Influence of broader geographic allograft sharing on outcomes and cost in smaller lung transplant centers

OBJECTIVE

On November 24, 2017, Organ Procurement and Transplantation Network implemented a change to lung allocation replacing donor service area with a 250 nautical mile radius around donor hospitals. We sought to evaluate the experience of a small to medium size center following implementation.

METHODS

Patients (47 pre and 54 post) undergoing lung transplantation were identified from institutional database from January 2016 to October 2019. Detailed chart review and analysis of institutional cost data was performed. Univariate analysis was performed to compare eras.

RESULTS

Similar short-term mortality and primary graft dysfunction were observed between groups. Decreased local donation (68% vs 6%; P < .001), increased travel distance (145 vs 235 miles; P = .004), travel cost ($8626 vs $14,482; P < .001), and total procurement cost ($60,852 vs $69,052; P = .001) were observed postimplementation. We also document an increase in waitlist mortality postimplementation (6.9 vs 31.6 per 100 patient-years; P < .001).

CONCLUSIONS

Following implementation of the new allocation policy in a small to medium size center, several changes were in accordance with policy intention. However, concerning shifts emerged, including increased waitlist mortality and resource utilization. Continued close monitoring of transplant centers stratified by size and location are paramount to maintaining global availability of lung transplantation to all Americans regardless of geographic residence or socioeconomic status.

Methylprednisolone Treatment in Brain Death-Induced Lung Inflammation-A Dose Comparative Study in Rats

Background: The process of brain death (BD) leads to a pro-inflammatory state of the donor lung, which deteriorates its quality. In an attempt to preserve lung quality, methylprednisolone is widely recommended in donor lung management. However, clinical treatment doses vary and the dose-effect relation of methylprednisolone on BD-induced lung inflammation remains unknown. The aim of this study was to investigate the effect of three different doses methylprednisolone on the BD-induced inflammatory response.

Methods: BD was induced in rats by inflation of a Fogarty balloon catheter in the epidural space. After 60 min of BD, saline or methylprednisolone (low dose (5 mg/kg), intermediate dose (12.5 mg/kg) or high dose (22.5 mg/kg)) was administered intravenously. The lungs were procured and processed after 4 h of BD. Inflammatory gene expressions were analyzed by RT-qPCR and influx of neutrophils and macrophages were quantified with immunohistochemical staining.

Results: Methylprednisolone treatment reduced neutrophil chemotaxis as demonstrated by lower IL-8-like CINC-1 and E-selectin levels, which was most evident in rats treated with intermediate and high doses methylprednisolone. Macrophage chemotaxis was attenuated in all methylprednisolone treated rats, as corroborated by lower MCP-1 levels compared to saline treated rats. Thereby, all doses methylprednisolone reduced TNF-α, IL-6 and IL-1β tissue levels. In addition, intermediate and high doses methylprednisolone induced a protective anti-inflammatory response, as reflected by upregulated IL-10 expression when compared to saline treated brain-dead rats.

Conclusion: We showed that intermediate and high doses methylprednisolone share most potential to target BD-induced lung inflammation in rats. Considering possible side effects of high doses methylprednisolone, we conclude from this study that an intermediate dose of 12.5 mg/kg methylprednisolone is the optimal treatment dose for BD-induced lung inflammation in rats, which reduces the pro-inflammatory state and additionally promotes a protective, anti-inflammatory response.

Underutilization of potential donors for lung transplantation at a tertiary care center in North India

Objective:

Lung transplantation is infrequently performed in India due to several constraints, and whether the poor lung transplantation rates in India are due to a lack of eligible lung donors is unclear. In this study, we explored the availability of donors for lung transplantation.

Materials and Methods:

This was a retrospective analysis of all brain-dead participants who underwent assessment of eligibility for lung donation between August 2015 and June 2018. All participants underwent a detailed clinical evaluation that included history, physical examination, arterial blood gas analysis, chest radiograph, and bronchoscopy. The final eligibility for lung donation was assessed using the existing “ideal” criteria and the less stringent “extended” criteria.

Results:

A total of 55 brain-dead participants (41 [74.5%] males) were assessed for eligibility for lung donation. The mean (standard deviation [SD]) age of the participants was 38.4 (17.2) years. The mean (SD) duration of prior invasive mechanical ventilation at the time of assessment was 4 (3.1) days, with a mean (SD) partial pressure of arterial oxygen: inspired oxygen fraction ratio (PaO₂:FiO₂) of 326.6 (153.5). The proportion of participants who were found suitable for lung donation was 16 (29.1%) and 35 (63.6%) on employing the ideal and the extended criteria, respectively. Inadequate oxygenation status, abnormal chest radiograph, and sepsis were the most common reasons for excluding participants using either criteria. Despite the availability of adequate lung donors, only one lung transplantation could be performed.

Conclusion:

Even with the most stringent criteria for lung assessment, nearly one-third of the brain-dead participants had lungs suitable for lung transplantation. Lack of eligible lung donors is not a reason for the poor lung transplantation rates in India.