Download presentation
Presentation is loading. Please wait.
Published byArabella Parsons Modified over 9 years ago
1
How Marginal can the Marginal Donor Be? J H DARK Freeman Hospital University of Newcastle
2
NUMBER OF LUNG TRANSPLANTS REPORTED BY YEAR AND PROCEDURE TYPE ISHLT NOTE: This figure includes only the lung transplants that are reported to the ISHLT Transplant Registry. As such, this should not be construed as representing changes in the number of lung transplants performed worldwide. 2009
4
Number of solid organ donors and lung transplantations- UK UK Transplant
5
Up to 40% of donors yielding lungs for transplant in some parts of the World
6
Lung Transplant Referrals for CF Freeman Hospital 1994-2004
10
Lung Transplantation for Cystic Fibrosis Actual Survival
12
Marginal Donors Landmarks Classical Criteria Harjula et al JTCVS 1987; 94:874-880
13
Ideal lung donor selection criteria Age < 55 yr ABO compatibility Clear chest radiograph PaO 2 (FiO 2 100 % + 5 cm H 2 O PEEP) > 40 kPa (PaO 2 /FiO 2 ) Smoking < 20 pack-years Absence of chest trauma Lack of previous cardiopulmonary surgery Absence of organisms on sputum Gram stain Absence of purulent bronchoscopic secretions Aggressive management of lung donors classified as unacceptable: Excellent recipient survival one year after transplantation Straznicka, M et al., JTCVS August 2002, Volume 124, Number 2 250-258
14
Marginal Donors Landmarks Classical Criteria Sudaresan et al “Successful outcome of lung transplantation is not compromised by the use of marginal donor lungs” JTCVS, 1995; 109:1075-79
15
Marginal Donors Landmarks Classical Criteria Sudaresan et al “Successful outcome of lung transplantation is not compromised by the use of marginal donor lungs” JTCVS, 1995; 109:1075-79 Orens et al “A review of lung transplant donor acceptability criteria” JHLT 2003; 22:1183-1200
16
TABLE IISUMMARY OF LITERATURE FOR THE USE OF OLDER LUNG DONORS nDesign Outcome Novick et al (1999) 284/5,052RetrospectiveDecreased survival Meyer et al (2000) 23/1,800RetrospectiveNo adverse affect on intermediate survival Bhorade et al (2000) 9/52RetrospectiveNo adverse affect on ventilator time, hospital stay or hospital survival Hosenpud et al (2001) 15,465RetrospectiveRisk factor for 1- and 5-year mortality. Adapted from Orens et al, JHLT 2003;22:1183-1200
17
TABLE III SUMMARY OF LITERATURE FOR DONOR BLOOD GASES (PaO2/F1O2 <300) n Study Design Outcome Harjula et al (1987) 1 Case report Primary graft failure Shumway et al (1994) 25 (1) Case series No adverse affect Sandaresan et al (1995) 6 Retrospective review No adverse affect Adapted from Orens et al, JHLT 2003;22:1183-1200
18
TABLE IV SUMMARY OF LITERATURE FOR ABNORMAL DONOR CHEST X-RAY Reference nDesign Outcome (survival) Gabbay et al (1999) 39/64 Retrospective review No adverse affect Sundaresan et al (1995) 39/44 Retrospective review No adverse affect Bhorade et al (2000) 5/52 Retrospective review No adverse affect Adapted from Orens et al, JHLT 2003;22:1183-1200
19
TABLE V SUMMARY OF LITERATURE FOR DONOR LUNG ISCHEMIC TIME (ISCHEMIC TIME >5 TO 6 HOURS) Reference nDesign Outcome (survival) Snell et al (1996) 63/106 Retrospective review Reduced long term Novick et al (1999) 5,052 Retrospective review No adverse affect of registry data except when older donor age Gammie et al (1999) 60/392 Retrospective review No adverse affect Fiser et al (2001) 15/136 Retrospective review No adverse affect Kshettry et al (1996) 8/83 Retrospective review No adverse affect Adapted from Orens et al, JHLT 2003;22:1183-1200
20
TABLE VII SUMMARY OF LITERATURE FOR DONOR SMOKING HISTORY Reference nDesign Outcome (survival) Gabbay et al (1999) 5/64 Retrospective review No adverse affect Sundaresan et al (1995) 9/44 Retrospective review No adverse affect Bhorade et al (2000) 15/52 Retrospective review No adverse affect (average 36 pack- years) No differences in short-term outcome with regard to post-operative ventilation or oxygenation, nor long-term survival to 2.5 to 3 years. Adapted from Orens et al, JHLT 2003;22:1183-1200
21
Marginal Donors Is there other Evidence?
22
Marginal Donors Is there other Evidence? Ware et al, (Lancet 2002) assessed 29 pairs of lungs rejected for use. 83% had no or mild pulmonary oedema, 74% had intact alveolar fluid clearance and 62% had normal histology
23
Marginal Donors Is there other Evidence? Fisher et al (Thorax 2004) assessed inflammatory markers in lungs not used for transplant. There was no difference in BAL IL8 or neutrophil counts in the excluded lungs. Trend towards more infection in used lungs
24
Marginal Donors What is New? Where are we in 2010? What are the limits?
25
Marginal Donors AGE
26
TABLE IISUMMARY OF LITERATURE FOR THE USE OF OLDER LUNG DONORS nDesign Outcome Novick et al (1999) 284/5,052RetrospectiveDecreased survival Meyer et al (2000) 23/1,800RetrospectiveNo adverse affect on intermediate survival Bhorade et al (2000) 9/52RetrospectiveNo adverse affect on ventilator time, hospital stay or hospital survival Hosenpud et al (2001) 15,465RetrospectiveRisk factor for 1- and 5-year mortality. Adapted from Orens et al, JHLT 2003;22:1183-1200
27
ADULT LUNG TRANSPLANTS (1/1995-6/2001) Risk Factors for 1 Year Mortality Donor Age
28
ADULT LUNG TRANSPLANTS (1/1995-6/1997) Risk Factors for 5 Year Mortality Donor Age
29
HEART TRANSPLANTS : Donor Age by Year of Transplant
30
MEAN AGE OF CARDIAC DONORS IN THE UK, 1990 - 2002
31
Cause of Death of all Organ Donors(%) UK 1989-2002
32
Marginal Donors OXYGENATION
33
TABLE III SUMMARY OF LITERATURE FOR DONOR BLOOD GASES (PaO2/F1O2 <300) n Study Design Outcome Harjula et al (1987) 1 Case report Primary graft failure Shumway et al (1994) 25 (1) Case series No adverse affect Sandaresan et al (1995) 6 Retrospective review No adverse affect Adapted from Orens et al, JHLT 2003;22:1183-1200 No Lower limit defined from the literature
34
From Luckraz et al JHLT 2005;24:470-473
35
Marginal Donors OXYGENATION Luckraz et al JHLT 2005;24:470-473 350 patients, all paired lungs, one institution Higher 30 day mortality No overall increase But 300 were HLTx, Ischaemic times c 3hrs
36
Aggressive management of lung donors classified as unacceptable: Excellent recipient survival one year after transplantation Straznicka, M et al. JTCVS August 2002, Volume 124, Number 2 250-258 Division of Cardiothoracic Surgery, University of California, Davis Medical Centre, Sacramento
37
Hypothesis Donor lungs with unacceptable PaO 2 /FiO 2 ratios (<20 kPa) can be made acceptable with aggressive management and that 30-day and 1- year recipient outcomes with these lungs would not be significantly different than outcomes of recipients with traditionally ideal lungs Aggressive management of lung donors classified as unacceptable: Excellent recipient survival one year after transplantation Straznicka, M et al., JTCVS August 2002, Volume 124, Number 2 250-258
38
Results of OPO management Aggressive management of lung donors classified as unacceptable: Excellent recipient survival one year after transplantation Straznicka, M et al., JTCVS August 2002, Volume 124, Number 2 250-258 103 = 13.7 kPa 463 = 61.7 kPa
39
Kaplan-Meier survival curves Aggressive management of lung donors classified as unacceptable: Excellent recipient survival one year after transplantation Straznicka, M et al., JTCVS August 2002, Volume 124, Number 2 250-258
40
Conclusion Aggressive organ procurement management of donors initially considered unacceptable may increase the number of lungs available for transplantation Aggressive management of lung donors classified as unacceptable: Excellent recipient survival one year after transplantation Straznicka, M et al., JTCVS August 2002, Volume 124, Number 2 250-258
41
Marginal Donors SMOKING?
42
TABLE VII SUMMARY OF LITERATURE FOR DONOR SMOKING HISTORY Reference nDesign Outcome (survival) Gabbay et al (1999) 5/64 Retrospective review No adverse affect Sundaresan et al (1995) 9/44 Retrospective review No adverse affect Bhorade et al (2000) 15/52 Retrospective review No adverse affect (average 36 pack- years) No differences in short-term outcome with regard to post- operative ventilation or oxygenation, nor long-term survival to 2.5 to 3 years. Adapted from Orens et al, JHLT 2003;22:1183-1200
43
Marginal Donors SMOKING? Oto et al Transplantation 2004; 78:599-606 Significant early effect on oxygenation, ventilation time, and hospital stay, particularly for current and heavy dose smokers
46
Marginal Donors SMOKING? Oto et al Transplantation 2004; 78:599-606 Significant early effect on oxygenation, ventilation time, and hospital stay, particularly for current and heavy dose smokers Almost half donors fell into the high-risk category
47
Marginal Donors INFECTION?
48
Marginal Donors INFECTION? A positive donor gram stain does not predict outcome following lung transplantation Weill et al JHLT 2002; 21:555-558
49
Marginal Donors INFECTION? A positive donor gram stain does not predict outcome following lung transplantation Weill et al JHLT 2002; 21:555-558 Bacterial colonisation of the donor lower airways is a predictor of poor outcome in lung transplantation Avlonitis et al, EJCTS 2003; 24:601-607
50
Marginal Donors Bacterial colonisation of the donor lower airways is a predictor of poor outcome in lung transplantation Avlonitis et al, EJCTS 2003; 24:601-607 115 patients, donor BAL cultured 46% positive culture Longer ventilation, ITU, hospital stay for recipients with bacterially infected donors Worse short and log-term outcome No increase in BOS in one-year survivors
51
Avlonitis et al, EJCTS 2003; 24:601-607
52
Total Marginal Organs
53
Mean duration of Ventilation
54
Re-intubated (%)
55
Tracheostomy
56
Transplantation 2006;82:1273-9
57
Marginal Donors Conclusions Many indicators of “Marginality” have a price, at least in terms of early dysfunction, and eventually overall survival These risks, minimised by better donor care and improved post-op management, are still worth taking for our recipient population
58
Marginal Donors Conclusions Many indicators of “Marginality” have a price, at least in terms of early dysfunction, and eventually overall survival These risks, minimised by better donor care and improved post-op management, are still worth taking for our recipient population Who receives the marginal organ is unresolved
59
THE END
Similar presentations
© 2025 SlidePlayer.com. Inc.
All rights reserved.