Donation after Brain Death versus Donation after Circulatory Death: Lung Donor Management Issues

Abstract

Lung transplantation (LTx) has traditionally been limited by a lack of suitable donor lungs. With the recognition that lungs are more robust than initially thought, the size of the donor pool of available lungs has increased dramatically in the past decade. Donation after brain death (DBD) and donation after circulatory death (DCD) lungs, both ideal and extended are now routinely utilized. DBD lungs can be damaged. There are important differences in the public's understanding, legal and consent processes, intensive care unit strategies, lung pathophysiology, logistics, and potential-to-actual donor conversion rates between DBD and DCD. Notwithstanding, the short- and long-term outcomes of LTx from any of these DBD versus DCD donor scenarios are now similar, robust, and continue to improve. Large audits suggest there remains a large untapped pool of DCD (but not DBD) lungs that may yet further dramatically increase lung transplant numbers. Donor scoring systems that might predict the donor conversion rates and lung quality, the role of ex vivo lung perfusion as an assessment and lung resuscitation tool, as well as the potential of donor lung quality biomarkers all have immense promise for the clinical field.

Recent advances in lung transplantation

“…Donation after brain death (DBD) donors represent the traditional and largest source of donor lungs, and relaxing ideal criteria to allow the use of marginal donor organs that meet extended criteria has increased the numbers of lungs available for transplant 14 . Another source of donor lungs that is increasingly being used to help meet the persistent shortage of donor lungs is that of donation after circulatory death (DCD) donors, a source that remains considerably underutilized but could significantly increase the pool of donor lungs, especially when coupled with donor lung resuscitation and evaluation using ex vivo lung perfusion (EVLP).…”

Lung transplantation: a review of the optimal strategies for referral and patient selection

“…Simply put, a well-resourced unit performing more than 50–100 LTx per annum over a period of years will most likely perform more successful transplants and, arguably, be more inclined to adjust their selection criteria to manage isolated complex cases with greater facility, including bridge to transplant with extracorporeal membrane oxygenation (ECMO), ex vivo lung perfusion and ventilation (EVLP) and the use of donation after circulatory death donors (DCD), both of which may expand the donor pool. 13–19 Moreover, larger units, in broad-based transplant-focused hospitals may well be able to develop mutually beneficial relationships with other key service providers so that cutting edge work can be undertaken, particularly where expertise in conditions such as human immunodeficiency virus (HIV) infection and Hepatitis C is required to secure optimum results, let alone multi-organ transplant procedures such as lung–kidney or more commonly, (heart) lung–liver transplants. 20–23…”