Lung Transplantation With Grafts From Elderly Donors: A Single-Center Experience

Lung Transplantation With Grafts From Elderly Donors: A Single-Center Experience M. C. Dezza, P. C. Parigi, V. Corno, A. Lucianetti, D. Pinelli, M. Zambelli, M. Guizzetti, A. Aluffi, F. Tagliabue, M. Platto, D. Codazzi, M. Triggiani, and M. Colledan ABSTRACT Introduction. Use of extended criteria donors is one of the strategies to face the scarcity of donors for lung transplantation. Methods. Between November 2002 and May 2009, we performed 52 LTs in 50 recipients, 10 of whom (group A) received lungs from donors aged 55 years or older (median, 58.5; range, 56 – 66 years) for comparison with 28 patients (group B) transplanted with lungs from donors younger than 55 years (median, 25.5; range, 15–54 years). We excluded 9 children and 3 recipients of combined liver plus lung transplantations from the study. Results. Recipient age, gender, and indications for transplantation did not differ significantly between the 2 groups. Neither were there significant differences in PaO2/FiO2 ratios before lung retrieval, or length of the ischemic time The first PaO2/FiO2 on arrival to the intensive care unit (ICU) and the median length of ICU stay were similar. All patients, except 2 who died in the operating theatre, were extubated between 3 and 216 hours after the transplantation. Hospital mortality was similar in both groups: 3 patients in group A and 2 in group B (P ⫽ .1). The median portions of the predicted 1-second forced expiratory volume (FEV1) at 6 months after transplantation did not differ in the 2 groups: 62.4% in group A versus 70% in group B (P ⫽ .85). Conclusion. Lung grafts from donors older than 55 years can be effectively used for transplantation, thus increasing the total organ pool. UNG transplantation (LT) is limited by the shortage of suitable donors. Several methods to increase the number of grafts have been adopted, such as the use of lobar transplantations either from living related or deceased donors and the use of lungs from donations after cardiac death. Another concept to overcome the shortage of donor organs is the use of lungs from marginal donors,1 including individuals older than 55 years. We reviewed our experience with transplantation of lungs from donors older than 55 years of age.

L

METHODS Between November 2002 and May 2009, we performed 52 LT-in 50 recipients: 10 recipients received lungs from donors aged 55 years or older and 28 from donors aged younger than 55 years. We excluded from the study 9 children and 3 recipients of combined liver plus lung transplantations. Comparisons of val-

ues between the groups were performed with the unpaired Student t test or the Fisher exact test. The software package SPSS 13 for Windows (SPSS Inc. Chicago, Ill, United States) was used for the analysis.

RESULTS

Among the 38 patients in this study, 10 (group A) underwent transplantation with lungs from donors aged From Chirurgia III (M.C.D., V.C., A.L., D.P., M.Z., M.G., A.A., F.T., M.P., M.C.), Pneumologia (P.C.P.), Terapia Intensiva Pediatrica (D.C.), and Cardiochirurgia (M.T.), Centro Trapianto di Fegato e di Polmone, Ospedali Riuniti di Bergamo, Italy. Address reprint requests to Michele Colledan, Chirurgia III, Centro Trapianto di Fegato e di Polmone, Ospedali Riuniti, Largo Barozzi, 1, 24128 Bergamo, Italy. E-mail: mcolledan@ ospedaliriuniti.bergamo.it

0041-1345/10/$–see front matter doi:10.1016/j.transproceed.2010.03.093

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Transplantation Proceedings, 42, 1262–1264 (2010)

GRAFTS FROM ELDERLY DONORS

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55 years or older (median, 58.5 years; range, 56 – 66) and 28 (group B) from donors younger than 55 years (median, 25.5 years; range, 15–54). The median ventilation time before the harvest, donor pulmonary function before lung retrieval (as assessed by PaO2/FiO2 at mechanical ventilation with an FiO2 of 1.0, and positive endexpiratory pressure of 5 cm H20), and graft ischemic time did not differ significantly between the 2 groups (Table 1). Recipient median age was 35.5 years (range, 21.20 – 66.05) in group B and 39.9 years (range, 23.3– 68.6) in group A (P ⫽ .2). The most common indication for transplantation was cystic fibrosis in both groups: 16/28 (57.1%) in group B versus 5/10 (50%) in group A (P ⫽ .7). The median portions of the predicted 1-second forced expiratory volume (FEV1) at the time of listing was 21% (range, 17%–59%) in group A and 26% (range, 15%–52%) in group B (P ⫽ .8). Four patients (40%) in group A and 3 patients (11%) in group B received intensive care including mechanical ventilation support (P ⫽ .06) The number of single lung transplantations in group A was 4 versus 3 in group B (P ⫽ .06). Cardiopulmonary bypass (CPB) was used in 10/28 group B recipients (36%) and 2/10 group recipients A (20%; P ⫽ .4). One patient in each group died in the operating theatre due to cardiac arrest (group A) and graft failure (group B), respectively. The initial graft function assessed by the first PaO2/FiO2 on arrival in the intensive care unit (ICU) did not differ between the 2 groups, namely, 231 (range, 124 –340) in group A versus 253 (range, 148 – 477) in group B (P ⫽ .3). The median length of mechanical ventilation after transplantation was 72 hours (range, 8 –216) in group A versus 24 hours (range, 3–192) in group B (P ⫽ .02) and the median stay in the ICU was 7 days (range, 1–27) and 3.5 days (range, 1– 80), respectively (P ⫽ .6). In-hospital deaths were related to the following: primary nonfunction in group Table 1. Donor Characteristics Donor ⬍ 55 (n ⫽ 28)

Median age (y) Female/Male Cause of death Cerebrovascular accident Cerebral hypoxia Tumor Head injury Other Median ventilation time before harvest (d) Median final Pa02 before harvest (mm Hg) Median total ischemic time (min) 1st lung Median total ischemic time (min) 2nd lung Positive smoking history

Donor ⬎ 55 (n ⫽ 10)

25 (15–54) 10/18

58 (56–66) 4/6

11

8

0 1 14 2 2 (1–10)

1 0 1 0 2 (1–5)

P

⬍.01 1 .06 1 1 .05 1 .82

478.5 (300–600)

494 (358–555)

.78

251 (120–495)

240 (120–340)

.6

360 (245–540)

320 (300–455)

.8

7

2

B (n ⫽ 1) and to sepsis due to Serratia species (n ⫽ 1) or B-Cepacea (n ⫽ 1) in group A. One patient in group B underwent retransplantation of a single lung due to bronchial anastomotic dehiscence. The median FEV1 at 6 months did not differ between the 2 groups: 62.4% (group A) versus 70% (group B; P ⫽ .85). The incidence of Bronchiolitis Obliterans Syndrome (BOS) was not different for the 2 groups: 2/28 (7%) in group B and 1/10 (10%) in group A (P ⫽ .9). The actuarial 6-, 24-, and 36-month survival rates were 70%, 56%, and 42% in group A versus 92.8%, 87.7%, and 79.7% in group B, respectively (P ⫽ .02). In group B 1 patient developed severe BOS, eventually surcumbing at 25 months after LT. Another recipient died at 8 months after LT due to B-Cepacia sepsis. In group A 1 recipient of a single lung developed cancer in the native lung, eventually succumbing at 18 months after LT; another recipient 5 months after sequential bilateral LT, using CPB, developed a systemic invasive Aspergillosis, which involved the brain and the ascending aorta and a pseudoaneurysm that was surgically repaired using a bovine pericardium patch. Four months later he died due to rupture of the ascending aorta from recurrence of the mycotic infection. DISCUSSION

Attempts to expand the donor pool have been applied in most solid organ transplantations. Extension of the age limit for lung donors has evolved much less rapidly than that for other organs, likely secondary to the perceived fragile nature of pulmonary allografts.2 This study was undertaken to evaluate the effect of donor age on early and late graft function and on patient survival. Univariate analysis appeared to show a significant difference in patient survival according to donor age, but all 5 deaths among elderly donors were explained by factors other than graft function. Moreover, most of the evaluated points—initial graft function, median stay in the ICU, in-hospital deaths, and FEV1 at 6 months— did not differ between the 2 groups. The Hannover group reported that “high urgency” status on the waiting list significantly increased the risk for posttransplantation mortality.3 In our analyses the number of recipients who had a “high urgency” status was greater in the group that received older donor organs, even though the difference was not significant. In summary, our limited, retrospective experience showed that lungs from donors older than 55 years can be effectively used for LT with functional results substantially similar to those achievable with lungs from younger donors. ACKNOWLEDGMENTS

1

The authors wish to acknowledge the following Doctors from Cardiochirurgia, Ospedali Riuniti di Bergamo, Italy, for their constant support in the institution and intraoperative management of the cardiopulmonary bypass: Amando Gamba, MD, Domenico Giordano, Maurizio Merlo, MD, Claudio Seddio,

1264 MD, Samuele Pentiricci, MD, Caterina Simon, MD Amedeo Terzi, MD, Vitali Pak, MD, and Mikahil Dodonov, MD.

REFERENCES 1. Pierre AF, Semine Y, Hutcheon MA, et al: Marginal donor lungs: a reassessment. J Thorac Cardiovascular Surg 123:421, 2002

DEZZA, PARIGI, CORNO ET AL 2. Meyer DM, Bennett LE, Novick RJ, et al: Effect of donor age and ischemic time on intermediate survival and morbidity after lung transplantation. Chest 118:1255, 2000 3. Fisher S, Gohrbandt B, Struckmeier, et al: Lung transplantation with lungs from donors fifty years of age and older. J Thorac Cardiovasc Surg 129:919, 2005