Beware Cold Agglutinins in Organ Donors! Ex Vivo Lung Perfusion From an Uncontrolled Donation After Circulatory-Determination-of-Death Donor With a Cold Agglutinin: A Case Report

Abstract

Background We began to recover lungs from uncontrolled Donation after Circulatory Determination of Death donors to assess for transplant suitability by ex-vivo lung perfusion (EVLP) and computed tomography (CT) scan. Our first case had a cold agglutinin with an interesting outcome. Case Report A 60-year-old male collapsed at home and was pronounced dead by Emergency Medical Services personnel. Next-of-kin consented for lung retrieval and the decedent was ventilated and transported. Lungs were flushed with cold Perfadex™, removed, and stored cold. The lungs did not flush well. Medical history revealed a recent hemolytic anemia, and a known cold agglutinin. Warm non-ventilated ischemic time was 51 minutes. O2-ventilated ischemia was 141 minutes. Total cold ischemic time was 6.5 hours. At cannulation for EVLP, established clot was retrieved from both pulmonary arteries. At initiation of EVLP with Steen solution™, tiny red aggregates were observed initially. With warming, the aggregates disappeared; the perfusate became red. After 1 hour, EVLP was stopped because of florid pulmonary edema. The lungs were cooled to 20°C; tiny red aggregates formed again in the perfusate. Ex-vivo CT scan showed areas of pulmonary edema and a pyramidal right middle lobe opacity. Dissection showed multiple pulmonary emboli – the likely cause of death. However, histology showed agglutinated RBCs in the microvasculature in pre- and post-EVLP biopsies, which may have contributed to inadequate parenchymal preservation. Conclusion Organ donors with cold agglutinins may not be suitable because of the impact of hypothermic preservation.

Evolving Trend of EVLP: Advancements and Emerging Pathways

“…Special case was reported that a donor with medical history of hemolytic anemia and known cold agglutinin, whose lungs had a total cold ischemia time of 6.5 h. Established clots and aggregates could be observed from the initiation of EVLP, leading to florid pulmonary edema and cessation of EVLP. Impact of hypothermic preservation on cold agglutinin donors should be consulted before assessment [39].…”