Current status and further potential of lung donation after circulatory death

Abstract

Lung transplantation is the only successful treatment option for endstage lung diseases. Over the last decades, lung transplantation has steadily improved, and in parallel, indications were broadened and contraindication eased. While the demand is still increasing worldwide, a chronic organ shortage remains the primary limiting factor in lung transplantation. A concerning wait-list mortality is currently reported by the Organ Procurement and Transplantation Network (OPTN), increasing within a decade from 15% to 20%. 1 Since more than 50 years, donation after brain death (DBD) has been the leading source of deceased donation worldwide. In DBD donors, the lung is the most fragile and vulnerable of all solid organs, and only 15%-30% of these lungs are generally utilized for transplantation. 1 One reason is a neurogenic pulmonary edema caused by upregulation of inflammatory mediators attributed to brain death. Besides this, lungs are vulnerable due to frequent aspiration of gastric contents, pulmonary infections, contusion, and ventilation-associated lung injury. To overcome the critical organ shortage, many centers have started to use marginal donor lungs, size reduced allografts, and, in few cases, living lobar donation. However, the latter attempts have just led to a small increase in the donor pool so far. In contrast, the

Lung recruitment after cardiac arrest during procurement of atelectatic donor lungs is a protective measure in lung transplantation

“…Furthermore, no blood-circulated inflation procedures in lung procurement from a DCD donor potentially contribute to the reported favorable post-transplant outcomes of this LTx category. The survival outcome of controlled DCD LTx was better than expected and comparable to that of the standard LTx using brain-dead donor lungs in previous studies ( 22 , 23 ). We speculate that this unexpectedly satisfactory clinical outcome can be partly attributed to the DCD procurement process in which lung recruitment is performed after circulatory arrest.…”

Lung transplantation from donation after circulatory death, evolution, and current status in the United States

“…speculated that this could be a result of warm ischemia increasing pulmonary edema in the donor allograft, which could be quickly resolved with fluid balance in the ICU 18 . Many studies have reported that the survival rate of lung transplant recipients from DCD lung donors is comparable to that of DBD lung donors 4,10,17–21 . Similarly, our analysis showed no significant difference in survival between those who underwent lung transplantation from donors with DCD lungs compared to those with DBD lungs.…”

“…Compared to DBD lung recipients, recipients of DCD lungs were more likely to experience PGD3 at 72 h post‐transplant, require post‐transplant ventilation, and require post‐transplant dialysis. Most studies on PGD metrics for DCD show slightly worse trends than those for DBD in the first post‐operative hours, however, functions improve quickly 4,15–18 . Villavicencio et al.…”

“…DCD is an important source in the US and expanding the donor pool to include it is necessary because the number of patients needing lung transplants exceeds the number of donors available 4,18 . In the US, DCD lung utilization is primarily limited to geographic regions with higher relative demand for donor lung availability, such as the northeast area 22 .…”

“…Transplants with lungs from donors after circulatory determination of death have increased since the report by Love et al. in 1993 1–5 . According to the International Society for Heart and Lung Transplantation registry, the rate of lung transplantation from donation after circulatory death (DCD) increased from .6% in 2003 to 13.5% in 2016 2 .…”