1
|
Lazzeri C, Bonizzoli M, Di Valvasone S, Peris A. Uncontrolled Donation after Circulatory Death Only Lung Program: An Urgent Opportunity. J Clin Med 2023; 12:6492. [PMID: 37892627 PMCID: PMC10607380 DOI: 10.3390/jcm12206492] [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: 08/23/2023] [Revised: 09/20/2023] [Accepted: 09/27/2023] [Indexed: 10/29/2023] Open
Abstract
Uncontrolled donation after circulatory death (uDCD) represents a potential source of lungs, and since Steen's 2001 landmark case in Sweden, lungs have been recovered from uDCD donors and transplanted to patients in other European countries (France, the Netherlands, Spain and Italy) with promising results. Disparities still exist among European countries and among regions in Italy due to logistical and organizational factors. The present manuscript focuses on the clinical experiences pertaining to uDCD lungs in North America and European countries and on different lung maintenance methods. Existing experiences (and protocols) are not uniform, especially with respect to the type of lung maintenance, the definition of warm ischemic time (WIT) and, finally, the use of ex vivo perfusion (available in the last several years in most centers). In situ lung cooling may be superior to protective ventilation, but this process may be difficult to perform in the uDCD setting and is also time-consuming. On the other hand, the "protective ventilation technique" is simpler and feasible in every hospital. It may lead to a broader use of uDCD lung donors. To date, the results of lung transplants performed after protective ventilation as a preservation technique are scarce but promising. All the protocols comprise, among the inclusion criteria, a witnessed cardiac arrest. The detectable differences included preservation time (240 vs. 180 min) and donor age (<55 years in Spanish protocols and <65 years in Toronto protocols). Overall, independently of the differences in protocols, lungs from uDCD donors show promising results, and the possibility of optimizing ex vivo lung perfusion may broaden the use of these organs.
Collapse
Affiliation(s)
- Chiara Lazzeri
- Intensive Care Unit and Regional ECMO Referral Center Emergency Department, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134 Florence, Italy (A.P.)
| | | | | | | |
Collapse
|
2
|
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.
Collapse
Affiliation(s)
- Kentaro Noda
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | | | | |
Collapse
|
3
|
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
|
4
|
Faccioli E, Verzeletti V, Rea F, Schiavon M. Lung donation after circulatory death: A single-centre experience with uncontrolled donors with some considerations. TRANSPLANTATION REPORTS 2022. [DOI: 10.1016/j.tpr.2022.100117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
|
5
|
Tanaka S, Hoyos Mejía L, Romero Román A, Campo-Cañaveral de la Cruz JL, Crowley Carrasco S, Naranjo Gómez JM, Córdoba Peláez MDM, Sánchez Calle Á, Gil Barturen M, Varela de Ugarte A, Gómez-de-Antonio D. Evaluation of Uncontrolled Donation After Circulatory Death Lungs by Conventional In Situ Effluent Gas Analysis and Ex Vivo Lung Perfusion. Arch Bronconeumol 2022; 58:569-571. [PMID: 35312549 DOI: 10.1016/j.arbres.2021.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/03/2021] [Accepted: 06/10/2021] [Indexed: 11/02/2022]
Affiliation(s)
- Shin Tanaka
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Manuel de Falla s/n, Majadahonda, Madrid 28222, Spain
| | - Lucas Hoyos Mejía
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Manuel de Falla s/n, Majadahonda, Madrid 28222, Spain.
| | - Alejandra Romero Román
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Manuel de Falla s/n, Majadahonda, Madrid 28222, Spain
| | - Jose Luis Campo-Cañaveral de la Cruz
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Manuel de Falla s/n, Majadahonda, Madrid 28222, Spain
| | - Silvana Crowley Carrasco
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Manuel de Falla s/n, Majadahonda, Madrid 28222, Spain
| | - Jose Manuel Naranjo Gómez
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Manuel de Falla s/n, Majadahonda, Madrid 28222, Spain
| | - Maria Del Mar Córdoba Peláez
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Manuel de Falla s/n, Majadahonda, Madrid 28222, Spain
| | - Álvaro Sánchez Calle
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Manuel de Falla s/n, Majadahonda, Madrid 28222, Spain
| | - Mariana Gil Barturen
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Manuel de Falla s/n, Majadahonda, Madrid 28222, Spain
| | - Andrés Varela de Ugarte
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Manuel de Falla s/n, Majadahonda, Madrid 28222, Spain
| | - David Gómez-de-Antonio
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Manuel de Falla s/n, Majadahonda, Madrid 28222, Spain
| |
Collapse
|
6
|
Gori F, Fumagalli J, Lonati C, Carlin A, Leonardi P, Biancolilli O, Rossetti A, Righi I, Tosi D, Palleschi A, Rosso L, Morlacchi LC, Blasi F, Vivona L, Florio G, Scaravilli V, Valenza F, Zanella A, Grasselli G. Lung Biomolecular Profile and Function of Grafts from Donors after Cardiocirculatory Death with Prolonged Donor Warm Ischemia Time. J Clin Med 2022; 11:jcm11113066. [PMID: 35683455 PMCID: PMC9181171 DOI: 10.3390/jcm11113066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/30/2022] [Accepted: 05/23/2022] [Indexed: 11/16/2022] Open
Abstract
The acceptable duration of donor warm ischemia time (DWIT) after cardiocirculatory death (DCD) is still debated. We analyzed the biomolecular profile and function during ex vivo lung perfusion (EVLP) of DCD lungs and their correlation with lung transplantation (LuTx) outcomes. Donor data, procurement times, recipient outcomes, and graft function up to 1 year after LuTx were collected. During EVLP, the parameters of graft function and metabolism, perfusate samples to quantify inflammation, glycocalyx breakdown products, coagulation, and endothelial activation markers were obtained. Data were compared to a cohort of extended-criteria donors after brain death (EC-DBD). Eight DBD and seven DCD grafts transplanted after EVLP were analyzed. DCD’s DWIT was 201 [188;247] minutes. Donors differed only regarding the duration of mechanical ventilation that was longer in the EC-DBD group. No difference was observed in lung graft function during EVLP. At reperfusion, “wash-out” of inflammatory cells and microthrombi was predominant in DCD grafts. Perfusate biomolecular profile demonstrated marked endothelial activation, characterized by the presence of inflammatory mediators and glycocalyx breakdown products both in DCD and EC-DBD grafts. Early graft function after LuTx was similar between DCD and EC-DBD. DCD lungs exposed to prolonged DWIT represent a potential resource for donation if properly preserved and evaluated.
Collapse
Affiliation(s)
- Francesca Gori
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (J.F.); (O.B.); (V.S.); (G.G.)
| | - Jacopo Fumagalli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (J.F.); (O.B.); (V.S.); (G.G.)
| | - Caterina Lonati
- Center of Preclinical Research, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Andrea Carlin
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (A.C.); (P.L.); (A.P.); (L.R.); (F.B.); (L.V.); (G.F.); (F.V.)
| | - Patrizia Leonardi
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (A.C.); (P.L.); (A.P.); (L.R.); (F.B.); (L.V.); (G.F.); (F.V.)
| | - Osvaldo Biancolilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (J.F.); (O.B.); (V.S.); (G.G.)
| | - Antonello Rossetti
- Hospital Medical Direction, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Ilaria Righi
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy; (I.R.); (D.T.)
| | - Davide Tosi
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy; (I.R.); (D.T.)
| | - Alessandro Palleschi
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (A.C.); (P.L.); (A.P.); (L.R.); (F.B.); (L.V.); (G.F.); (F.V.)
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy; (I.R.); (D.T.)
| | - Lorenzo Rosso
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (A.C.); (P.L.); (A.P.); (L.R.); (F.B.); (L.V.); (G.F.); (F.V.)
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy; (I.R.); (D.T.)
| | - Letizia Corinna Morlacchi
- Respiratory Unit & Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (A.C.); (P.L.); (A.P.); (L.R.); (F.B.); (L.V.); (G.F.); (F.V.)
- Respiratory Unit & Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Luigi Vivona
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (A.C.); (P.L.); (A.P.); (L.R.); (F.B.); (L.V.); (G.F.); (F.V.)
| | - Gaetano Florio
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (A.C.); (P.L.); (A.P.); (L.R.); (F.B.); (L.V.); (G.F.); (F.V.)
| | - Vittorio Scaravilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (J.F.); (O.B.); (V.S.); (G.G.)
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (A.C.); (P.L.); (A.P.); (L.R.); (F.B.); (L.V.); (G.F.); (F.V.)
| | - Franco Valenza
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (A.C.); (P.L.); (A.P.); (L.R.); (F.B.); (L.V.); (G.F.); (F.V.)
- Department of Anesthesia and Critical Care, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
| | - Alberto Zanella
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (J.F.); (O.B.); (V.S.); (G.G.)
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (A.C.); (P.L.); (A.P.); (L.R.); (F.B.); (L.V.); (G.F.); (F.V.)
- Correspondence: ; Tel.: +39-02-55033674; Fax: +39-02-55033230
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (J.F.); (O.B.); (V.S.); (G.G.)
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (A.C.); (P.L.); (A.P.); (L.R.); (F.B.); (L.V.); (G.F.); (F.V.)
| |
Collapse
|
7
|
Van Raemdonck D, Ceulemans LJ, Neyrinck A, Levvey B, Snell GI. Donation After Circulatory Death in lung transplantation. Thorac Surg Clin 2022; 32:153-165. [PMID: 35512934 DOI: 10.1016/j.thorsurg.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The continuing shortage of pulmonary grafts from donors after brain death has led to a resurgence of interest in lung transplantation from donors after circulatory death (DCD). Most lungs from donors after withdrawal from life-sustaining therapy can be recovered rapidly and transplanted directly without ex-vivo assessment in case functional warm ischemic time is limited to 30 to 60 min. The potential of the DCD lung pool is still underutilized and should be maximized in countries with existing legislation. Countries lacking a DCD pathway should be encouraged to develop national ethical, professional, and legal frameworks to address public and professional concerns.
Collapse
Affiliation(s)
- Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, UZ Gasthuisberg, Herestraat 49, Leuven B-3000, Belgium; Department of Chronic Diseases and Metabolism, KU Leuven University, Leuven, Belgium.
| | - Laurens J Ceulemans
- Department of Thoracic Surgery, University Hospitals Leuven, UZ Gasthuisberg, Herestraat 49, Leuven B-3000, Belgium; Department of Chronic Diseases and Metabolism, KU Leuven University, Leuven, Belgium
| | - Arne Neyrinck
- Department of Anesthesiology, University Hospitals Leuven, UZ Gasthuisberg, Herestraat 49, Leuven B-3000, Belgium; Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium
| | - Bronwyn Levvey
- Lung Transplant Service, The Alfred Hospital and Monash University, 55 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Gregory I Snell
- Lung Transplant Service, The Alfred Hospital and Monash University, 55 Commercial Road, Melbourne, Victoria 3004, Australia
| |
Collapse
|
8
|
Santos PARD, Teixeira PJZ, Moraes Neto DMD, Cypel M. Donation after circulatory death and lung transplantation. J Bras Pneumol 2022; 48:e20210369. [PMID: 35475865 PMCID: PMC9064622 DOI: 10.36416/1806-3756/e20210369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 12/17/2021] [Indexed: 11/17/2022] Open
Abstract
Lung transplantation is the most effective modality for the treatment of patients with end-stage lung diseases. Unfortunately, many people cannot benefit from this therapy due to insufficient donor availability. In this review and update article, we discuss donation after circulatory death (DCD), which is undoubtedly essential among the strategies developed to increase the donor pool. However, there are ethical and legislative considerations in the DCD process that are different from those of donation after brain death (DBD). Among others, the critical aspects of DCD are the concept of the end of life, cessation of futile treatments, and withdrawal of life-sustaining therapy. In addition, this review describes a rationale for using lungs from DCD donors and provides some important definitions, highlighting the key differences between DCD and DBD, including physiological aspects pertinent to each category. The unique ability of lungs to maintain cell viability without circulation, assuming that oxygen is supplied to the alveoli-an essential aspect of DCD-is also discussed. Furthermore, an updated review of the clinical experience with DCD for lung transplantation across international centers, recent advances in DCD, and some ethical dilemmas that deserve attention are also reported.
Collapse
Affiliation(s)
- Pedro Augusto Reck Dos Santos
- . Department of Cardiothoracic Surgery, Mayo Clinic (AZ) USA.,. Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre (RS) Brasil
| | - Paulo José Zimermann Teixeira
- . Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre (RS) Brasil.,. Departamento de Clínica Médica, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre (RS) Brasil
| | | | - Marcelo Cypel
- . Division of Thoracic Surgery, University of Toronto, University Health Network, Toronto (ON) Canada
| |
Collapse
|
9
|
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]
|
10
|
De Beule J, Vandendriessche K, Pengel LHM, Bellini MI, Dark JH, Hessheimer AJ, Kimenai HJAN, Knight SR, Neyrinck AP, Paredes D, Watson CJE, Rega F, Jochmans I. A systematic review and meta-analyses of regional perfusion in donation after circulatory death solid organ transplantation. Transpl Int 2021; 34:2046-2060. [PMID: 34570380 DOI: 10.1111/tri.14121] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/16/2021] [Accepted: 09/20/2021] [Indexed: 12/29/2022]
Abstract
In donation after circulatory death (DCD), (thoraco)abdominal regional perfusion (RP) restores circulation to a region of the body following death declaration. We systematically reviewed outcomes of solid organ transplantation after RP by searching PubMed, Embase, and Cochrane libraries. Eighty-eight articles reporting on outcomes of liver, kidney, pancreas, heart, and lung transplants or donor/organ utilization were identified. Meta-analyses were conducted when possible. Methodological quality was assessed using National Institutes of Health (NIH)-scoring tools. Case reports (13/88), case series (44/88), retrospective cohort studies (35/88), retrospective matched cohort studies (5/88), and case-control studies (2/88) were identified, with overall fair quality. As blood viscosity and rheology change below 20 °C, studies were grouped as hypothermic (HRP, ≤20 °C) or normothermic (NRP, >20 °C) regional perfusion. Data demonstrate that RP is a safe alternative to in situ cold preservation (ISP) in uncontrolled and controlled DCDs. The scarce HRP data are from before 2005. NRP appears to reduce post-transplant complications, especially biliary complications in controlled DCD livers, compared with ISP. Comparisons for kidney and pancreas with ISP are needed but there is no evidence that NRP is detrimental. Additional data on NRP in thoracic organs are needed. Whether RP increases donor or organ utilization needs further research.
Collapse
Affiliation(s)
- Julie De Beule
- Transplantation Research Group, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | | | - Liset H M Pengel
- Nuffield Department of Surgical Sciences, Centre for Evidence in Transplantation, University of Oxford, Oxford, UK
| | - Maria Irene Bellini
- Department of Emergency Medicine and Surgery, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - John H Dark
- Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| | - Amelia J Hessheimer
- Department of General & Digestive Surgery, Institut Clínic de Malalties Digestives i Metabòliques (ICMDM), Hospital Clínic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Hendrikus J A N Kimenai
- Division of Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Simon R Knight
- Nuffield Department of Surgical Sciences, Centre for Evidence in Transplantation, University of Oxford, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Arne P Neyrinck
- Department of Cardiovascular Sciences, Anesthesiology and Algology, KU Leuven, Leuven, Belgium.,Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - David Paredes
- Donation and Transplant Coordination Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Christopher J E Watson
- Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.,The NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - Filip Rega
- Department of Cardiovascular Sciences, Cardiac Surgery, KU Leuven, Leuven, Belgium.,Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Ina Jochmans
- Transplantation Research Group, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Musso V, Mendogni P, Scaravilli V, Morlacchi LC, Croci GA, Palleschi A. Extended-criteria uncontrolled DCD donor for a fragile recipient: A case report about a challenging yet successful lung transplantation. Int J Surg Case Rep 2020; 77S:S67-S71. [PMID: 33046417 PMCID: PMC7876926 DOI: 10.1016/j.ijscr.2020.09.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/02/2020] [Accepted: 09/05/2020] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Lung donation after circulatory death (DCD) has proved to be an effective strategy for expanding the donor pool, but is still considered challenging. We report a successful case of lung procurement from an extended-criteria uncontrolled DCD. PRESENTATION OF CASE We evaluated the lungs of an uncontrolled DCD from a hospital without extracorporeal membrane oxygenation (ECMO) program. The donor was a non-smoker 20-year old male with a history of cardiomyopathy, cardiocirculatory arrests, and Lennox-Gastaut syndrome. Cardiac arrest occurred in a swimming pool, and bronchoscopy showed signs of inhalation. We employed our usual normothermic in-situ open-ventilated lung approach. After retrieval, lungs were stored on ice, then evaluated with ex-vivo lung perfusion (EVLP) and judged suitable for transplantation. The recipient was a 26-year old female with cystic fibrosis on long-term oxygen therapy, on the waitlist for up to 21 months due to her anthropomorphic characteristics. She required central VA-ECMO support during bilateral lung transplantation. Primary graft dysfunction (PGD) within the first 72 h reached grade 3; post-operative peripheral VV-ECMO support was discontinued two days after surgery. The patient was discharged 28 days after surgery; she is alive two years after transplantation with no signs of rejection nor anastomotic complications. DISCUSSION Despite the spreading use of lungs from controlled DCD, perplexities remain on uncontrolled DCD, namely: severe PDG, postoperative mortality, airway complications. CONCLUSION Our case report suggests that good results can be achieved with uncontrolled DCD despite the presence of relative contraindications: inhalation of water, prolonged ischemic times and recipient in poor conditions.
Collapse
Affiliation(s)
- Valeria Musso
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico of Milan, Milan, Italy; Università degli Studi di Milano, Milan, Italy
| | - Paolo Mendogni
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico of Milan, Milan, Italy.
| | - Vittorio Scaravilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico of Milan, Milan, Italy
| | - Letizia Corinna Morlacchi
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio Alberto Croci
- Division of Pathology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandro Palleschi
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico of Milan, Milan, Italy
| |
Collapse
|
14
|
Ungerman E, Khoche S, Subramani S, Bartels S, Fritz AV, Martin AK, Subramanian H, Devarajan J, Knight J, Boisen ML, Gelzinis TA. The Year in Cardiothoracic Transplantation Anesthesia: Selected Highlights from 2019. J Cardiothorac Vasc Anesth 2020; 34:2889-2905. [PMID: 32782193 DOI: 10.1053/j.jvca.2020.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/08/2020] [Indexed: 11/11/2022]
Abstract
The highlights in cardiothoracic transplantation focus on the recent research pertaining to heart and lung transplantation, including expansion of the donor pool, the optimization of donors and recipients, the use of mechanical support, the perioperative and long-term outcomes in these patient populations, and the use of transthoracic echocardiography to diagnose rejection.
Collapse
Affiliation(s)
- Elizabeth Ungerman
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Swapnil Khoche
- Department of Anesthesiology, University of California San Diego, San Diego, CA
| | - Sudhakar Subramani
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Steven Bartels
- Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
| | - Ashley Virginia Fritz
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic Florida, Jacksonville, FL
| | - Archer Kilbourne Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic Florida, Jacksonville, FL
| | - Harikesh Subramanian
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - Joshua Knight
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Michael L Boisen
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Theresa A Gelzinis
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA.
| |
Collapse
|
15
|
Coll E, Miñambres E, Sánchez-Fructuoso A, Fondevila C, Campo-Cañaveral de la Cruz JL, Domínguez-Gil B. Uncontrolled Donation After Circulatory Death: A Unique Opportunity. Transplantation 2020; 104:1542-1552. [PMID: 32732830 DOI: 10.1097/tp.0000000000003139] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Uncontrolled donation after circulatory death (uDCD) refers to donation from persons who die following an unexpected and unsuccessfully resuscitated cardiac arrest. Despite the large potential for uDCD, programs of this kind only exist in a reduced number of countries with a limited activity. Barriers to uDCD are of a logistical and ethical-legal nature, as well as arising from the lack of confidence in the results of transplants from uDCD donors. The procedure needs to be designed to reduce and limit the impact of the prolonged warm ischemia inherent to the uDCD process, and to deal with the ethical issues that this practice poses: termination of advanced cardiopulmonary resuscitation, extension of advanced cardiopulmonary resuscitation beyond futility for organ preservation, moment to approach families to discuss donation opportunities, criteria for the determination of death, or the use of normothermic regional perfusion for the in situ preservation of organs. Although the incidence of primary nonfunction and delayed graft function is higher with organs obtained from uDCD donors, overall patient and graft survival is acceptable in kidney, liver, and lung transplantation, with a proper selection and management of both donors and recipients. Normothermic regional perfusion has shown to be critical to achieve optimal outcomes in uDCD kidney and liver transplantation. However, the role of ex situ preservation with machine perfusion is still to be elucidated. uDCD is a unique opportunity to improve patient access to transplantation therapies and to offer more patients the chance to donate organs after death, if this is consistent with their wishes and values.
Collapse
Affiliation(s)
| | - Eduardo Miñambres
- Intensive Care Unit and Donor Coordination Unit, Hospital Universitario Marqués de Valdecilla-IDIVAL, Universidad de Cantabria, Santander, Spain
| | - Ana Sánchez-Fructuoso
- Nephrology Department, Hospital Universitario Clínico San Carlos, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | | | | | | |
Collapse
|
16
|
Healey A, Watanabe Y, Mills C, Stoncius M, Lavery S, Johnson K, Sanderson R, Humar A, Yeung J, Donahoe L, Pierre A, de Perrot M, Yasufuku K, Waddell TK, Keshavjee S, Cypel M. Initial lung transplantation experience with uncontrolled donation after cardiac death in North America. Am J Transplant 2020; 20:1574-1581. [PMID: 31995660 DOI: 10.1111/ajt.15795] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 12/12/2019] [Accepted: 01/08/2020] [Indexed: 01/25/2023]
Abstract
Uncontrolled donation after cardiac death (uDCD) has the potential to ameliorate the shortage of suitable lungs for transplant. To date, no lung transplant data from these donors are available from North America. We describe the successful use of these donors using a simple method of in situ lung inflation so that the organ can be protected from warm ischemic injury. Forty-four potential donors were approached, and family consent was obtained in 30 cases (68%). Of these, the lung transplant team evaluated 16 uDCDs on site, and 14 were considered for transplant pending ex vivo lung perfusion assessment. Five lungs were ultimately used for transplant (16.7% use rate from consented donors). The mean warm ischemic time was 2.8 hours. No primary graft dysfunction grade 3 was observed at 24, 48, or 72 hours after transplant. Median intensive care unit stay was 5 days (range: 2-78 days), and median hospital stay was 17 days (range: 8-100 days). The 30-day mortality was 0%. Four of 5 patients are alive at a median of 651 days (range: 121-1254 days) with preserved lung function. This study demonstrates the proof of concept and the potential for uDCD lung donation using a simple donor intervention.
Collapse
Affiliation(s)
- Andrew Healey
- Trillium Gift of Life Network, Toronto, Ontario, Canada.,Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Division of Critical Care, Department of Medicine, William Osler Health System, Brampton, Ontario, Canada
| | - Yui Watanabe
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Caitlin Mills
- Trillium Gift of Life Network, Toronto, Ontario, Canada
| | | | - Susan Lavery
- Trillium Gift of Life Network, Toronto, Ontario, Canada
| | - Karen Johnson
- Trillium Gift of Life Network, Toronto, Ontario, Canada
| | | | - Atul Humar
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan Yeung
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Laura Donahoe
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Pierre
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Marc de Perrot
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kazuhiro Yasufuku
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas K Waddell
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
17
|
|
18
|
Parent B, Caplan A, Angel L, Kon Z, Dubler N, Goldfrank L, Lindner J, Wall SP. The unique moral permissibility of uncontrolled lung donation after circulatory death. Am J Transplant 2020; 20:382-388. [PMID: 31550420 PMCID: PMC6984986 DOI: 10.1111/ajt.15603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 08/28/2019] [Accepted: 09/12/2019] [Indexed: 01/25/2023]
Abstract
Implementing uncontrolled donation after circulatory determination of death (uDCDD) in the United States could markedly improve supply of donor lungs for patients in need of transplants. Evidence from US pilot programs suggests families support uDCDD, but only if they are asked permission for using invasive organ preservation procedures prior to initiation. However, non-invasive strategies that confine oxygenation to lungs may be applicable to the overwhelming majority of potential uDCDD donors that have airway devices in place as part of standard resuscitation. We propose an ethical framework for lung uDCDD by: (a) initiating post mortem preservation without requiring prior permission to protect the opportunity for donation until an authorized party can be found; (b) using non-invasive strategies that confine oxygenation to lungs; and (c) maintaining strict separation between the healthcare team and the organ preservation team. Attempting uDCDD in this way has great potential to obtain more transplantable lungs while respecting donor autonomy and family wishes, securing public support, and enabling authorized persons to affirm or cease preservation decisions without requiring evidence of prior organ donation intent. It ensures prioritization of life-saving, the opportunity to allow willing donors to donate, and respect for bodily integrity while adhering to current ethical norms.
Collapse
Affiliation(s)
- Brendan Parent
- NYU Langone Health, Department of Population Health,
Division of Medical Ethics, New York, NY USA
| | - Arthur Caplan
- NYU Langone Health, Department of Population Health,
Division of Medical Ethics, New York, NY USA
| | - Luis Angel
- NYU Langone Transplant Institute, New York, NY USA
| | - Zachary Kon
- NYU Langone Transplant Institute, New York, NY USA
| | - Nancy Dubler
- NYU Langone Health, Department of Population Health,
Division of Medical Ethics, New York, NY USA
| | - Lewis Goldfrank
- NYU Langone Health, Ronald O. Perelman Department of
Emergency Medicine, New York, NY USA
| | - Jacob Lindner
- NYU Langone Health, Department of Population Health,
Division of Medical Ethics, New York, NY USA,University of Pennsylvania, History and Sociology of
Science Department, Philadelphia, PA USA
| | - Stephen P. Wall
- NYU Langone Health, Ronald O. Perelman Department of
Emergency Medicine, New York, NY USA,NYU Langone Health, Department of Population Health,
Division of Health and Behavior, New York, NY USA
| |
Collapse
|
19
|
Donation after circulatory death in lung transplantation—five-year follow-up from ISHLT Registry. J Heart Lung Transplant 2019; 38:1235-1245. [DOI: 10.1016/j.healun.2019.09.007] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 09/08/2019] [Accepted: 09/09/2019] [Indexed: 12/12/2022] Open
|