Should We Reconsider Lung Transplantation Through Uncontrolled Donation After Circulatory Death?

Abstract

Lung transplantation through controlled donation after circulatory death (cDCD) has slowly gained universal acceptance with reports of equivalent outcomes to those through donation after brain death. In contrast, uncontrolled DCD (uDCD) lung use is controversial and requires ethical, legal and medical complexities to be addressed in a limited time. Consequently, uDCD lung use has not previously been reported in the United States. Despite these potential barriers, we present a case of a patient with multiple gunshot wounds to the head and the body who was unsuccessfully resuscitated and ultimately became an uDCD donor. A cytomegalovirus positive recipient who had previously consented for CDC high-risk, DCD and participation in the NOVEL trial was transplanted from this uDCD donor, following 3 hours of ex vivo lung perfusion. The postoperative course was uneventful and the recipient was discharged home on day 9. While this case represents a “best-case scenario,” it illustrates a method for potential expansion of the lung allograft pool through uDCD after unsuccessful resuscitation in hospitalized patients.

Expanding the horizons: Uncontrolled donors after circulatory death for lung transplantation—First comparison with brain death donors

“…13,14 Periods of hypoxia and unstable hemodynamics have shown to have a negative impact in lung function after transplantation in the laboratory. 34 Therefore, EVLP might not be as effective when warm ischemic damage is the concern. The donor suffered massive volume replacement therapy (9563 mL packed red blood cells, 3445 mL plasma, 3049 mL platelets, and 5 L saline) and was recovered after three episodes of pulseless electrical activity.…”

An experimental study of the recovery of injured porcine lungs with prolonged normothermic cellularex vivolung perfusion following donation after circulatory death

“…Suzuki et al . reported a successful DCD transplant after EVLP using a donor who suffered multiple episodes of cardiac arrest after severe penetrating trauma. The lungs demonstrated steady improvement in airway pressure and PVR, as well as good gas exchange, over 3 h of EVLP and were subsequently transplanted.…”

Donation after cardiac death for lung transplantation

“…Although the early reported experience with this approach resulted in unacceptably increased PGD rates, the utility of ex-vivo lung perfusion (EVLP) may be of particular interest in this setting as both optimization of lungs and minimization of risks are feasible [45,46]. The legislative prerequisites and clinical complexity documented with the Spanish experience with uncontrolled DCD lung transplantation have to be considered the future challenge [47]. In most nations, organ donation is viewed as the ultimate altruistic gift and significant progress is needed to achieve public awareness of the potential benefits for the recipients currently not surviving the waiting time for lungs.…”