Maximizing the Utilization of Donor Organs Offered for Lung Transplantation

Abstract

The number of patients awaiting lung transplantation (LT) and waiting time for surgery is increasing. In Australia, LT rates are 4. 6/million population/yr, which despite low organ donation rates, are the highest published in the world. The Australian organ allocation system allows identification of marginal donors and therapeutic manipulation where appropriate. This study aims to assess the impact of utilization of marginal donors and aggressive donor management. A comparison between published donor criteria and local practice is made, allowing assessment of the effect of using marginal donors on outcome. Donor management included antibiotic therapy, strict fluid management, physiotherapy, bronchoscopy and bronchial toilet, and alteration of ventilatory settings including initiation of pressure support. Blood gases were repeated to assess the results of interventions. Between January 1, 1995 and May 31, 1998, we performed 140 transplants from 112 of 219 (51%) lung donor offers. Of these donors, 48 (43%) satisfied all published criteria for suitable donor organs (Group 1 = ideal donors) and 64 (57%) did not (Group 2 = marginal donors). Criteria breached by the marginal donors were: an initial ratio of arterial oxygen pressure to fraction of inspired oxygen (PaO2/FIO2) < 300 mm Hg (n = 20), abnormal radiology (n = 39), pulmonary infection (n = 24), 20 pack-years smoking (n = 5) and age > 55 yr (n = 4). Therapeutic manipulation resulted in improvement in the PaO2/FIO2 ratio in 20 donors (Group 3) who would not otherwise have been used. Immediate and 24 h postoperative gas exchange and length of intensive care unit (ICU) stay was not different for recipients from donors from all three groups. Overall survival was 94% at 30 d, 83% at 1 yr, 70% at 2 yr, and 62% at 3 yr and was not significantly different from the three groups. We conclude that organ utilization can be maximized by therapeutic manipulation and utilization of marginal donors without compromising results from transplantation.

Brain death and its implications for management of the potential organ donor

“…On the other hand, smoking history, age, positive Gram stain, number of days on ventilator, or localized abnormality on the chest radiograph may not be associated with increased perioperative risk, and should not by themselves preclude transplantation. 103,132 Organ procurement All the above strategies for donor management have to be continued during organ procurement to ensure optimal organ preservation and posttransplant function. The anesthesiologist of the harvesting team often plays a crucial role in assessing the adequacy of actual fluid resuscitation and vasoactive medication in use.…”

Transbronchial administration of adenoviral-mediated interleukin-10 gene to the donor improves function in a pig lung transplant model

“…Over the years, the donor selection criteria have been expanded to the use of 'nonideal' lung donors. [3][4][5][6] However, this strategy can contribute to an increased risk of immediate graft dysfunction that in turn may lead to enhanced rejection and impaired long-term graft function. 3,[7][8][9] Hence, the development of new strategies to repair and improve the quality of donor lungs could have a tremendous impact on the number of transplants performed as well as on the outcome after transplantation.…”

Diretrizes para manutenção de múltiplos órgãos no potencial doador adulto falecido: Parte III. Recomendações órgãos específicas

“…Studies have shown that the performance of a bronchoscopy, along with frequent pulmonary suction (respiratory physical therapy) and pulmonary expansion ventilation techniques (using PEEP), results in a significant increase in both the quality of the donor organs and in the number of transplantable organs (D) (29) (C). (56,(59)(60)(61)(62) A bronchoscopy can be performed either by a local hospital physician or by the transplant team surgeon (D). (28) During the bronchoscopy, respiratory fluids should be collected (bronchoalveolar lavage fluid) for Gram staining and cultures with the aim of guiding eventual antibiotic therapy (D).…”

“…(6,29,57,63) Recommendations -A bronchoscopy is indicated for all potential lung donors (D) (29) (C). (56,(59)(60)(61)(62) Strong Recommendation. -If a bronchoscopy cannot be performed at the hospital of origin, clinicians should inform the team responsible for removing the organs that this test could not be performed.…”