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How Marginal can the Marginal Donor Be?

How Marginal can the Marginal Donor Be?. J H DARK Freeman Hospital University of Newcastle. NUMBER OF LUNG TRANSPLANTS REPORTED BY YEAR AND PROCEDURE TYPE.

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How Marginal can the Marginal Donor Be?

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  1. How Marginal can the Marginal Donor Be? J H DARK Freeman Hospital University of Newcastle

  2. NUMBER OF LUNG TRANSPLANTS REPORTED BY YEAR AND PROCEDURE TYPE NOTE: This figure includes only the lung transplants that are reported to the ISHLT Transplant Registry. As such, this should not be construed as representing changes in the number of lung transplants performed worldwide. ISHLT 2009

  3. Number of solid organ donors and lung transplantations- UK UK Transplant

  4. Up to 40% of donors yielding lungs for transplant in some parts of the World

  5. Lung Transplant Referrals for CF Freeman Hospital 1994-2004

  6. Lung Transplant Referrals for CF Freeman Hospital 1994-2004

  7. Lung Transplant Referrals for CF Freeman Hospital 1994-2004

  8. Lung Transplant Referrals for CF Freeman Hospital 1994-2004

  9. Lung Transplantation for Cystic Fibrosis Actual Survival

  10. Marginal Donors Landmarks • Classical Criteria Harjula et al JTCVS 1987; 94:874-880

  11. Ideal lung donor selection criteria Age < 55 yr ABO compatibility Clear chest radiograph PaO2 (FiO2 100 % + 5 cm H2O PEEP) > 40 kPa (PaO2/FiO2) Smoking < 20 pack-years Absence of chest trauma Lack of previous cardiopulmonary surgery Absence of organisms on sputum Gram stain Absence of purulent bronchoscopic secretions Aggressive management of lung donors classified as unacceptable: Excellent recipient survival one year after transplantation Straznicka, M et al., JTCVS August 2002, Volume 124, Number 2 250-258

  12. Marginal Donors Landmarks • Classical Criteria • Sudaresan et al “Successful outcome of lung transplantation is not compromised by the use of marginal donor lungs” JTCVS, 1995; 109:1075-79

  13. Marginal Donors Landmarks • Classical Criteria • Sudaresan et al “Successful outcome of lung transplantation is not compromised by the use of marginal donor lungs” JTCVS, 1995; 109:1075-79 • Orens et al “A review of lung transplant donor acceptability criteria” JHLT 2003; 22:1183-1200

  14. TABLE II SUMMARY OF LITERATURE FOR THE USE OF OLDER LUNG DONORS n Design Outcome Novick et al (1999) 284/5,052 Retrospective Decreased survival Meyer et al (2000) 23/1,800 Retrospective No adverse affect on intermediate survival Bhorade et al (2000) 9/52 Retrospective No adverse affect on ventilator time, hospital stay or hospital survival Hosenpud et al (2001) 15,465 Retrospective Risk factor for 1- and 5-year mortality . Adapted from Orens et al, JHLT 2003;22:1183-1200

  15. TABLE III SUMMARY OF LITERATURE FOR DONOR BLOOD GASES (PaO2/F1O2 <300) n Study Design Outcome Harjula et al (1987) 1 Case report Primary graft failure Shumway et al (1994) 25 (1) Case series No adverse affect Sandaresan et al (1995) 6 Retrospective review No adverse affect Adapted from Orens et al, JHLT 2003;22:1183-1200

  16. TABLE IV SUMMARY OF LITERATURE FOR ABNORMAL DONOR CHEST X-RAY Reference n Design Outcome (survival) Gabbay et al (1999) 39/64 Retrospective review No adverse affect Sundaresan et al (1995) 39/44 Retrospective review No adverse affect Bhorade et al (2000) 5/52 Retrospective review No adverse affect Adapted from Orens et al, JHLT 2003;22:1183-1200

  17. TABLE V SUMMARY OF LITERATURE FOR DONOR LUNG ISCHEMIC TIME (ISCHEMIC TIME >5 TO 6 HOURS) Reference n Design Outcome (survival) Snell et al (1996) 63/106 Retrospective review Reduced long term Novick et al (1999) 5,052 Retrospective review No adverse affect of registry data except when older donor age Gammie et al (1999) 60/392 Retrospective review No adverse affect Fiser et al (2001) 15/136 Retrospective review No adverse affect Kshettry et al (1996) 8/83 Retrospective review No adverse affect Adapted from Orens et al, JHLT 2003;22:1183-1200

  18. TABLE VII SUMMARY OF LITERATURE FOR DONOR SMOKING HISTORY Reference n Design Outcome (survival) Gabbay et al (1999) 5/64 Retrospective review No adverse affect Sundaresan et al (1995) 9/44 Retrospective review No adverse affect Bhorade et al (2000) 15/52 Retrospective review No adverse affect (average 36 pack- years) No differences in short-term outcome with regard to post-operative ventilation or oxygenation, nor long-term survival to 2.5 to 3 years. Adapted from Orens et al, JHLT 2003;22:1183-1200

  19. Marginal Donors Is there other Evidence?

  20. Marginal Donors Is there other Evidence? Ware et al, (Lancet 2002) assessed 29 pairs of lungs rejected for use. 83% had no or mild pulmonary oedema, 74% had intact alveolar fluid clearance and 62% had normal histology

  21. Marginal Donors Is there other Evidence? Fisher et al (Thorax 2004) assessed inflammatory markers in lungs not used for transplant. There was no difference in BAL IL8 or neutrophil counts in the excluded lungs. Trend towards more infection in used lungs

  22. Marginal Donors What is New? Where are we in 2010? What are the limits?

  23. Marginal Donors AGE

  24. TABLE II SUMMARY OF LITERATURE FOR THE USE OF OLDER LUNG DONORS n Design Outcome Novick et al (1999) 284/5,052 Retrospective Decreased survival Meyer et al (2000) 23/1,800 Retrospective No adverse affect on intermediate survival Bhorade et al (2000) 9/52 Retrospective No adverse affect on ventilator time, hospital stay or hospital survival Hosenpud et al (2001) 15,465 Retrospective Risk factor for 1- and 5-year mortality . Adapted from Orens et al, JHLT 2003;22:1183-1200

  25. ADULT LUNG TRANSPLANTS(1/1995-6/2001)Risk Factors for 1 Year MortalityDonor Age

  26. ADULT LUNG TRANSPLANTS(1/1995-6/1997)Risk Factors for 5 Year MortalityDonor Age

  27. HEART TRANSPLANTS: Donor Age by Year of Transplant

  28. MEAN AGE OF CARDIAC DONORS IN THE UK, 1990 - 2002

  29. Cause of Death of all Organ Donors(%) UK 1989-2002

  30. Marginal Donors OXYGENATION

  31. TABLE III SUMMARY OF LITERATURE FOR DONOR BLOOD GASES (PaO2/F1O2 <300) n Study Design Outcome Harjula et al (1987) 1 Case report Primary graft failure Shumway et al (1994) 25 (1) Case series No adverse affect Sandaresan et al (1995) 6 Retrospective review No adverse affect No Lower limit defined from the literature Adapted from Orens et al, JHLT 2003;22:1183-1200

  32. From Luckraz et al JHLT 2005;24:470-473

  33. Marginal Donors OXYGENATION Luckraz et al JHLT 2005;24:470-473 350 patients, all paired lungs, one institution Higher 30 day mortality No overall increase But 300 were HLTx, Ischaemic times c 3hrs

  34. Aggressive management of lung donors classified as unacceptable: Excellent recipient survival one year after transplantation Straznicka, M et al. JTCVS August 2002, Volume 124, Number 2 250-258 Division of Cardiothoracic Surgery, University of California, Davis Medical Centre, Sacramento

  35. Hypothesis Donor lungs with unacceptable PaO2/FiO2 ratios (<20 kPa) can be made acceptable with aggressive management and that 30-day and 1-year recipient outcomes with these lungs would not be significantly different than outcomes of recipients with traditionally ideal lungs Aggressive management of lung donors classified as unacceptable: Excellent recipient survival one year after transplantation Straznicka, M et al., JTCVS August 2002, Volume 124, Number 2 250-258

  36. Results of OPO management 103 = 13.7 kPa 463 = 61.7 kPa Aggressive management of lung donors classified as unacceptable: Excellent recipient survival one year after transplantation Straznicka, M et al., JTCVS August 2002, Volume 124, Number 2 250-258

  37. Kaplan-Meier survival curves Aggressive management of lung donors classified as unacceptable: Excellent recipient survival one year after transplantation Straznicka, M et al., JTCVS August 2002, Volume 124, Number 2 250-258

  38. Conclusion Aggressive organ procurement management of donors initially considered unacceptable may increase the number of lungs available for transplantation Aggressive management of lung donors classified as unacceptable: Excellent recipient survival one year after transplantation Straznicka, M et al., JTCVS August 2002, Volume 124, Number 2 250-258

  39. Marginal Donors SMOKING?

  40. TABLE VII SUMMARY OF LITERATURE FOR DONOR SMOKING HISTORY Reference n Design Outcome (survival) Gabbay et al (1999) 5/64 Retrospective review No adverse affect Sundaresan et al (1995) 9/44 Retrospective review No adverse affect Bhorade et al (2000) 15/52 Retrospective review No adverse affect (average 36 pack- years) No differences in short-term outcome with regard to post-operative ventilation or oxygenation, nor long-term survival to 2.5 to 3 years. Adapted from Orens et al, JHLT 2003;22:1183-1200

  41. Marginal Donors SMOKING? Oto et al Transplantation 2004; 78:599-606 Significant early effect on oxygenation, ventilation time, and hospital stay, particularly for current and heavy dose smokers

  42. Marginal Donors SMOKING? Oto et al Transplantation 2004; 78:599-606 Significant early effect on oxygenation, ventilation time, and hospital stay, particularly for current and heavy dose smokers Almost half donors fell into the high-risk category

  43. Marginal Donors INFECTION?

  44. Marginal Donors INFECTION? A positive donor gram stain does not predict outcome following lung transplantation Weill et al JHLT 2002; 21:555-558

  45. Marginal Donors INFECTION? A positive donor gram stain does not predict outcome following lung transplantation Weill et al JHLT 2002; 21:555-558 Bacterial colonisation of the donor lower airways is a predictor of poor outcome in lung transplantation Avlonitis et al, EJCTS 2003; 24:601-607

  46. Marginal Donors Bacterial colonisation of the donor lower airways is a predictor of poor outcome in lung transplantation Avlonitis et al, EJCTS 2003; 24:601-607 115 patients, donor BAL cultured 46% positive culture Longer ventilation, ITU, hospital stay for recipients with bacterially infected donors Worse short and log-term outcome No increase in BOS in one-year survivors

  47. Avlonitis et al, EJCTS 2003; 24:601-607

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