LUNG DONOR REFERRAL CRITERIA
1. Acceptable General Organ Donor Criteria
2. Age 5-65 years
3. No significant untreatable lung disease (and no known significant pleural disease for DCD lung donation)
4. Arterial blood gases on 100% FiO2 and 5cm PEEP >250mmHg (or equivalent PaO2/Fio2 ratio)
REQUIRED DONOR INFORMATION FOR ALLOCATION
1. Accurate lung disease and treatment history |
[especially smoking (cigarettes and marijuana), asthma and aspiration may determine single vs bilateral lung transplant considerations] |
|
2. Accurate height and race |
(used to estimate total lung capacity) |
|
3. Weight |
(only used in consideration of combined heart/lung transplant) |
|
4. Investigations |
- |
ABO Blood group |
ORGAN ALLOCATION AND DISTRIBUTION
The recognised Lung Transplant Unit in the state of the donor's hospital is offered the donation as detailed below. They have 20 minutes to respond to the offer.
State of donor hospital |
Lung Transplant Unit |
|
QLD |
- |
QLD |
NSW, ACT |
- |
NSW |
VIC, TAS |
- |
VIC |
WA |
- |
WA |
SA, NT |
- |
On rotation through above states |
If the home state declines the offer, then the lung donation offer is made on to the non-home state recognised Lung Transplant Units, with a 20 minute response time. The non-home state offer is based upon a rotation kept by each state donor co-ordination team, such that the first non-home state offer is rotated through each transplanting state in strict turn. If the first non-home state declines the offer, the next is asked until all units have been asked.
If all recognised lung transplant units refuse the offer it is then rotated through any units that have non-nationals awaiting transplantation.
The acceptance of lungs by a unit depends on a large variety of technical and logistic factors, including the availability of a suitable potential recipient (see below).
INDIVIDUAL PATIENT ALLOCATION
The allocation of donor lungs is complicated by the considerable issues of logistics and the permutations/combinations of the different options of potential lung (and or heart) transplant that a cardiothoracic transplant unit need to consider when donor organs are offered. Donor lungs will be allocated considering the following criteria:
1. ABO compatibility
2. Size compatibility
3. The absence of a positive T cell crossmatch
Where more than one potential recipient meets the above criteria the first choice will be determined by the following process:
4. Clinical urgency*
Logistics**
Long-term outcome benefit***
5. Recipient waiting time, all other factors being equal
* Clinical urgency: Graded by level of support required and evidence of rapidity of deterioration of underlying indication for transplant.
- Level of support includes but not limited to the following
- ECMO
- Invasive mechanical ventilation
- Non-invasive ventilation
- High-flow O2 requirement
- Low-flow O2 requirement
- Prolonged or recurrent hospitalisation
- Other support devices such as continuous IV therapies
- Rapidity of deterioration includes, but not limited to
- change in NYHA functional Class or MRC grade
- significant fall in lung function parameters
- significant fall in PaO2
- significant rise in PaCO2
- significant fall in 6 Minute Walk Test distance
- need for escalation in level of support as above
- time course of progression of radiological changes
- development of symptomatic pulmonary hypertension
- development of refractory right heart failure** Logistics includes
- Time of retrieval and operation room availability
- Location of recipients and/or donor: (local, interstate, international)
- Type (ie. road or air) and availability of transport to bring recipient to the transplant centre, and to take retrieval team to donor hospital
- Availability of required team members for the retrieval, lung transplant(s) and related cardiac transplants (paired donor heart or domino heart transplant)
- Experience of team members
- Availability of ICU beds
- Operation type (lobar, single, bilateral, heart/lung)
- Availability of crossmatching
- Concerns regarding donor instability
- Donor family wishes regarding timing
*** Long-term outcome benefit includes
- Comorbidities such as osteoporosis, gastroesophageal reflux, known coronary or peripheral vascular disease, carriage of panresistant organisms, poor rehabilitation potential, history of malignancy, advanced age, lack of compliance, morbid obesity or malnutrition and other relative contraindications for lung transplantation which have been shown to be associated with an inferior outcome benefit.
ELIGIBILITY OF POTENTIAL RECIPIENTS FOR LUNG TRANSPLANTATION
Lung transplantation is a highly effective treatment for advanced lung disease; however its use is limited by the scarcity of suitable donor organs. For this reason, lung transplantation is offered only to patients who have end-stage lung disease (life expectancy less than two years without transplantation), and who have exhausted all alternative treatment options. Infant lung transplants (currently not available in Australia and New Zealand) and living related lung transplants have their own specific issues and are not included in these Guidelines.
Assessment, listing and transplantation can only occur after careful evaluation by a recognised multidisciplinary Australian or New Zealand Lung Transplant Unit. Lung transplantation is a complex therapy with significant risks, and a careful evaluation of all organ systems (with appropriate specialist advice as needed) is mandatory to evaluate a potential patient’s risk of short and long-term morbidity and mortality. As there may be significant co-morbidities and contraindications, it follows that not all possible recipients will prove acceptable for transplantation.
There are recent international guidelines that were formulated with Australian input, and Australian and New Zealand units broadly follow these recommendations with local interpretation (Orens JB et al, International guidelines for the selection of lung transplant candidates: 2006 Update. J Heart Lung Transplant 2006;25:745-56).
Inclusion Criteria include:
Exclusion Criteria include (but not limited to):
Date of protocol: August 2002
Updated August 2006
Updated January 2008
Updated March 2009