Extended donor criteria in lung transplantation: Impact on organ allocation

Abstract

Objective: Some reports have documented a higher early mortality with the use of extended criteria donors in lung transplantation. None have evaluated how outcomes compare with the use of these organs for single and bilateral transplantation or whether this practice results in a higher incidence of early bronchiolitis obliterans syndrome.Methods: We performed a retrospective review of case notes, intensive therapy unit database, and donor details. Between January 1, 2000, and December 31, 2004, 201 patients underwent lung or heart-lung transplantation.Results: Eighty-three (41.3%) patients received organs deemed marginal on the basis of at least one of the following criteria: donor age greater than 55 years, duration of ventilation greater than 5 days, purulent secretions or inflammation at bronchoscopy, smoking of 20 or more cigarettes per day, abnormality on chest roentgenogram, or PO 2 /fraction of inspired oxygen ratio of less than 300 mm Hg immediately before donor organ procurement. Recipients of marginal lungs had a higher incidence of severe (grade 3) primary graft dysfunction (43.9% vs 27.4%, P ϭ .015) and 90-day organ-specific mortality (15.7% vs 5.1%, P ϭ .012). Bilateral transplantation carried a significantly higher 30-day mortality if performed with marginal organs (17.0% vs 2.7% with standard donor organs, P ϭ .005). Thirty-day mortality was not significantly different for the transplantation of single marginal or standard donor lungs. Cumulative survival and survival free of bronchiolitis obliterans syndrome was not affected by marginal donor status. Conclusion:Transplantation of extended criteria donor lungs leads to a higher incidence of primary graft dysfunction. Bilateral transplantation with these organs seems to confer less reserve, resulting in a higher early mortality rate. Medium-term functional outcome is, however, not adversely affected by the relaxation of donor criteria.

Clinical grade allogeneic human mesenchymal stem cells restore alveolar fluid clearance in human lungs rejected for transplantation

“…There is a worldwide gap between the supply and demand for transplantable organs, and this gap is enlarging (19). However, another major issue is that the use of marginal donor lungs is associated with an increased incidence of primary graft dysfunction, with poor early and long-term outcomes in recipients of such suboptimal organs (3). Hence, transplant teams tend to be conservative in the selection of donor lungs (29).…”

The Societal Impact of Single Versus Bilateral Lung Transplantation for Chronic Obstructive Pulmonary Disease

“…Although the introduction of the Lung Allocation Score (LAS) (2) in May, 2005, has shortened the average time spent awaiting lung transplantation (3), potential recipients continue to die on the waitlist (4). To address the lung shortage, institutions have turned to extended-criteria donors (5,6) and donors after circulatory determination of death (7)(8)(9)(10)(11). Despite these strategies, a substantial gap remains between the supply of and demand for transplantable lungs.…”

Lung transplantation for chronic obstructive pulmonary disease

“…146 Many studies reported approximately 50 to 100 recipients of extended criteria lungs compared to approximately equal or larger numbers of recipients of standard lungs and found no significant differences in lung function, or short-or long-term survival up to 1 year following transplantation. [147][148][149][150][151][152] However, a number of similarly sized studies suggested caution in proceeding with transplantation using extended criteria donor lungs based on increased rates of early or late mortality, 153,154 increased primary graft dysfunction either in the postoperative period or after 1 or more years after transplant, 153,155 longer ICU courses, or prolonged hospital stays. 155 Interpretation of these studies is generally difficult because of the moderately small numbers of patients with widely varying characteristics and multiple paths to qualification as an extended criteria donor.…”