American Journal of Transplantation 2008; 8: 1282–1289
Blackwell Munksgaard
C 2008 The Authors
C 2008 The American Society of
Journal compilation Transplantation and the American Society of Transplant Surgeons
doi: 10.1111/j.1600-6143.2008.02231.x
Early Lung Transplantation Success Utilizing
Controlled Donation After Cardiac Death Donors
G. I. Snella, ∗ , B. J. Levveya , T. Otob , R. McEgana ,
D. Pilcherc , A. Daviesc , S. Marascod
and F. Rosenfeldtd
a
Lung Transplant Service, Department of Allergy,
Immunology and Respiratory Medicine, Alfred Hospital
and Monash University, Melbourne, Australia
b
Department of Thoracic Surgery, Okayama University,
Okayama, Japan
c
Intensive Care Unit, Alfred Hospital and Monash
University, Melbourne, Australia
d
Department of Cardiothoracic Surgery, Alfred Hospital
and Monash University, Melbourne, Australia
∗ Corresponding author: A/Prof G. Snell,
g.snell@alfred.org.au
Donation-after cardiac death (DCD) donor organs have
potential to significantly alleviate the shortage of
transplantable lungs. However, only limited data so far
describes DCD lung transplantation (LTx) techniques
and results. This study aims to describe the Alfred Hospital’s early and intermediate outcomes following DCD
donor LTx. Following careful experimentation and consultation DCD guidelines were created to utilize Maastricht category III lung donors from either the ICU or
operating room(OR), with a warm ischemic time(WIT)
of <60 min. Between May 2006 and December 2007,
22 referred DCD donors led to 11 attempted retrievals
after withdrawal, resulting in 8 actual bilateral LTx (2
donors did not arrest in prescribed period and 1 donor
had nonacceptable lungs). ICU WIT = 38.4 min (range
20–54, OR WIT = 12.7 min (11–15), p < 0.05. Post-LTx,
1 pulmonary hypertensive patient required ECMO for
PGD3. The mean group pO2/FiO2 ratio at 24 hours was
307.7 (240–507) with an ICU stay of 9.5 days (2–21) and
ward stay of 21.5 days (11–76). All 8 survive at a mean
of 311 days (10–573) with good performance status and
lung function. In conclusion, the use of Maastricht category III lungs for human LTx is associated with acceptable early clinical outcomes.
Key words: Donation referral, donor management,
early graft function, lung transplantation, nonbeating
heart donor
Received 15 December 2007, revised 29 February 2008
and accepted for publication 2 March 2008
1282
Introduction
Lung transplantation (LTx) is limited by the availability
of transplantable donor lungs. Traditionally, donation-after
brain death (DBD) donors have provided a vast majority
of lungs for LTx, however donation-after cardiac death
(DCD) donors are now being utilized for clinical transplantation (1–3). In theory this ‘new’ source of organs
has great potential, but the description of outcomes is
thus far limited to case reports and only small published
series.
In fact, even among the human DCD cases performed differing techniques of assessment, preservation and recovery have been used depending on the Maastricht category
descriptor of the donor (Table 1) (4). Based on the local ethical and legal framework (5), an individual center will have
commenced DCD LTx using a particular donor category. De
Antonio and coworkers reported a series utilizing category
I donors (6). They describe a 29% incidence of severe primary graft dysfunction (PGD) and a 69% 1-year survival.
Steen reported the use of a single category II donor with
good initial graft function, but death occurred from a nonrespiratory cause by 6 months (1). The successful use of
category III donors has been reported in abstract form (7–
11) and anecdote (2,12), with our group recently publishing
a case report detailing the technique and definitions (13).
Category IV retrieval is limited to two positive case reports
(14,15).
On a world scale, the recent upsurge in DCD LTx activity in
the area of category III donors is likely to continue. The organ transplant breakthrough collaborative has made DCD
category III transplantation in general a US priority (16).
Similar approaches by organ procurement organizations
and individual LTx units in Australia, UK, the Netherlands
and Canada are producing a similar result (17). Notwithstanding, detailed early and intermediate term outcome
measures are yet to be published for category III donor
lung transplants.
This study aims to present the Alfred Hospital’s small series of early and intermediate term LTx results utilizing
category III DCD donors. Based on this evolving experience, it becomes apparent that precise definitions, and
the prospective recording of donor and recipient details
and outcomes, are mandated to properly audit this ‘new’
advance.
Early Lung Transplant Success from DCD Donors
Table 1: Donation after cardiac death (DCD) donors: Maastricht
workshop categories, as per (4)
1
2
3
4
Dead on arrival
Unsuccessful resuscitation
Awaiting cardiac arrest/cessation of futile treatment
Cardiac arrest in brain dead donor
absence of cardiac output and the start of cold flush preservation (13). In
principle, the aim is to reduce the WIT as much as practical, but based
on the existing literature (2) and our own experiments (18,19), we are prepared to accept lungs for transplant with a WIT less than 60 min. We note
there is a second WIT that occurs at the time of lung implantation, but have
deliberately excluded this from the definition (21).
Donor assessment, recipient selection and donor/recipient
matching
Methods
Creating an institutional guideline
Prospectively, a large animal model was used to assess DCD donor LTx
preservation and surgical techniques (18). The initial focus was on DCD
lung-only recovery, but to optimize transplantation opportunities and efficiencies, DCD multiorgan recovery was also modeled (18,19). As detailed
elsewhere (13), with the ultimate endorsement of numerous hospital and
external agencies (specifically including the Alfred Hospital Ethics Committee), an Institutional DCD Guideline was created to cover in-house DCD
lung-only recovery (20). A variation of this guideline was also formulated to
facilitate lung recovery as part of a multiorgan DCD donor procedure from
other institutions.
Although the DCD donation process will be intrinsically directed by the general philosophical, practical and legal constraints of the donor hospital (5), it
is notable that any LTx unit DCD guideline must consider specific lung requirements, parameters and management principles (Table 2). Unless specified, the warm ischemic time (WIT) was defined as the time between the
Table 2: DCD lung donor management guidelines
(1) General medical acceptance criteria and contraindications as
per National Guidelines (42). The results of prior arterial blood
gases and X rays must be known and interpreted. Calculation
of the University of Wisconsin DCD Evaluation Tool score was
sought where practical (12).
(2) Specific lung DCD donor acceptance criteria
a. Age <55 years
b. PaO 2 > 300mmHg ( on FiO 2 1.0)
c. Relatively normal chest x-ray
d. Time for cardiothoracic recovery team to be on site
before withdrawal (aim for >2 h to enable meeting with
operating room, intensive care and other donor organ
recovery surgical staff)
(3) Specific lung DCD donor contraindications
a. Prior thoracic surgery
(4) Specific features of lung DCD donor pathway
a. Protect airway via
i. Aspiration of nasogastric (if present) prior to extubation
ii. If possible withdraw treatment with endotracheal tube in
situ, alternatively reintubate as soon as practical after
death (may require skilled anesthetist if upper airway
edema or trauma). Avoid pressure on abdominal organs
until cuffed airway protection in place
b. Administer heparin 50 000 IU as per local practice
premortem, or if not possible, add to flush preservation
solution post-mortem
c. Ventilate donor 10 min after arrest (12)
d. Donor bronchoscopy recommended
e. In the event of late, unexpected operating room delay,
consider topical cooling via pleural intercostal catheters to
gain up to a further 6 h after death (1,18)
American Journal of Transplantation 2008; 8: 1282–1289
We have described our Alfred approach to lung donor referral, assessment
and general management elsewhere (22,23). DCD donor assessment attempted to incorporate the features of the University of Wisconsin DCD
Evaluation Tool (12,13). Recipient selection is based on International Guidelines (24). Donor-recipient matching was generally undertaken according to
our standard protocol, which has been described previously (23,25). Recipients chosen to receive DCD organs were particularly ill individuals at
high risk of death on the waiting list. They had been generally consented
about the use of extended donor organs (including DCD lungs), but following discussion with the Ethics Committee, specific consent for DCD
transplantation was not required. Prospective donor-recipient T- and B-cell
lymphocytotoxic cross-matching was performed in all patients.
Lung procurement, preservation and transplantation
Following reintubation of the donor after the 2 or 5 min stand-off time (as
per local legal or administrative requirements), a rapid sternotomy and pulmonary arterial cannulation was initiated (Table 2). Subsequent lung preservation with Perfadex (Vitrolife, Goteborg, Sweden), lung recovery and transplantation followed standard practice (13,22,23,25). In order to avoid inadvertent cardiac stimulation, ventilation starts at 10 min after cardiac standstill
(12). When participating in a DCD multiorgan recovery procedure the thoracic team assists the liver team with clamping of the thoracic aorta (19).
At the time of lung implantation, a retrograde pulmonary venous flush and
antegrade pulmonary artery flush are performed to remove any pulmonary
microemboli.
Postoperative management
A postoperative fluid management regimen was instituted encompassing
both respiratory and cardiovascular management algorithms and targeting
a central venous pressure <7 mmHg, where mean arterial pressure and
cardiac index permitted (26). The protocol provided an algorithm for early
extubation where the ratio PaO 2 /FiO 2 was >200. PGD was defined and
managed as per recent International guidelines (26,27). Triple immunosuppression was achieved, and acute rejection and bronchiolitis obliterans syndrome (BOS) were diagnosed and treated, according to standard protocols
and practice (22,23,25,28). All patients received prophylactic antibiotics on
the basis of known or suspected donor and recipient microbiology results.
Ganciclovir was used as prophylaxis against CMV where indicated. Surveillance bronchoscopy and transbronchial biopsies were performed strictly
according to protocol at 2, 4, 8,12, 26, 52 and 78 weeks post-LTx (25).
Statistics
Data were expressed as means unless otherwise stated. Comparisons
were made between groups using the Fisher exact test for categorical variables, the unpaired Student’s t-test for parametric continuous data and the
Mann-Whitney test for nonparametric continuous data.
Results
Between May 2006 and December 2007 there were 22 referrals of lungs from DCD donors from six hospitals. Eleven
were considered but not taken further because: lungs were
1283
1284
28
55
18
26
26
16
17
36
4
5
6
7
8
9
10
11
Female
Female
Male
Male
Female
Male
Male
Male
Male
Male
Male
Gender
Local
Local
Interstate
Interstate
In-house
Local
In-house
In-house
In-house
Interstate
Interstate
Site
Hypoxia
CVA
MVA
Hypoxia
MVA
MVA
MVA
MVA
MVA
MVA
MVA
Medical
diagnosis
584
543
463
337
465
308
422
289
353
549
166
Last PaO 2 /
ratio FiO 2
MVA = motor vehicle accident; CVA = cerebrovascular accident.
25
24
22
Age
(years)
1
2
3
Donor
no.
Table 3: The demographics and features of the 11 potential DCD donors
Lower lobe
consolidation
Midzone
change
Normal
Normal
Basal changes
Basal changes
Perihilar haze
Apical changes
Perhilar haze
Normal
Left basal collapse
Chest x-ray
appearance
Minor
Nil
Blood
Nil
Blood
Minor
Minor
Moderate
Nil
Nil
Minor
Airway
secretions
Extubation
Cease inotropes
Extubation
Extubation
Extubation
Extubation
Extubation
Extubation
Extubation
Extubation
Extubation
Extubation
Withdrawal
mode
327
1355
1052
720
690
413
990
420
138
735
734
Time from
referral-withdrawal (minutes)
Lungs
Lungs, liver, kidneys
No donation in
90 minutes
Lungs
Lungs, kidneys
Lungs
Visualized lungs
Not suitable
No donation in
90 min
Lungs, liver,
kidneys
Lungs, liver,
kidney, pancreas
Lungs, kidney
Organs
recovered
Snell et al.
American Journal of Transplantation 2008; 8: 1282–1289
Early Lung Transplant Success from DCD Donors
Systolic blood pressure after withdrawal (mmHg)
Actual donor 1
Actual donor 2
No donation <90mins
Actual donor 3
Actual donor 4
Actual donor 5
Nonacceptable donor
No donation <90mins
Actual donor 6
Actual donor 7
Actual donor 8
250
200
150
100
50
Figure 1: The systolic blood pressure response after donor extubation in 11 potential
DCD lung donors: 8 actual and 3 not realized.
0
0
medically not suitable (n = 4, consolidation, poor gas exchange, excessive smoking history), progressed to become brain dead (n = 4, 3 of which were ultimately recovered as DBD lung donors), donor legal or logistic issues
(n = 2) and no suitable recipient (n = 1). Eleven potential
DCD donors from five hospitals were considered acceptable on all criteria and a retrieval team was put in place
(Table 3). The blood pressure response after donor extubation in these 11 donors is shown in Figure 1. On eight
occasions suitable lungs were recovered (= actual donor)
while two donors failed to arrest in the prescribed 90 min
window (= no donation <90 min) and 1 donor arrested but
the excised specimen was rejected after careful inspection
(= nonacceptable donor).
The actual time lines of lung recovery are shown in Figures
2 and 3. It can be seen that the ICU withdrawals typically
had a longer WIT when compared to Operating Room withdrawals [38.4 min (range 20–54), versus 12.7 min (range
11–15), p < 0.05].
5
10
15
20
25
30
35
40
45
Time (minutes)
shown in Tables 4 and 5. Notably, airway complications and
clinically significant acute allograft rejection (A grade >2)
were not seen, with all patients completing the planned
biopsy schedule. The detailed first 72 h PaO 2 /FiO 2 ratios
are shown in Figure 4. Recipient three was supported on
an extracorporeal membrane oxygenator (ECMO) for 60 h
and therefore only T0 and T72 figures are available, while
recipients 6,7 and 8 were extubated within the first day
and without arterial blood gases beyond T24. The mean
PaO 2 /FiO 2 ratio at T24 was 307.7 (range 240–507, excluding 1 patient on ECMO).
The associations between the WIT and the PaO 2 /FiO 2 ratios at 24 h and the duration of ICU stay (essentially trends
only given the small numbers) are shown in Figures 5 and
6 (p = not significant).
Discussion
The demographics, early and intermediate clinically important outcomes of the eight actual LTx recipients are
This case series demonstrates very acceptable early and
intermediate results from LTx using category III DCD donor
lungs, thereby confirming and extending the previous case
report, anecdotes and abstracts (7–12).
Figure 2: The time line of lung recovery following withdrawal
for ICU DCD donors.
Figure 3: The time line of lung recovery following withdrawal
for operating room DCD donors.
American Journal of Transplantation 2008; 8: 1282–1289
1285
Snell et al.
Table 4: Recipient demographics and outcomes from DCD donor lung transplantation
Recipient
no.
Age
(years)
Medical
diagnosis
Gender
1
34
Female
2
57
Female
3
19
Female
4
63
Male
Primary pulmonary
hypertension
Emphysema
5
6
7
8
Mean
60
38
23
42
42
Female
Male
Female
Female
Emphysema
Cystic fibrosis
Re-LTx BOS
LAM
Primary pulmonary
hypertension
Emphysema
Pretransplant
therapies/
features
NYHA
class
Overall cold
ischemic time
(min)
ICU
stay
(days)
Ward
stay
(days)
Survival
(days)
I.V. prostacyclin
IV
368
14
17
633
BiPAP
pCO 2 110 mmHg
I.V. prostacyclin
NYHA class IV
BiPAP
pCO 2 86 mmHg
BiPAP
-
IV
600
7
16
515
IV
420
7
11
386
IV
376
18
76
350
IV
III
IV
IV
609
548
560
459
443
21
4
2
3
9.5
11
11
13
17
21.5
303
129
112
65
311
I.V. = intravenous; NYHA = New York Heart Association; BiPAP = bilevel positive airway pressure support; BOS = bronchiolitis obliterans
syndrome; LAM = lymphangioleiomyomatosis.
To start DCD donor lung transplantation in an organ donation system unfamiliar with DCD transplantation in general has taken a significant amount of effort and time formulating guidelines and educating staff. However, despite
only a small number of Australian hospitals currently set
up to contribute DCD donors, at present we have been
referred one donor per month. Eight of 22 (36%) have
converted to actual lung transplants, consistent with our
institutions high overall acceptance rate for DBD donors
(22,23). One additional donor (5%) was not matchable for
size and a further 3 (15%) of these 22 potential DCD
donors became DBD donors. These results are consistent with those published by Olson et al. on the impact
of DCD donation on DBD numbers, and indicate a DCD
program contributes additively to the overall organ donor
pool, with a minimal impact on potential thoracic organ
recovery.
The current series describes scenarios where the withdrawal of donor support occurs in ICU and in the OR. We
note advantages and disadvantages of both approaches
but, as has been found previously (12,13,29,30), either approach is feasible and should simply reflect local sensitivities and practicalities. In our opinion, multiorgan DCD recovery is somewhat complex, requiring rapid vascular access for abdominal organ perfusion, and is best managed
with an OR withdrawal. On the other hand, the more relaxed time frames of lung-only recovery allow an ICU withdrawal, a situation that caters better to the sensitivities of
family and staff, particularly if there is a distinct possibility cardiac arrest might not occur in the requisite 90-min
window. There are minor technical issues specifically related to multiorgan DCD transplantation that are described
elsewhere (12,19), but clinical results appear satisfactory
either way.
Table 5: Early and intermediate outcomes from DCD donor lung transplantation
Recipient
no.
Early clinical
issues
1
2
PGD 2
No
3
PGD 3
ECMO
Basal collapse
Deconditioned
Basal collapse
Deconditioned
No
No
No
4
5
6
7
8
Intermediate
clinical
Airway
issues
complication
Any cause
readmission
Highest
rejection
grade#
3 month
%Predicted
FEV 1
Best
%Predicted
FEV 1
Current
BOS
status
Current
overall
status
A1,B0
A1,B0
59
117
100
127
0
1
Alive, NYHA I
Alive, NYHA I
A1,B0
76
84
0
Alive, NYHA I
No
15% late fall
in FEV 1
No
No
No
No
No
Yes
FEV 1 fall
No
No
No
CMV colitis
A0,B2
60
78
0
Alive, NYHA I
No
No
No
A0,B0
95
104
0
Alive, NYHA I
No
No
No
No
No
No
No
No
Nausea
A0,B0
A1,B0
A0,B0
103
62
N/A
113
62
66
0
0
0
Alive, NYHA I
Alive, NYHA I
Alive, NYHA I
PGD = Primary Graft Dysfunction; ECMO = extracorporeal membrane oxygenator; FEV 1 = forced expiratory volume in 1 second; NYHA
= New York Heart Association; N/A = patient not yet reached this point, # see (23, 30).
1286
American Journal of Transplantation 2008; 8: 1282–1289
Early Lung Transplant Success from DCD Donors
PaO 2/FiO2 ratio
Warm ischemic time (minutes)
700
60
Recipient 1
600
Recipient 2
500
Recipient 3
400
Recipient 4
300
Recipient 5
50
40
30
R2 = 0.39
Recipient 6
200
Recipient 7
100
Recipient 8
20
10
0
T0
T6
T12
T18
T24
T48
T72
Time (hrs) post LTx
0
0
100
200
300
400
500
600
Recipient PaO2 /FiO2 ratio at 24 hours post-LTx
Figure 4: Recipient PaO 2 /FiO 2 ratios for the first 72 h postLTx.
The assessment of DCD donors remains challenging.
Firstly, the predictability of a cardiac arrest within the protocol defined 90 min is important for DCD lung recovery
in general, with real concerns about family and staff perception, and the tying up of precious Operating Room time
and surgical staff if the process does not proceed to donation. We experienced two such events at interstate hospitals from the 11 realistic donors we have considered. The
University of Wisconsin DCD Evaluation Tool (12) is considered to aid this process, but we have found calculations of
a specific value to be impractical. The DCD Evaluation Tool
suggests the single greatest predictor of subsequent early
postextubation arrest is the absence of spontaneous ventilation, but not all ICU staff are willing to test for this, with
concerns about family sensitivities and the potential to provoke donor distress or hemodynamic instability. The DCD
Tool also suggests that the cessation of inotropic support
in a patient requiring it will lead to a shorter agonal period
(12). The data in Figure 1 support this: a lower withdrawal
systolic blood pressure predicts earlier arrest.
Figure 5: The association between the PaO 2 /FiO 2 ratios at
24 h and WIT.
significantly beyond 60 min) may require reconsideration
of this strategy.
The definitions of WIT become very important as DCD LTx
enters routine clinical practice and LTx units attempt to
compare the outcomes of varying techniques and ischemic
injury therapies (13). Indeed, there are a number of theoretical but practical therapies, aimed at preventing PGD,
which should be considered in clinical DCD LTx practice
today. Potential novel strategies include DCD donor premortem treatment with N-acetyl cysteine (32) or surfactant
(33) or preimplantation treatment with nitroglycerin (34),
nitric oxide (35) or surfactant (36). The definitions of DCD
transplantation and WIT are also relevant when attempting
to cross compare different types of DCD donor, for example: category III versus category I. Our numbers are too
small, and the patient group too heterogeneous to draw
any solid conclusions, but Figures 5 and 6 at least raise
Warm ischemic time (minutes)
The second challenge for DCD donor assessment relates
to the detail of local clinical DCD guidelines. Indeed, with
theoretical concerns about ‘interventions’ on a patient who
is yet to die, the initial lung assessment may be limited to
historical data without bronchoscopic evaluation or even
arterial blood gases on standard settings (5,20,23). Moreover, as distinct from the DBD circumstance, the DCD
donor can aspirate stomach contents in the agonal phase
or even post mortem (related to simultaneous abdominal
organ recovery) (17–19), and there is the added but poorly
characterized deleterious effect of variable warm ischemia
prior to cold flush preservation (2,18). Although immediate
pre-LTx graft performance could potentially be assessed
by ex vivo lung perfusion (1,18,31) or the measurement of
IL-1beta in donor bronchial lavage fluid (32), our DCD team
have elected to use our standard DBD medical and surgical
clinical assessments. Extended WIT DCD lung donors (i.e.
American Journal of Transplantation 2008; 8: 1282–1289
60
50
40
30
R2 = 0.29
20
10
0
0
5
10
15
20
25
ICU stay (days)
Figure 6: The association between the duration of ICU stay
and WIT.
1287
Snell et al.
the possibility that WIT may influence clinical outcomes.
The exact point of onset of a relevant ischemic allograft
injury, and the tolerable duration of WIT, is yet to be determined, but for lungs appears beyond 60 minutes. Although
there have been significant numbers of DCD donor renal
transplants performed over the years, clear WIT definitions
have not been reached (21,38). Therefore, we encourage
individual LTx units to record critical time-points, including
the timing of systolic hypotension, cardiac arrest, ventilation reinstitution and the onset of cold flush perfusion (13).
With careful database management, hopefully at an international level, the clinical correlations of warm ischemia
can eventually be explored.
These DCD donors have contributed 16% extra transplants
beyond the cadaveric LTx performed over the same period,
translating to at least equal results at this point for these
8 individuals at high risk of waiting list mortality. Unquestionably, the next test for DCD donor lungs relates to their
potential to develop premature chronic allograft rejection
or BOS. On the one hand the ischemic allograft may create
an inflammatory milieu that leads to fibrosis and graft loss
(2). Alternatively, the absence of the ‘brain storm’ inflammatory injury associated with DBD donors (2), the low rate
of acute rejection so far noted, and the very reasonable absolute values of lung function already seen at 3 months in
this small cohort, may even prove protective given these
are known associations of chronic lung rejection (39). Furthermore, the solid and comparable long-term (10 year)
outcomes from renal DCD transplantation bode well (40).
The only other series of extended results of DCD donor LTx
describes outcomes using 17 category I donors (6). There
are differences in the nature of the ischemic injury, with
donors in their series having up to 15 min without a circulation and thereafter external cardiopulmonary resuscitation
(mean WIT 118 min, 95%CI 44–192) until conversion to hypothermic ECMO and topical cooling (mean preservation
time 181 min, 95%CI 88–274). The results of this approach
include PGD grade 3 in 29% [compared with our 13% in
our DCD series and 18% in our overall DBD cohort (41)],
82% 1 month survival (our series 100%), 23% Grade >A2
rejection (our series 0%), 12% bronchial stenoses (our series 0%) and 7% BOS at 1 year (our series has insufficient
data to comment). Overall, it is apparent that category I
DCD transplantation is clearly very challenging to initiate
and resource, and our work suggests category III DCD
transplantation appears a simpler option, and at least as
successful.
In conclusion, the use of Maastricht category III lungs for
human LTx is associated with very acceptable early clinical
outcomes. Lungs can be recovered from scenarios where
the withdrawal of treatment in the donor takes place in either the ICU or Operating Room, and irrespective of the
recovery of other organs for transplantation. The absolute
clinical limit of useable lung WIT is unknown, but is at least
60 min. Graft WIT definitions and documentation are impor1288
tant in auditing and cross-comparing results. Although longterm LTx outcomes (particularly BOS) using DCD lungs are
yet to be characterized, it is now justifiable to use these
organs to facilitate LTx opportunities for our waiting list
patients.
Acknowledgments
The authors acknowledge the support of Australian Rotary Health Research
Fund, Margaret Pratt Foundation, Rotary Club of Williamstown and Alfred
Foundation.
References
1. Steen S, Sjoberg T, Pierre L, Liao Q, Eriksson L, Algotsson L. Transplantation of lungs from a non-heart-beating donor. Lancet 2001;
357: 825–829.
2. Van Raemdonck DE, Rega FR, Neyrinck AP, Jannis N, Verleden
GM, Lerut TE. Non-heart-beating donors. Semin Thorac Cardiovasc
Surg 2004; Winter 16: 309–321.
3. Egan TM. Non-heart beating donors in thoracic transplantation. J
Heart Lung Transplant 2004; 23: 3–10.
4. Kootstra G. Statement on non-heart-beating donor programs.
Transplant Proc 1995; 27: 2965.E
5. Snell GI, Levvey BJ, Williams TJ. Non-heart beating organ donation. Intern Med J 2004; 34: 501–503.
6. de Antonio DG, Marcos R, Laporta R et al. Results of clinical lung
transplant from uncontrolled non-heart-beating donors. J Heart
Lung Transplant 2007; 26: 529–534.
7. Erasmus MS, Van Der Bij W, Verschuuren EAM. Non-heart-beating
lung donation in The Netherlands: The first experience. J Heart
Lung Transplant 2006; 25(Suppl): S63.
8. Love RB, D’Alessandro AM, Cornwell RA, Meyer KM. Ten year experience with human lung transplantation from non-heart beating
donors. J Heart Lung Transplant 2003; 22(Suppl): S87.
9. Butt TA, Aitchison JD, Corris PA, Wardle J, Clark S, Dark JH. Lung
transplantation from deceased donors without pre treatment. J
Heart Lung Transplant 2007; 26: S110.
10. Van Raemdonck DV, Verleden GM, Dupont L et al. Initial experience with lung transplantation from non-heart-beating donors. J
Heart Lung Transplant 2008; 27: 198–199.
11. Mason DP, Murthy SC, Budev MM, Mehta AC, McNeil AM,
Pettersson GB. Early experience with lung transplantation using
donors after cardiac death. J Heart Lung Transplant 2008; 27: 199.
12. Edwards J, Mulvania P, Robertson V et al. Maximizing organ donation opportunities through donation after cardiac death. Crit Care
Nurse 2006; 26: 101–115.
13. Oto T, Levvey B, McEgan R et al. A practical approach to clinical lung transplantation from a Maastricht Category III donor with
cardiac death. J Heart Lung Transplant 2007; 26: 196–199.
14. Oto T, Rowland M, Griffiths AP et al. Third-time lung transplant
using extended criteria lungs. Ann Thorac Surg 2007; 84: 642–644.
15. Shennib H. Discussion on Egan TM et al. A strategy to increase the
donor pool: Use of cadaver lungs for transplantation. Ann Thorac
Surg 1991; 52: 1120–1121.
16. Punch JD, Hayes DH, LaPorte FB, McBride V, Seely MS. Organ
donation and utilization in the United States, 1996–2005. Am J
Transplant 2007; 7(5 Pt 2): 1327–1338.
17. Dark J. Personal communication. 2007.
18. Snell GI, Oto T, Levvey B et al. Evaluation of techniques for lung
transplantation following donation after cardiac death. Ann Thorac
Surg 2006; 81: 2014–2019.
American Journal of Transplantation 2008; 8: 1282–1289
Early Lung Transplant Success from DCD Donors
19. Snell G, Levvey B, Oto T et al. Effect of multiorgan donation after
cardiac death retrieval on lung performance. Aust New Zealand J
Surg 2008; 78: 262–265.
20. Ryan G. Bayside Health Clinical Guideline: Donation after cardiac death. Available from http://intranet.baysidehealth.org.au/
assets/contactfile/1/DonationaftercardiacdeathGlineRev2.pdf Accessed 26/2/8.
21. Halazun KJ, Al-Mukhtar A, Aldouri A, Willis S, Ahmad N. Warm ischemia in transplantation: Search for a consensus definition. Transplant Proc 2007; 39: 1329–1331.
22. Gabbay E, Williams TJ, Griffiths AP et al. Maximizing the utilization
of donor organs offered for lung transplantation. Am J Respir Crit
Care Med 1999; 160: 265–271.
23. Snell GI, Griffiths A, Macfarlane L et al. Maximizing thoracic organ
transplant opportunities: The importance of efficient coordination.
J Heart Lung Transplant 2000; 19: 401–407.
24. Orens JB, Boehler A, de Perrot M et al. A review of lung transplant donor acceptability criteria. J Heart Lung Transplant 2003;
22: 1183–1200.
25. Esmore DS, Brown R, Buckland M et al. Techniques and results in
bilateral sequential single lung transplantation. The National Heart
& Lung Replacement Service. J Card Surg 1994; 9: 1–14.
26. Pilcher DV, Scheinkestel CD, Snell GI, Davey-Quinn A, Bailey MJ,
Williams TJ. High central venous pressure is associated with prolonged mechanical ventilation and increased mortality after lung
transplantation. J Thorac Cardiovasc Surg 2005; 129: 912–918.
27. Christie JD, Carby M, Bag R, Corris P, Hertz M, Weill D. Report of
the ISHLT Working Group on Primary Lung Graft Dysfunction part
II: definition. A consensus statement of the International Society
for Heart and Lung Transplantation. J Heart Lung Transplant 2005;
24: 1454–1459.
28. Snell GI, Westall GP. Immunosuppression for lung transplantation:
Evidence to date. Drugs 2007; 67: 1531–1539.
29. Olson L, Kisthard J, Cravero L et al. Livers transplanted from donors
after cardiac death occurring in the ICU or the operating room have
excellent outcomes. Transplant Proc 2005; 37: 1188–1193.
30. Johnson SR, Pavlakis M, Khwaja K et al. Intensive care unit extubation does not preclude extrarenal organ recovery from donors
after cardiac death. Transplantation 2005; 80: 1244–1250.
American Journal of Transplantation 2008; 8: 1282–1289
31. Aitchison JD, Orr HE, Flecknell PA, Kirby JA, Dark JH. Functional
assessment of non-heart-beating donor lungs: Prediction of posttransplant function. Eur J Cardiothorac Surg 2001; 20: 187–194.
32. Rega FR, Vanaudenaerde BM, Wuyts WA et al. IL-1beta in
bronchial lavage fluid is a non-invasive marker that predicts the
viability of the pulmonary graft from the non-heart-beating donor.
J Heart Lung Transplant 2005; 24: 20–28.
33. Rega FR, Wuyts WA, Vanaudenaerde BM et al. Nebulized N-acetyl
cysteine protects the pulmonary graft inside the non-heart-beating
donor. J Haert Lung Tarnsplant 2005; 24: 1369–1377.
34. Boglione M, Morandini M, Barrenechea M, Rubio R, Aguilar D.
Surfactant treatment in a non-heart-beating donor rat lung transplantation model. Transplant Proc 2001; 33: 2554–2556.
35. Egan TM, Hoffmann SC, Sevala M, Sadoff JD, Schlidt SA. Nitroglycerin reperfusion reduces ischemia-reperfusion injury in nonheart-beating donor lungs. J Heart Lung Transplant 2006; 25: 110–
119.
36. Takashima S, Koukoulis G, Inokawa H, Sevala M, Egan TM. Inhaled
nitric oxide reduces ischemia-reperfusion injury in rat lungs from
non-heart-beating donors. J Thorac Cardiovasc Surg 2006; 132:
132–139.
37. Nonaka M, Kadokura M, Takaba T. Effects of initial low flow reperfusion and surfactant administration on the viability of perfused
cadaveric rat lungs. Lung 1999; 177: 37–43.
38. Sohrabi S, Navarro A, Asher J et al. Agonal period in potential nonheart-beating donors. Transplant Proc 2006; 38: 2629–2630.
39. Estenne M, Maurer JR, Boehler A et al. Bronchiolitis obliterans
syndrome 2001: An update of the diagnostic criteria. J Heart Lung
Transplant 2002; 21: 297–310.
40. Bernat JL, D’Alessandro AM, Port FK et al. Report of a National
Conference on Donation after cardiac death. Am J Transplant 2006;
6: 281–291.
41. Oto T, Griffiths AP, Levvey BJ, Pilcher DV, Williams TJ, Snell GI.
Definitions of primary graft dysfunction after lung transplantation:
Differences between bilateral and single lung transplantation. J
Thorac Cardiovasc Surg 2006; 132: 140–147.
42. Australasian Transplant Coordinators Association. National Guidelines for Organ and Tissue Donation. 2006; Available from
http://www.atca.org.au/files/ATCAguidelines Accessed 15/9/07.
1289