Special issues in the management and selection of the donor for lung transplantation

Abstract

Lung transplantation is a viable treatment option for select patients with end-stage lung disease. Two issues hamper progress in transplantation: first, donor shortage is a major limitation to increasing the number of transplants performed. Secondly, recipient outcomes remain disappointing when compared with other solid organ transplant results. Outcomes are limited by primary graft dysfunction (PGD), the posttransplant acute lung injury that increases both short-and long-term mortality. Attempts to overcome donor shortage have included aggressively managing solid organ donors to increase the number of donor lungs suitable for transplantation. Yet, the quality of the lung donor is likely to be related to the probability of the recipient experiencing PGD. PGD is the culmination of a series of insults, hemodynamic, metabolic, and inflammatory, that begin with the brain dead donor and result in poor recipient outcomes. Understanding the mechanism of donor lung injury resulting from brain death and the possible treatment strategies for its inhibition could help to increase the number of usable lungs and decrease the rate of PGD in the recipient. Here we present a review of the key pathways which result in donor lung injury, and follow this with a brief review of recent biomarkers that are proving to be instrumental to our ability to predict truly unsuitable lungs, and our ability to predict and hopefully prevent or treat recipients with subsequent lung injury.

Human immunology studies using organ donors: Impact of clinical variations on immune parameters in tissues and circulation

“…Consistent with most current donor management strategies, ~85-90% of donors received steroids, vasopressors, or thyroid hormone after brain death declaration; 55% of donors received a transfusion (either packed RBC or platelets) during their hospitalization; and 46% of donors sustained ALI during their hospitalization. [29][30][31] A small fraction of donors (10.5%) also developed infections, as measured by positive cultures in blood or urine.…”

Massive donor transfusion potentially increases recipient mortality after lung transplantation

“…However, there is a large discrepancy between the number of suitable lung donors for transplant and the number of patients on the waiting list, resulting in many potential recipients dying on the waiting list or being removed due to clinical decline. 1 Given this challenge, there is increasing pressure to expand the donor pool. However, compared to other solid organs, overall survival after lung transplantation is limited and efforts to reduce primary graft dysfunction (PGD) risk may cause reticence with respect to certain lung donors, thus potentially further reducing the donor pool.…”

Brain Death: Assessment, Controversy, and Confounding Factors

“…20 Progression of ischemia or distortion of the medulla oblongata and hypothalamus results in additional sympathetic outflow as endogenous catecholamine stores are released, causing hypertension, tachycardia, and vasoconstriction in an effort to maintain cerebral perfusion pressure. 13,14,17,18,20,21 Initially brain stem distortion results in a hypertensive state as a reflex response, an attempt to maintain brain perfusion. Final brain stem dysfunction or herniation, with total loss of catecholamine regulation, causes total loss of sympathetic control and typically occurs in 2 phases.…”