|
1
|
Spielberg DR, Melicoff E, Heinle JS, Hosek K, Mallory GB. Differential donor management of pediatric vs adult organ donors and potential impact on pediatric lung transplantation. J Heart Lung Transplant 2022; 42:522-532. [PMID: 36564335 DOI: 10.1016/j.healun.2022.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 11/08/2022] [Accepted: 11/10/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Despite clinical progress over time, a shortage of suitable donor organs continues to limit solid organ transplantation around the world. Lungs are the organs most likely to be assessed as unsuitable during donor management among all transplantable organs. Although the number of lung transplants performed in children is limited, death on the wait list remains a barrier to transplant success for many potential transplant candidates. Optimizing organ donor management can yield additional organs for transplant candidates. METHODOLOGY We accessed the Donor Management Goal (DMG) Registry to evaluate the efficiency and efficacy of donor management in the procurement of lungs for transplantation. Further, we stratified donors by age and compared pediatric age cohorts to adult cohorts with respect to attainment of donor management target goals and successful pathway to transplantation. We utilized recipient data from the Organ Procurement Transplantation Network (OPTN) to put this data into context. The DMG bundle consists of nine physiologic parameters chosen as end-points guiding donor management for potential organ donors. The number of parameters fulfilled has been regarded as an indication of efficacy of donor management. RESULTS We noted a markedly lower number of organ donors in the pediatric age group compared to adults. On the other hand, the number of donors greatly exceeds the number of infants, children and adolescents who undergo lung transplantation. Organs transplanted per donor peaks in the adolescent age group. At initial donor referral, DMG bundle attainment is lower in all age groups and improves during donor management. With respect to oxygenation, there is less overall improvement in younger donors compared to older donors during donor management. When donors who yield lungs for transplantation are compared to those whose lungs were not transplanted, oxygenation improved more substantially during donor management. Furthermore, improved oxygenation correlated with the total number of organs transplanted per donor. CONCLUSIONS In the face of continued wait list mortality on the pediatric lung transplant wait list, the number of young donors may not be a limiting factor. We believe that this dataset provides evidence that management of young pediatric donors is not as consistent or efficient as the management of older donors, potentially limiting the number of life-saving organs for pediatric lung transplant candidates. Across all ages, optimizing donor lung management may increase the potential to transplant multiple other organs.
Collapse
Affiliation(s)
- David R Spielberg
- Section of Pediatric Pulmonology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas; Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ernestina Melicoff
- Section of Pediatric Pulmonology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Jeffrey S Heinle
- Division of Congenital Heart Surgery, Texas Children's Hospital; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Kathleen Hosek
- Department of Quality Assurance, Texas Children's Hospital, Houston, Texas
| | - George B Mallory
- Section of Pediatric Pulmonology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas.
| |
Collapse
|
|
2
|
Pulmonary vein stenosis: Treatment and challenges. J Thorac Cardiovasc Surg 2021; 161:2169-2176. [DOI: 10.1016/j.jtcvs.2020.05.117] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/19/2020] [Accepted: 05/23/2020] [Indexed: 11/15/2022]
|
|
3
|
Toprak D, Midyat L, Freiberger D, Boyer D, Fynn-Thompson F, Visner G. Outcomes of mechanical support in a pediatric lung transplant center. Pediatr Pulmonol 2017; 52:360-366. [PMID: 27787952 DOI: 10.1002/ppul.23535] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 06/02/2016] [Accepted: 07/02/2016] [Indexed: 12/28/2022]
Abstract
Pediatric lung transplantation is a lifesaving option for patients with end stage lung disease, although the scarcity of suitable donor organs results in long wait times and increased waitlist mortality. Many pediatric centers consider mechanical ventilatory support, such as long-term invasive ventilation and ECMO, a contraindication to lung transplantation. We hypothesized that current survival rates and outcomes for patients on mechanical ventilatory support in the pre-transplant period were not remarkably different. In our retrospective analysis we included patients between the ages of 0-21 years listed for lung transplantation from deceased donors between 2007 and 2014 at our institution. One-year survival outcomes were compared between three groups of patients: (i) patients bridged to transplant on ECMO (n = 6, 1-year survival = 67%); (ii) patients needing mechanical ventilation (either through endotracheal intubation or tracheostomy) but not ECMO (n = 12, 1-year survival = 75%); and (iii) patients who did not need endotracheal ventilation, tracheostomy, or ECMO (n = 25, 1-year survival = 88%). Comparison of outcomes of transplanted patients between these three groups were not statistically different in terms of successful hospital discharge and 1-year survival rates (P > 0.05). We believe that "bridging" the end-stage lung disease patient with long-term mechanical ventilation and/or ECMO support is a reasonable option in selected patients until suitable donors become available. Pediatr Pulmonol. 2017;52:360-366. © 2016 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Demet Toprak
- Division of Respiratory Diseases, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Levent Midyat
- Division of Respiratory Diseases, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dawn Freiberger
- Division of Respiratory Diseases, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Debra Boyer
- Division of Respiratory Diseases, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Francis Fynn-Thompson
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gary Visner
- Division of Respiratory Diseases, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
|
4
|
Lancaster TS, Miller JR, Epstein DJ, DuPont NC, Sweet SC, Eghtesady P. Improved waitlist and transplant outcomes for pediatric lung transplantation after implementation of the lung allocation score. J Heart Lung Transplant 2016; 36:520-528. [PMID: 27866928 DOI: 10.1016/j.healun.2016.10.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 09/08/2016] [Accepted: 10/12/2016] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Although the lung allocation score (LAS) has not been considered valid for lung allocation to children, several additional policy changes for pediatric lung allocation have been adopted since its implementation. We compared changes in waitlist and transplant outcomes for pediatric and adult lung transplant candidates since LAS implementation. METHODS The United Network for Organ Sharing database was reviewed for all lung transplant listings during the period 1995 to June 2014. Outcomes were analyzed based on date of listing (pre-LAS vs post-LAS) and candidate age at listing (adults >18 years, adolescents 12 to 17 years, children 0 to 11 years). RESULTS Of the 39,962 total listings, 2,096 (5%) were for pediatric candidates. Median waiting time decreased after LAS implementation for all age groups (adults: 379 vs 83 days; adolescents: 414 vs 104 days; children: 211 vs 109 days; p < 0.001). The proportion of candidates reaching transplant increased after LAS (adults: 52.6% vs 71.6%, p < 0.001; adolescents: 40.3% vs 61.6%, p < 0.001; children: 42.4% vs 50.9%, p = 0.014), whereas deaths on the waitlist decreased (adults: 28.0% vs 14.4%, p < 0.001; adolescents: 33.1% vs 20.9%, p < 0.001; children: 32.2% vs 25.0%; p = 0.025), despite more critically ill candidates in all groups. Median recipient survival increased after LAS for adults and children (adults: 5.1 vs 5.5 years, p < 0.001; children: 6.5 vs 7.6 years, p = 0.047), but not for adolescents (3.6 vs 4.3 years, p = 0.295). CONCLUSIONS Improvements in waiting time, mortality and post-transplant survival have occurred in children after LAS implementation. Continued refinement of urgency-based allocation to children and broader sharing of pediatric donor lungs may help to maximize these benefits.
Collapse
Affiliation(s)
- Timothy S Lancaster
- Section of Pediatric Cardiothoracic Surgery, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Jacob R Miller
- Section of Pediatric Cardiothoracic Surgery, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Deirdre J Epstein
- Section of Pediatric Cardiothoracic Surgery, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Nicholas C DuPont
- Section of Pediatric Cardiothoracic Surgery, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Stuart C Sweet
- Division of Pediatric Allergy, Immunology and Pulmonary Medicine, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Pirooz Eghtesady
- Section of Pediatric Cardiothoracic Surgery, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, Missouri, USA.
| |
Collapse
|
|
5
|
Abstract
The Ethics Committee of The Transplantation Society convened a meeting on pediatric deceased donation of organs in Geneva, Switzerland, on March 21 to 22, 2014. Thirty-four participants from Africa, Asia, the Middle East, Oceania, Europe, and North and South America explored the practical and ethical issues pertaining to pediatric deceased donation and developed recommendations for policy and practice. Their expertise was inclusive of pediatric intensive care, internal medicine, and surgery, nursing, ethics, organ donation and procurement, psychology, law, and sociology. The report of the meeting advocates the routine provision of opportunities for deceased donation by pediatric patients and conveys an international call for the development of evidence-based resources needed to inform provision of best practice care in deceased donation for neonates and children.
Collapse
|
|
6
|
Eberlein M, Reed RM. Donor to recipient sizing in thoracic organ transplantation. World J Transplant 2016; 6:155-164. [PMID: 27011913 PMCID: PMC4801791 DOI: 10.5500/wjt.v6.i1.155] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 10/21/2015] [Accepted: 12/08/2015] [Indexed: 02/05/2023] Open
Abstract
Donor-to-recipient organ size matching is a critical aspect of thoracic transplantation. In the United States potential recipients for lung transplant and heart transplant are listed with limitations on donor height and weight ranges, respectively. Height is used as a surrogate for lung size and weight is used as a surrogate for heart size. While these measures are important predictors of organ size, they are crude surrogates that fail to incorporate the influence of sex on organ size. Independent of other measures, a man’s thoracic organs are approximately 20% larger than a woman’s. Lung size can be better estimated using the predicted total lung capacity, which is derived from regression equations correcting for height, sex and age. Similarly, heart size can be better estimated using the predicted heart mass, which adjusts for sex, age, height, and weight. These refined organ sizing measures perform better than current sizing practice for the prediction of outcomes after transplantation, and largely explain the outcome differences observed after sex-mismatch transplantation. An undersized allograft is associated with worse outcomes. In this review we examine current data pertaining to size-matching in thoracic transplantation. We advocate for a change in the thoracic allocation mechanism from a height-or-weight-based strategy to a size-matching process that utilizes refined estimates of organ size. We believe that a size-matching approach based on refined estimates of organ size would optimize outcomes in thoracic transplantation without restricting or precluding patients from thoracic transplantation.
Collapse
|
|
7
|
Tsuang WM, Chan KM, Skeans MA, Pyke J, Hertz MI, Israni AJ, Robbins-Callahan L, Visner G, Wang X, Wozniak TC, Valapour M. Broader Geographic Sharing of Pediatric Donor Lungs Improves Pediatric Access to Transplant. Am J Transplant 2016; 16:930-7. [PMID: 26523747 DOI: 10.1111/ajt.13507] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 07/29/2015] [Accepted: 08/24/2015] [Indexed: 01/25/2023]
Abstract
US pediatric transplant candidates have limited access to lung transplant due to the small number of donors within current geographic boundaries, leading to assertions that the current lung allocation system does not adequately serve pediatric patients. We hypothesized that broader geographic sharing of pediatric (adolescent, 12-17 years; child, <12 years) donor lungs would increase pediatric candidate access to transplant. We used the thoracic simulated allocation model to simulate broader geographic sharing. Simulation 1 used current allocation rules. Simulation 2 offered adolescent donor lungs across a wider geographic area to adolescents. Simulation 3 offered child donor lungs across a wider geographic area to adolescents. Simulation 4 combined simulations 2 and 3. Simulation 5 prioritized adolescent donor lungs to children across a wider geographic area. Simulation 4 resulted in 461 adolescent transplants per 100 patient-years on the waiting list (range 417-542), compared with 206 (range 180-228) under current rules. Simulation 5 resulted in 388 adolescent transplants per 100 patient-years on the waiting list (range 348-418) and likely increased transplant rates for children. Adult transplant rates, waitlist mortality, and 1-year posttransplant mortality were not adversely affected. Broader geographic sharing of pediatric donor lungs may increase pediatric candidate access to lung transplant.
Collapse
Affiliation(s)
- W M Tsuang
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - K M Chan
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan Health System, Ann Arbor, MI
| | - M A Skeans
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN
| | - J Pyke
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN
| | - M I Hertz
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN.,Department of Medicine, University of Minnesota, Minneapolis, MN
| | - A J Israni
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN.,Department of Medicine, University of Minnesota, Minneapolis, MN.,Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | | | - G Visner
- Division of Pulmonary and Respiratory Diseases, Boston Children's Hospital, Boston, MA
| | - X Wang
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN
| | - T C Wozniak
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - M Valapour
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH.,Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN
| |
Collapse
|
|
8
|
Lung Transplantation. PATHOLOGY OF TRANSPLANTATION 2016. [PMCID: PMC7153460 DOI: 10.1007/978-3-319-29683-8_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The therapeutic options for patients with advanced pulmonary parenchymal or vascular disorders are currently limited. Lung transplantation remains one of the few viable interventions, but on account of the insufficient donor pool only a minority of these patients actually undergo the procedure each year. Following transplantation there are a number of early and late allograft complications such as primary graft dysfunction, allograft rejection, infection, post-transplant lymphoproliferative disorder and late injury that is now classified as chronic lung allograft dysfunction. The pathologist plays an essential role in the diagnosis and classification of these myriad complications. Although the transplant procedures are performed in selected centers patients typically return to their local centers. When complications arise it is often the responsibility of the local pathologist to evaluate specimens. Therefore familiarity with the pathology of lung transplantation is important.
Collapse
|
|
9
|
Blatter J, Sweet S. Lung Transplantation in Cystic Fibrosis: Trends and Controversies. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2015; 28:237-243. [PMID: 26697265 DOI: 10.1089/ped.2015.0564] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
This article is not an overview of all facets of lung transplantation in cystic fibrosis (CF), but rather it is intended as a review of current allocation controversies, as well as of trends in diagnostics and management in lung transplant recipients and in patients with end-stage lung disease. Despite changes in donor and recipient selection, long-term survival in pediatric lung transplant has continued to be limited by chronic lung allograft dysfunction (CLAD). Due to, in part, this short survival benefit, transplant continues to be an appropriate option for only a subset of pediatric patients with CF. The feasibility of transplant as a therapeutic option is also affected by the limited pediatric organ supply, which has moreover contributed to controversy over lung allocation. Debates over the allocation of this scarce resource, however, may also help to drive innovation in the field of lung transplant. Longer pretransplant survival-as aided by new lung bypass technologies, for example-could help to alleviate organ shortages, as well as facilitate the transport of organs to suitable pediatric recipients. Improved diagnosis and treatment for CLAD and for antibody-mediated rejection have the potential to extend survival in pediatric lung transplant. Regardless, the relative rarity of transplant could pose future challenges for pediatric lung transplant programs, which require adequate numbers of patients to maintain proper expertise.
Collapse
Affiliation(s)
- Joshua Blatter
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine , St. Louis, Missouri
| | - Stuart Sweet
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine , St. Louis, Missouri
| |
Collapse
|
|
10
|
Abstract
Cardiothoracic transplantation has significantly impacted the lives of pediatric patients with advanced cardiopulmonary failure. The current state of lung transplantation in children as well as its ongoing and future challenges are discussed.
Collapse
|
|
11
|
Affiliation(s)
- George B Mallory
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.
| |
Collapse
|
|
12
|
|
|
13
|
Abstract
Research in pulmonary transplantation is actively evolving in quality and scope to meet the challenges of a growing population of lung allograft recipients. In 2013, research groups leveraged large publicly available datasets in addition to multicenter research networks and single-center studies to make significant contributions to our knowledge and clinical care in the areas of donor use, clinical transplant outcomes, mechanisms of rejection, infectious complications, and chronic allograft dysfunction.
Collapse
Affiliation(s)
- Jamie L Todd
- 1 Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | | | | |
Collapse
|