DONOR CRITERIA
Lung transplantation wsa first successfullly performed as Heart/Lung Transplant, which may hvae led to conservative age limits of the donor more related to cardiac risk factors. Lung function does decline with age but an increase in donor age without smoking or severe environmental factors operating would appear to make only slight differences. it is report that although not individually, risk factors of age ( >50 years) and donor cold ischemic time ( >7 hours) when combined have a detectable adverse effect on recipient outcome. However, increasing the donor age limit to <65 years seems a reasonable approach while maintaining a short (< 7 hours) cold ischemic time.
CLEAR CHEST X-RAY - The use of donors with abnormalties on chest x-ray has been reported, usually following a period of intensive donor management with quite acceptable outcomes. Potential approaches to consider include: donor management( bronchoscopic removal of secretions, positive end-expiratory pressure(PEEP), suctioning and physiotherapy); using one lung only if unilateral abnormality, or bilateral lung transplantation on the basis of a better post operative reserve.
ARTERIAL BLOOD GAS CRITERIA - Generally donors with PaO2<300 mmHg on FiO2=1.0 and PEEP = 5cmH2O will have clear cut radiographic abnormalities. In the absence of other clear problems, almost 50% of donors apparently failing arterial blood gas (ABG) criteria will improve with management and or time and will prove suitable for lung donation.
NO EVIDENCE OF ASPIRATION, SEPSIS, OR PURULENT SECRETIONS AT BRONCHOSCOPY - Lungs that are clearly heavily infected, especially if appropriate antibiotic therapy has been instituted, will be generally unsuitable for transplantation. A few thick secretions that are easily removed , without rapid return of more purulent secretions, is almost certainly acceptable. Even in the setting of known aspiration, if the blood gas gases are good and there are few secretions, the donor will be suitable.
SPUTUM OR BRONCIAL LAVAGE GRAM STAIN - Bronchial lavage should be performed to give the recipient team a head start on culture. Unless fungal elements or heavy bacterial contamination is present, bronchial washing gram stain it itself should not be used as an absolute contraindication to lung transplant.
SMOKING HISTORY = 20 PACK-YEARS - A smoking history of 10 cigarettes/day carries a low risk for lung cancer and chronic obstructive pulmonary disease. A change to a 20 cigarette/day smoking history would almost double the risk of lung cancer but only slightly increase the risk of COPD.
OTHER ISSUES - Careful inspection of the lungs at the time of organ procurement should be performed to look for serious lung contusion or laceration, although minor bruising is acceptable. The use of asthmatic donors ( usually mild, well, and controlled) does not seem to effect the recipient.
Donor Selection
The impact of undersized lungs transplanted into recipients undergoing transplantation for COPD was reported. The cutoff criterion was lungs tha were undersized >10% based on calculated donor total lung capacity. The outcomes of these patients were compared with outcomes of recipients undergoing transplantation for COPD who did not receive undersized lungs. The undersized lung group had significantly worse survival. Undersized lung recipients also had prolonged mechanical ventilation and hospital length stay.
(Source: Highlights From the 98th International Conference of the American Thoracic Society, May 17-22, 2002, Atlanta, Georgia)
Size matching in lung transplantation - Height is used in allocation of donor lungs as an indirect estimate of thoracic size. Total lung capacity(TLC), determined by both height and sex, could be a more accurate functional estimation of thoracic size. In a study, neither sex mismatch nor TLC mismatch were related to clinical or functional complications. Allocation of donor lungs based upon height alone leads to a substantial mismatch in total lung capacity caused by sex mismatch. The absence of complications suggests that a great height donor/recipient discrepancy can be accepted for allocation than previously assumed. (Source: J.P. Ouwens, Lung Transplantation Group, University Hospital Groningen, The Netherlands.)
Donor Age Does Not Affect Recipients Survival after Lung Transplantation - Patients undergoing lung transplantation from older donors fare just as well as those whose donors are younger, a new study shows. To find out if older age should be a contraindication for organ transplantation, 13 patients were followed who received organs from donors older than 50 and 22 patients who received organs from younger donors. The primary end point was survival at 1-year-post transplant, with secondary end points of number and total days of hospitalization, development of BOS, and pulmonary function tests. Donor age had not statistically significant impact on 1-year survival.At 1 year, 16 of the 22 patients in the younger donor group were alive compared to 10 of the 13 i the older donor group. There was also no statistically significant effect on the incidence of hospitalization or of BOS or on lung function parameters between the two groups at 1 year. One patient in the younger donor group developed BOS, compared with two in the older donor group. Percent of lung function, as measured by forced vital capacity and forced expiratory volume was 2.34 and 1.69 in the younger donor group, compared to 2.17 and 1.54 in the older donor group. The conclusion was that there is no reason to pass over potential donors ages 55 or older.(Source: ATS, By Charles Laino, Seatlle, Washington)
Liberalization of donor criteria for lung transplantation - (Added 10/4/04) -Purpose of review: The greatest factor limiting the number of lung transplants performed each year is the availability of acceptable donors. Liberalization of currently accepted donor criteria would allow for an increase in the number of donor lungs procurable. This would help treat
those patients on the ever-expanding transplant waiting list.Recent findings: The generally accepted criteria for an acceptable donor are: age less than 55 years, clear chest radiograph, PaO2/FiO2 ratio greater than 300, and a clear bronchoscopy. Historically these parameters have little evidence-based support. Numerous recent studies of patients transplanted with nonstandard lungs show no difference in outcomes when compared with those transplanted with lungs that met all criteria. However, a few studies have noted that certain donor criteria could predict short-term adverse outcome. The specific criteria implicated as risk factors are donor age and prolonged graft ischemic time in conjunction with advanced donor age. Although caution is justified when transplanting nonstandard lungs with multiple risk factors into high-risk patients, liberalization of the criteria now is well supported. (Source: Current Opinion in Organ Transplantation. September 2004)
