see also: Health Lung transplant patient dies

(see also, below) Lung transplant breakthrough

Lung transplantation
 from non-heart-beating donors¹

ABSTRACT:

Swedish researchers report in The Lancet a new way to preserve lungs for transplantation. Lungs are usually taken from heart-beating brain-dead donors. If the lungs are cooled, however, they can be preserved for 12-24 hours after the heart has stopped. Stig Steen and colleagues transplanted the lung of a 54-year-old man who had died from a heart attack. The researchers cooled the lungs with a special preservation solution and then removed them for transplantation into a 54-year-old woman with chronic obstructive pulmonary disease. This technique might help overcome the shortage of lungs for transplantation, especially in societies where criteria for brain death are not accepted.¹

Lung transplantation  from non-heart-beating donors:  Review

In the March 17, 2001 Journal of The Lancet, a report that though lung transplantation from non-heart beating donors remains experimental a Swedish team has successfully performed the procedure.

In Transplantation of lungs from a non-heart-beating donor¹ Prof Stig Steen MD, and team of colleagues from the Heart-Lung Division, University Hospital of Lund, told the Lancet that they began to prepare for this procedure several years ago: 

At the beginning of 1997, we started to prepare for a clinical study. We asked doctors, nurses, hospital chaplains, judges, teachers, philosophers, theologians, and ordinary citizens across Sweden about how lungs could be transplanted from a non-heart-beating donor. From this consultation, we learned that any type of surgery on a dead body within 1 h of death was ethically unsound, but that if topical cooling of the lungs could be accomplished without leaving scars, then the planned procedure ought to be acceptable.

We therefore returned to the laboratory and developed an efficient technique for topical cooling of the lungs in animals by puncture-placement of intrapleural cannulae for infusion of a cold (4ºC) lung-preservation solution  . . . With this technique, the lungs are compressed and are transformed into a semi-solid state, which is more easily cooled.¹

In the same year, the team met with Chief of Staff, the Chairman of the Medical Ethical Research Committee, and "hospital legal and ethical experts to discuss potential ethical problems with the use of lungs from non-heart-beating (human) donors."

The discussion raised two main concerns. First, what back-up the recipients could be offered if the transplanted lungs should for unexpected reasons fail, and second, whether an extra burden would be added to the next of kin if the question of lung donation was raised within 1 h of death.¹

After a hearing at the government's medical ethics council the team's project was fully accepted. Their first donor was a patient who died of a heart attack in a cardiac intensive care unit after failed resuscitation.   Using a salt solution, the organs were preserved by cooling down the dead person's body.

Before starting the cooling process, and hour after death, physicians gained permission from the next of kin . It was during that brief hour of 'cooling down' that the body was made ready for the relatives, who were then given time to be alone with the deceased.

Once the lungs were removed a mixture of blood and a preservation fluid was pumped through the lungs for a period of 8 hours and 18 minutes, keeping them healthy and enabling the doctors to assess whether they were still in working order.

The recipient was a 54-year-old woman with chronic obstructive lung disease, who quit smoking in 1993, " when she became oxygen-dependent."¹

The results:

A ventilation-perfusion scintigram of the recipient showed no great mismatch; the right lung had 51% and the left lung 49% of the ventilation. Right lung transplantation was done. The phrenic nerve had adhered to the teflon reinforced staple line after the lung-volume reduction surgery, and had to be carefully dissected free. There were also strong adherences between the lung and the diaphragm. Otherwise the transplantation was not difficult, and did not require extracorporeal circulation. The donor lung showed excellent function only 5 min after the start of reperfusion and ventilation, as judged by blood gases and carbon-dioxide curves. The patient was taken to the intensive-care unit 2 h after the start of reperfusion. The fractional concentration of oxygen in inspired gas was 0·3, giving 100% arterial saturation; pulmonary-arterial pressure was normal.

The first 2 weeks after the operation were free of complications. The patient was haemodynamically stable and was weaned from ventilatory support without difficulty on the first day after surgery. The first chest radiograph taken after extubation (18 h after the start of reperfusion) is shown in figure 3. The saturation was good with administration of oxygen at 2-3 L/min through a nasal cannula, and carbon dioxide concentrations in the blood were normal. The patient was mobile the day after the operation, and was transferred to the ward on the third postoperative day. The bacterial culture taken from the donor lung was negative.¹

Critics are hoping that Stig Steen and colleagues experimental procedure will prove to be of "particular value in those societies in which criteria for brain death are not accepted. It should also increase the donor pool in all countries."²  In a review of Steen's paper, important ethical issues are raised.

Steen's group consulted widely in Sweden and obtained agreement. We are unaware of any other group having done this for therapies that raise similar issues. Can the consensus that Steen obtained be applied to other societies? We doubt it. For example, in the UK the distrust of doctors following well-publicised scandals especially regarding organ retention will adversely affect this ethical framework. We also wonder whether the UK media is prepared to engage in such a debate in a mature way.

Next, those units with patients who are potential donors must be prepared to revise their thinking to allow the procedures for organ preservation and retrieval. Anticipation of potential donor status, the need for heparinisation at the time of death, the availability of facilities for organ cooling, rapid ascertainment of the wishes of patients and relatives, quick access to centralised data records, and willingness of the carers to allow the transplant team access to the recently deceased person are other difficulties that have to be faced. Conventional practice is to separate the carers for the dying patient from the recipient team to prevent any conflicts of interest. Steen and colleagues' procedure seems to demand mingling of these interests, so transplant co-ordinators will have to monitor the situation carefully. The energy required of a team to effect a successful transplant with urgency is considerable and the commitment of others (for example, pathologists) would have to be agreed in advance. Major logistic changes would be needed.

Another issue is detailed functional assessment of the organ before transplantation. Steen's group has shown convincingly that detailed assessment is possible, and that there is time to identify factors contraindicating use of an organ. Such assessment should improve the quality of transplantation.

The doubtful point in Steen and colleagues paper is their view that the risk of death due to unexpected complications after transplantation is minimal and that when the graft fails an urgent call for new donor lungs and re-transplantation could save the patient's life. These are remote hopes; complications, some fatal, do occur after transplantation, and the chances of finding new organs are poor, at least in the UK. Despite this reservation, Steen and colleagues' report should encourage a wider ethical debate about the potential for the use of non-heart-beating donors. For transplantation to become a successful form of therapy, the supply of donors must be increased.²

1. Stig Steen, Trygve Sjöberg, Leif Pierre, Qiuming Liao, Leif Eriksson, Lars Algotsson, Transplantation of lungs from a non-heart-beating donor,  The Lancet Volume 357, Number 9259 17 March 2001 http://www.thelancet.com/journal/vol357/iss9259/artid/15520

 2. Martin J Elliott, George Mallory Jnr, Asgar Khagani ,The Lancet Volume 357, Number 9259 17 March 2001Commentary:  Transplantation from non-heart-beating donors  Lancet March 17, Volume 357, Number 9259 http://www.thelancet.com/journal/vol357/iss9259/full/llan.357.9259.editorial_and_review.15542.1

PLEASE NOTE: In order to review most articles, one must sign up and obtain a user ID and password.  I found this system to be very accessible, taking only moments to complete.  Access can then be made to a wealth of FREE archives.  The URL for the LANCET HOME PAGE:  http://www.thelancet.com/home

An article in today's BBC, headlines  "Lung transplant breakthrough -- Organs can be preserved after death Scientists have found a way to increase the number of lungs available for transplant surgery.

Donor organs are in short supply in general in the UK, but the shortage of lungs is particularly severe.
This is because up to 80% of potential donor organs have to be discarded because they do not work well enough.

This break through doesn't come without criticism.  While "use of non-heart-beating donors  may be of particular value in those societies in which criteria for brain death are not accepted" - Martin J Elliott, et. al, also adds,  "It should also increase the donor pool in all countries."

THE LANCET

Volume 357, Number 9259
17 March 2001

Transplantation from non-heart-beating donors

Lung transplantation remains an experimental procedure. 92% of lung transplants are done in patients between the ages of 18 and 65, predominantly for emphysema, cystic fibrosis, pulmonary fibrosis, and pulmonary hypertension. The 5-year survival for this group is 45-50%; it is worse in children. Obliterative bronchiolitis is the commonest terminal event.1 Other crucial problems are supply of donor organs and the quality of their management and preservation.2 Ways of dealing with the inadequate supply range from transplanting single lungs to using live related donors.3

The use of non-heart-beating donors, as described by Stig Steen and colleagues in today's Lancet may be of particular value in those societies in which criteria for brain death are not accepted. It should also increase the donor pool in all countries. However, only time will tell whether organs from non-heart-beating donors function as well as organs from conventional donor sources, especially since duration of organ ischaemia, a known risk factor for death,1 can be difficult to control in such cases. The potential for using organs from non-heart-beating donors has been emphasised before in experimental work in which all organs can be retrieved by placing patients on cardiopulmonary support even some time after death.4 Such a procedure represents a form of reanimation of potential viable organs. Thus, if increasing the donor supply is the primary goal, such donors should be considered. Steen's paper raises several important issues.

An important issue is consensus on the ethics of the procedure. Steen's group consulted widely in Sweden and obtained agreement. We are unaware of any other group having done this for therapies that raise similar issues. Can the consensus that Steen obtained be applied to other societies? We doubt it. For example, in the UK the distrust of doctors following well-publicised scandals especially regarding organ retention will adversely affect this ethical framework. We also wonder whether the UK media is prepared to engage in such a debate in a mature way.

Next, those units with patients who are potential donors must be prepared to revise their thinking to allow the procedures for organ preservation and retrieval. Anticipation of potential donor status, the need for heparinisation at the time of death, the availability of facilities for organ cooling, rapid ascertainment of the wishes of patients and relatives, quick access to centralised data records, and willingness of the carers to allow the transplant team access to the recently deceased person are other difficulties that have to be faced. Conventional practice is to separate the carers for the dying patient from the recipient team to prevent any conflicts of interest. Steen and colleagues' procedure seems to demand mingling of these interests, so transplant co-ordinators will have to monitor the situation carefully. The energy required of a team to effect a successful transplant with urgency is considerable and the commitment of others (for example, pathologists) would have to be agreed in advance. Major logistic changes would be needed.

Another issue is detailed functional assessment of the organ before transplantation. Steen's group has shown convincingly that detailed assessment is possible, and that there is time to identify factors contraindicating use of an organ. Such assessment should improve the quality of transplantation.

The doubtful point in Steen and colleagues paper is their view that the risk of death due to unexpected complications after transplantation is minimal and that when the graft fails an urgent call for new donor lungs and re-transplantation could save the patient's life. These are remote hopes; complications, some fatal, do occur after transplantation, and the chances of finding new organs are poor, at least in the UK. Despite this reservation, Steen and colleagues' report should encourage a wider ethical debate about
the potential for the use of non-heart-beating donors. For transplantation to become a successful form of therapy, the supply of donors must be increased.

*Martin J Elliott, George Mallory Jnr, Asgar Khagani


*Department of Cardiothoracic Surgery, and Department of Transplant Surgery, Great Ormond Street Hospital, London WC1N 3JH; and Department of Cardiothoracic Surgery, Harefield Hospital, Harefield, Middlesex (e-mail:martin.elliott@gosh-tr.nthames.nhs.uk)

1 International Society of Heart and Lung Transplantation. Online registry at www.ishlt.org/regist_heart-lung_main.htm (accessed on March 12, 2001)

2 Huddleston CB, Mendeloff EN. Heart and lung preservation for transplantation. J
Cardiac Surg 2000; 15: 108-21. [PubMed]

3 Starnes VA, Woo MS, MacLaughlin, et al. Comparison of outcomes between living
donor and cadaveric lung transplantation in children. Ann Thoracic
Surg 1999; 68: 2279-84. [PubMed]

4 Fukushima N, Shirakura R, Chang JC, et al. Successful experimental multiorgan
transplant from non-heart-beating donors using percutaneous cardiopulmonary support.
ASAIO J 1998; 44: M525-28. [PubMed]

The full article in the Lancet is on page

http//www.thelancet.com/journal/vol357/iss9259/artid/15520 However I believe you might need a password. If you cannot access this article let me know and I will forward it to you. The following is the BBC report

http//news.bbc.co.uk/hi/english/health/newsid_1222000/1222007.stm

Friday, 16 March, 2001, 0028 GMT

Lung transplant breakthrough

Organs can be preserved after death Scientists have found a way to increase the number of lungs available for transplant surgery.

Donor organs are in short supply in general in the UK, but the shortage of lungs is particularly severe.
This is because up to 80% of potential donor organs have to be discarded because they do not work well enough.

As a result, as many as 40% of people with cystic fibrosis die while waiting for a transplant.
Until now lungs, in common with many other organs, are only removed from donors while their heart is still beating.

This is because the organs deteriorate rapidly once they do not receive a regular supply of oxygen, and doctors have no method of measuring how well they are functioning once the patient has died. But Swedish doctors have successfully used lungs taken from a donor hours after their heart had stopped beating.

The donor was a patient who died of a heart attack in a cardiac intensive care unit after failed resuscitation. Cooling down The organs were preserved by cooling down the dead person's body using a salt solution.

Doctors gained permission from the next of kin before starting the cooling process an hour after death. The next of kin was given time with the body while it was cooled.

After two hours, the lungs were removed and a mixture of blood and a preservation fluid was pumped through them for the next eight hours. Not only did this keep the lungs healthy, it also enabled doctors for the first time to assess whether they were still in working order.

Eventually, the right lung was successfully transplanted into a 54-year-old woman with chronic obstructive lung disease.

The donor lung began to work very well shortly after transplantation, and remained effective five months after surgery.

Researchers from University Hospital, Lund, carried out the procedure after discussions with doctors, nurses, hospital chaplains and judges.

Lead researcher Dr Stig Steen said the lung function of non-smokers was usually good, even in old age.

He said "Most patients in Sweden who need new lungs have chronic obstructive pulmonary disease and are 60 years of age or older.

"When all hospitals and ambulance personnel in Sweden have received training in non-heart-beating lung donation, we hope that there will be enough donor lungs of good quality for all patients who could benefit from a lung transplant".

Ethical concerns

Professor John Dark, head of the heart and lung transplant unit at the Freeman Hospital, Newcastle Upon Tyne, told BBC News Online that the solution used by the Swedish team to preserve the lung had probably also helped to improve its function.

However, he said that to carry out the procedure on a wide scale would present logistical problems, not least that work would have to be started on the dead person's body before permission to use the organs had been sought from relatives.

But he said "It might be possible to increase the number of lung transplants carried out in this country by 20-25%.

"There would also be other benefits to being able to preserve lungs for a longer time. For instance it would mean that transplant surgery could take place in daylight hours."

Mr Martin Elliott, head of cardiothoracic transplantation at Great Ormond Street Hospital for Sick Children in London, said a mature public debate was needed on the future of transplantation.

He told BBC News Online "This has huge potential to free up organs that would make a tremendous difference to an enormous amount of people.

"But first we need a rational debate, and to build a relationship of trust with the public.   "By involving the people who do transplants in  a public debate we could agree the best way forward without these people being seen as something out of Burke and Hare."

The research is published in The Lancet medical journal.


 BBC News Online

The full article in the Lancet is on page

http//www.thelancet.com/journal/vol357/iss9259/artid/15520 However I believe you might need a password. If you cannot access this article let me know and I will forward it to you. The following is the BBC report

http//news.bbc.co.uk/hi/english/health/newsid_1222000/1222007.stm

Friday, 16 March, 2001, 0028 GMT