Lungs From the Controlled Donation After Circulatory Determination of Death Donor: Perspectives From the United States and Beyond

Use of lungs for transplant from controlled donation after circulatory determination of death donors varies internationally—because of awareness or differences in health care systems? See the article from Mooney et al on page 1207. Use of lungs for transplant from controlled donation after circulatory determination of death donors varies internationally—because of awareness or differences in health care systems? See the article from Mooney et al on page 1207. The concept of using lungs from controlled donation after circulatory determination of death (cDCDD) donors originated in the United States. The initial experimental work of one of the authors (T.M.E.) showing that cDCDD lungs could be transplanted (1.Egan TM Lambert Jr, CJ Reddick RL Ulicny Jr, KS Keagy BA Wilcox BR. A strategy to increase the donor pool: The use of cadaver lungs for transplantation.Ann Thorac Surg. 1991; 52: 1113-1121Abstract Full Text PDF PubMed Scopus (216) Google Scholar) was converted to clinical reality by Love and others in Wisconsin (2.Love RB Stringham J Chomiak PN Pellett JR Mentzer Jr, RM First successful lung transplantation using a nonheart-beating donor [abstract].J Heart Lung Transplant. 1995; 14 (Suppl): S88Google Scholar). In Australia, Canada, parts of Eurotransplant and the United Kingdom, cDCDD donors compose at least 20% of all pulmonary transplants. The lung may be the most suitable organ for cDCDD donation, with its tolerance (once inflated) to ischemia and the putative gain from avoiding the almost invariably injurious process of brainstem death. In this issue, Mooney et al used data from the SRTR database over slightly more than 8 years to analyze quality and utilization of lungs recovered from cDCDD donors in the United States (3.Mooney JJ Hedlin H Mohabir PK Lung quality and utilization in controlled donation after circulatory determination of death within the United States.Am J Transplant. 2016; 16 (et al): 1207-1215Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar. They found that lung utilization for lung transplant (LTx) was dismally low (2.1%) compared with 21% lung utilization from donation after neurologic determination of death (DNDD) donors (i.e. donors after brain death) and notably lower in the United States compared with some other countries. Almost 8000 cDCDD donors yielded 162 LTx; annual U.S. cDCDD activity is similar to that of the United Kingdom, with a lower DNDD donor rate and a population one-fifth the size. Although 57 of 58 U.S. organ procurement organizations (OPOs) participated in any organ recovery from cDCDD donors, only 35 OPOs transplanted lungs from a cDCDD donor. Of 84 LTx centers, only 26 (31%) performed LTx from a cDCDD donor. Activity is disproportionately distributed. Half of all LTx from cDCDD donors in the United States occurred at just two centers, and 80% occurred at the seven most prolific centers that use cDCDD donors for LTx. Linear regression showed a relationship between LTx center volume and LTx from cDCDD donors; however, just as there are two “outlier” high-volume high-use centers that account for 50% of all cDCDD donors for LTx, there are two high-volume centers with minimal or no experience with LTx from cDCDD donors. With so many LTx centers never having transplanted lungs from a cDCDD donor, the relationship between LTx center volume and lung utilization from cDCDD donors may be artifactual. Are the lungs as good? Some markers, such as oxygenation (increasingly recognized as a poor discriminator), were a little worse in the cDCDD donors. However, for lungs actually transplanted, a wealth of evidence shows that short- and medium-term outcomes are identical to those in DNDD donors (4.Krutsinger D Reed RM Blevins A Lung transplantation from donation after cardiocirculatory death: A systematic review and meta-analysis.J Heart Lung Transplant. 2015; 34 (et al): 675-684Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar, as in this series by Mooney et al (3.Mooney JJ Hedlin H Mohabir PK Lung quality and utilization in controlled donation after circulatory determination of death within the United States.Am J Transplant. 2016; 16 (et al): 1207-1215Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar). The main issue is more likely one of manpower and funding. A major factor in cDCDD lung utilization in the United States versus other countries may be the way transplant costs are borne in the U.S. health care system. After death is declared, OPOs generally pay by the minute for the operating room for cDCDD donors, discouraging a long wait for donor death. In addition, many LTx centers will not pay for costly airplane transport charges without a donor bronchoscopy, and there is a perception that the risk of an aborted or “dry” run from cDCDD donors is high. Mooney et al (3.Mooney JJ Hedlin H Mohabir PK Lung quality and utilization in controlled donation after circulatory determination of death within the United States.Am J Transplant. 2016; 16 (et al): 1207-1215Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar) cite a single-center experience in which 40% of cDCDD donor recovery attempts were aborted. In a small sample of other centers queried, the dry-run rate was slightly lower but was still 30% higher for cDCDD than DNDD donors. There is a dearth of reliable predictors of donor death within an acceptable time period. Many OPOs require that a certified LTx surgeon or senior fellow recover lungs for transplant. Recoveries are time consuming and not very remunerative; only the LTx procedure is revenue generating for the health care system and the providers. In contrast, western European countries have short travel times, often by road, with salaried surgical teams and, sometimes, collaborative retrieval arrangements. In the United Kingdom, any distant retrieval is performed by the local transplant center, with a centrally funded arrangement. The authors suggest that evaluation with ex vivo lung perfusion (EVLP) (5.Cypel M Yeung JC Liu M Normothermic ex vivo lung perfusion in clinical lung transplantation.N Engl J Med. 2011; 364 (et al): 1431-1440Crossref PubMed Scopus (758) Google Scholar) could increase cDCDD lung utilization. However, EVLP is expensive, is little used to date in the United States, and has unresolved questions: Which lungs need assessment, and by whom? And who pays, especially if the lungs are not transplanted? It is clear that lungs from cDCDD donors are not well utilized in the United States. Mooney and colleagues are to be congratulated for bringing this to the attention of the LTx community. What is good for the rest of the world would benefit patients in the United States. Management of cDCDD donors must be targeted toward maximum gain for potential LTx recipients. There is much to learn from the Australian experience, in which targeted interventions improved cDCDD yield. Better algorithms are required to identify when death will occur after support is withdrawn. The role of EVLP in evaluating cDCDD donor lungs must be better defined. Finally, reimbursement and allocation issues must be resolved to increase LTx from cDCDD donors in the United States. The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.

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