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.
Objective
Donor blood transfusion has been identified as a potential risk factor for primary graft dysfunction and by extension early mortality. We sought to define the contributing risk of donor transfusion on early mortality for lung transplant.
Methods
Donor and recipient data were abstracted from the OPTN database updated through 6/30/14, which included 86,398 potential donors and 16,255 transplants. Using the UNOS 4-level designation of transfusion (no blood, 1–5 units, 6–10 units, and >10 units - massive), all-cause mortality at 30-days was analyzed using logistic regression adjusted for confounders (ischemic time, donor age, recipient diagnosis, LAS and recipient age and recipient BMI). Secondary analyses assessed 90-day, 1-year mortality and hospital length of stay.
Results
Of the 16,255 recipients transplanted, 8,835 (54.35%) donors received at least one transfusion. Among those transfused, 1,016 (6.25%) received a massive transfusion, defined as >10 units. Those donors with massive transfusion were most commonly young trauma patients. Following adjustment for confounding variables, donor massive transfusion was significantly associated with an increased risk in 30-day (p = .03) and 90-day recipient mortality (p= 0.01) but not 1-year mortality (p = 0.09). There was no significant difference in recipient length of stay or hospital free days with respect to donor transfusion.
Conclusions
Massive donor blood transfusion (>10 units) was associated with early recipient mortality after lung transplantation. Conversely, sub-massive donor transfusion was not associated with increased recipient mortality. The mechanism of increased early mortality in recipients of lungs from massively transfused donors is unclear and needs further study, but is consistent with excess mortality seen with primary graft dysfunction in the first 90 days post-transplant.
Summary
Antibody‐Mediated Rejection (AMR) due to donor‐specific antibodies (DSA) is associated with poor outcomes after lung transplantation. Currently, there are no guidelines regarding the selection of treatment protocols. We studied how DSA characteristics including titers, C1q, and mean fluorescence intensity (MFI) values in undiluted and diluted sera may predict a response to therapeutic plasma exchange (TPE) and inform patient prognosis after treatment. Among 357 patients consecutively transplanted without detectable pre‐existing DSAs between 01/01/16 and 12/31/18, 10 patients were treated with a standardized protocol of five TPE sessions with IVIG. Based on DSA characteristics after treatment, all patients were divided into three groups as responders, partial responders, and nonresponders. Kaplan–Meier Survival analyses showed a statistically significant difference in patient survival between those groups (P = 0.0104). Statistical analyses showed that MFI in pre‐TPE 1:16 diluted sera was predictive of a response to standardized protocol (R2 = 0.9182) and patient survival (P = 0.0098). Patients predicted to be nonresponders who underwent treatment with a more aggressive protocol of eight TPE sessions with IVIG and bortezomib showed improvements in treatment response (P = 0.0074) and patient survival (P = 0.0253). Dilutions may guide clinicians as to which patients would be expected to respond to a standards protocol or require more aggressive treatment.
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