ReviewA review of lung transplant donor acceptability criteria
Section snippets
Background
Generally accepted donor criteria include donor age <55 years.2, 3, 4 However, several recently published reports have shown that older donor lungs can be transplanted successfully. Older donor age might theoretically have beneficial as well as detrimental effects on overall outcome. These effects are attributable to the age and the lung tissue or the donor’s aging immune system. Older lungs may have increased susceptibility to certain cancers and infection, and sub-clinical emphysematous
Arterial blood gases
The origin of the “standard” arterial blood gas criteria for evaluating the suitability of the potential pulmonary donor is shrouded in the mists of time. In 1987 Harjula et al15 described a single case of peri-operative graft failure in which the arterial partial pressure of oxygen (Pao2) was < 100 mm Hg, with a fraction of inspired oxygen (Fio2) of 0.4 (i.e., Pao2/Fio2 ratio <250), and it is likely the acceptability ratio of 300 (Pao2 of 120 mm Hg on an Fio2 of 0.4) was then arbitrarily
Chest X-ray findings
Traditional donor requirements26 include a “clear” chest X-ray (CXR), even though it is well recognized that plain radiology may underestimate structural abnormalities.
Typically, donor CXR reflects the state of hydration, degree of neurogenic pulmonary edema, presence of pulmonary contusion or sepsis and gross antemortem pathologic results. The literature on radiologic features is even less precise than the descriptions of gas exchange because it relies to a greater degree on subjective
Background
Historically, donor lung infection has always been considered an absolute contraindication for lung transplantation.28, 29, 30, 31 This is one of the reasons why many potential multiorgan donors will not become actual lung donors.32 The brain-dead donor is at risk for airway aspiration. Endotracheal intubation and mechanical ventilation of the donor after brain insult is a necessary standard practice. Length of intubation is associated with colonization of the tracheobronchial tree and
Graft ischemic time
The upper limit of acceptable graft ischemic time is still unknown. Acceptance of graft ischemic times in excess of the 4 to 6 hours currently generally tolerated would allow for improved geographic sharing of organs and potentially improved donor lung utilization. Acceptance of longer cold ischemia times may also facilitate organ recovery from non–heart-beating donors.
Although some early reports suggested that increasing ischemic times in heart43 and lung grafts44 negatively impacts
Allograft size matching
Historically, size matching has been considered important in lung transplantation. In fact, several recent reports have shown that there is considerable latitude in size discrepancy between donor and recipient, but the amount of tolerable size mismatch is unknown. What are the potential complications associated with size mismatching? The use of a graft that is too small for the thoracic cavity of the recipient may result in a pleural space problem, with prolonged tube drainage and increased
Transplant literature
There are no published studies in the field of lung transplantation that specifically address post-transplant outcomes with respect to donor smoking history. The generally accepted criterion for an ideal donor is a smoking history of ≤20 pack-years.67 A smoking history of >20 pack-years falls into the category of a “marginal” donor. Several studies have addressed the outcome of marginal donors, but none includes sufficient numbers of >20-pack-year donors for meaningful sub-group analysis.1, 15,
History of cancer in the donor
In 1997, the Cincinnati Transplant Tumor Registry reported on 270 patients who received organs from donors with malignancies.88 Of these patients, 107 (40%) developed tumors that were confined to the allograft or spread to distant organs. The most common donor-transmitted cancer was renal-cell carcinoma, followed by primary lung cancer, malignant melanoma, choriocarcinoma and breast cancer. Experience from the pioneering era of transplantation, when the risk of cancer transmission was not
Background
ABO incompatibility between donor and recipient has always been considered an absolute contraindication to solid organ transplantation, but not to grafting of tissues such as skin and cornea.97 Patients transplanted with organs from ABO-incompatible donors will likely develop hyperacute rejection. The immediate immune reaction between circulating recipient-derived antibodies and antigen-presenting cells in the donor organ will trigger an acute inflammatory reaction that leads to widespread
The asthmatic donor
There is a paucity of information on the use of lung allografts harvested from donors with a history of asthma. The English-language medical literature includes only 2 articles describing a total of 3 recipients of lungs from asthmatic donors. The available information is summarized in what follows.
Ghosh and colleagues106 reported the development of acute airway obstruction in a patient who received a heart–lung bloc from a 15-year-old asthmatic boy. Ostensibly the donor was mildly asthmatic
Length of mechanical ventilation
Prolonged endotracheal intubation and mechanical ventilation of the donor may affect acceptability by increasing the risk of ventilator-associated pneumonia and ventilator-induced lung injury. Data related to the impact of these factors in lung transplantation are scant. Greater than 2 days of mechanical ventilation is an independent risk factor for ventilator- associated pneumonia (VAP) and the crude rate of VAP has been estimated as 1% to 3% per day of intubation and mechanical ventilation.112
Cause of donor death
Although it has been speculated that the cause of donor death may influence the long-term outcome of the transplant, there has been only one retrospective study revealing a higher incidence of both acute and chronic rejection from traumatic brain-death donors as compared with recipients of causes other than brain death.114 Brain injury may lead to upregulation of proinflammatory cytokines, potentially affecting the donor lung and having an influence on the amount of ischemia–reperfusion injury.
Background
There is no particular gender matching in lung transplantation and the effects of gender on donor and recipients are largely unknown. However, due to lung-size considerations, large male recipients more often receive lungs from a male than a female donor. Smaller recipients are more often females and more often receive smaller female lungs. Victims of fatal traumatic head injuries are more often males, and most of these donor lungs are given to male recipients.116 In this way, gender may
References (120)
- et al.
Marginal lung donorsa reassessment
J Thorac Cardiovasc Surg
(2002) - et al.
Augmented age-associated innate immune responses contribute to negative inotropic and lusitropic effects of lipopolysaccharide and interferon gamma
J Mol Cell Cardiol
(2001) - et al.
Influence of graft ischemic time and donor age on survival after lung transplantation
J Heart Lung Transplant
(1999) - et al.
Effect of donor age and ischemic time in intermediate survival and morbidity after lung transplantation
Chest
(2000) - et al.
Early lung allograft function in twin recipients from the same donorrisk factor analysis
Ann Thorac Surg
(1996) - et al.
Liberalization of donor criteria may expand the donor pool without adverse consequence in lung transplantation
J Heart Lung Transplant
(2000) - et al.
The registry of the International Society for Heart and Lung Transplantationeighteenth official report—2001
J Heart Lung Transplant
(2001) - et al.
Proper donor selection for heart–lung transplantation. The Stanford experience
J Thorac Cardiovasc Surg
(1987) - et al.
Donor-acquired fat embolism causing primary organ failure after lung transplantation
Ann Thorac Surg
(1995) - et al.
Pulmonary thromboembolectomy of donor lungs prior to lung transplantation
Ann Thorac Surg
(1999)
Liberalization of donor criteria in lung and heart–lung transplantation
Ann Thorac Surg
Donor criteria and evaluation
Clin Chest Med
The pulmonary donor
Clin Chest Med
The donor lunginfectious and pathologic factors affecting outcome in lung transplantation
J Thorac Cardiovasc Surg
Infectious complications following isolated lung transplantation
Chest
Donor-transmitted pneumonia in experimental lung allografts; successful prevention with donor antibiotic therapy
J Thorac Cardiovasc Surg
A positive donor gram stain does not predict the development of pneumonia, oxygenation or duration of mechanical ventilation following lung transplantation
J Heart Lung Transplant
Influence of graft ischemic time on outcome following lung transplantation
J Heart Lung Transplant
Impact of graft ischemia time on outcomes after bilateral sequential single-lung transplantation
Ann Thorac Surg
Low potassium dextran preservation solution improves lung function after human lung transplantation
J Thorac Cardiovasc Surg
Lung size matching for double lung transplantation based on the submammary thoracic perimeter. Accuracy and functional results
J Thorac Cardiovasc Surg
Donor selection for single and double lung transplantation. Chest size matching and other factors influencing posttransplantation vital capacity
Chest
Donor lung procurementassessment and operative technique
Ann Thorac Surg
Donor acquired small cell lung cancer following pulmonary transplantation
Chest
Bronchogenic carcinoma in lung transplant recipients
J Heart Lung Transplant
Bronchogenic carcinoma complicating lung transplantation
J Heart Lung Transplant
Role of preoperative cessation of smoking and other factors in postoperative pulmonary complicationsa blinded prospective study of coronary artery bypass patients
Mayo Clin Proc
Relationship between the duration of the preoperative smoke-free period and the incidence of postoperative pulmonary complications after pulmonary surgery
Chest
Preoperative prediction of pulmonary complications following thoracic surgery
Chest
Risk of tumor transmission in transplantation from donors with primary brain tumorsan Australian and New Zealand Registry report
Transplant Proc
Transmission of donor cancer into cardiothoracic transplant recipients
Surgery
Cardiopulmonary exercise testing after single and double lung transplantation
Chest
Transmission of donor lymphocytes in clinical lung transplantation
Transplant Int
Chronological aging and photoaging of dendritic cells
Clin Exp Dermatol
Longevity in vitro of human CD4+ T helper cell clones derived from young donors and elderly donors, or from progenitor cellsage associated differences in cell surface molecule expression and cytokine secretion
Biogerontology
Successful outcome of lung transplantation is not compromised by the use of marginal donor lungs
J Thorac Cardiovasc Surg
Maximizing the utilization of donor organs offered for lung transplantation
Am J Respir Crit Care Med
The effect of fluid therapy on alveolar arterial oxygen gradient in brain-dead organ donors
Transplantation
Donor cerebral tissue pulmonary emboli in a functioning transplanted lung
Clin Transplant
Donor cerebral emboli as a cause of acute graft dysfunction in lung transplantation
J Heart Lung Transplant
Improved oxygenation and increased lung donor recovery with high-dose steroid administration after brain death
J Heart Lung Transplant
Unilateral donor lung dysfunction does not preclude successful contralateral single lung transplantation
J Thorac Cardiovasc Surg
Application of pulmonary vein gas analysisa novel approach which may increase the pool of potential lung transplant donors
J Heart Lung Transplant
Lung transplantationa decade of experience
Ann Surg
The lung donorspecial considerations
Transplant Proc
Donor selection for pulmonary transplantation
Transplant Proc
Selection and management of the lung donor
Whence the lungs? A study to assess suitability of donor lungs for transplantation
Transplantation
Cited by (302)
Computed tomography–based machine learning for donor lung screening before transplantation
2024, Journal of Heart and Lung TransplantationDonor respiratory multidrug-resistant bacteria and lung transplantation outcomes
2024, Journal of InfectionValidation of a novel donor lung scoring system based on the updated lung Composite Allocation Score
2024, American Journal of TransplantationEx vivo lung perfusion in donation after circulatory death: A post hoc analysis of the Normothermic Ex Vivo Lung Perfusion as an Assessment of Extended/Marginal Donors Lungs trial
2024, Journal of Thoracic and Cardiovascular SurgeryRisk factors and prognosis of airway complications in lung transplant recipients: A systematic review and meta-analysis
2023, Journal of Heart and Lung TransplantationDonor hyperoxia is a novel risk factor for severe cardiac primary graft dysfunction
2023, Journal of Heart and Lung Transplantation