Donation after Circulatory Death in Lung Transplantation

Recipient Outcome after DCD Donation

Emory Transplant Center was referred a woman in her mid-fifties with advanced chronic obstructive pulmonary disorder. At the time of the referral, she was on supplemental oxygen at rest of three to four liters per minute. The Emory Lung Transplant Program team agreed that despite the optimum medical therapy she was receiving, a lung transplant would confer both a survival advantage as well as a quality-of-life advantage.

Despite medical suitability for transplant, the patient spent several months on the lung transplant waitlist without a suitable donor offer. At the time of listing, the patient had a Lung Allocation Score (LAS) below the 50th percentile. That, coupled with the fact that her blood group was O, meant that the patient could potentially wait several years before receiving a lung transplant. In order to facilitate lung transplantation in a reasonable time frame, our team, led by surgical director, Mani Daneshmand, MD, decided to accept a lung donor whose lungs were procured after cardiac death. This was the first case of lung transplantation using a DCD Donor (Donation after Circulatory Death) performed at Emory.

Donation after Circulatory Death

Conventionally, brain death has been the impetus toward identification of suitable organ donors. The concept of brain death is based on a legal definition. Brain death is the irreversible loss of all functions of the brain and brain stem. The declaration of brain death is by necessity rigorous. Currently, the vast majority of organs transplanted in the United States are procured from brain dead donors. Many severely brain injured patients will not meet the strict definition of brain death because, despite the fact that they will never regain consciousness, they maintain some basic brain stem functions such as a gag reflex. However, given that there is a significant shortage of organs for donation – to the point that many characterize it as a public health concern – the transplant community has been working to develop the concept of DCD. The DCD framework can potentially help both donor families who are in search of some meaningful good to come of their tragedy, as well as recipients who otherwise have limited access to donors. In potential DCD cases, artificial life support devices, such as the ventilator, are removed from the patient. The patient is allowed to progress naturally to cardiac arrest with death declared by their treating physician. It is only at that point where the organ transplant team becomes involved.

DCD organ donation, by necessity, requires significant care coordination as well as strict policy guidelines. Hospital critical care teams initiate the DCD process by alerting organ procurement organizations (OPO) of a family’s decision to discontinue life-sustaining treatment. It is at this stage where coordinators from the OPO meet with the patient’s family to explain the options involved, and to begin evaluation to determine if the patient is medically suitable for DCD. If a family decides to move forward, the patient care team will bring the donor to the operating room where organ donation can occur. The patient’s medical team will remove the ventilator that has been artificially breathing for that patient and will discontinue intravenous vasoactive medications. The treating team assesses for full cardiopulmonary arrest and the patient is declared deceased.

After a mandatory five-minute hands-off time, the procurement team is allowed in the room. The team reconnects the person to the ventilator to keep the lungs oxygenated, administers heparin to prevent blood clots and then recovers the organ for transplant. From this point on, organs procured from a DCD donor are similar to those procured from a conventionally brain dead donor.

Recipient Outcome Post-Transplant

Lung transplantation using DCD has shown that, in skillful hands, recipients experience comparable short- and long-term outcomes. In this case, our recipient underwent a successful bilateral lung transplant and was extubated the following morning. She spent two weeks as an inpatient before discharge and left the hospital without the need for supplemental oxygen. The recipient goes to pulmonary rehab three days a week and has quadrupled her six-minute walk distance. We are very hopeful that she will continue to enjoy an excellent quality of life.

Usage of DCD in the Future

Emory Transplant Center’s first DCD lung transplant highlights the center’s innovative approach toward improving organ transplant access to patients in need.

It is important that critical care specialists understand that this modality exists. In the United States, DCD lung transplant only accounts for 2 percent of all lung transplants, where it accounts for more than 10 percent of cases in European centers. While DCD donation is not likely to fix the organ shortage by itself, critical care medicine providers should feel empowered to contact their local OPO, Life Link of Georgia, for example, for any patient they believe may potentially qualify.

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