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Vail EA, Wang X, Schaubel DE, Reese PP, Cantu E, Martin ND, Abt PL, Olthoff KM, Kerlin MP, Christie JD, Neuman MD. Lung Donation and Transplant Recipient Outcomes at Independent vs Hospital-Based Donor Care Units. JAMA Netw Open 2024; 7:e2417107. [PMID: 38916893 PMCID: PMC11200140 DOI: 10.1001/jamanetworkopen.2024.17107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 03/26/2024] [Indexed: 06/26/2024] Open
Abstract
Importance Centralizing deceased organ donor management and organ recovery into donor care units (DCUs) may mitigate the critical organ shortage by positively impacting donation and recipient outcomes. Objective To compare donation and lung transplant outcomes between 2 common DCU models: independent (outside of acute-care hospitals) and hospital-based. Design, Setting, and Participants This is a retrospective cohort study of Organ Procurement and Transplantation Network deceased donor registry and lung transplant recipient files from 21 US donor service areas with an operating DCU. Characteristics and lung donation rates among deceased donors cared for in independent vs hospital-based DCUs were compared. Eligible participants included deceased organ donors (aged 16 years and older) after brain death, who underwent organ recovery procedures between April 26, 2017, and June 30, 2022, and patients who received lung transplants from those donors. Data analysis was conducted from May 2023 to March 2024. Exposure Organ recovery in an independent DCU (vs hospital-based DCU). Main Outcome and Measures The primary outcome was duration of transplanted lung survival (through December 31, 2023) among recipients of lung(s) transplanted from cohort donors. A Cox proportional hazards model stratified by transplant year and program, adjusting for donor and recipient characteristics was used to compare graft survival. Results Of 10 856 donors in the starting sample (mean [SD] age, 42.8 [15.2] years; 6625 male [61.0%] and 4231 female [39.0%]), 5149 (primary comparison group) underwent recovery procedures in DCUs including 1466 (28.4%) in 11 hospital-based DCUs and 3683 (71.5%) in 10 independent DCUs. Unadjusted lung donation rates were higher in DCUs than local hospitals, but lower in hospital-based vs independent DCUs (418 donors [28.5%] vs 1233 donors [33.5%]; P < .001). Among 1657 transplant recipients, 1250 (74.5%) received lung(s) from independent DCUs. Median (range) duration of follow-up after transplant was 734 (0-2292) days. Grafts recovered from independent DCUs had shorter restricted mean (SE) survival times than grafts from hospital-based DCUs (1548 [27] days vs 1665 [50] days; P = .04). After adjustment, graft failure remained higher among lungs recovered from independent DCUs than hospital-based DCUs (hazard ratio, 1.85; 95% CI, 1.28-2.65). Conclusions and Relevance In this retrospective analysis of national donor and transplant recipient data, although lung donation rates were higher from deceased organ donors after brain death cared for in independent DCUs, lungs recovered from donors in hospital-based DCUs survived longer. These findings suggest that further work is necessary to understand which factors (eg, donor transfer, management, or lung evaluation and acceptance practices) differ between DCU models and may contribute to these differences.
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Affiliation(s)
- Emily A. Vail
- Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Penn Center for Perioperative Outcomes Research and Transformation, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Xingmei Wang
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Douglas E. Schaubel
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Peter P. Reese
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
- Penn Transplant Institute, Philadelphia, Pennsylvania
| | - Edward Cantu
- Penn Transplant Institute, Philadelphia, Pennsylvania
- Division of Cardiothoracic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia
| | - Niels D. Martin
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia
| | - Peter L. Abt
- Penn Transplant Institute, Philadelphia, Pennsylvania
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia
| | - Kim M. Olthoff
- Penn Transplant Institute, Philadelphia, Pennsylvania
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia
| | - Meeta P. Kerlin
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Jason D. Christie
- Penn Transplant Institute, Philadelphia, Pennsylvania
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Mark D. Neuman
- Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Penn Center for Perioperative Outcomes Research and Transformation, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
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2
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Abdoul N, Legeai C, Cantrelle C, Mercier O, Olland A, Mordant P, Thomas PA, Jougon J, Tissot A, Maury JM, Sage E, Dorent R. Impact of ex vivo lung perfusion on brain-dead donor lung utilization: The French experience. Am J Transplant 2022; 22:1409-1417. [PMID: 35000283 DOI: 10.1111/ajt.16953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 12/17/2021] [Accepted: 01/04/2022] [Indexed: 01/25/2023]
Abstract
Ex vivo lung perfusion (EVLP) is a valuable method for expanding the lung donor pool. Its indications currently differ across centers. This national retrospective cohort study aimed to describe the profile of donors with lungs transplanted after EVLP and determine the effectiveness of EVLP on lung utilization. We included brain-dead donors with at least one lung offered between 2012 and 2019 in France. Lungs transplanted without or after EVLP were compared with those that were rejected. Donor group phenotypes were determined with multiple correspondence analysis (MCA). The association between donor factors and lung transplantation was assessed with a multivariable multinomial logistic regression. MCA revealed that donors whose lungs were transplanted after EVLP had profiles similar to the donors whose lungs were declined and quite different from those of donors with lungs transplanted without EVLP. Donor predictors of graft nonuse included age ≥50 years, smoking history, PaO2 /FiO2 ratio ≤300 mmHg, abnormal chest imaging, and purulent secretions. EVLP increased utilization of lungs from donors with a smoking history, PaO2 /FiO2 ratio ≤300 mmHg, and abnormal chest imaging.
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Affiliation(s)
| | | | | | - Olaf Mercier
- Department of Thoracic Surgery and Lung Transplantation, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - Anne Olland
- Department of Thoracic Surgery, University Hospital Strasbourg, Strasbourg, France
| | - Pierre Mordant
- Division of Thoracic and Vascular Surgery, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris University, Paris, France
| | | | - Jacques Jougon
- Department of Thoracic Surgery, Haut-Leveque Hospital, Bordeaux University, Bordeaux, France
| | - Adrien Tissot
- Department of Pneumology, Thorax Institute, Nantes University Hospital, Nantes, France
| | - Jean-Michel Maury
- Department of Thoracic Surgery, Lung and Lung Transplantation, Louis Pradel Hospital, Lyon, France
| | - Edouard Sage
- Department of Thoracic Surgery and Lung Transplantation, Foch Hospital, Suresnes, France
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3
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Swanson EA, Patel MS, Hutchens MP, Niemann CU, Groat T, Malinoski DJ, Sally MB. Critical care and ventilatory management of deceased organ donors impact lung use and recipient graft survival. Am J Transplant 2021; 21:4003-4011. [PMID: 34129720 DOI: 10.1111/ajt.16719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 06/10/2021] [Accepted: 06/10/2021] [Indexed: 01/25/2023]
Abstract
Current risk-adjusted models for donor lung use and lung graft survival do not include donor critical care data. We sought to identify modifiable donor physiologic and mechanical ventilation parameters that predict donor lung use and lung graft survival. This is a prospective observational study of donors after brain death (DBDs) managed by 19 Organ Procurement Organizations from 2016 to 2019. Demographics, mechanical ventilation parameters, and critical care data were recorded at standardized time points during donor management. The lungs were transplanted from 1811 (30%) of 6052 DBDs. Achieving ≥7 critical care endpoints was a positive predictor of donor lung use. After controlling for recipient factors, donor blood pH positively predicted lung graft survival (OR 1.48 per 0.1 unit increase in pH) and the administration of dopamine during donor management negatively predicted lung graft survival (OR 0.19). Tidal volumes ≤8 ml/kg predicted body weight (OR 0.65), and higher positive end-expiratory pressures (OR 0.91 per cm H2 O) predicted decreased donor lung use without affecting lung graft survival. A randomized clinical trial is needed to inform optimal ventilator management strategies in DBDs.
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Affiliation(s)
- Elizabeth A Swanson
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Madhukar S Patel
- Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Michael P Hutchens
- Operative Care Division, Section of Surgical Critical Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Claus U Niemann
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA.,Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Tahnee Groat
- Operative Care Division, Section of Surgical Critical Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Darren J Malinoski
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA.,Operative Care Division, Section of Surgical Critical Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Mitchell B Sally
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA.,Operative Care Division, Section of Surgical Critical Care, VA Portland Health Care System, Portland, Oregon, USA
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4
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Courtwright AM, Wilkey B, Devarajan J, Subramani S, Martin AK, Fritz AV, Cassara CM, Boisen ML, Bottiger BA, Pollak A, Maisonave Y, Gelzinis TA. The Year in Cardiothoracic Transplant Anesthesia: Selected Highlights From 2020 Part I - Lung Transplantation. J Cardiothorac Vasc Anesth 2021; 36:33-44. [PMID: 34670721 DOI: 10.1053/j.jvca.2021.09.013] [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: 08/17/2021] [Revised: 09/08/2021] [Accepted: 09/10/2021] [Indexed: 11/11/2022]
Abstract
This special article focuses on the highlights in cardiothoracic transplantation literature in the year 2020. Part I encompasses the recent literature on lung transplantation, including the advances in preoperative assessment and optimization, donor management, including the use of ex-vivo lung perfusion, recipient management, including those who have been infected with coronavirus disease 2019, updates on the perioperative management, including the use of extracorporeal membrane oxygenation, and long-term outcomes.
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Affiliation(s)
| | - Barbara Wilkey
- Department of Anesthesiology, University of Colorado, Boulder, CO
| | | | - Sudhakar Subramani
- Department of Anesthesiology, University of Iowa Hospitals & Clinics, Iowa City, IA
| | - Archer Kilbourne Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic Florida, Jacksonville, FL
| | - Ashley Virginia Fritz
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic Florida, Jacksonville, FL
| | - Christopher M Cassara
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Michael L Boisen
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - Angela Pollak
- Department of Anesthesiology, Duke University, Durham, NC
| | | | - Theresa A Gelzinis
- University of Pittsburgh, Corresponding Author, UPMC Presbyterian Hospital, Pittsburgh, PA.
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Yu J, Xu C, Lee JS, Alder JK, Wen Z, Wang G, Gil Silva AA, Sanchez PG, Pilewsky JM, McDyer JF, Wang X. Rapid postmortem ventilation improves donor lung viability by extending the tolerable warm ischemic time after cardiac death in mice. Am J Physiol Lung Cell Mol Physiol 2021; 321:L653-L662. [PMID: 34318693 DOI: 10.1152/ajplung.00011.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Uncontrolled donation after cardiac death (uDCD) contributes little to ameliorating donor lung shortage due to rapidly progressive warm ischemia after circulatory arrest. Here, we demonstrated non-hypoxia improves donor lung viability in a novel uDCD lung transplant model undergoing rapid ventilation after cardiac death and compared the evolution of ischemia-reperfusion injury in mice that underwent pulmonary artery ligation (PAL). The tolerable warm ischemia time at 37ºC was initially determined in mice using a modified PAL model. The donor lung following PAL was also transplanted into syngeneic mice and compared to those that underwent rapid ventilation or no ventilation at 37ºC prior to transplantation. Twenty-four hours following reperfusion, lung histology, PaO2/FIO2 ratio, and inflammatory mediators were measured. Four hours of PAL had little impact on PaO2/FIO2 ratio and acute lung injury score in contrast to significant injury induced by 5 hours of PAL. Four-hour PAL lungs showed an early myeloid-dominant inflammatory signature when compared to naïve lungs and substantially injured five-hour PAL lungs. In the context of transplantation, unventilated donor lungs showed severe injury after reperfusion, whereas ventilated donor lungs showed minimal changes in PaO2/FIO2 ratio, histologic score, and expression of inflammatory markers. Taken together, the tolerable warm ischemia time of murine lungs at 37oC can be extended by maintaining alveolar ventilation for up to 4 hours. Non-hypoxic lung warm ischemia-reperfusion injury shows an early transcriptional signature of myeloid cell recruitment and extracellular matrix proteolysis prior to blood-gas barrier dysfunction and significant tissue damage.
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Affiliation(s)
- Junyi Yu
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Acute Lung Injury Center of Excellence, University of Pittsburgh, Pittsburgh, PA, United States.,Hand and Microsurgery Department, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Che Xu
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Acute Lung Injury Center of Excellence, University of Pittsburgh, Pittsburgh, PA, United States.,Department of Biotherapy, Second Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Janet S Lee
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Acute Lung Injury Center of Excellence, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jonathan K Alder
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Acute Lung Injury Center of Excellence, University of Pittsburgh, Pittsburgh, PA, United States
| | - Zongmei Wen
- Department of Anesthesia, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Guifang Wang
- Department of Respiratory Medicine, Huashan Hospital,Fudan University School of Medicine, Shanghai, China
| | - Agustin Alejandro Gil Silva
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Acute Lung Injury Center of Excellence, University of Pittsburgh, Pittsburgh, PA, United States
| | - Pablo G Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Joseph M Pilewsky
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Acute Lung Injury Center of Excellence, University of Pittsburgh, Pittsburgh, PA, United States
| | - John F McDyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Acute Lung Injury Center of Excellence, University of Pittsburgh, Pittsburgh, PA, United States.,Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Xingan Wang
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Acute Lung Injury Center of Excellence, University of Pittsburgh, Pittsburgh, PA, United States.,Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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6
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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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Teijeiro-Paradis R, Cypel M, Del Sorbo L. Protective Mechanical Ventilation in Organ Donors: A Lifesaving Maneuver. Am J Respir Crit Care Med 2020; 202:167-169. [PMID: 32433890 PMCID: PMC7365355 DOI: 10.1164/rccm.202005-1559ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Ricardo Teijeiro-Paradis
- Interdepartmental Division of Critical Care MedicineUniversity of TorontoToronto, Ontario, Canadaand
| | - Marcelo Cypel
- Division of Thoracic SurgeryUniversity of TorontoToronto, Ontario, Canada
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care MedicineUniversity of TorontoToronto, Ontario, Canadaand
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