Donation after circulatory death and lung transplantation

Santos, Pedro Augusto Reck dos; Teixeira, Paulo José Zimermann; Moraes Neto, Daniel Messias de; Cypel, Marcelo

doi:10.36416/1806-3756/e20210369

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Jornal Brasileiro de Pneumologia

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REVIEW AND UPDATE ARTICLE • J. bras. pneumol. 48 (02) • 2022 • https://doi.org/10.36416/1806-3756/e20210369 copy

Donation after circulatory death and lung transplantation

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Lung transplantation is the most effective modality for the treatment of patients with end-stage lung diseases. Unfortunately, many people cannot benefit from this therapy due to insufficient donor availability. In this review and update article, we discuss donation after circulatory death (DCD), which is undoubtedly essential among the strategies developed to increase the donor pool. However, there are ethical and legislative considerations in the DCD process that are different from those of donation after brain death (DBD). Among others, the critical aspects of DCD are the concept of the end of life, cessation of futile treatments, and withdrawal of life-sustaining therapy. In addition, this review describes a rationale for using lungs from DCD donors and provides some important definitions, highlighting the key differences between DCD and DBD, including physiological aspects pertinent to each category. The unique ability of lungs to maintain cell viability without circulation, assuming that oxygen is supplied to the alveoli-an essential aspect of DCD-is also discussed. Furthermore, an updated review of the clinical experience with DCD for lung transplantation across international centers, recent advances in DCD, and some ethical dilemmas that deserve attention are also reported.

Keywords:
Tissue and organ procurement; Brain death; Lung transplantation; Respiratory insufficiency

Standard Criteria for Lung Accepetance for Clinical Transplantation
Age < 55 years
Clear chest X-ray
Adequate gas exchange PAO₂ > 300 mmHg and FiO₂ 100%
Smoking history < 20 pack-years
No evidence of aspiration/purulent secretions on bronchoscopy
No history of primary pulmonary disease or active pulmonary infection
Absence of organisms on gram-stained sputum smear
Absence of chest trauma
Challenges-Donor management-Lungs
Attention to the volume status
Mechanical ventilation management
Hygiene of the airways
Potential infectious sources
Careful assessment of medical history
Continuous discussions with the family

Categories	Maastricht	Modified Maastricht
I	Dead on arrival at hospital	Found dead IA - Out of hospital IB - In-hospital
II	Death with unsuccessful resuscitation	Witnessed cardiac arrest IIA - Out of hospital IIB - In-hospital
III	Awaiting cardiac death	Withdrawal of life-sustaining therapy
IV	Cardiac arrest while brain dead	Cardiac arrest in a brain-dead patient prior to organ recovery
V		Euthanasia

Author	Year	DCD/DBD cases	DCD/DBD 1-year survival, %	DCD/DBD 5-year survival, %	DCD/DBD PGD, %^C	ICU LOS	Hospital LOS
De Oliveira et al.⁴¹41 De Oliveira NC, Osaki S, Maloney JD, Meyer KC, Kohmoto T, D'Alessandro AM, et al. Lung transplantation with donation after cardiac death donors: long-term follow-up in a single center. J Thorac Cardiovasc Surg. 2010;139(5):1306-1315. https://doi.org/10.1016/j.jtcvs.2010.02.004 https://doi.org/10.1016/j.jtcvs.2010.02....	2010	18/282	88/87	81.9/63.3	PGD Grade 2 or 3 within 72 h: 33.3/26.1	4/6	17/20
Van De Wauver et al.⁴²42 Van De Wauwer C, Verschuuren EA, van der Bij W, Nossent GD, Erasmus ME. The use of non-heart-beating lung donors category III can increase the donor pool. Eur J Cardiothorac Surg. 2011;39(6):e175-e180. https://doi.org/10.1016/j.ejcts.2011.01.035 https://doi.org/10.1016/j.ejcts.2011.01....	2011	35/77	91/91	73/66	PGD Grade 3 at 72 h: 6/11	4/5	32/33
Sabashnikov et al.⁴³43 Sabashnikov A, Patil NP, Popov A-F, Soresi S, Zych B, Weymann A, et al. Long-term results after lung transplantation using organs from circulatory death donors: a propensity score-matched analysis†. Eur J Cardiothorac Surg. 2016;49(1):46-53. https://doi.org/10.1093/ejcts/ezv051 https://doi.org/10.1093/ejcts/ezv051...	2015	60/120	86.1/84.2	50.8/66.4	PGD Grade 3 at 72 h: 5/9	5/6	30/32
Ruttens et al.⁴⁴44 Ruttens D, Martens A, Ordies S, Verleden SE, Neyrinck AP, Vos R, et al. Short- and Long-term Outcomes After Lung Transplantation From Circulatory-Dead Donors: A Single-Center Experience. Transplantation. 2017;101(11):2691-2694. https://doi.org/10.1097/TP.0000000000001678 https://doi.org/10.1097/TP.0000000000001...	2017	59/331	87.3/90.9	70.9/78	Highest PGD < 72 h: 44.1/47.7	16.3/14.4	41.1/38.1
Costa et al.⁴⁵45 Costa J, Shah L, Robbins H, Raza K, Sreekandth S, Arcasoy S, et al. Use of Lung Allografts From Donation After Cardiac Death Donors: A Single-Center Experience. Ann Thorac Surg. 2018;105(1):271-278. https://doi.org/10.1016/j.athoracsur.2017.07.023 https://doi.org/10.1016/j.athoracsur.201...	2018	46/237	91/92	78/75^a	PGD Grade 3 at 72 h: 13/17	N/A	22/18*
Qaqish et al.²⁵25 Qaqish R, Watanabe Y, Hoetzenecker K, Yeung J, Chen M, Pierre A, et al. Impact of donor time to cardiac arrest in lung donation after circulatory death. J Thorac Cardiovasc Surg. 2021;161(4):1546-1555.e1. https://doi.org/10.1016/j.jtcvs.2020.04.181 https://doi.org/10.1016/j.jtcvs.2020.04....	2021	180/1088	N/A	8.0/6.9^b	PGD Grade 2 and 3 at 72 h: 17.2 and 13.9/9, respectively	4.0	23/25

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[1] Correspondence to:
Pedro Augusto Reck dos Santos. Department of Cardiothoracic Surgery, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, 85054, AZ, USA. Tel.: 1 412 3989072. E-mail: reckdossantos.pedro@mayo.edu