Impact of the Opioid Epidemic on Lung Transplantation: Donor, Recipient, and Discard Characteristics

Cryoanalgesia in Lung Transplantation - A Systematic Review and Meta-analysis

Background

Lung transplantation is a crucial treatment for end-stage lung diseases. However, postoperative pain management remains a significant challenge. Therefore, this study aims to examine the implications of adoption cryoanalgesia on lung transplantation pain control protocol.

Methods

Three databases were searched for studies comparing cryoanalgesia versus standard of care analgesia in patients after lung transplantation. The primary outcome was opioid consumption throughout the entire hospitalization, at postoperative day (POD) 7 and at POD 14 addressed with Morphine Milligram Equivalents (MME). The secondary outcomes were maximum reported pain score at POD 7, hospital length of stay (LOS) and time until extubation. Mean differences (MDs) with 95% confidence intervals (CIs) were calculated for continuous outcomes.

Results

A total of 5 studies encompassing 485 patients undergoing lung transplantation were included, of whom 228 underwent cryoanalgesia. Compared to standard of care, cryoanalgesia demonstrated significant reduction in opioid consumption at POD 7 (MD: -96.79 MME, 95% CI -183.40 to -10.18, p=0.03), at POD 14 (MD -225,26 MME; 95% CI -366.58 to -83.94; p<0.01) and throughout the entire hospitalization (MD: -307.76 MME, 95% CI -461.72 to -153.79, p<0.01). In addition, there was a significant reduction in pain scores in the cryoanalgesia group (MD: -1.10 points, 95% CI -1.77 to -0.43, p<0.01). However, no significant differences were found regarding hospital LOS or time until extubation.

Conclusions

This meta-analysis indicates that cryoanalgesia effectively reduces opioid requirements and pain levels in lung transplant patients.

Impact of donor age ≥65 years on graft survival in large lung transplant cohorts

BACKGROUND

Although the demand for allografts continuously surpasses the supply, the majority of lungs offered for transplant are declined based on various factors, including donor age. This in turn sustains the wait-list mortality of patients with end-stage pulmonary disease.

METHODS

In this single-center, observational cohort study, we investigated the impact of donor age on graft survival. We additionally compared our center's data to data reported to the International Society for Heart and Lung Transplantation (ISHLT) Thoracic Organ Transplant Registry. Kaplan-Meier method was used to describe overall graft survival. Multivariate Cox proportional hazards regression was used to assess clinical features associated with graft loss.

RESULTS

Between January 2010 and December 2023, Alfred performed 1,101 single and double lung transplants and the combined ISHLT cohort totaled 32,200 transplants. At Alfred, grafts originating from donors ≥65 years were used in 13.3% of lung transplant cases and univariate analysis showed no impact of donor age ≥65 on graft survival (hazard ratio [HR] 0.86, p = 0.34). In the combined cohort, North America had a lower proportion of donors aged ≥65 years compared to Europe and the Alfred (2.4% vs 9.8% vs 13.3%, p < 0.001). The univariate analysis showed a negative impact of donor age ≥65 on graft survival (HR 1.16, p < 0.001). However, this did not hold in a multivariate model (HR 1.06, p = 0.298) when adjusted for center experience and recipient characteristics.

CONCLUSIONS

Donor age might impact outcomes to a lesser degree than previously suggested. Therefore, appropriately assessed age-extended lungs should be routinely considered for lung transplantation.

Effect of the opioid crisis on the liver transplantation donor pool: A national analysis

BACKGROUND

Over the last decade there has been a surge in overdose deaths due to the opioid crisis. We sought to characterize the temporal change in overdose donor (OD) use in liver transplantation (LT), as well as associated post-LT outcomes, relative to the COVID-19 era.

METHODS

LT candidates and donors listed between January 2016 and September 2022 were identified from the Scientific Registry of Transplant Recipients database. Trends in LT donors and changes related to OD were assessed pre- versus post-COVID-19 (February 2020).

RESULTS

Between 2016 and 2022, most counties in the United States experienced an increase in overdose-related deaths (n = 1284, 92.3%) with many counties (n = 458, 32.9%) having more than a doubling in drug overdose deaths. Concurrently, there was an 11.2% increase in overall donors, including a 41.7% increase in the number of donors who died from drug overdose. In pre-COVID-19 overdose was the 4th top mechanism of donor death, while in the post-COVID-19 era, overdose was the 2nd most common cause of donor death. OD was younger (OD: 35 yrs, IQR 29-43 vs. non-OD: 43 yrs, IQR 31-56), had lower body mass index (≥35 kg/cm2, OD: 31.2% vs. non-OD: 33.5%), and was more likely to be HCV+ (OD: 28.9% vs. non-OD: 5.4%) with lower total bilirubin (≥1.1 mg/dL, OD: 12.9% vs. non-OD: 20.1%) (all p < .001). Receipt of an OD was not associated with worse graft survival (HR .94, 95% CI .88-1.01, p = .09).

CONCLUSIONS

Opioid deaths markedly increased following the COVID-19 pandemic, substantially altering the LT donor pool in the United States.

Cardiac allograft vasculopathy in heart transplant recipients from hepatitis C viremic donors

BACKGROUND

Recent studies suggest the transplantation of Hepatitis C (HCV) hearts from viremic donors is associated with comparable 1 year survival to nonviremic donors. Though HCV viremia is a known risk factor for accelerated atherosclerosis, data on cardiac allograft vasculopathy (CAV) outcomes are limited. We compared the incidence of CAV in heart transplant recipients from HCV viremic donors (nucleic acid amplification test positive; NAT+) compared to non-HCV infected donors (NAT-).

METHODS

We retrospectively reviewed annual coronary angiograms with intravascular ultrasound from April 2017 to August 2020 at two large cardiac transplant centers. CAV was graded according to ISHLT guidelines. Maximal intimal thickness (MIT) ≥ 0.5 mm was considered significant for subclinical disease.

RESULTS

Among 270 heart transplant recipients (mean age 54; 77% male), 62 patients were transplanted from NAT+ donors. CAV ≥ grade 1 was present in 8.8% of the NAT+ versus 16.8% of the NAT- group at 1 year, 20% versus 28.8% at 2 years, and 33.3% versus 41.5% at 3 years. After adjusting for donor age, donor smoking history, recipient BMI, recipient, hypertension, and recipient diabetes, NAT+ status did not confer increased risk of CAV (HR.80; 95% CI.45-1.40, p = 0.43) or subclinical IVUS disease (HR.87; 95% CI.58-1.30, p = 0.49). Additionally, there was no difference in the presence of rapidly progressive lesions on IVUS.

CONCLUSION

Our data show that NAT+ donors conferred no increased risk for early CAV or subclinical IVUS disease following transplantation in a cohort of heart transplant patients who were treated for HCV, suggesting the short-term safety of this strategy to maximize the pool of available donor hearts.

Outcomes following heart or bilateral-lung transplantation from donors who died of drug toxicity in British Columbia, Canada

INTRODUCTION

The illicit drug toxicity (overdose) crisis has worsened across Canada; between 2016 and 2021, more than 28,000 individuals have died of drug toxicity. Organ donation from persons who experience drug toxicity death (DTD) has increased in recent years. This study examines whether survival after heart or bilateral-lung transplantation differed by donor cause of death.

METHODS

We studied transplant recipients in British Columbia who received heart (N = 110) or bilateral-lung (N = 223) transplantation from deceased donors aged 12-70 years between 2013 and 2019. Transplant recipient survival was compared by donor cause of death from drug toxicity or other. Five-year Kaplan-Meier estimates of survival and 3-year inverse probability treatment weighted Cox proportional hazards models were conducted.

RESULTS

DTD donors made up 36% (40/110) of heart and 24% (54/223) of bilateral-lung transplantations. DTD donors were more likely to be young, white, and male. Unadjusted 5-year recipient survival was similar by donor cause of death (heart: 87% for DTD and 86% for non-DTD, p = .75; bilateral- lung: 80% for DTD and 76% for non-DTD, p = .65). Adjusted risk of mortality at 3-years post-transplant was similar between recipients of DTD and non-DTD donor heart (hazard ratio [HR]: .94, 95% confidence interval (CI): .22-4.07, p = .938) and bilateral-lung (HR: 1.06, 95% CI: .41-2.70, p = .908).

CONCLUSION

Recipient survival after heart or bilateral-lung transplantation from DTD donors and non-DTD donors was similar. Donation from DTD donors is safe and should be considered more broadly to increase organ donation.

One-year immunologic outcomes of lung transplantation utilizing hepatitis C-viremic donors

Little is known about the effects of hepatitis C viremia on immunologic outcomes in the era of direct-acting antivirals. We conducted a prospective, single-arm trial of lung transplantation from hepatitis C-infected donors into hepatitis C-naïve recipients (n = 21). Recipients were initiated on glecaprevir-pibrentasvir immediately post-transplant and were continued on therapy for a total of 8 weeks. A control group of recipients of hepatitis C-negative lungs were matched 1:1 on baseline variables (n = 21). The primary outcome was the frequency of acute cellular rejection over 1-year post-transplant. Treatment with glecaprevir-pibrentasvir was well tolerated and resulted in viremia clearance after a median of 16 days of therapy (IQR 10-24 days). At one year, there was no difference in incidence of acute cellular rejection (71.4% vs. 85.7%, P = .17) or rejection requiring treatment (33.3% vs. 57.1%, P = .12). Mean cumulative acute rejection scores were similar between groups (.46 [SD ± .53] vs. .52 [SD ± .37], P = .67). Receipt of HCV+ organs was not associated with acute rejection on unadjusted Cox regression analysis (HR .55, 95% CI .28-1.11, P = .09), or when adjusted for risk factors known to be associated with acute rejection (HR .57, 95% CI .27-1.21, P = .14). Utilization of hepatitis C infected lungs with immediate treatment leads to equivalent immunologic outcomes at 1 year.

The Year in Cardiothoracic Transplant Anesthesia: Selected Highlights From 2020 Part I - Lung Transplantation

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.

Direct-Acting Antivirals and Organ Transplantation: Is There Anything We Can't Do?

The opioid epidemic has resulted in an increase in organ donors with hepatitis C virus (HCV) infection in the United States. With the development of direct-acting antiviral regimens that offer high sustained virologic response rates even in the setting of immunosuppression after transplantation, these HCV-viremic organs are now being offered to transplant candidates with or without preexisting HCV infection. Strategies for HCV treatment with HCV-viremic organs have included delayed and preemptive approaches. This review will discuss key studies in the different solid organ transplants, recent reports of adverse events, and ethical and regulatory considerations. The efficacy of current HCV therapies has created this important opportunity to improve survival for patients with end-organ failure through greater access to organ transplantation and decreased waitlist mortality rate.

Donor management using a specialized donor care facility is associated with higher organ utilization from drug overdose donors

Drug overdoses have tripled in the United States over the last two decades. With the increasing demand for donor organs, one potential consequence of the opioid epidemic may be an increase in suitable donor organs. Unfortunately, organs from donors dying of drug overdose have poorer utilization rates than other groups of brain-dead donors, largely due to physician and recipient concerns about viral disease transmission. During the study period of 2011 to 2016, drug overdose donors (DODs) account for an increasingly greater proportion of the national donor pool. We show that a novel model of donor care, known as specialized donor care facility (SDCF), is associated with an increase in organ utilization from DODs compared to the conventional model of hospital-based donor care. This is likely related to the close relationship of the SDCF with the transplant centers, leading to improved communication and highly efficient donor care.

Ex vivo perfusion in lung transplantation and removal of HCV: the next level

The large gap between high demand and low availability of lungs is still a limiting factor for lung transplantation which leads to important mortality rates on the waiting list. In the last years, with the advent of potent direct-acting antivirals (DAAs), donors carrying active hepatitis C (HCV) infection became an important source in expanding the donor pool. Recent clinical trials exploring different treatment regimens post-transplantation when using HCV-positive abdominal and thoracic organs into HCV-negative recipients have shown encouraging results. Although early data shows no toxicity and similar survival rates when compared to non-HCV organ transplantation, long-term outcomes evaluating the effect of either the transmission of HCV into the recipients or the deliberate use of DAAs to treat the virus remains absent. An important and innovative strategy to overcome this limitation is the possibility of mitigating viral transmission with the use of ex vivo donor organ treatment prior to transplantation. Recent pre-clinical and clinical studies explore the use of ex vivo perfusion and the removal of HCV prior to transplantation with the addition of other innovative therapies, which will be reviewed in this article.