More on lungs donated after uncontrolled circulatory death
Two new studies show excellent success rates but low utilization rates and complex logistics.
Spain has long pioneered the utilization of organs derived from donors who died of uncontrolled circulatory /cardiac (uDCD) death outside the controlled environment of hospital care, partly due to assumed universal donation consent. Last year we reported from Madrid on the first comparison of long-term post-transplant outcomes between 38 of these uDCD derived lungs and 292 lung transplants from conventional brain dead (DBD) derived lungs (5). EVLP was performed in 21% of the uDCD lungs. Although some early and late outcomes for transplant recipients were not different, including time in ICU, length of hospital stay, primary graft dysfunction (PGD) rates and chronic graft dysfunction, overall survival was significantly lower for patients who had received lungs from uDCD donors (5).
Since then, a couple of new studies on this topic have been published.
Another Spanish group from Santander (6) report evaluation of nine uDCD lungs , of which eight were transplanted, and two subjected to EVLP. Mean no-flow time was circa 10 minutes and mean time from cardiac arrest to topical cooling was 1.6 hours. Total mean ischemic time was just over 11 hours! Although the authors point out that “the logistic complexity of procuring lungs from uDCDs for transplantation requires the development of new strategies designed to facilitate this type of donation,” their results in terms of excellent overall survival (one-month, one-year, and five-year survival rates were 100%, 87.5%, and 87.5%, respectively) seem to justify the effort.
The latest study, from Toronto (7) also recognizes the relevance of a new strategy. They use a simple method of in situ lung inflation so that the organ can be protected from warm ischemic injury. Of 44 potential donors, family consent was obtained in 30 (68%), the lung transplant team evaluated 16 uDCDs on site, and 14 were considered for transplantation pending ex vivo lung perfusion (EVLP) assessment. Mean warm ischemic time was 2.8 hours. Five lungs were ultimately transplanted.
Interestingly, no PGD grade 3 was observed after transplant. The 30‐day mortality was 0% and four out of five patients were alive at a median of 651 days with preserved lung function. The authors conclude, “this study demonstrates the proof of concept and the potential for uDCD lung donation using a simple donor intervention.”
The authors claim their report is the first data on successful uDCD lung transplantation from North America. The theoretical donor potential of uncontrolled DCD lungs is, of course, many times that of lungs donated under controlled medical care conditions – some sources suggest at least 80,000 in Nth America. But the complexity of logistics have so far proved to be a real challenge.
5. Valdivia D et al, Expanding the horizons: Uncontrolled donors after circulatory death for lung transplantation – First comparison with brain death donors. Clin Transplant. 2019 Apr 2:e13561. doi: 10.1111/ctr.13561 (link to abstract)
6. Borja Suberviola et al, Excellent Long-Term Outcome With Lungs Obtained From Uncontrolled Donation After Circulatory Death. Am J transplant. 19 (4) , 1195-1201 , Apr 2019 (link to abstract)
7. A Healey et al, Initial Lung Transplantation Experience with Uncontrolled Donation after Cardiac Death in North America (Toronto) Amer. J Transplant 2020 Jan (link to abstract)
Xvivo Insights PB-2020-02-27