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Lung Donation After Circulatory Death And The Potential Role Of Ex Vivo Lung Perfusion


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Bryan A. Whitson, MD, PhD
The Ohio State University Wexner Medical Center
Columbus, OH, USA
Bryan.whitson@osumc.edu



Worldwide, lung transplantation is growing and our collective outcomes are improving. These improvements are a culmination of our collective advances in patient selection, preoperative management, surgical experience, and meticulous postoperative and longitudinal care. Further increases in our ability to offer this life-giving therapy to patients in need is, and will be, limited by the availability of numbers of donors of sufficient quality. In order to meet the demand, non-traditional (i.e., brain-dead donors (DBD)), approaches need to be pursued. Lung donation after circulatory death (DCD) is one potential avenue. Although this approach may provide the ability for more people who wish to be an organ donor to be an organ donor there is some trepidation on the part of transplant programs to venture into this area because of concerns of potential risks [1]. The concomitant, more widespread adoption of ex-vivo lung perfusion (EVLP) may allow for the management of that potential risk, the assessment of the DCD lung donor, and enhanced recovery.

The International Society for Heart and Lung Transplantation (IISHLT) has supported the development of a DCD Registry [1,2]. Recently, this registry was evaluated and data from 10 participating institutions in North America, Europe, and Australia was analyzed. In these centers, 306 DCD donor lung transplants were performed. The vast majority were Maastricht Category III recoveries. These donors were compared to an almost 10-fold larger DBD donor cohort. The 30-day and 1-year survival between these donor cohorts were not different [2].

These types of data are increasing and demonstrate that the approach to DCD lung donation can occur. However, the underlying theme that is being further elucidated is the deliberate programmatic approach to the success attained at these center. Examples of these approaches are standardization as much as possible in heparinization, withdrawal of life support, donor extubation, recovery technique, and the utilization of EVLP [1-3]. Among programs the duration of time that is allowed between withdrawal of life support and cardiac arrest is varied with the vast majority being less than 60 minutes. Some programs have been willing to expand that time to 120 minutes. There is a modest degree of variability between centers with this risk [2].

A powerful tool that has great potential to allow for DCD lung use expansion is EVLP. As our readers know, the EVLP experience has been growing worldwide and the results that we are seeing are impressive. Combining EVLP with DCD donation has some important upsides. First, this approach allows for a period of assessment while the lung is being perfused. This is time to see if there was any injury to the lung with the hurried procurement [1,3]. Second, since there is variability in the ability to heparinize pre-recovery, the perfusion and flush period allows for washout of (micro) thrombus. Third, over time, we will have the ability to actively intervene on the lung to improve quality. Fourth, the risk to the recipient is mitigated. With the added time to observe the donor lung on EVLP, a center can be more assured that the DCD lung is of adequate quality and then proceed to the initial steps of the operation only when they are assured that a viable transplant may be performed. This limits the risk to the recipient who may have an operation initiated and then be committed to a sub-optimal lung out of necessity.

A future and expanded potential for DCD and EVLP partnership is in the utilization of uncontrolled DCD lung donors (uDCDD). There are multiple hurdles, societal, ethical, regulatory, technical, that need to be addressed. Broad application of this uDCDD approach is in its infancy though it will be the next frontier and EVLP will need to play a role [4].

Further international experience and the sharing of protocols and techniques will undoubtedly increase the comfort with DCD lung donation. EVLP will allow for the DCD lung to be assessed thoroughly prior to transplant. This combination will increase access and improve outcomes in our lung transplant patients. ■

Disclosure Statement: The author has no conflicts of interest to disclose.


References:

  1. Lung transplantation using controlled donation after circulatory death donors: Trials and tribulations. Cypel M, Levvey B, Van Raemdonck D, Erasmus M, Dark J, Mason D, Glanville AR, Chambers D, Edwards L, Stehlik J, Hertz M, Whitson BA, Yusen RD, Hopkins P, Snell G, Keshavjee S. J Heart Lung Transplant. 2016 Jan;35(1):146-7.
  2. International Society for Heart and Lung Transplantation Donation After Circulatory Death Registry Report. Cypel M, Levvey B, Van Raemdonck D, Erasmus M, Dark J, Love R, Mason D, Glanville AR, Chambers D, Edwards LB, Stehlik J, Hertz M, Whitson BA, Yusen RD, Puri V, Hopkins P, Snell G, Keshavjee S; International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2015 Oct;34(10):1278-82.
  3. Uncontrolled Donation After Circulatory Determination of Death Donors (uDCDDs) as a Source of Lungs for Transplant. Egan TM, Requard JJ 3rd. Am J Transplant. 2015 Aug;15(8):2031-6.
  4. DCD lung donation: donor criteria, procedural criteria, pulmonary graft function validation and preservation. Erasmus ME, van Raemdonck D, Akhtar MZ, Neyrinck A, de Antonio DG, Varela A, Dark J. Transpl Int. 2015 Dec 31



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