Review Article
Lung Transplantation from Donation after Circulatory Determination of Death: A Contemporary Review
Hoyos Mejía L and Gómez de Antonio D*
Department Thoracic Surgery and Lung Transplantation, Hospital Puerta de Hierro-Majadahonda, Madrid, Spain
*Corresponding author: Gómez de Antonio D, Department Thoracic Surgery and Lung Transplantation, Hospital Puerta de Hierro-Majadahonda, Madrid, Spain
Published: 14 Apr, 2017
Cite this article as: Hoyos Mejía L, Gómez de Antonio D.
Lung Transplantation from Donation
after Circulatory Determination of
Death: A Contemporary Review. Clin
Surg. 2017; 2: 1404.
Abstract
During the last decade many strategies are developed in order to expand the donor pool. One of the strategies that bring more attention is the use of grafts from donors after circulatory death (DCD), also frequently referred to as nonheart-beating donors (NHBD). Here we offer a short and compressible, state of the art review of lung transplantation from DCD.
Introduction
Lung transplantation (LTx) represents a life-saving therapy for patients with end-stage lung
disease. Since the first successful LTx, 50 years ago [1], the number of patients listed for transplant
has been steadily increasing. However, that increase has been constantly challenged by a donor
shortage. Of the available organ donors, only 20% are typically acceptable for lung donation.
Although the selection process may vary between institutions, there are common criteria for ideal
donors (Table 1) [2,3]. Donation after brain death (DBD) constituted the primary source for LTx.
Multiple approaches have been developed to overcome the shortage of grafts for LTx, such as living
lobar donation, use of extended criteria donors, ex vivo lung perfusion (EVLP), and donation after
cardiac death, also known as donation after circulatory death (DCD) [4,5]. This article reviews
DCDLTx and its value in increasing the LTx donor pool.
After the first report of successful LTx with DCD by Hardy in 1963 [1] the use of DCD donor
went hold apart until begins of 1990s, when Thomas Egan and colleagues revisited the possibility
of using lungs from DCDs, reopening the door for others to investigate the viability of these grafts
related to warm ischemia and best preservation [6]. During the late 90s and early 2000s, experimental
evidence came to light, determining warm ischemic time longer than 90 minutes might be extreme,
confirming topical cooling as the best way to preserve lungs in situ for DCD, the importance of
retrograde perfusion in these donors, and ex vivo evaluation as a potential tool to improve graft
quality [3-8]. During de presents years the use of DCD lungs has grown internationally with DCD
lungs accounting for 2% of lung transplants in the United States, 5% in Canada, 4.4% in Europe,
13.3% in the United Kingdom, and 22.5% in Australia [7].
Classification
The first international workshop for DCD was held in Maastricht in the Netherlands in 1995 to
characterize potential donors after cardiac (modified in 2003), defining DCD categories according to
the circumstances of the donor’s death [8,9] (Table 2). Category I (dead on arrival), II (unsuccessful
resuscitation) and V (in hospital patient) were considered to be uncontrolled donors (uDCD)
does patient who suffer from unexpected cardiac arrest and/or unsuccessful cardiopulmonary
resuscitation. In these scenarios, evaluation of graft function a priori is not feasible. Whereas category
III (awaiting cardiac arrest) and IV (cardiac arrest in a brain-dead donor) were considered to be
controlled donors (cDCD) scenario entails withdrawal of life-support measures in the intensive care
unit (ICU) or operating room. Benefits of DCD donation include the ability to allocate the organ in
advance, relative ability to predict cardiac arrest, and opportunity to evaluate graft function.
Controlled DCD
The cDCD are the perfect scenario for scheduling the procedure, assess graft viability extensible
controlled recipient selection and careful communication with the donor’s relatives. Potential
donors for cDCD are typically patients with irreversible cerebral injury, high spinal cord injury, or
end-stage musculoskeletal disorders that are expected to die within 60 mins following withdrawal
of life-support (WLS). Most centers use the same donor criteria for as for DBD donation (Table 1).
Recently, some countries (Belgium, Holland) have started to consider donation after euthanasia.
These donors are included in Maastricht III category.
In all cases, donation is completely independent from the
decision of WLST. Only when a certain patient is considered for lung
donation, a Transplant Coordinator contacts the potential donor’s
relatives for consent.
In addition to standard criteria, specific procedural criteria play
an important role in determining whether to accept the controlled
cDCD lung or not; first the likelihood of death following WLS: Several
algorithms have been developed in order to predict the expiration of
potential cDCD donors based on patient clinical status. (Wisconsin
Algorithm, UNOS Algorithm) [10-12]. Use of these predictive tools
has further improved the ability to define eligibility for lung donation
in the cDCD setting. Second important criteria is the time frame of
each step in the cDCD, recently, the International Society for Heart
and Lung Transplantation (ISHLT) DCDD Registry proposed a
time-point; T0: withdrawal of life-sustaining therapies (WLST) OR
euthanasia. T1: oxygen saturation o80%. T2: systolic blood pressure
of 50 mmHg. T3: cessation of cardiac output/asystole. T4: resumed lung inflation/ventilation. T5: start of pulmonary flush. The intervals
of times for T0 to T2 (Interval 1), T0 to T3 (Interval 2), T0 to T5
(Interval 3) and T2 to T5 (Interval 4) [13].
Donor management
Once the decision has been made based on Hospital protocol and
family wishes, the potential donor is carried out by the ICU personnel
in the operating room (OR) or stays in the ICU, closely monitored:
Invasive arterial pressure (systolic, diastolic and mean). Heart rate
and rhythm, respiratory rate, O2 saturation and diuresis. Then WLST
(mechanical ventilation, ECLS, IV drug) starts until cardiac arrest. A
time limit of two hours to cardiac arrest is accepted, after which the
patient is returned to the ICU.
After cardiac arrest a period of no-touch from 2 to 20 mins
(depending on local protocols) is observed [14,15]. Most programs
adopted a 5 min no-touch period to confirm death.
Some controversy surrounds the criteria for declaration of death,
but most groups accept death declared by the ICU staff, independent of the transplant team, based on cardiopulmonary criteria, defined
as irreversible or permanent cessation of respiration and circulation
after a certain period of time [16,17]. Signs of death are determined via
absence of heart sounds, pulse, and lack of spontaneous respiration
during a no touch period of 5 mins using the Institute of Medicine
recommendations, providing there is no hypothermia, drowning,
penetrating trauma or suspected intoxication [18].
During the period between withdrawal of support and actual
cardiac arrest, there have been described some events that correlate
with quality of the organs. The agonal phase (AP) is defined as the
period of time between limitation and declaration of death (Interval
2). Some research has suggested an inverse correlation between the
length of the AP and graft viability and function [19-22]. Warm
ischemic time (WIT) defined by The American Society of Transplant
Surgeons (ASTS) as the period of time between withdrawal of lifesustaining
therapies and graft cold perfusion (Interval 3). However,
these guidelines also define a ‘true warm ischemic time’, which is the
interval between significant ischemic insult and initiation of cold
perfusion, considering that the real ischemic damage starts when
mean arterial pressure (mAP) drops below 60 mmHg [15] (Interval
4). As in AP some research link prolong WIT with lower PaO2/
FiO2 ratio and longer ICU stay after transplant 40 [21,23-25]. Today
most groups accept WIT of 60 to 90 mins of WIT, depending on the
definitions.
The procurement process is similar to a brain death donor in
terms of evaluation and surgical technique, there are two crucial
aspect that differ; First, after determination of death by the ICU staff
the donor is quickly reintubated and ventilation restarted as donor
is transferred to the OR (if the WLST was on the ICU). The airway
is checked by bronchoscopy in order to rule out aspiration during
the agonal phase. Simultaneously, fast opening of the chest and flush
perfusion through the pulmonary artery is performed [26,27].
Uncontrolled DCD
In contrast to the controlled DCD, the uncontrolled DCD
donation represents a complicate scenario were neither time nor
circumstances of death are known, so the success of the procedure
depends on a really organized network of pre-hospital and hospital
emergency services, and transplant coordinator skills and motivation
to request consent for organ donation. For this reason, only fourteen
years after Steen´s report, only the Madrid group is reporting a
consistent number of lung transplantations from uDCD [28].
Donor Management
The uDCD program includes a medical and surgical
multidisciplinary team on site upon arrival of the potential donor.
This team includes surgeons, anesthesiologists, perfusionist and
nurses. Also essential are the out-of-hospital emergency teams,
trained to provide high quality basic and advanced life support [29].
A potential uDCD is considered after a witnessed cardiac arrest,
when emergency unit’s starts basic and advanced resuscitation maneuvers within 15 mins and after 30 mins of advanced CPR
there is no recovery of spontaneous circulation. The patient is then
transported to the emergency department under advanced CPR. In
the ER death is declared by the ICU staff independent of the transplant
team based on cardiopulmonary criteria, defined as describe before
[16-18].
Once legal permission for preservation is obtained, heparin
(3 to 5 mg/kg) is given to the potential donor to reduce the risk of
pulmonary thromboembolism [30-33] cold Perfadex® at 4°C (Medisan,
Uppsala, Sweden) is instilled through chest drains into both pleural
cavities to bring lung temperature below 21°C [28,34,35] and venoarterial
extracorporeal membrane oxygenation is implemented for
abdominal organ preservation, with insertion of a Fogarty catheter
supra-diaphragmatically to prevent abdominal solutions entering
the chest [36,29] accepting a maximum warm ischemic time period
(from absence of circulation until effective topical cooling of 90 mins.
After topical cooling the procurement process is similar to cDCD
in term of evaluation and surgical technique, there are two crucial
aspects that differ;
1.-There is a period of time between topical cooling and definitive
intravascular preservation (flush), that should not exceed 240 mins
[10,11,16].
2.-There is no way to evaluate these grafts before arrest, so after
the initial solution flush (60 ml/kg of cool Perfadex), additional 300 ml
of donor blood are passed through the system and gas analysis from
the left atrium and each pulmonary vein is done with temperature
correction, seeking a partial pressure of oxygen greater than 400 mm
Hg [28,37-46] (Figure 1).
Table 1
Table 2
Figure 1
Table 3
Results
Controlled DCD
Two decades have passed since initial successful cDCDLTx [47].
Several series from individual institutions and national organizations
have been reported [48-52] (Table 4A,4B).
Today these donors represent about 10% of average transplant
volume worldwide. Only a few reports have showed worse outcomes
with respect to primary graft dysfunction (PGD) and bronchiolitis
obliterans syndrome (BOS) [50,53]. A growing international
multicenter registry reported outcomes comparable to DBD in terms
of early and intermediate survival [54,55] More recently ISHLT
DCD registry published the biggest multicenter series[13] with 306
LTx with no differences in DCD and DBD in survival. Thirty-day
survival was 96% in the DCD group and 97% in the DBD group,
and 1-year survival was 89% in the DCD group and 88% in the DBD
group. Five year survival was 61% in both groups. Median hospital
stay after transplant was 18 days in the DCD group and 16 days in
the DBD group. Very interesting in this report is the finding that
the mechanism of death within the DCD group seemed to influence
short-term recipient survival. Of the 11 deaths within 30 days of transplant, 6 involved donors with head trauma.
Ex vivo lung perfusion (EVLP) in cDCD
Ex vivo lung perfusion has become a potentially useful tool to
reassess, preserve or recover grafts, thus expanding the donor pool.
The Toronto group reported in 2012 fifty lung transplants following
EVLP, 22 of which were from cDCD, with similar outcomes when
compared to the control group (no EVLP perfusion) [56]. They
advocate the use of EVLP in cDCD grafts due to concerns regarding
the incidence of primary graft dysfunction. With this strategy, they
have increased to 2 hours the acceptable time between withdrawal
of life-support and cardiac arrest. More recently the same group
reported the results of 28 EVLP with no differences on survival
compared to a cohort of DBDLTx (1 and 5 year 85% and 54% vs.
86% and 62%). They also found that DCD plus EVLP group showed
shorter hospital stay (media 18 days vs. 24 days, respectably) and a
trend toward shorter length of mechanical ventilation (2 vs. 3 days)
[57].
Successful outcomes in the cDCD situation have been reported
without EVLP by other groups [20,49]. In fact, only 13% of all
transplants reported form cDCD donors in the ISHLT DCD registry
in 2013 and 2015, were performed after EVLP assessment [45]. It
seems that EVLP may well prove to be a valuable tool to improve
utilization of these donor lungs, especially when extended donor
criteria are used however further studies are necessary to better define
the role of EVLP in this context.
Uncontrolled DCD
Results published from LTx utilizing uDCD is scarce, even
though the interest on this kind of donors is growing in the lasts
years, only a few reports of successful uDCD around the world have
been published [45]. The most active programs are in Spain. In our
experience, approximately 5% of all potential uDCD become effective
lung donors. The primary reasons for rejection of a donor include lack
of family consent and prolonged ischemic times. After preservation of
potentially suitable organs, the main reasons for not implanting lungs
are gastric aspiration, pulmonary contusion, or suspected pulmonary
embolism.
As for May 2015, we have performed 49 lung transplants from
uDCD .We found an incidence of grade 3 PGD of 37%, and 30 day
mortality 16%. One, 3 and 5 years survival rates were 70, 62 and 54%
respectively [58]. Chronic allograft rejection rates at 3 and 5 years
are 23% and 54% respectively, comparable to those reported in the
international registry [59-63]. After many year working with uDCD
we found that young donor who are close to the ischemia conservative
times, a faster cool down of those grafts and short topical cooling
period are the most reliable factors for viable LTx.
EVLP and uDCD
The first successful lung transplantation form uDCD published
by Steen and co-workers [64] was done with the use of an ex vivo
lung perfusion system. From 2009 to 2014 we adopted EVLP as an
additional tool to evaluate certain grafts prior to implantation. In that
period have been able to perform 11 uDCD lung transplants after EVLP evaluation (7 with EVLP following Toronto protocol and 4
with Organ Care portable system), with inconsistent results in terms
of PGD (5 patients developed grade 3 PGD) [65].
While EVLP is hoped to improve graft function and reduce PGD,
it appears that with uDCD PGD is still a major concern. Current
EVLP systems focus on preservation solutions specifically designed
to dry the lungs, which is a crucial factor after brain death and in
some cases of cDCD. In uDCD, the principal foe is warm ischemia,
leading to immediate cell death and architectural damage ending in
pulmonary edema. We speculate that the mode of vascular injury
increases the risk of PGD despite extra vascular water extraction and
excellent performance ex vivo.
Table 4a
Table 4b
Conclusion
DCD LTx has become a valuable and reliable approach to expand the donor pool and in some scenarios even superior to DBD donors, It is seems that the avoidance of inflammatory mediators resulting from brain death may prove to favor DCDLTx compared with DBD. Concerns regarding assessment of uDCD lungs before transplantation may be mitigated by EVLP, especially in the future when introduction of novel pharmacologic or biologic therapies using EVLP may lead to improved graft function. Our experience with DCDLTx using standardized selection, procurement, and implantation techniques has been good. The education of transplant coordinators, physicians, and surgeons will be critical in expanding the usefulness of this promising source of donor organs.
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