Donation after circulatory death in lung transplantation-five-year follow-up from ISHLT Registry

Van Raemdonck D1, Keshavjee S2, Levvey B3, Cherikh WS4, Snell G3, Erasmus M5, Simon A6, Glanville AR7, Clark S8, D’Ovidio F9, Catarino P10, McCurry K11, Hertz MI12, Venkateswaran R13, Hopkins P14, Inci I15, Walia R16, Kreisel D17, Mascaro J18, Dilling DF19, Camp P20, Mason D21, Musk M22, Burch M23, Fisher A8, Yusen RD17, Stehlik J24, Cypel M2;

International Society for Heart and Lung Transplantation. (Leuven, Belgium. Electronic address: Heart Lung Transplant. 2019 Dec;38(12):1235-1245. doi: 10.1016/j.healun.2019.09.007.

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This study aimed to examine intermediate-term outcomes of lung transplantation (LTx) recipients from donors after circulatory death (DCD).

We examined the International Society for Heart and Lung Transplantation (ISHLT) Thoracic Transplant Registry data for patients transplanted between January 2003 and June 2017 at 22 centers in North America, Europe, and Australia participating in the DCD Registry. The distribution of continuous variables was summarized as median and interquartile range (IQR) values. Wilcoxon rank sum test was used to compare distribution of continuous variables and chi-square or Fisher’s exact test for categorical variables. Kaplan-Meier survival rates after LTx from January 2003 to June 2016 were compared between DCD-III (Maastricht category III withdrawal of life-sustaining therapy [WLST]) only and donors after brain death (DBD) using the log-rank test. Risk factors for 5-year mortality were investigated using Cox multivariate proportional-hazards model.

The study cohort included 11,516 lung transplants, of which 1,090 (9.5%) were DCD lung transplants with complete data. DCD-III comprised 94.1% of the DCD cohort. Among the participating centers, the proportion of DCD-LTx performed each year increased from 0.6% in 2003 to 13.5% in 2016. DCD donor management included extubation in 91%, intravenous heparin in 53% and pre-transplant normothermic ex vivo donor lung perfusion in 15%. The median time interval from WLST to cardiac arrest was 15 minutes (IQR: 11-22 minutes) and to cold flush 32 minutes (IQR: 26-41minutes). Compared with DBD, donor age was higher in DCD-III donors (46 years [IQR: 34-55] vs 40 years [IQR: 24-52]), bilateral LTx was performed more often (88.3% vs 76.6%), and more recipients had chronic obstructive pulmonary disease and emphysema as their transplant indication. Five-year survival rates were comparable (63% vs 61%, p = 0.72). In multivariable analysis, recipient and donor ages, indication diagnosis, procedure type (single vs bilateral and double LTx), and transplant era (2003-2009 vs 2010-2016) were independently associated with survival (p < 0.001), but donor type was not (DCD-III vs DBD; hazard ratio, 1.04 [0.90-1.19], p = 0.61).

This ISHLT DCD Registry report with 5-year follow-up demonstrated similar favorable long-term survival in DCD-III and DBD lung donor recipients at 22 experienced centers globally. These data indicate that moreextensive use of DCD-LTx would increase donor organ availability and may reduce waiting list mortality.

Copyright © 2019 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.            KEYWORDS: donor lung allograft; donors after circulatory death; lung transplantation; mortality risk factors; survival.
PMID:  31777330     DOI: