abstract
Despite the benefits of abdominal normothermic regional perfusion (A-NRP) for abdominal grafts in controlled donation after circulatory death (cDCD), there is limited information on the effect of A-NRP on the quality of the cDCD lungs. We aimed to study the effect of A-NRP in lungs obtained from cDCD and its impact on recipients´ outcomes. This is a study comparing outcomes of lung transplants (LT) from cDCD donors (September 2014 to December 2021) obtained using A-NRP as the abdominal preservation method. As controls, all lung recipients transplanted from donors after brain death (DBD) were considered. The primary outcomes were lung recipient 3-month, 1-year, and 5-year survival. A total of 269 LT were performed (60 cDCD and 209 DBD). There was no difference in survival at 3 months (98.3% cDCD vs. 93.7% DBD), 1 year (90.9% vs. 87.2%), and 5 years (68.7% vs. 69%). LT from the cDCD group had a higher rate of primary graft dysfunction grade 3 at 72 h (10% vs. 3.4%; p < .001). This is the largest experience ever reported with the use of A-NRP combined with lung retrieval in cDCD donors. This combined method is safe for lung grafts presenting short-term survival outcomes equivalent to those transplanted through DBD.
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Affiliation(s)
- Victor Mora
- Service of Neumology, Lung Transplantation Unit, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Maria Angeles Ballesteros
- Transplant Coordination Unit & Service of Intensive Care, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Sara Naranjo
- Service of Thoracic Surgery, Lung Transplantation Unit, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Laura Sánchez
- Service of Thoracic Surgery, Lung Transplantation Unit, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Borja Suberviola
- Transplant Coordination Unit & Service of Intensive Care, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - David Iturbe
- Service of Neumology, Lung Transplantation Unit, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Bonifacio Cimadevilla
- Service of Anesthesia, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Sandra Tello
- Service of Neumology, Lung Transplantation Unit, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Carlos Alvarez
- Service of Thoracic Surgery, Lung Transplantation Unit, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Eduardo Miñambres
- Transplant Coordination Unit & Service of Intensive Care, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain.,School of Medicine, University of Cantabria, Santander, Spain
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8
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Controlled DCD Lung Transplantation: Circumventing Imagined and Real Barriers- Time for an International Taskforce? J Heart Lung Transplant 2022; 41:1198-1203. [DOI: 10.1016/j.healun.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 05/03/2022] [Accepted: 06/08/2022] [Indexed: 11/22/2022] Open
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9
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Lee ACH, Edobor A, Wigakumar T, Lysandrou M, Johnston LK, McMullen P, Mirle V, Diaz A, Piech R, Rose R, Jendrisak M, di Sabato D, Shanmugarajah K, Fung J, Donington J, Madariaga ML. Donor leukocyte trafficking during human ex vivo lung perfusion. Clin Transplant 2022; 36:e14670. [PMID: 35396887 PMCID: PMC9540615 DOI: 10.1111/ctr.14670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 03/09/2022] [Accepted: 04/04/2022] [Indexed: 11/30/2022]
Abstract
Background Ex vivo lung perfusion (EVLP) is used to assess and preserve lungs prior to transplantation. However, its inherent immunomodulatory effects are not completely understood. We examine perfusate and tissue compartments to determine the change in immune cell composition in human lungs maintained on EVLP. Methods Six human lungs unsuitable for transplantation underwent EVLP. Tissue and perfusate samples were obtained during cold storage and at 1‐, 3‐ and 6‐h during perfusion. Flow cytometry, immunohistochemistry, and bead‐based immunoassays were used to measure leukocyte composition and cytokines. Mean values between baseline and time points were compared by Student's t test. Results During the 1st hour of perfusion, perfusate neutrophils increased (+22.2 ± 13.5%, p < 0.05), monocytes decreased (−77.5 ± 8.6%, p < 0.01) and NK cells decreased (−61.5 ± 22.6%, p < 0.01) compared to cold storage. In contrast, tissue neutrophils decreased (−22.1 ± 12.2%, p < 0.05) with no change in monocytes and NK cells. By 6 h, perfusate neutrophils, NK cells, and tissue neutrophils were similar to baseline. Perfusate monocytes remained decreased, while tissue monocytes remained unchanged. There was no significant change in B cells or T cell subsets. Pro‐inflammatory cytokines (IL‐1b, G‐CSF, IFN‐gamma, CXCL2, CXCL1 granzyme A, and granzyme B) and lymphocyte activating cytokines (IL‐2, IL‐4, IL‐6, IL‐8) increased during perfusion. Conclusions Early mobilization of innate immune cells occurs in both perfusate and tissue compartments during EVLP, with neutrophils and NK cells returning to baseline and monocytes remaining depleted after 6 h. The immunomodulatory effect of EVLP may provide a therapeutic window to decrease the immunogenicity of lungs prior to transplantation.
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Affiliation(s)
| | - Arianna Edobor
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | | | - Maria Lysandrou
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Laura K Johnston
- Office of Shared Research Facilities, University of Chicago, Chicago, Illinois, USA
| | - Phillip McMullen
- Department of Pathology, University of Chicago, Chicago, Illinois, USA
| | - Vikranth Mirle
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Ashley Diaz
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Ryan Piech
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Rebecca Rose
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | | | - Diego di Sabato
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | | | - John Fung
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Jessica Donington
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
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10
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Ex-vivo lung perfusion therapies. Curr Opin Organ Transplant 2022; 27:204-210. [DOI: 10.1097/mot.0000000000000961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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11
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Krischak MK, Au S, Halpern SE, Olaso DG, Moris D, Snyder LD, Barbas AS, Haney JC, Klapper JA, Hartwig MG. Textbook surgical outcome in lung transplantation: Analysis of a US national registry. Clin Transplant 2022; 36:e14588. [PMID: 35001428 DOI: 10.1111/ctr.14588] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/08/2021] [Accepted: 01/05/2022] [Indexed: 11/30/2022]
Abstract
Textbook surgical outcome (TO) is a novel composite quality measure in lung transplantation (LTx). Compared to one-year survival metrics, TO may better differentiate center performance, and motivate improvements in care. To understand the feasibility of implementing this metric, we defined TO in LTx using US national data, and evaluated its ability to predict post-transplant outcomes and differentiate center performance. Adult patients who underwent isolated LTx between 2016-2019 were included. TO was defined as freedom from post-transplant length of stay >30 days, 90-day mortality, intubation or extracorporeal membrane oxygenation at 72 hours post-transplant, post-transplant ventilator support lasting ≥5 days, postoperative airway dehiscence, inpatient dialysis, pre-discharge acute rejection, and grade 3 primary graft dysfunction at 72 hours. Recipient and donor characteristics and post-transplant outcomes were compared between patients who achieved and failed TO. Of 8959 lung transplant recipients, 4664 (52.1%) achieved TO. Patient and graft survival were improved among patients who achieved TO (both log-rank p<0.0001). Among 62 centers, adjusted rates of TO ranged from 27.0% to 72.4% reflecting a wide variability in center-level performance. TO defined using national data may represent a novel composite metric to guide quality improvement in LTx across US transplant centers. Summary: In this study we defined textbook outcome (TO) for lung transplantation (LTx) using US national data. We found that achievement of TO was associated with improved post-transplant survival, and wide variability in center-level LTx performance. These findings suggest that TO could be readily implemented to compare quality of care among US LTx centers. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | - Sandra Au
- School of Medicine, Duke University, Durham, NC, USA
| | | | - Danae G Olaso
- School of Medicine, Duke University, Durham, NC, USA
| | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Laurie D Snyder
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Andrew S Barbas
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - John C Haney
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jacob A Klapper
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Matthew G Hartwig
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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12
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Rubio Muñoz JJ, Dominguez-Gil González B, Miñambres García E, Del Río Gallegos F, Pérez-Villares JM. Role of normothermic perfusion with ECMO in donation after controlled cardiac death in Spain. Med Intensiva 2021; 46:31-41. [PMID: 34794913 DOI: 10.1016/j.medine.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 01/26/2020] [Accepted: 01/31/2020] [Indexed: 02/07/2023]
Abstract
Spain has become one of the most active countries in donation after controlled cardiac death, using normothermic abdominal perfusion with ECMO in more than 50% of all donors - a situation contributed to by the creation of mobile teams to support hospitals lacking this technology. The donation process must be respectful of the wishes and values of the patients and their relatives, especially if there is pre mortem manipulation, and the absence of cerebral perfusion should be guaranteed. The liver is the most benefited organ by reducing biliary complications as well as the loss of grafts. In renal transplantation, the technique could contribute to reduce the incidence of delayed graft function. In addition, the procedure is compatible with surgical rapid recovery in hypothermia when there is also lung donation. The future lies in the consolidation of cardiac donation by extending normothermic perfusion to the thoracic cavity.
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Affiliation(s)
- J J Rubio Muñoz
- Servicio de Medicina Intensiva, Unidad de Coordinación de Trasplantes, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain.
| | | | - E Miñambres García
- Coordinación Regional de Trasplantes de la Comunidad de Cantabria, Servicio de Medicina Intensiva del Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - F Del Río Gallegos
- Coordinación Regional de Trasplantes de la Comunidad de Madrid, Servicio de Medicina Intensiva del Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - J M Pérez-Villares
- Coordinador Regional de Trasplantes de la Comunidad de Andalucía, Servicio de Medicina Intensiva del Hospital Universitario Virgen de las Nieves, Granada, Spain
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13
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Halpern SE, Au S, Kesseli SJ, Krischak MK, Olaso DG, Bottiger BA, Haney JC, Klapper JA, Hartwig MG. Lung transplantation using allografts with more than 8 hours of ischemic time: A single-institution experience. J Heart Lung Transplant 2021; 40:1463-1471. [PMID: 34281776 PMCID: PMC8570997 DOI: 10.1016/j.healun.2021.05.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/04/2021] [Accepted: 05/13/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Six hours was historically regarded as the limit of acceptable ischemic time for lung allografts. However, broader sharing of donor lungs often necessitates use of allografts with ischemic time >6 hours. We characterized the association between ischemic time ≥8 hours and outcomes after lung transplantation using a contemporary cohort from a high-volume institution. METHODS Patients who underwent primary isolated bilateral lung transplantation between 1/2016 and 5/2020 were included. Patients bridged to transplant with extracorporeal membrane oxygenation or mechanical ventilation, and ex-vivo perfusion cases were excluded. Recipients were stratified by total allograft ischemic time <8 hours (standard) vs ≥8 hours (long). Perioperative outcomes and post-transplant survival were compared between groups. RESULTS Of 358 patients, 95 (26.5%) received long ischemic time (≥8 hours) lungs. Long ischemic time recipients were more likely to be male and have donation after circulatory death donors than standard ischemic time recipients. On unadjusted analysis, long and standard ischemic time recipients had similar survival, and similar rates of grade 3 primary graft dysfunction at 72 hours, extracorporeal membrane oxygenation post-transplant, acute rejection within 30 days, reintubation, and post-transplant length of stay. After adjustment, long and standard ischemic time recipients had comparable risks of mortality or graft failure. CONCLUSIONS In a modern cohort, use of lung allografts with "long" ischemic time ≥8 hours were associated with acceptable perioperative outcomes and post-transplant survival. Further investigation is required to better understand how broader use impacts post-lung transplant outcomes and the implications for smarter sharing under an evolving national allocation policy.
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Affiliation(s)
| | - Sandra Au
- School of Medicine, Duke University, Durham, North Carolina
| | - Samuel J Kesseli
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | | | - Danae G Olaso
- School of Medicine, Duke University, Durham, North Carolina
| | - Brandi A Bottiger
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - John C Haney
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jacob A Klapper
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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14
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Campo-Cañaveral de la Cruz JL, Crowley Carrasco S, Tanaka S, Romero Román A, Hoyos Mejía L, Gil Barturen M, Sánchez Calle Á, García Fadul C, Aguilar Pérez M, Pérez Redondo M, Naranjo Gómez JM, Royuela A, Córdoba Peláez M, Varela de Ugarte A, Gómez de Antonio D. Lung transplantation from uncontrolled and controlled donation after circulatory death: similar outcomes to brain death donors. Transpl Int 2021; 34:2609-2619. [PMID: 34570381 DOI: 10.1111/tri.14120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/20/2021] [Accepted: 09/20/2021] [Indexed: 11/26/2022]
Abstract
Controlled donation after circulatory death donors (cDCD) are becoming a frequent source of lungs grafts worldwide. Conversely, lung transplantations (LTx) from uncontrolled donors (uDCD) are sporadically reported. We aimed to review our institutional experience using both uDCD and cDCD and compare to LTx from brain death donors (DBD). This is a retrospective analysis of all LTx performed between January 2013 and December 2019 in our institution. Donor and recipient characteristics were collected and univariate, multivariate and survival analyses were carried out comparing the three cohorts of donors. A total of 239 (84.7%) LTx were performed from DBD, 29 (10.3%) from cDCD and 14 (5%) from uDCD. There were no statistically significant differences in primary graft dysfunction grade 3 at 72 h, 30- and 90-day mortality, need for extracorporeal membrane oxygenation after procedure, ICU and hospital length of stay, airway complications, CLAD incidence or survival at 1 and 3 years after transplant (DBD: 87.1% and 78.1%; cDCD: 89.7% and 89.7%; uDCD: 85.7% and 85.7% respectively; P = 0.42). Short- and mid-term outcomes are comparable between the three types of donors. These findings may encourage and reinforce all types of donation after circulatory death programmes as a valid and growing source of suitable organs for transplantation.
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Affiliation(s)
- Jose Luis Campo-Cañaveral de la Cruz
- Thoracic Surgery and Lung Transplantation Department, Hospital Universitario Puerta de Hierro-Majadahonda, Universidad Autónoma de Madrid., Madrid, Spain
| | - Silvana Crowley Carrasco
- Thoracic Surgery and Lung Transplantation Department, Hospital Universitario Puerta de Hierro-Majadahonda, Universidad Autónoma de Madrid., Madrid, Spain
| | - Shin Tanaka
- Department of General Thoracic Surgery/Organ Transplant Center, Okayama University Hospital, Okayama, Japan
| | - Alejandra Romero Román
- Thoracic Surgery and Lung Transplantation Department, Hospital Universitario Puerta de Hierro-Majadahonda, Universidad Autónoma de Madrid., Madrid, Spain
| | - Lucas Hoyos Mejía
- Thoracic Surgery and Lung Transplantation Department, Hospital Universitario Puerta de Hierro-Majadahonda, Universidad Autónoma de Madrid., Madrid, Spain
| | - Mariana Gil Barturen
- Thoracic Surgery and Lung Transplantation Department, Hospital Universitario Puerta de Hierro-Majadahonda, Universidad Autónoma de Madrid., Madrid, Spain
| | - Álvaro Sánchez Calle
- Thoracic Surgery and Lung Transplantation Department, Hospital Universitario Puerta de Hierro-Majadahonda, Universidad Autónoma de Madrid., Madrid, Spain
| | - Christian García Fadul
- Pneumology Department, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Myriam Aguilar Pérez
- Pneumology Department, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Marina Pérez Redondo
- Intensive Care Unit, Transplant Coordinator, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Jose Manuel Naranjo Gómez
- Thoracic Surgery and Lung Transplantation Department, Hospital Universitario Puerta de Hierro-Majadahonda, Universidad Autónoma de Madrid., Madrid, Spain
| | - Ana Royuela
- Biostatistics Unit, Puerta de Hierro Biomedical Research Institute (IDIPHISA), CIBERESP, Madrid, Spain
| | - Mar Córdoba Peláez
- Thoracic Surgery and Lung Transplantation Department, Hospital Universitario Puerta de Hierro-Majadahonda, Universidad Autónoma de Madrid., Madrid, Spain
| | - Andrés Varela de Ugarte
- Thoracic Surgery and Lung Transplantation Department, Hospital Universitario Puerta de Hierro-Majadahonda, Universidad Autónoma de Madrid., Madrid, Spain
| | - David Gómez de Antonio
- Thoracic Surgery and Lung Transplantation Department, Hospital Universitario Puerta de Hierro-Majadahonda, Universidad Autónoma de Madrid., Madrid, Spain
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15
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Halpern SE, Jawitz OK, Raman V, Choi AY, Haney JC, Klapper JA, Hartwig MG. Aggressive pursuit and utilization of non-ideal donor lungs does not compromise post-lung transplant survival. Clin Transplant 2021; 35:e14414. [PMID: 34218467 DOI: 10.1111/ctr.14414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 06/06/2021] [Accepted: 06/28/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Organ procurement organizations (OPOs) vary in willingness to pursue and utilize non-ideal donor lungs; implications of these practices for lung transplant (LTx) recipients remain unclear. We examined associations between OPO-level behavior toward non-ideal donors and post-LTx outcomes. METHODS Adult lung donors and corresponding adult first-time LTx recipients in the 2008-2019 UNOS registry were included. Non-ideal donors had any of age > 50, smoking history ≥20 pack-years, PaO2 /FiO2 ratio ≤350, donation after circulatory death, or increased risk status. OPOs were classified as least, moderately, or most aggressive based on non-ideal donor pursuit, consent attainment, lung recovery, and transplantation. Post-transplant outcomes were compared among aggressiveness strata. RESULTS Of 22,795 recipients, 6229 (27.3%), 8256 (36.2%), and 8310 (36.5%) received lungs from least, moderately, and most aggressive OPOs, respectively. Moderately aggressive OPOs had the highest recipient rates of pre-discharge acute rejection, grade 3 primary graft dysfunction, postoperative extracorporeal membrane oxygenation, and longest lengths of stay. After adjustment, moderately and most aggressive OPOs had similar risks of recipient mortality as least aggressive OPOs. CONCLUSIONS The most and least aggressive OPOs achieve similar patient survival and short-term post-LTx outcomes. Aggressive pursuit and utilization of non-ideal donor lungs by less aggressive OPOs would likely expand the donor pool, without compromising recipient outcomes.
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Affiliation(s)
| | - Oliver K Jawitz
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Vignesh Raman
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Ashley Y Choi
- School of Medicine, Duke University, Durham, North Carolina, USA
| | - John C Haney
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Jacob A Klapper
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
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16
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Bacterial Pneumonia in Brain-Dead Patients: Clinical Features and Impact on Lung Suitability for Donation. Crit Care Med 2021; 48:1760-1770. [PMID: 33009101 DOI: 10.1097/ccm.0000000000004631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To appraise the epidemiological features of bacterial pneumonia and its impact on lung suitability for donation in brain-dead patients managed with protective ventilatory settings. DESIGN Retrospective observational study. SETTING Six ICUs from two university-affiliated hospitals. PATIENTS Brain-dead adult patients managed in the participating ICUs over a 4-year period. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among the 231 included patients, 145 (62.8%) were classified as ideal or extended-criteria potential lung donors at ICU admission and the remaining 86 patients having baseline contraindication for donation. Culture-proven aspiration pneumonia and early-onset ventilator-associated pneumonia occurred in 54 patients (23.4%) and 15 patients (6.5%), respectively (overall pneumonia incidence, 29.9%). Staphylococcus aureus and Enterobacterales were the most common pathogens. Using mixed-effects Cox proportional hazard models, age (adjusted hazard ratio, 0.98; 95% CI [0.96-0.99]), anoxic brain injury (3.55 [1.2-10.5]), aspiration (2.29 [1.22-4.29]), and not receiving antimicrobial agents at day 1 (3.56 [1.94-6.53]) were identified as independent predictors of pneumonia occurrence in the whole study population. Analyses restricted to potential lung donors yielded similar results. Pneumonia was associated with a postadmission decrease in the PaO2/FIO2 ratio and lower values at brain death, in the whole study population (estimated marginal mean, 294 [264-323] vs 365 [346-385] mm Hg in uninfected patients; p = 0.0005) as in potential lung donors (299 [248-350] vs 379 [350-408] mm Hg; p = 0.04; linear mixed models). Lungs were eventually retrieved in 31 patients (34.4%) among the 90 potential lung donors with at least one other organ harvested (pneumonia prevalence in lung donors (9.7%) vs nondonors (49.2%); p = 0.0002). CONCLUSIONS Pneumonia occurs in one-third of brain-dead patients and appears as the main reason for lung nonharvesting in those presenting as potential lung donors. The initiation of antimicrobial prophylaxis upon the first day of the ICU stay in comatose patients with severe brain injury could enlarge the pool of actual lung donors.
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17
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Ehrsam JP, Benden C, Immer FF, Inci I. Current status and further potential of lung donation after circulatory death. Clin Transplant 2021; 35:e14335. [PMID: 33948997 DOI: 10.1111/ctr.14335] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 04/22/2021] [Accepted: 04/27/2021] [Indexed: 12/13/2022]
Abstract
Chronic organ shortage remains the most limiting factor in lung transplantation. To overcome this shortage, a minority of centers have started with efforts to reintroduce donation after circulatory death (DCD). This review aims to evaluate the experimental background, the current international clinical experience, and the further potential and challenges of the different DCD categories. Successful strategies have been implemented to reduce the problems of warm ischemic time, thrombosis after circulatory arrest, and difficulties in organ assessment, which come with DCD donation. From the currently reported results, controlled-DCD lungs are an effective and safe method with good mid-term and even long-term survival outcomes comparable to donation after brain death (DBD). Primary graft dysfunction and onset of chronic allograft dysfunction seem also comparable. Thus, controlled-DCD lungs should be ceased to be treated as marginal and instead be promoted as an equivalent alternative to DBD. A wide implementation of controlled-DCD-lung donation would significantly decrease the mortality on the waiting list. Therefore, further efforts in establishment of legislation and logistics are crucial. With regard to uncontrolled DCD, more data are needed analyzing long-term outcomes. To help with the detailed assessment and improvement of uncontrolled or otherwise questionable grafts after retrieval, ex-vivo lung perfusion is promising.
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Affiliation(s)
- Jonas P Ehrsam
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland.,Department of Thoracic Surgery, Cantonal Hospital Aarau, Zurich, Switzerland
| | | | | | - Ilhan Inci
- Department of Thoracic Surgery, Cantonal Hospital Aarau, Zurich, Switzerland.,University of Zurich Faculty of Medicine, Zurich, Switzerland
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18
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Halpern SE, McConnell A, Peskoe SB, Raman V, Jawitz OK, Choi AY, Neely ML, Palmer SM, Hartwig MG. A three-tier system for evaluation of organ procurement organizations' willingness to pursue and utilize nonideal donor lungs. Am J Transplant 2021; 21:1269-1277. [PMID: 33048423 PMCID: PMC7920904 DOI: 10.1111/ajt.16347] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/16/2020] [Accepted: 09/28/2020] [Indexed: 01/25/2023]
Abstract
Lungs from "nonideal," but acceptable donors are underutilized; however, organ procurement organization (OPO) metrics do not reflect the extent to which OPO-specific practices contribute to these trends. We developed a comprehensive system to evaluate nonideal lung donor avoidance, or risk aversion among OPOs. Adult donors in the UNOS registry who donated ≥1 organ for transplantation between 2007 and 2018 were included. Nonideal donors had any of age>50, smoking history ≥20 pack-years, PaO2 /FiO2 ratio ≤350, donation after circulatory death, or increased risk status. OPO-level risk aversion in donor pursuit, consent attainment, lung recovery, and transplantation was assessed. Among 83916 donors, 70372 (83.9%) were nonideal. Unadjusted OPO-level rates of nonideal donor pursuit ranged from 81 to 100%. In a three-tier system of overall risk aversion, tier 3 OPOs (least risk-averse) had the highest rates of nonideal donor pursuit, consent attainment, lung recovery, and transplantation. Tier 1 OPOs (most risk-averse) had the lowest rates of donor pursuit, consent attainment, and lung recovery, but higher rates of transplantation compared to tier 2 OPOs (moderately risk-averse). Risk aversion varies among OPOs and across the donation process. OPO evaluations should reflect early donation process stages to best differentiate over- and underperforming OPOs and encourage optimal OPO-specific performance.
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Affiliation(s)
| | - Alec McConnell
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Sarah B. Peskoe
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Vignesh Raman
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Oliver K. Jawitz
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Megan L. Neely
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Scott M. Palmer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Matthew G. Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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19
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Sef D, Verzelloni Sef A, Mohite P, Stock U, Trkulja V, Raj B, Garcia Saez D, Mahesh B, De Robertis F, Simon A. Utilization of extracorporeal membrane oxygenation in DCD and DBD lung transplants: a 2-year single-center experience. Transpl Int 2020; 33:1788-1798. [PMID: 32989785 DOI: 10.1111/tri.13754] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/26/2020] [Accepted: 09/22/2020] [Indexed: 01/23/2023]
Abstract
Donation after circulatory death (DCD) has the potential to expand the lung donor pool. We aimed to assess whether DCD affected the need for perioperative extracorporeal membrane oxygenation (ECMO) and perioperative outcomes in lung transplantation (LTx) as compared to donation after brain death (DBD). All consecutive LTxs performed between April 2017 and March 2019 at our tertiary center were analyzed. Donor and recipient preoperative characteristics, utilization of ECMO, and perioperative clinical outcomes were compared between DCD and DBD LTx. Multivariate models (frequentist and Bayes) were fitted to evaluate an independent effect of DCD on the intra- and postoperative need for ECMO. Out of 105 enrolled patients, 25 (23.8%) were DCD LTx. Donors' and preoperative recipients' characteristics were comparable between the groups. Intraoperatively, mechanical circulatory support (MCS) was more common in DCD LTx (56.0% vs. 36.2%), but the adjusted difference was minor (RR = 1.16, 95% CI 0.64-2.12; P = 0.613). MCS duration, and first and second lung ischemia time were longer in the DCD group. Postoperatively, DCD recipients more commonly required ECMO (32.0% vs. 7.5%) and the difference remained considerable after adjustment for the pre- and intraoperative covariates: RR = 4.11 (95% CI 0.95-17.7), P = 0.058, Bayes RR = 4.15 (95% CrI 1.28-13.0). Sensitivity analyses (two DCD-DBD matching procedures) supported a higher risk of postoperative ECMO need in DCD patients. Incidence of delayed chest closure, postoperative chest drainage, and renal replacement therapy was higher in the DCD group. Early postoperative outcomes after DCD LTx appeared generally comparable to those after DBD LTx. DCD was associated with a higher need for postoperative ECMO which could influence clinical outcomes. However, as the DCD group had a significantly higher use of EVLP with more common ECMO preoperatively, this might have contributed to worse outcomes in the DCD group.
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Affiliation(s)
- Davorin Sef
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust, Harefield Hospital, London, UK
| | - Alessandra Verzelloni Sef
- Department of Anaesthesia and Critical Care, Royal Brompton & Harefield NHS Foundation Trust, Harefield Hospital, London, UK
| | - Prashant Mohite
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust, Harefield Hospital, London, UK
| | - Ulrich Stock
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust, Harefield Hospital, London, UK
| | - Vladimir Trkulja
- Department of Pharmacology, Zagreb University School of Medicine, Zagreb, Croatia
| | - Binu Raj
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust, Harefield Hospital, London, UK
| | - Diana Garcia Saez
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust, Harefield Hospital, London, UK
| | - Balakrishnan Mahesh
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust, Harefield Hospital, London, UK
| | - Fabio De Robertis
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust, Harefield Hospital, London, UK
| | - Andre Simon
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust, Harefield Hospital, London, UK
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20
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van der Mark SC, Hoek RAS, Hellemons ME. Developments in lung transplantation over the past decade. Eur Respir Rev 2020; 29:29/157/190132. [PMID: 32699023 PMCID: PMC9489139 DOI: 10.1183/16000617.0132-2019] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 01/30/2020] [Indexed: 12/12/2022] Open
Abstract
With an improved median survival of 6.2 years, lung transplantation has become an increasingly acceptable treatment option for end-stage lung disease. Besides survival benefit, improvement of quality of life is achieved in the vast majority of patients. Many developments have taken place in the field of lung transplantation over the past decade. Broadened indication criteria and bridging techniques for patients awaiting lung transplantation have led to increased waiting lists and changes in allocation schemes worldwide. Moreover, the use of previously unacceptable donor lungs for lung transplantation has increased, with donations from donors after cardiac death, donors with increasing age and donors with positive smoking status extending the donor pool substantially. Use of ex vivo lung perfusion further increased the number of lungs suitable for lung transplantation. Nonetheless, the use of these previously unacceptable lungs did not have detrimental effects on survival and long-term graft outcomes, and has decreased waiting list mortality. To further improve long-term outcomes, strategies have been proposed to modify chronic lung allograft dysfunction progression and minimise toxic immunosuppressive effects. This review summarises the developments in clinical lung transplantation over the past decade. Many developments have taken place in lung transplantation over the last decade: indications have broadened, donor criteria expanded, allocations systems changed, and novel therapeutic interventions implemented, leading to improved long-term survivalhttp://bit.ly/2vnpwc1
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Affiliation(s)
- Sophie C van der Mark
- Dept of Pulmonary Medicine, Division of Interstitial Lung Disease, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands.,Authors contributed equally
| | - Rogier A S Hoek
- Dept of Pulmonary Medicine, Division of Lung Transplantation, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands.,Authors contributed equally
| | - Merel E Hellemons
- Dept of Pulmonary Medicine, Division of Interstitial Lung Disease, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands .,Dept of Pulmonary Medicine, Division of Lung Transplantation, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
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21
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Rubio Muñoz JJ, Dominguez-Gil González B, Miñambres García E, Del Río Gallegos F, Pérez-Villares JM. Role of normothermic perfusión with ECMO in donation after controlled cardiac death in Spain. Med Intensiva 2020; 46:S0210-5691(20)30066-8. [PMID: 32564985 DOI: 10.1016/j.medin.2020.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 01/26/2020] [Accepted: 01/31/2020] [Indexed: 02/07/2023]
Abstract
Spain has become one of the most active countries in donation after controlled cardiac death, using normothermic abdominal perfusion with ECMO in more than 50% of all donors - a situation contributed to by the creation of mobile teams to support hospitals lacking this technology. The donation process must be respectful of the wishes and values of the patients and their relatives, especially if there is pre mortem manipulation, and the absence of cerebral perfusion should be guaranteed. The liver is the most benefited organ by reducing biliary complications as well as the loss of grafts. In renal transplantation, the technique could contribute to reduce the incidence of delayed graft function. In addition, the procedure is compatible with surgical rapid recovery in hypothermia when there is also lung donation. The future lies in the consolidation of cardiac donation by extending normothermic perfusion to the thoracic cavity.
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Affiliation(s)
- J J Rubio Muñoz
- Servicio de Medicina Intensiva, Unidad de Coordinación de Trasplantes, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España.
| | | | - E Miñambres García
- Coordinación Regional de Trasplantes de la Comunidad de Cantabria, Servicio de Medicina Intensiva del Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, España
| | - F Del Río Gallegos
- Coordinación Regional de Trasplantes de la Comunidad de Madrid, Servicio de Medicina Intensiva del Hospital Universitario Clínico San Carlos, Madrid, España
| | - J M Pérez-Villares
- Coordinador Regional de Trasplantes de la Comunidad de Andalucía, Servicio de Medicina Intensiva del Hospital Universitario Virgen de las Nieves, Granada, España
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22
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Choi AY, Jawitz OK, Raman V, Mulvihill MS, Halpern SE, Barac YD, Klapper JA, Hartwig MG. Predictors of nonuse of donation after circulatory death lung allografts. J Thorac Cardiovasc Surg 2020; 161:458-466.e3. [PMID: 32563573 DOI: 10.1016/j.jtcvs.2020.04.111] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Despite growing evidence of comparable outcomes in recipients of donation after circulatory death and donation after brain death donor lungs, donation after circulatory death allografts continue to be underused nationally. We examined predictors of nonuse. METHODS All donors who donated at least 1 organ for transplantation between 2005 and 2019 were identified in the United Network for Organ Sharing registry and stratified by donation type. The primary outcome of interest was use of pulmonary allografts. Organ disposition and refusal reasons were evaluated. Multivariable regression modeling was used to assess the relationship between donor factors and use. RESULTS A total of 15,458 donation after circulatory death donors met inclusion criteria. Of 30,916 lungs, 3.7% (1158) were used for transplantation and 72.8% were discarded primarily due to poor organ function. Consent was not requested in 8.4% of donation after circulatory death offers with donation after circulatory death being the leading reason (73.4%). Nonuse was associated with smoking history (P < .001), clinical infection with a blood source (12% vs 7.4%, P = .001), and lower PaO2/FiO2 ratio (median 230 vs 423, P < .001). In multivariable regression, those with PaO2/FiO2 ratio less than 250 were least likely to be transplanted (adjusted odds ratio, 0.03; P < .001), followed by cigarette use (0.28, P < .001), and donor age >50 (0.75, P = .031). Recent transplant era was associated with significantly increased use (adjusted odds ratio, 2.28; P < .001). CONCLUSIONS Nontransplantation of donation after circulatory death lungs was associated with potentially modifiable predonation factors, including organ procurement organizations' consenting behavior, and donor factors, including hypoxemia. Interventions to increase consent and standardize donation after circulatory death donor management, including selective use of ex vivo lung perfusion in the setting of hypoxemia, may increase use and the donor pool.
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Affiliation(s)
| | - Oliver K Jawitz
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Vignesh Raman
- Department of Surgery, Duke University Medical Center, Durham, NC
| | | | | | - Yaron D Barac
- The Division of Cardiovascular and Thoracic Surgery, Rabin Medical Center, Petach-Tikva, Israel
| | - Jacob A Klapper
- Department of Surgery, Duke University Medical Center, Durham, NC
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23
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Donor Leukocyte Trafficking and Damage-associated Molecular Pattern Expression During Ex Vivo Lung Perfusion. Transplant Direct 2020; 6:e532. [PMID: 32195323 PMCID: PMC7056278 DOI: 10.1097/txd.0000000000000968] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/27/2019] [Accepted: 11/08/2019] [Indexed: 01/03/2023] Open
Abstract
Background. While ex vivo lung perfusion (EVLP) has become established in lung transplantation, the cellular processes occurring during this period are not yet fully understood. Prior studies demonstrated that donor leukocytes (DLs) migrate from the graft into the perfusate during EVLP, but the distribution of DLs in graft and perfusate compartments has not been characterized. Moreover, cell death of DLs has been implicated in mediating graft injury during EVLP, but the underlying mechanisms have not been elucidated. We hypothesized the following: (1) there is a nonspecific migration of DLs from the graft into perfusate and (2) cell death of DLs releases damage-associated molecular patterns (DAMPs) that contribute to the inflammatory milieu during EVLP. Methods. EVLP was performed on rat lungs for 3 hours (N = 6). At the end of EVLP, flow cytometry was used to quantify the distribution of different DL cell types in both the graft and perfusate compartments. During EVLP, the perfusate was also sampled hourly to measure levels of DAMPs and downstream inflammatory cytokines generated during EVLP. Results. At the conclusion of EVLP, there was a significantly higher proportion of T and B cells present in the perfusate compartment compared with the graft compartment. There was a time-dependent increase in extracellular DNA and tumor necrosis factor α in the perfusate during EVLP. Conclusions. T cells and B cells are enriched in the perfusate compartment during EVLP. Cell death of DLs contributes to an accumulation of DAMPs during EVLP.
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24
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Miñambres E, Ruiz P, Ballesteros MA, Álvarez C, Cifrián JM, Atutxa L, Ventoso A, Castillo F, Gastaca M. Combined lung and liver procurement in controlled donation after circulatory death using normothermic abdominal perfusion. Initial experience in two Spanish centers. Am J Transplant 2020; 20:231-240. [PMID: 31265753 DOI: 10.1111/ajt.15520] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 06/01/2019] [Accepted: 06/21/2019] [Indexed: 01/25/2023]
Abstract
Combining simultaneously lung and liver procurement in controlled donation after circulatory death (cDCD) using normothermic abdominal perfusion (NRP) for abdominal grafts and cooling and rapid recovery technique (RR) for the lungs increases the complexity of the procurement procedure and might injure the grafts. A total of 19 cDCDs from two centers using this combined procedure were evaluated, and 16 liver and 21 lung transplantations were performed. As controls, 34 donors after brain death (DBDs) were included (29 liver and 41 lung transplantations were performed). Two cDCD liver recipients developed primary nonfunction (12.5%). No cases of ischemic cholangiopathy were observed among cDCD recipients. The 1-year and 2-year liver recipients survival was 87.5% and 87.5% for the cDCD group, and 96% and 84.5% for the DBD group, respectively (P = .496). The 1-year and 2-year lung recipients survival was 84% and 84% for the cDCD group and 90% and 90% for the DBD group, respectively (P = .577). This is the largest experience ever reported in cDCD with the use of NRP combined with RR of the lungs. This combined method offers an outstanding recovery rate and liver and lung recipients survival comparable with those transplanted with DBDs. Further studies are needed to confirm our findings.
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Affiliation(s)
- Eduardo Miñambres
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, University of Cantabria, Santander, Spain
| | - Patricia Ruiz
- Hepatobiliary Surgery and Liver Transplantation Unit, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Bilbao, Spain
| | - Maria Angeles Ballesteros
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Carlos Álvarez
- Service of Thoracic Surgery, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Jose Manuel Cifrián
- Service of Neumology, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Lander Atutxa
- Transplant Coordination Unit & Service of Intensive Care, Donostia University Hospital, San Sebastian, Spain
| | - Alberto Ventoso
- Hepatobiliary Surgery and Liver Transplantation Unit, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Bilbao, Spain
| | - Federico Castillo
- Hepatobiliary Surgery and Liver Transplantation Unit, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Mikel Gastaca
- Hepatobiliary Surgery and Liver Transplantation Unit, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Bilbao, Spain
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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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Combined Thorax-Abdomen Extraction in Controlled Cardiac Death (Maastricht Type III) Donors. Transplant Proc 2019; 51:3037-3039. [PMID: 31711583 DOI: 10.1016/j.transproceed.2019.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Donation after circulatory death (DCD) or controlled cardiac death (Maastricht type III donors) is that in which the irreversible cessation of circulatory and respiratory function occurs after the withdrawal of life-sustaining therapies. The shortage of available donor lungs has prompted the development of programs of controlled DCD for lung transplantation. The combined thorax-abdomen extraction in these cases is carried out only in a few centers in Spain, being even more exceptional considering the combined use of super rapid lung extraction with abdominal normothermic regional perfusion. The success achieved with the first cases of combined thorax-abdomen extraction in Maastricht type III donors in Navarra shows that it is a feasible and safe procedure.
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Wilkey BJ, Abrams BA. Mitigation of Primary Graft Dysfunction in Lung Transplantation: Current Understanding and Hopes for the Future. Semin Cardiothorac Vasc Anesth 2019; 24:54-66. [DOI: 10.1177/1089253219881980] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Primary graft dysfunction (PGD) is a form of acute lung injury that develops within the first 72 hours after lung transplantation. The overall incidence of PGD is estimated to be around 30%, and the 30-day mortality for grade 3 PGD around 36%. PGD is also associated with the development of bronchiolitis obliterans syndrome, a specific form of chronic lung allograft dysfunction. In this article, we will discuss perioperative strategies for PGD prevention as well as possible future avenues for prevention and treatment.
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Valdivia D, Gómez de Antonio D, Hoyos L, Campo‐Cañaveral de la Cruz JL, Romero A, Varela de Ugarte A. Expanding the horizons: Uncontrolled donors after circulatory death for lung transplantation—First comparison with brain death donors. Clin Transplant 2019; 33:e13561. [DOI: 10.1111/ctr.13561] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 02/24/2019] [Accepted: 03/22/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Daniel Valdivia
- Department of Thoracic Surgery and Lung Transplantation Hospital Universitario Puerta de Hierro‐Majadahonda Madrid Spain
| | - David Gómez de Antonio
- Department of Thoracic Surgery and Lung Transplantation Hospital Universitario Puerta de Hierro‐Majadahonda Madrid Spain
| | - Lucas Hoyos
- Department of Thoracic Surgery and Lung Transplantation Hospital Universitario Puerta de Hierro‐Majadahonda Madrid Spain
| | | | - Alejandra Romero
- Department of Thoracic Surgery and Lung Transplantation Hospital Universitario Puerta de Hierro‐Majadahonda Madrid Spain
| | - Andrés Varela de Ugarte
- Department of Thoracic Surgery and Lung Transplantation Hospital Universitario Puerta de Hierro‐Majadahonda Madrid Spain
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Suberviola B, Mons R, Ballesteros MA, Mora V, Delgado M, Naranjo S, Iturbe D, Miñambres E. Excellent long-term outcome with lungs obtained from uncontrolled donation after circulatory death. Am J Transplant 2019; 19:1195-1201. [PMID: 30582287 DOI: 10.1111/ajt.15237] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 12/04/2018] [Accepted: 12/08/2018] [Indexed: 01/25/2023]
Abstract
We aimed to propose a simple and effective preservation method in lungs procured for transplantation from uncontrolled donation after circulatory death (uDCD) associated with excellent long-term results. Outcome measures for lung recipients were survival and primary graft dysfunction (PGD) grade 3. Survival was estimated using the Kaplan-Meier method. A total of 9 lung uDCDs were evaluated and 8 lung transplants were performed. Mean no-flow time was 9.8 minutes (standard deviation [SD] 8.6). Mean time from cardiac arrest to topical cooling was 96.8 minutes (SD 16.8). Preservation time was 159 minutes (SD 31). Ex vivo lung perfusion was used to assess lung function prior to transplantation in 2 cases. Mean recipient age was 60.8 years (SD 3.1), and mean total ischemic time was 678 minutes (SD 132). PGD grade 3 was observed in 2 cases (25%). The 1-month, 1-year, and 5-year survival rates were 100%, 87.5%, and 87.5%, respectively. Mean follow-up was 52 months. The logistic complexity of procuring lungs from uDCDs for transplantation requires the development of new strategies designed to facilitate this type of donation. A program based on strict selection criteria, using a simple and effective preservation technique, may recover lung grafts with excellent long-term posttransplant outcomes.
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Affiliation(s)
- Borja Suberviola
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Roberto Mons
- Service of Thoracic Surgery, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Maria Angeles Ballesteros
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Victor Mora
- Service of Neumology, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - María Delgado
- Service of Thoracic Surgery, Complexo Hospitalario Universitario A Coruña, La Coruña, Spain
| | - Sara Naranjo
- Service of Thoracic Surgery, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - David Iturbe
- Service of Neumology, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Eduardo Miñambres
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain.,School of Medicine, University of Cantabria, Santander, Spain
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van Zanden JE, Jager NM, Daha MR, Erasmus ME, Leuvenink HGD, Seelen MA. Complement Therapeutics in the Multi-Organ Donor: Do or Don't? Front Immunol 2019; 10:329. [PMID: 30873176 PMCID: PMC6400964 DOI: 10.3389/fimmu.2019.00329] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 02/08/2019] [Indexed: 12/18/2022] Open
Abstract
Over the last decade, striking progress has been made in the field of organ transplantation, such as better surgical expertise and preservation techniques. Therefore, organ transplantation is nowadays considered a successful treatment in end-stage diseases of various organs, e.g. the kidney, liver, intestine, heart, and lungs. However, there are still barriers which prevent a lifelong survival of the donor graft in the recipient. Activation of the immune system is an important limiting factor in the transplantation process. As part of this pro-inflammatory environment, the complement system is triggered. Complement activation plays a key role in the transplantation process, as highlighted by the amount of studies in ischemia-reperfusion injury (IRI) and rejection. However, new insight have shown that complement is not only activated in the later stages of transplantation, but already commences in the donor. In deceased donors, complement activation is associated with deteriorated quality of deceased donor organs. Of importance, since most donor organs are derived from either brain-dead donors or deceased after circulatory death donors. The exact mechanisms and the role of the complement system in the pathophysiology of the deceased donor have been underexposed. This review provides an overview of the current knowledge on complement activation in the (multi-)organ donor. Targeting the complement system might be a promising therapeutic strategy to improve the quality of various donor organs. Therefore, we will discuss the complement therapeutics that already have been tested in the donor. Finally, we question whether complement therapeutics should be translated to the clinics and if all organs share the same potential complement targets, considering the physiological differences of each organ.
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Affiliation(s)
- Judith E. van Zanden
- Department of Surgery, University Medical Center Groningen, Groningen, Netherlands
| | - Neeltina M. Jager
- Department of Surgery, University Medical Center Groningen, Groningen, Netherlands
| | - Mohamed R. Daha
- Department of Nephrology, Leiden University Medical Center, Leiden, Netherlands
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, Groningen, Netherlands
| | - Michiel E. Erasmus
- Department of Thoracic Surgery, University Medical Center Groningen, Groningen, Netherlands
| | | | - Marc A. Seelen
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, Groningen, Netherlands
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Villavicencio MA, Axtell AL, Spencer PJ, Heng EE, Kilmarx S, Dalpozzal N, Funamoto M, Roy N, Osho A, Melnitchouk S, D’Alessandro DA, Tolis G, Astor T. Lung Transplantation From Donation After Circulatory Death: United States and Single-Center Experience. Ann Thorac Surg 2018; 106:1619-1627. [DOI: 10.1016/j.athoracsur.2018.07.024] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 06/06/2018] [Accepted: 07/09/2018] [Indexed: 11/25/2022]
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33
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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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Abstract
Lung transplantation can improve quality of life and prolong survival for individuals with end-stage lung disease, and many advances in the realms of both basic science and clinical research aspects of lung transplantation have emerged over the past few decades. However, many challenges must yet be overcome to increase post-transplant survival. These include successfully bridging patients to transplant, expanding the lung donor pool, inducing tolerance, and preventing a myriad of post-transplant complications that include primary graft dysfunction, forms of cellular and antibody-mediated rejection, chronic lung allograft dysfunction, and infections. The goal of this manuscript is to review salient recent and evolving advances in the field of lung transplantation.
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Affiliation(s)
- Keith C Meyer
- UW Lung Transplant & Advanced Pulmonary Disease Program, Section of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Del Rio JM, Maerz D, Subramaniam K. Noteworthy Literature Published in 2017 for Thoracic Transplantation Anesthesiologists. Semin Cardiothorac Vasc Anesth 2018; 22:49-66. [DOI: 10.1177/1089253217749893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Thoracic organ transplantation constitutes a significant proportion of all transplant procedures. Thoracic solid organ transplantation continues to be a burgeoning field of research. This article presents a review of remarkable literature published in 2017 regarding perioperative issues pertinent to the thoracic transplant anesthesiologists.
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Affiliation(s)
- J. Mauricio Del Rio
- Duke University, Durham, NC, USA
- Duke University Medical Center, Durham, NC, USA
| | - David Maerz
- University of Pittsburgh, Pittsburgh, PA, USA
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kathirvel Subramaniam
- University of Pittsburgh, Pittsburgh, PA, USA
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Rouzeau C, Lecomte E, Cailleton A, Cornuault M, Boulinguiez C, Labourot P, Reignier J, Guitton C. Prélèvements multiorganes de type Maastricht III en médecine intensive–réanimation. Organisation et retour d’expérience paramédicale dans un service pilote. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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38
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Bozso SJ, Nagendran J. Life After Death: Breathing Life Into Lung Transplantation From Donation After Circulatory Death Donors. Am J Transplant 2017; 17:2507-2508. [PMID: 28678405 DOI: 10.1111/ajt.14413] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 06/07/2017] [Accepted: 06/25/2017] [Indexed: 01/25/2023]
Affiliation(s)
- S J Bozso
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - J Nagendran
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada.,Alberta Transplant Institute, Edmonton, Alberta, Canada.,Canadian National Transplant Research Program, Edmonton, Alberta, Canada
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