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Donor Selection: Pivotal for Transplantation

Donor Selection: Pivotal for Transplantation . Vaidehi Kaza M.D, M.P.H. Donor Optimization- Case Mr. S. 55 year old male with IPF ER hypoxia and needing mechanical ventilation Later needing VVECMO. Donor organ available Pertinent issues: 40 yrs , male Smoked 1-2 PPD for 15 yrs

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Donor Selection: Pivotal for Transplantation

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  1. Donor Selection: Pivotal for Transplantation VaidehiKaza M.D, M.P.H

  2. Donor Optimization- Case Mr. S • 55 year old male with IPF • ER hypoxia and needing mechanical ventilation • Later needing VVECMO

  3. Donor organ available Pertinent issues: 40 yrs, male Smoked 1-2 PPD for 15 yrs Pao2 is 340 on 100% CXR with RML infiltrate, pulmonary edema

  4. Review Current statistics Donor selection Specific donor risk factors New innovations Cases

  5. AVERAGE CENTER VOLUMELung Transplants: January 1, 2000 - June 30, 2011 ISHLT 2012 J Heart Lung Transplant.  2012 Oct; 31(10): 1045-1095

  6. ADULT LUNG TRANSPLANTS (1/1998-6/2010)Risk Factors For 1 Year Mortality with 95% Confidence Limits Center Volume p < 0.0001 ISHLT 2012 J Heart Lung Transplant.  2012 Oct; 31(10): 1045-1095

  7. UTSW 2012 Acceptable 30 day and 1 year survival

  8. Lung Transplantation Donor Selection Recipient Characteristics • Listing • LAS median at transplantation • Death on wait list

  9. Current statistics Donor selection Specific donor risk factors New innovations Cases

  10. Emerging Sources of Transplantable donor lungs • Cadaveric donation after cardiac death. • 30% of donor lung pool • local, political legal system • Extended spectrum of transplantable donor lungs

  11. Ideal Donor Clin Chest Med. 2011 Jun;32(2):223-32

  12. Reality Small fraction of available donor pool

  13. Extended Donor Pool Smoking, prior history of asthma, aspiration, infection, Pulmonary edema Age, prior cancer Hepatitis. Late problems Early : PGD Fungal, smoking etc

  14. Extended donor – transplant outcomes. Review of UNOS from July 1999 to July 2008 10,333 lung transplants performed in US Median follow up 2.5 years Study looked at degree of compliance with current donor guidelines and effect of variance on survival Age, ABO, CXR, Pao2, Smoking, aspiration, purulent secretions

  15. Ann ThoracSurg 2010; 89 (6) 1756-1764

  16. Current statistics Donor selection Specific donor risk factors New innovations Cases

  17. Impact of Specific Donor Factors Donor age Donor history of smoking Donor history of malignancy Donor history of infection Gas exchange Preservative solution Size

  18. DONOR AGE DISTRIBUTION FOR LUNG TRANSPLANTS BY ERA ISHLT Transplants with unknown donor age were excluded from this tabulation. 2012 J Heart Lung Transplant.  2012 Oct; 31(10): 1045-1095

  19. Donor Age

  20. Donor Age Current ideal donor pool represents 29% of total deaths less than 75 yrs of age Extended donor pool represents 54% of the same Donor age 50-60 Donor age >60

  21. UNOS database study The Journal of Heart and Lung Transplantation, Volume 32, Issue 8, August 2013, Pages 760–768

  22. Donor Age > 50 • March 1998 to 2003 • 49 recipients with donor age > 50 compared to 244 controls The Journal of Thoracic and Cardiovascular Surgery, Volume 129, Issue 4, April 2005, Pages 919–925

  23. Donor Age > 60 • PAH, IPF, use of CPB greater risk for death 30 days after lung transplantation • Early BOS was cause of death in those who survived atleast 90days The Journal of Thoracic and Cardiovascular Surgery, Volume 133, Issue 2, February 2007, Pages 525–531

  24. Donors with older age to be considered However, older age combined with longer ischemic times is considered risk for worse survival Older organs need to used with caution in high risk patients such as pulmonary hypertension and pulmonary fibrosis

  25. Donor smoking • 532 lung transplants • Survival in smoking ( 65.8%) vs non smoking donors (48.3%) • Worse survival in the group with > 40 pack smoking Transplantation JournalIssue: Volume 95(3), 15 February 2013, p 513–518

  26. Donor smoking history Transplantation. 2012 Nov 29. [Epub ahead of print]

  27. Transplantation. 2012 Nov 29. [Epub ahead of print]

  28. UK Study Era: July 1999 to Dec 2010 1295 Tx, 39% smoking donors

  29. Donor History of Malignancy American Journal of Transplantation 2011; 11: 1140–1147 Recent of active malignancy absolute contraindications Brain tumors: GBM ( two reported cases of transmission) Presumed cured cancer Transmission of breast cancer and melanoma

  30. American Journal of Transplantation 2011; 11: 1140–1147

  31. Deceased donors with prior history of malignancy: UNOS update Transplantation Issue: Volume 84(2), 27 July 2007, pp 272-274 Data from 2000-2005 (39,455) 2% with deceased donor organs with prior history of cancer Most common was nonmelanoma skin cancer, CNS malignancies, carcinoma in-situ of cervix High suspicion in those with non traumatic cerebral hemorrhage Prompt lymph node examination

  32. Donor Infection Infection is common post 48 hrs of mechanical ventilation Bronchial secretions are seen frequently Careful selection of organs and prophylactic treatment is essential. No indication that donors should be excluded solely on basis of duration of mechanical ventilation Positive donor gram stain does not predict post transplant pneumonia Transplant Proc 1993;25:1155–1156

  33. Mr N • 74 year old male with IPF • Functional otherwise, rapid decline early 2012 • Donor available with acceptable Pao2, bronch cultures MRSA

  34. Considerations for donor infections 14-21 day course of antibiotics Rethink use of induction Avoid second dose of IL-R antagonists Screening and aggressive monitoring of recipient

  35. Gas exchange The PaO2/FiO2 ratio can be easily affected by reversible processes such as retained secretions, pulmonary edema, and atelectasis In donors with unilateral abnormalities, low ABG may improve after removal of unacceptable lung intraop Direct pulmonary vein sampling right and left Higher oxygen values compared to radial artery catheter sampling.

  36. Donor Management • Brain death and lung injury • Direct trauma, aspiration, VLI, pneumonia • Autonomic crisis, sympathetic storm • Optimal tidal volume • Recruitment strategies • Bronchoscopy • Hemodynamic management • Fluid management, ionotropes, ( vasopressin), CVP and PA catheter to know filling ProcAm ThoracSoc, 6 (2009), pp. 28–38

  37. Donor Preservative Solution Basic concept to preserve organ viability at 4º C Pulmonary artery ante grade and retrograde flush Pretreatment with prostaglandins ( PGE1) Transport inflated ( not hyperinflated, airway pressure of 10-15cm)

  38. J Heart Lung Transplant.2011 Apr;30(4):414-9

  39. The pH should be adjusted to 7.4 shortly before use by the addition of a suitable buffer such as THAM/TRIS (tromethamine USP), 1 mmol per liter of Perfadex

  40. Preservative solution Right main stem Vanishing Right Bronchus Intermedius

  41. Size The Journal of Heart and Lung Transplantation, Volume 32, Issue 9, September 2013, Pages 849–860 Size should be decided in multidisciplinary team Donor predicted total lung capacity (TLC) is between 67% and 100% of the recipient PAH, CF, match and upto 120% predicted TLC(pTLC) Pulm fibrosis : safe donor pTLC 15-20% above or below , an ideal target between recipient and donor TLC

  42. Current statistics Donor selection Specific donor risk factors New innovations Cases

  43. New innovations Am J Transplant 2008; 8 (10) 2140-2148 Am J Transplant 2006; 6 (3) 544-551 Immune signatures in donor lung : prediction for post transplant outcomes PCR assay high interleukin (IL)-6:IL-10 ratio was most predictive of 30-day mortality Gene expression profiling can also identify signatures associated with PGD. Microarray analysis identified four genes (ATP11B, FGFR2, EGLN1, and MCPH1) overexpressed in donor lungs : PGD

  44. Current statistics Donor selection Specific donor risk factors New innovations Cases

  45. Mr S CT chest no evidence of emphysema or nodules Repeat Bronchoscopy with no endobronchial lesions and no repooling of secretions, no airway erythema ECHO with LV dysfunction, and onsite was being given fluids Lasix and PEEP, antibiotics , repeat Pa02 520 on 100% Fio2 Successfully transplanted. MRSA in donor, recipient treated for 21 days

  46. Case 1 27 year male with T- bone motor vehicle collision CXR: right chest tube, right rib fractures Pa02 325-417 CT chest with right lung “ contusion” , hemopneumothorax Bronch: bloody secretions

  47. Extubated POD 1 • Pneumo on right • ? Right small contusion

  48. Case 2 • 24 year old with history of TBI • RML consolidation • Bronch with secretions on RML

  49. Summary Transplant Surgeons Transplant Pulmonary Donor Net Coordinator On site coordinator Successful Transplantation Current statistics Donor selection Specific donor risk factors New innovations Cases

  50. Questions!

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