1 University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and.
2 Carolina Donor Services, Durham, North Carolina.
Ann Am Thorac Soc. 2017 Sep;14(Supplement_3):S251. doi: 10.1513/AnnalsATS.201609-687MG.
To address the lung donor shortage, we obtained institutional review board and US Food and Drug Administration approval to transplant lungs recovered from uncontrolled donation after circulatory determination of death donors (uDCDDs).
To compare outcomes of recipients of lungs recovered from uDCDDs vs. brain-dead donors.
After consent and screening, lungs recovered from uDCDDs were assessed by 4 hours ex vivo lung perfusion (EVLP) and computed tomography (CT) scan.
Over the course of 29 months, 502 potential uDCDDs younger than 66 years were identified in a single county, with death declaration by emergency medical services and four emergency departments in this and two other countries. We determined reasons that lungs from these uDCDDs were not able to be transplanted: uDCDDs could not have lungs recovered (224), next-of-kin could not be found or refused to discuss (67), next-of-kin refused (48), medical examiner case (39), logistics/missed (35), and miscellaneous (35). There were 247 medical contraindications: 141 pulmonary and 106 nonpulmonary. Lungs were recovered from 31 uDCDDs. Thirteen lungs did not have EVLP: 5 injured lungs (one pulmonary embolism [PE] with perforated infarct, two motor vehicle crash with severe injuries, one adhesion, and one lightning strike), two large PE, two prolonged ischemic time, two obvious chronic obstructive pulmonary disease, one technical, and one consent withdrawn. Eighteen lungs had EVLP: 10 with immediate edema (three PE, three unknown down time, three long ischemic time, and one ruptured aneurysm into L pleural space, making long cardiopulmonary resuscitation ineffective), and one myocarditis, possible lung involvement. In three lungs, CT showed edema after EVLP: one poor flush and poor EVLP performance, one edema after myocardial infarction (MI) with 10-year history of chronic heart failure, and one edema with MI, resuscitated, arrested again. One concurrent pneumonia was diagnosed by bronchoscopy, CT, and cultures; one patient had chronic obstructive pulmonary disease with small subpleural blebs and poor collapse, confirmed by CT. Two uDCDDs with MIs were suitable but not transplanted: no consented recipient from one large blood type B uDCDD, and the senior surgeon was unavailable to transplant suitable lungs from a uDCDD and did not allow the transplant.
The objective was not met: no lungs from uDCDDs were transplanted. uDCDDs can be a source of lungs for transplant. Resolving logistical challenges and better use of first-person authorization, allowing organ recovery without next-of-kin consent or knowledge of death, could increase yield. Donor medical problems were higher than expected and may limit the effect of uDCDDs on the lung donor pool.
NCT01615484.
为了解决肺供体短缺的问题，我们获得了机构审查委员会和美国食品药品监督管理局的批准，对无心跳供体捐献者（uDCDD）捐献的肺进行移植。
比较从 uDCDD 中获得的肺与脑死亡供体的受体的结果。
在同意和筛选后，对来自 uDCDD 的肺进行 4 小时的体外肺灌注（EVLP）和计算机断层扫描（CT）检查。
在 29 个月的时间里，在一个县内确定了 502 名年龄在 66 岁以下的潜在 uDCDD，这些人是在这个县和另外两个国家的四个急诊部由紧急医疗服务部门宣布死亡的。我们确定了这些 uDCDD 的肺不能被移植的原因：uDCDD 不能有肺可回收（224），找不到或无法联系到近亲（67），近亲拒绝（48），法医案例（39），物流/错过（35），和其他原因（35）。有 247 例医学禁忌症：141 例肺部和 106 例非肺部。从 31 名 uDCDD 中回收了肺。有 13 个肺没有进行 EVLP：5 个受损肺（1 个肺栓塞[PE]伴有穿孔梗死，2 个机动车事故伴有严重损伤，1 个粘连，1 个雷击），2 个大 PE，2 个缺血时间延长，2 个明显的慢性阻塞性肺疾病，1 个技术问题，1 个同意撤回。18 个肺进行了 EVLP：10 个立即出现水肿（3 个 PE，3 个未知停机时间，3 个缺血时间延长，1 个破裂的动脉瘤进入 L 胸膜腔，使心肺复苏无效），1 个心肌炎，可能有肺部受累。在 3 个肺中，CT 显示 EVLP 后出现水肿：1 个冲洗不良和 EVLP 性能不佳，1 个心肌梗死后水肿（MI），有 10 年慢性心力衰竭病史，1 个 MI 后水肿，复苏后再次骤停。1 例通过支气管镜检查、CT 和培养诊断为并发肺炎；1 例患者患有慢性阻塞性肺疾病，伴有小的胸膜下泡和肺塌陷不佳，通过 CT 得到证实。2 例有 MI 的 uDCDD 适合但未进行移植：一名大型血型 B uDCDD 的未同意接受者，以及高级外科医生无法移植合适的 uDCDD 肺，并且不允许进行移植。
目标未达到：没有来自 uDCDD 的肺被移植。uDCDD 可以成为肺移植的来源。解决物流挑战和更好地利用第一人称授权，允许在没有近亲同意或不知道死亡的情况下进行器官回收，可以增加供体数量。供体的医疗问题高于预期，可能会限制 uDCDD 对肺供体库的影响。
NCT01615484。
