Should Lung Transplantation Be Performed Using Donation after Cardiac Death? The U.S. Experience
David P. Mason, Lucy Thuita, Joan M. Alster, Sudish C. Murthy, Marie M. Budev, Atul C. Mehta, Gosta B. Pettersson, Eugene H. Blackstone; Cleveland Clinic, Cleveland, OH
Comment on this Abstract
Objective: Single institution experience using donation after cardiac death (DCD) in lung transplantation (LTx) is limited and outcomes unclear. Therefore, we compared 1) survival of recipients of DCD lungs vs. that of those receiving lungs from donors meeting brain death criteria who were transplanted in the U.S., and 2) characteristics of recipients of DCD donation vs. brain death donation.
Methods: Donor, recipient and transplant variables, and follow-up data were obtained from the United Network for Organ Sharing (UNOS) for LTx from October 1987 to May 2007. Median follow-up among survivors of DCD LTx was 1 year, range 13 days to 8.6 years (unknown in 1). Unadjusted Kaplan-Meier survival estimates were compared for recipients of DCD organs vs. recipients of organs from brain death donors. To adjust the survival comparison for differences among recipients of DCD vs. brain death donor organs, a propensity score was developed incorporating recipient age, BMI, indication for transplant, diabetes, spirometry, single vs. double LTx, cold ischemic time, and donor age. The propensity score was used in a Cox proportional hazards model to adjust the comparison of survival for DCD vs. brain death donor LTx recipients.
Results: 14,939 transplants were performed, for which 36 patients received organs from DCD donors (9 single, 27 double LTx). Among the 36, 3 died, 1 each on days 1 and 11, and 1.54 years. Unadjusted survival at 1, 3, and 6 months and 1 and 2 years was 94%, 94%, 94%, 94%, and 87% for DCD donors, compared with 92%, 88%, 84%, 78%, and 69% for brain death donors (unadjusted P=.04; Figure). DCD recipients were more likely to undergo double LTx and have diabetes, a lower FEV1, and longer cold ischemic times. Once these were accounted for and propensity adjusted, survival was still better for DCD recipients, although P=.06.
Conclusion: Concern over organ quality and ischemia-reperfusion injury has limited the application of lung DCD. This analysis shows that DCD as practiced in the United States results in survival at least equivalent to that after brain death donation. However, it also demonstrates selection bias in choosing recipients for transplantation, particularly in performing more double LTx, making generalization regarding survival difficult. Nevertheless, the data support expanded experience with DCD.
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