Review
Donor management and lung preservation for lung transplantation

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Summary

Although lung transplantation has become a life-saving option for patients with end-stage lung disease, this intervention is hampered by a shortage of lungs in view of the growing number of people on the waiting list. Lungs are retrieved from only a small percentage of multiorgan donors, and the transplantation and intensive-care communities have recognised the need to develop innovative methods to expand the donor pool. Advancements in lung-preservation techniques in the preretrieval and postretrieval periods have increased the pool of available donors, and novel research and discoveries in this area have steadily improved post-transplantation adverse events. This Review summarises current best practice and the latest research on intensive-care management of a potential lung donor. We also discuss lung-preservation techniques, including advancements in normothermic ex-vivo lung perfusion, and the potential for a personalised medicine approach to the organ.

Introduction

Lung transplantation is an effective, life-saving therapy for patients with end-stage lung disease. Over the past three decades, advancements in surgical technique, immunosuppression, and post-transplantation management have led to substantially improved outcomes and a proliferation of transplantation programmes around the world. The main limiting factor is a shortage of suitable donors. Meticulous management of potential lung donors and appropriate preservation and treatment of potentially transplantable lungs is at the crux of expanding the donor pool, in view of the growing number of people on the waiting list and a shortage of donors.

Donor management and lung preservation refers to the steps taken after determination of death to preserve lung quality and optimise function after transplantation. Novel methods of donor management, lung preservation, and ex-vivo therapeutics have focused on minimising the incidence and effect of primary graft dysfunction (PGD) after transplantation. PGD is a type of lung dysfunction characterised by hypoxia and impaired ventilation associated with transplantation-related lung injury. It is generally due to capillary leak of the pulmonary vasculature leading to non-cardiogenic pulmonary oedema. PGD can be associated with systemic inflammatory response syndrome (SIRS) leading to circulatory shock and, in its most severe form, multisystem organ failure. The incidence of PGD ranges from 10% to 30%, and it is the greatest contributor to early mortality after transplantation (panel 1).1

This Review focuses on the latest advancements and research into donor management in intensive-care units, and on a detailed approach to preservation of donor lungs, including preservation solutions, mode of transport, optimum temperature, optimum ischaemic times, and ex-vivo therapeutic options for injured donor lungs.

Section snippets

Donor selection

Factors that affect donor selection for lungs can be divided into chronic donor factors and acquired donor factors (induced by the cause of death and perimortem period). Acquired donor factors are potentially modifiable by the specific management interventions outlined below. With advancements in technology, surgical technique, and immunosuppression, the past few decades have seen a shift from using a very conservative set of donor criteria to extended, or marginal, donor criteria (panel 2).

Preservation

Vigilant preservation helps protect against PGD and improves long-term graft function. Maintaining viability of the lungs depends on several preservation factors, including type of preservation solution and method of administration, storage temperature, lung inflation volume and pressure, mode of transportation, pharmacological agents, and ischaemic times.

At the start of organ recovery, the lungs are flushed with a preservation solution in an anterograde and retrograde manner to cool them and

Conclusions

Transplanted lungs are subjected to injuries ranging from the event causing death of the donor, to the inflammatory cascade in brain death. Further injuries are related to resuscitation of the donor and management in the intensive-care unit and on ventilation. Injury related to organ extraction, preservation, transport, and implantation then follows. Once implanted in the recipient, ischaemia-reperfusion injury is followed by immunological attack of the foreign organ by the recipient host. For

Search strategy and selection criteria

We searched PubMed and Medline with the key terms “lung transplant”, “preservation”, and “donor management”. The search was restricted to studies published in English, and the final search was done in October, 2012. We screened 277 references and included 75 in this Review. We examined the reference lists of selected publications for any additional original research, systematic reviews, or published abstracts of interest that did not come up in the original search.

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