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Bernat JL, Khush KK, Shemie SD, Hartwig MG, Reese PP, Dalle Ave A, Parent B, Glazier AK, Capron AM, Craig M, Gofton T, Gordon EJ, Healey A, Homan ME, Ladin K, Messer S, Murphy N, Nakagawa TA, Parker WF, Pentz RD, Rodríguez-Arias D, Schwartz B, Sulmasy DP, Truog RD, Wall AE, Wall SP, Wolpe PR, Fenton KN. Knowledge gaps in heart and lung donation after the circulatory determination of death: Report of a workshop of the National Heart, Lung, and Blood Institute. J Heart Lung Transplant 2024; 43:1021-1029. [PMID: 38432523 PMCID: PMC11132427 DOI: 10.1016/j.healun.2024.02.1455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 02/07/2024] [Accepted: 02/16/2024] [Indexed: 03/05/2024] Open
Abstract
In a workshop sponsored by the U.S. National Heart, Lung, and Blood Institute, experts identified current knowledge gaps and research opportunities in the scientific, conceptual, and ethical understanding of organ donation after the circulatory determination of death and its technologies. To minimize organ injury from warm ischemia and produce better recipient outcomes, innovative techniques to perfuse and oxygenate organs postmortem in situ, such as thoracoabdominal normothermic regional perfusion, are being implemented in several medical centers in the US and elsewhere. These technologies have improved organ outcomes but have raised ethical and legal questions. Re-establishing donor circulation postmortem can be viewed as invalidating the condition of permanent cessation of circulation on which the earlier death determination was made and clamping arch vessels to exclude brain circulation can be viewed as inducing brain death. Alternatively, TA-NRP can be viewed as localized in-situ organ perfusion, not whole-body resuscitation, that does not invalidate death determination. Further scientific, conceptual, and ethical studies, such as those identified in this workshop, can inform and help resolve controversies raised by this practice.
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Affiliation(s)
- James L Bernat
- Department of Neurology, Dartmouth Geisel School of Medicine, Hanover, New Hampshire.
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Sam D Shemie
- Division of Critical Care Medicine, Montreal Children's Hospital, McGill University, Montreal, PQ, Canada
| | - Matthew G Hartwig
- Division of Thoracic Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina
| | - Peter P Reese
- Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anne Dalle Ave
- Kennedy Institute of Ethics, Georgetown University, Washington, District of Columbia
| | - Brendan Parent
- Division of Medical Ethics and Department of Surgery, NYU Grossman School of Medicine, New York, New York
| | - Alexandra K Glazier
- Brown University, School of Public Health, Providence, Rhode Island; New England Donor Services, Waltham, Massachusetts
| | - Alexander M Capron
- Gould School of Law and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Matt Craig
- Lung Biology and Disease Branch, National Heart, Lung and Blood Institute, Bethesda, Maryland
| | - Teneille Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Elisa J Gordon
- Department of Surgery, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew Healey
- Department of Medicine McMaster University and William Osler Health System, Hamilton, Ontario, Canada
| | | | - Keren Ladin
- Research on Ethics, Aging, and Community Health (REACH Lab); Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts
| | - Simon Messer
- Department of Transplant, Golden Jubilee National Hospital, Clydebank, Scotland UK
| | - Nick Murphy
- Departments of Medicine and Philosophy, Western University, London, Ontario, Canada
| | - Thomas A Nakagawa
- University of Florida College of Medicine-Jacksonville, Department of Pediatrics, Division of Pediatric Critical Care Medicine, Jacksonville, Florida
| | - William F Parker
- Department of Medicine and Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Rebecca D Pentz
- Winship Cancer Institute, Emory University, Atlanta, Georgia
| | | | - Bryanna Schwartz
- Division of Cardiovascular Sciences, National Heart, Lung and Blood Institute, Bethesda, Maryland; Department of Cardiology, Children's National Medical Center, Washington, District of Columbia
| | - Daniel P Sulmasy
- The Kennedy Institute of Ethics and the Departments of Medicine and Philosophy, Georgetown University, Washington, District of Columbia
| | - Robert D Truog
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital; Center for Bioethics, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Anji E Wall
- Department of Surgery, Baylor University Medical Center, Dallas, Texas
| | - Stephen P Wall
- Ronald O. Perelman Department of Emergency Medicine; NYU Grossman School of Medicine and Department of Population Health, NYU, New York, New York
| | - Paul R Wolpe
- Center for Ethics, Department of Medicine, Emory University, Atlanta, Georgia
| | - Kathleen N Fenton
- Advanced Technologies and Surgery Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, and Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, Maryland
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Mora-Cuesta VM, Tello-Mena S, Izquierdo-Cuervo S, Iturbe-Fernández D, Sánchez-Moreno L, Ballesteros MA, Alonso-Lecue P, Ortíz-Portal F, Ferrer-Pargada D, Miñambres-García E, Cifrián-Martínez JM, Naranjo-Gozalo S. Bronchial Stenosis After Lung Transplantation From cDCD Donors Using Simultaneous Abdominal Normothermic Regional Perfusion: A Single-center Experience. Transplantation 2023; 107:2415-2423. [PMID: 37389647 DOI: 10.1097/tp.0000000000004698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
BACKGROUND Controlled donation after circulatory death (cDCD) has increased the number of lung donors significantly. The use of abdominal normothermic regional perfusion (A-NRP) during organ procurement is a common practice in some centers due to its benefits on abdominal grafts. This study aimed to assess whether the use of A-NRP in cDCD increases the frequency of bronchial stenosis in lung transplant (LT) recipients. METHODS A single-center, retrospective study including all LTs was performed between January 1, 2015, and August 30, 2022. Airway stenosis was defined as a stricture that leads to clinical/functional worsening requiring the use of invasive monitoring and therapeutic procedures. RESULTS A total of 308 LT recipients were included in the study. Seventy-six LT recipients (24.7%) received lungs from cDCD donors using A-NRP during organ procurement. Forty-seven LT recipients (15.3%) developed airway stenosis, with no differences between lung recipients with grafts from cDCD (17.2%) and donation after brain death donors (13.3%; P = 0.278). A total of 48.9% of recipients showed signs of acute airway ischemia on control bronchoscopy at 2 to 3 wk posttransplant. Acute ischemia was an independent risk factor for airway stenosis development (odds ratio = 2.523 [1.311-4.855], P = 0.006). The median number of bronchoscopies per patient was 5 (2-9), and 25% of patients needed >8 dilatations. Twenty-three patients underwent endobronchial stenting (50.0%) and each patient needed a median of 1 (1-2) stent. CONCLUSIONS Incidence of airway stenosis is not increased in LT recipients with grafts obtained from cDCD donors using A-NRP.
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Affiliation(s)
- Víctor M Mora-Cuesta
- Lung Transplant Unit, Respiratory Department Marqués de Valdecilla University Hospital, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Santander, Cantabria, Spain
| | - Sandra Tello-Mena
- Lung Transplant Unit, Respiratory Department Marqués de Valdecilla University Hospital, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Santander, Cantabria, Spain
| | - Sheila Izquierdo-Cuervo
- Lung Transplant Unit, Respiratory Department Marqués de Valdecilla University Hospital, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Santander, Cantabria, Spain
| | - David Iturbe-Fernández
- Lung Transplant Unit, Respiratory Department Marqués de Valdecilla University Hospital, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Santander, Cantabria, Spain
| | - Laura Sánchez-Moreno
- Thoracic Surgery, Lung Transplant Unit, Marqués de Valdecilla University Hospital, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Santander, Cantabria, Spain
| | - Maria Angeles Ballesteros
- Transplant Coordination Unit and Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, School of Medicine, Universidad de Cantabria, Santander, Cantabria, Spain
| | | | - Felix Ortíz-Portal
- Respiratory Department, Marqués de Valdecilla University Hospital, Santander, Cantabria, Spain
| | - Diego Ferrer-Pargada
- Respiratory Department, Marqués de Valdecilla University Hospital, Santander, Cantabria, Spain
| | - Eduardo Miñambres-García
- Transplant Coordination Unit and Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, School of Medicine, Universidad de Cantabria, Santander, Cantabria, Spain
| | - José M Cifrián-Martínez
- Lung Transplant Unit, Respiratory Department Marqués de Valdecilla University Hospital, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Santander, Cantabria, Spain
| | - Sara Naranjo-Gozalo
- Thoracic Surgery, Lung Transplant Unit, Marqués de Valdecilla University Hospital, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Santander, Cantabria, Spain
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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.
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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.)
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4
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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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5
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Expanding the Lung Donor Pool: Donation After Circulatory Death, Ex-Vivo Lung Perfusion and Hepatitis C Donors. Clin Chest Med 2023; 44:77-83. [PMID: 36774170 DOI: 10.1016/j.ccm.2022.10.006] [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: 02/11/2023]
Abstract
"Organ shortage remains a limiting factor in lung transplantation. Traditionally, donation after brain death has been the main source of lungs used for transplantation; however, to meet the demand of patients requiring lung transplantation it is crucial to find innovative methods for organ donation. The implementation of extended donors, lung donation after cardiac death (DCD), the use of ex-vivo lung perfusion (EVLP) systems, and more recently the acceptance of hepatitis C donors have started to close the gap between organ donors and recipients in need of lung transplantation. This article focuses on the expansion of donor lungs for transplantation after DCD, the use of EVLP in evaluating extended criteria lungs, and the use of lung grafts from donors with hepatitis C."
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6
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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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7
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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
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8
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Experimental Models of Ischemic Lung Damage for the Study of Therapeutic Reconditioning During Ex Vivo Lung Perfusion. Transplant Direct 2022; 8:e1337. [PMID: 35702630 PMCID: PMC9191352 DOI: 10.1097/txd.0000000000001337] [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: 03/21/2022] [Accepted: 04/07/2022] [Indexed: 11/26/2022] Open
Abstract
Background. Ex vivo lung perfusion (EVLP) may allow therapeutic reconditioning of damaged lung grafts before transplantation. This study aimed to develop relevant rat models of lung damage to study EVLP therapeutic reconditioning for possible translational applications. Methods. Lungs from 31 rats were exposed to cold ischemia (CI) or warm ischemia (WI), inflated at various oxygen fractions (FiO2), followed by 3 h EVLP. Five groups were studied as follow: (1) C21 (control): 3 h CI (FiO2 0.21); (2) C50: 3 h CI (FiO2 0.5); (3) W21: 1 h WI, followed by 2 h CI (FiO2 0.21); (4) W50: 1 h WI, followed by 2 h CI (FiO2 0.5); and (5) W2h: 2 h WI, followed by 1 h CI (FiO2 0.21). Following 3 h EVLP, we measured static pulmonary compliance (SPC), pulmonary vascular resistance, lung weight gain (edema), oxygenation capacity (differential partial pressure of oxygen), and protein carbonyls in lung tissue (oxidative stress), as well as lactate dehydrogenase (LDH, lung injury), nitrotyrosine (nitro-oxidative stress), interleukin-6 (IL-6, inflammation), and proteins (permeability edema) in bronchoalveolar lavage (BAL). Perivascular edema was quantified by histology. Results. No significant alterations were noted in C21 and C50 groups. W21 and W50 groups had reduced SPC and disclosed increased weight gain, BAL proteins, nitrotyrosine, and LDH. These changes were more severe in the W50 group, which also displayed greater oxidative stress. In contrast, both W21 and W50 showed comparable perivascular edema and BAL IL-6. In comparison with the other WI groups, W2h showed major weight gain, perivascular edema, SPC reduction, drop of differential partial pressure of oxygen, and massive increases of BAL LDH and proteins but comparable increase of IL-6 and biomarkers of oxidative stress. Conclusions. These models of lung damage of increasing severity might be helpful to evaluate new strategies for EVLP therapeutic reconditioning. A model combining 1 h WI and inflation at FiO2 of 0.5 seems best suited for this purpose by reproducing major alterations of clinical lung ischemia-reperfusion injury.
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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
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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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11
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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.
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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
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12
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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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13
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Egan TM, Haithcock BE, Lobo J, Mody G, Love RB, Requard JJ, Espey J, Ali MH. Donation after circulatory death donors in lung transplantation. J Thorac Dis 2022; 13:6536-6549. [PMID: 34992833 PMCID: PMC8662509 DOI: 10.21037/jtd-2021-13] [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: 02/09/2021] [Accepted: 02/23/2021] [Indexed: 12/13/2022]
Abstract
Transplantation of any organ into a recipient requires a donor. Lung transplant has a long history of an inadequate number of suitable donors to meet demand, leading to deaths on the waiting list annually since national data was collected, and strict listing criteria. Before the Uniform Determination of Death Act (UDDA), passed in 1980, legally defined brain death in the U.S., all donors for lung transplant came from sudden death victims [uncontrolled Donation after Circulatory Death donors (uDCDs)] in the recipient’s hospital emergency department. After passage of the UDDA, uDCDs were abandoned to Donation after Brain Death donors (DBDs)—perhaps prematurely. Compared to livers and kidneys, many DBDs have lungs that are unsuitable for transplant, due to aspiration pneumonia, neurogenic pulmonary edema, trauma, and the effects of brain death on lung function. Another group of donors has become available—patients with a devastating irrecoverable brain injury that do not meet criteria for brain death. If a decision is made by next-of-kin (NOK) to withdraw life support and allow death to occur by asphyxiation, with NOK consent, these individuals can have organs recovered if death occurs relatively quickly after cessation of mechanical ventilation and maintenance of their airway. These are known as controlled Donation after Circulatory Death donors (cDCDs). For a variety of reasons, in the U.S., lungs are recovered from cDCDs at a much lower rate than kidneys and livers. Ex-vivo lung perfusion (EVLP) in the last decade has had a modest impact on increasing the number of lungs for transplant from DBDs, but may have had a larger impact on lungs from cDCDs, and may be indispensable for safe transplantation of lungs from uDCDs. In the next decade, DCDs may have a substantial impact on the number of lung transplants performed in the U.S. and around the world.
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Affiliation(s)
- Thomas M Egan
- Department of Surgery, UNC at Chapel Hill, Chapel Hill, NC, USA
| | | | - Jason Lobo
- Department of Medicine, UNC at Chapel Hill, Chapel Hill, NC, USA
| | - Gita Mody
- Department of Surgery, UNC at Chapel Hill, Chapel Hill, NC, USA
| | - Robert B Love
- Department of Surgery, Feinberg School of Medicine, Chicago, IL, USA
| | | | - John Espey
- Department of Surgery, UNC at Chapel Hill, Chapel Hill, NC, USA
| | - Mir Hasnain Ali
- Department of Surgery, UNC at Chapel Hill, Chapel Hill, NC, USA
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14
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Potential of Donation After Unexpected Circulatory Death Programs Defined by Their Demographic Characteristics. Transplant Direct 2021; 8:e1263. [PMID: 34966838 PMCID: PMC8710346 DOI: 10.1097/txd.0000000000001263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 10/22/2021] [Indexed: 12/12/2022] Open
Abstract
Background. Donation after unexpected circulatory death (uDCD) donors are often suggested to increase the number of donor organs. In 2014, a uDCD protocol was implemented in three transplant centers in the Netherlands which unfortunately did not result in additional transplantations. This study was initiated to identify demographic factors influencing the potential success of uDCD programs. Methods. Dutch resuscitation databases covering various demographic regions were analyzed for potential donors. The databases were compared with the uDCD implementation project and successful uDCD programs in Spain, France, and Russia. Results. The resuscitation databases showed that 61% of all resuscitated patients were transferred to an emergency department. Age selection reduced this uDCD potential to 46% with only patients aged 18–65 years deemed eligible. Of these patients, 27% died in the emergency department. The urban region of Amsterdam showed the largest potential in absolute numbers (52 patients/y). Comparison with the uDCD implementation project showed large similarities in the percentage of potential donors; however, in absolute numbers, it showed a much smaller potential. Calculation of the potential per million persons and the extrapolation of the potential based on the international experience revealed the largest potential in urban regions. Conclusions. Implementation of a uDCD program should not only be based on the number of potential donors calculated from resuscitation databases. They show promising potential uDCD percentages for large rural regions and small urban regions; however, actual numbers per hospital are low, leading to insufficient exposure rates. It is, therefore, recommendable to limit uDCD programs to large urban regions.
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15
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Palleschi A, Rosso L, Ruggeri GM, Croci GA, Rossetti V, Citerio G, Grasselli G, Nosotti M, Zanella A. Overcoming the Limits of Reconditioning: Seventeen Hours of EVLP With Successful Transplantation From Uncontrolled Circulatory Death Donor. Transplantation 2021; 105:2620-2624. [PMID: 33496562 PMCID: PMC8612888 DOI: 10.1097/tp.0000000000003646] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 12/17/2020] [Accepted: 12/20/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Uncontrolled donation after circulatory death (DCD) donors are an extraordinary resource to increase the number of lungs available for transplantation. However, the risk of the warm ischemia resulting from cardiac arrest to irreversibly damage the organs is considerable. Moreover, graft preservation issues and organizational problems often worsen the dangerous effects of warm ischemia. Ex vivo lung perfusion (EVLP) enables us to evaluate and recondition lungs whose functionality is doubtful, as well as to overcome the difficulties related to time and logistics. METHODS We report the case of uncontrolled DCD lungs successfully treated with an exceptionally prolonged EVLP. Because the donor's blood count and liver biopsy showed signs of possible leukemia, EVLP was protracted up to 17 h while waiting for immunohistochemical analyses to rule out this diagnosis; eventually, the results came back negative, and the lungs were judged suitable for transplantation. RESULTS The recipient was a 32-y-old male individual with cystic fibrosis, colonized by Pandoraea pnomenusa. Bilateral transplantation required central extracorporeal membrane oxygenation. The patient was extubated after 36 h and was discharged 21 d after the operation. Despite early recolonization by Pandoraea pnomenusa and airway complications requiring pneumatic dilatation, he is alive and has a satisfactory respiratory function 15 mo after transplantation. CONCLUSIONS Uncontrolled DCD represents a challenge due to both logistical issues and the complexity of graft evaluation before procurement. EVLP with cellular perfusate could be a valuable tool to overcome these limits. Nonetheless, caution should be exercised when interpreting the effects of this technique on airway healing.
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Affiliation(s)
- Alessandro Palleschi
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Lorenzo Rosso
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giulia Maria Ruggeri
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio Alberto Croci
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Pathology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valeria Rossetti
- Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuseppe Citerio
- San Gerardo Hospital, ASST-Monza, Monza, Italy
- University of Milano-Bicocca, Milan, Italy
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mario Nosotti
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alberto Zanella
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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16
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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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17
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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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18
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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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19
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Pushing the Envelope for Donor Lungs. Semin Respir Crit Care Med 2021; 42:357-367. [PMID: 34030199 DOI: 10.1055/s-0041-1729859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The shortage of organ donors remains the major limiting factor in lung transplant, with the number of patients on the waiting list largely exceeding the number of available organ donors. Another issue is the low utilization rate seen in some types of donors. Therefore, novel strategies are continuously being explored to increase the donor pool. Advanced age, smoking history, positive serologies, and size mismatch are common criteria that decrease the rate of use when it comes to organ utilization. Questioning these limitations is one of the purposes of this review. Challenging these limitations by adapting novel donor management strategies could help to increase the rate of suitable lungs for transplantation while still maintaining good outcomes. A second goal is to present the latest advances in organ donation after controlled and uncontrolled cardiac death, and also on how to improve these lungs on ex vivo platforms for assessment and future specific therapies. Finally, pushing the limit of the donor envelope also means reviewing some of the recent improvements made in lung preservation itself, as well as upcoming experimental research fields. In summary, donor lung optimization refers to a global care strategy to increase the total numbers of available allografts, and preserve or improve organ quality without paying the price of early-, mid-, or long-term negative outcomes after transplantation.
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20
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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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21
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Campo-Canaveral De La Cruz JL, Dunne B, Lemaitre P, Rackauskas M, Pozniak J, Watanabe Y, Mariscal A, Yeung J, Yasufuku K, Pierre A, de Perrot M, Waddell TK, Cypel M, Keshavjee S, Donahoe L. Deceased-donor lobar lung transplant: A successful strategy for small-sized recipients. J Thorac Cardiovasc Surg 2021; 161:1674-1685. [DOI: 10.1016/j.jtcvs.2020.04.166] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 03/13/2020] [Accepted: 04/04/2020] [Indexed: 02/03/2023]
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22
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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.
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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
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23
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Zanierato M, Dondossola D, Palleschi A, Zanella A. Donation after circulatory death: possible strategies for in-situ organ preservation. Minerva Anestesiol 2020; 86:984-991. [DOI: 10.23736/s0375-9393.20.14262-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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24
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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.
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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
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25
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Miñambres E, Rodrigo E, Suberviola B, Valero R, Quintana A, Campos F, Ruiz-San Millán JC, Ballesteros MÁ. Strict selection criteria in uncontrolled donation after circulatory death provide excellent long-term kidney graft survival. Clin Transplant 2020; 34:e14010. [PMID: 32573027 DOI: 10.1111/ctr.14010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/29/2020] [Accepted: 06/04/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND We aimed to report our experience in uncontrolled donation after circulatory death (uDCD) kidney transplantation applying a strict donor selection and preservation criteria. METHODS All kidney recipients received a graft from a local uDCD. As controls, we included all renal transplants from local standard criteria donation after brain death (SDBD) donors. Normothermic regional perfusion was the preservation method in all cases. RESULTS A total of 19 kidneys from uDCD donors were included and 67 controls. Delayed graft function (DGF) was higher in the uDCD group (42.1% vs 17.9%; P = .033), whereas no differences were observed in primary nonfunction (0% cases vs 3% controls; P = .605). The estimated glomerular filtration rate was identical in both groups. No differences were observed in graft survival censored for death between the uDCD and the SDBD groups at 1-year (100% vs 95%) or 5-year follow-up (92% vs 91%). uDCD kidney recipients did not have higher risk of graft loss in the multivariate analysis adjusted by recipient age, cold ischemic time, presence of DGF, and second kidney transplant (HR: 0.4; 95% CI 0.02-6; P = .509). CONCLUSIONS Obtaining renal grafts from uDCD is feasible in a small city and provides similar outcomes compared to standard DBD donors.
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Affiliation(s)
- 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
| | - Emilio Rodrigo
- School of Medicine, University of Cantabria, Santander, Spain.,Service of Nephrology, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Borja Suberviola
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Rosalía Valero
- Service of Nephrology, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Alfredo Quintana
- Extrahospitalary Emergency, Gerencia de Atención Primaria-061, Santander, Spain
| | - Félix Campos
- Service of Urology, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Juan Carlos Ruiz-San Millán
- School of Medicine, University of Cantabria, Santander, Spain.,Service of Nephrology, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - María Á Ballesteros
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
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26
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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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27
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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.
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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
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28
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29
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Impact of the elderly donor on an abdominal organ transplantation program. Eur Surg 2020. [DOI: 10.1007/s10353-020-00637-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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30
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Kidney transplantation following uncontrolled donation after circulatory death. Curr Opin Organ Transplant 2020; 25:144-150. [DOI: 10.1097/mot.0000000000000742] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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31
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Sandoval E, Fernández-Cisneros A, Boada M. DCD lungs: is it all the same? Ann Cardiothorac Surg 2020; 9:54-55. [PMID: 32175241 DOI: 10.21037/acs.2019.11.07] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Elena Sandoval
- Department of Cardiovascular Surgery, ICCV. Hospital Clínic, Barcelona, Spain
| | | | - Marc Boada
- Department of Thoracic Surgery, ICR. Hospital Clínic, Barcelona, Spain
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32
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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.
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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
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33
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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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34
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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
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35
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Egan TM, Requard JJ. Overcoming challenges of lung recovery from uDCDDs - Felicidades! Am J Transplant 2019; 19:2391-2392. [PMID: 31220408 PMCID: PMC6996558 DOI: 10.1111/ajt.15506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Thomas M. Egan
- Professor of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina,President, Lung Banks of America, Chapel Hill, North Carolina
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36
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Tawil JN, Adams BA, Nicoara A, Boisen ML. Noteworthy Literature Published in 2018 for Thoracic Organ Transplantation. Semin Cardiothorac Vasc Anesth 2019; 23:171-187. [PMID: 31064319 DOI: 10.1177/1089253219845408] [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: 11/17/2022]
Abstract
Publications of note from 2018 are reviewed for the cardiothoracic transplant anesthesiologist. Strategies to expand the availability of donor organs were highlighted, including improved donor management, accumulating experience with increased-risk donors, ex vivo perfusion techniques, and donation after cardiac death. A number of reports examined posttransplant outcomes, including outcomes other than mortality, with new data-driven risk models. Use of extracorporeal support in cardiothoracic transplantation was a prominent theme. Major changes in adult heart allocation criteria were implemented, aiming to improve objectivity and transparency in the listing process. Frailty and prehabilitation emerged as targets of comprehensive perioperative risk mitigation programs.
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Affiliation(s)
| | | | | | - Michael L Boisen
- 4 University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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37
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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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