View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Erasmus University Digital Repository Transplant International ORIGINAL ARTICLE Impact of donor lung quality on post-transplant recipient outcome in the Lung Allocation Score era in Eurotransplant – a historical prospective study Jacqueline M. Smits1 , Jens Gottlieb2,3, Erik Verschuuren4, Patrick Evrard5, Rogier Hoek6, Christiane Knoop7,Gyorgy€ Lang8, Johanna M. Kwakkel-van Erp9, Robin Vos10 , Geert Verleden10, Benoit Rondelet11, Daniel Hoefer12, Frank Langer13, Rene Schramm14, Konrad Hoetzenecker8, Diana van Kessel15, Bart Luijk16, Leonard Seghers6, Tobias Deuse17, Roland Buhl18, Christian Witt19, Agita Strelniece1, Dave Green1, Erwin de Vries1, Guenter Laufer20 & Dirk Van Raemdonck21 1 Eurotransplant International Foundation, Leiden, The Netherlands SUMMARY 2 Department of Respiratory The aim of this study was to investigate whether there is an impact of Medicine, Hannover Medical School, donation rates on the quality of lungs used for transplantation and Hannover, Germany whether donor lung quality affects post-transplant outcome in the current 3 Biomedical Research in End-stage Lung Allocation Score era. All consecutive adult LTx performed in Euro- and Obstructive Disease (Breath), transplant (ET) between January 2012 and December 2016 were included German Centre for Lung Research = (DZL), Hannover, Germany (N 3053). Donors used for LTx in countries with high donation rate were younger (42% vs. 33% ≤45 years, P < 0.0001), were less often smok- 4 Department of Pulmonary < Medicine and Tuberculosis, ers (35% vs. 46%, P 0.0001), had more often clear chest X-rays (82% vs. University Medical Center 72%, P < 0.0001), had better donor oxygenation ratios (20% vs. 26% with Groningen, University of Groningen, PaO2/FiO2 ≤ 300 mmHg, P < 0.0001), and had better lung donor score Groningen, The Netherlands values (LDS; 28% vs. 17% with LDS = 6, P < 0.0001) compared with 5 Department of Intensive Care, donors used for LTx in countries with low donation rate. Survival rates for Centre Hospitalier Universitaire the groups LDS = 6 and ≥7 at 5 years were 69.7% and 60.9% (P = 0.007). Universite Catholique de Louvain, Lung donor quality significantly impacts on long-term patient survival. Namur Godinne, Belgium Countries with a low donation rate are more oriented to using donor 6 Department of Pulmonary lungs with a lesser quality compared to countries with a high donation Medicine, Erasmus University rate. Instead of further stretching donor eligibility criteria, the full potential Medical Center, Rotterdam, The of the donor pool should be realized. Netherlands 7 Department of Respiratory Medicine, Hopital^ Erasme, Brussels, Transplant International 2020; Belgium Key words 8 Department of Thoracic Surgery, donation, donor, expanded donor pool, lung clinical, outcome University Hospital, Vienna, Austria 9 Department of Respiratory Received: 26 July 2019; Revision requested: 2 September 2019; Accepted: 20 January 2020 Medicine, University Hospital Correspondence Antwerp and University of Antwerp, Jacqueline M. Smits MD, MSc, PhD, Eurotransplant International Foundation, PO BOX 2304, 2301 Antwerp, Belgium CH Leiden, The Netherlands. 10 Department of Respiratory Tel.: 31715795700; Medicine, University Hospital fax: 31715790057; Gasthuisberg, Leuven, Belgium e-mail: [email protected] 11 Department of Thoracic Surgery, Centre Hospitalier Universitaire Universite Catholique de Louvain, Namur Godinne, Belgium ª 2020 Eurotransplant International Foundation. Transplant International published by John Wiley & Sons Ltd on behalf of Steunstichting ESOT. 1 This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. doi:10.1111/tri.13582 Smits et al. 12 Department of Thoracic and Cardiovascular Surgery, University Hospital Innsbruck, Innsbruck, Austria 13 Department of Thoracic and Cardiovascular Surgery, University Hospital Saarland, Homburg, Germany 14 Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine-Westphalia, Ruhr-University Bochum, Bad Oeyenhausen, Germany 15 Department of Respiratory Medicine, St Antonius Hospital, Nieuwegein, The Netherlands 16 Division of Heart and Lungs, Department of Respiratory Medicine, University Medical Center Utrecht, Utrecht, The Netherlands 17 Department of Thoracic and Cardiovascular Surgery, University Hospital Eppendorf, Hamburg, Germany 18 Department of Respiratory Medicine, University Hospital Mainz, Mainz, Germany 19 Department of Respiratory Medicine, University Hospital Charite, Berlin, Germany 20 Department of Cardiac Surgery, University Hospital Vienna, Vienna, Austria 21 Department of Thoracic Surgery, University Hospital Gasthuisberg, Leuven, Belgium Out of the eight countries that collaborate within Introduction Eurotransplant, four had active lung transplant pro- Early and late survival have improved over the last dec- grams in the study period. These four countries have ades leading to an extension of listing indications. As a different donor legislative frameworks: Austria and Bel- result, referral for lung transplantation increased such gium use an opting-out system, where every citizen is that the number of patients on the lung transplant wait- considered an organ donor unless an active registration ing list outpaced the availability of donor organs. In against donation has taken place. Germany and the 2018, 1036 patients were on the lung transplant waiting Netherlands apply an opting-in system which requires list in Eurotransplant at year-end, while 719 had an active registration in order to be considered as received a lung transplant and 137 patients died await- organ donor. As a consequence, the number of lung ing an organ offer [1]. donors used for transplantation per million population Worldwide, only 20–30% of organ donors become was in 2018 for Austria: 9.8; for Belgium: 10.8; for lung donors [2,3]. The dramatic organ shortage encour- Germany: 3.8; and for the Netherlands: 4.7 (Fig. 1). ages centers to expand lung donor suitability criteria in Furthermore, waiting list mortality rates in countries order to maximize recovery and usage rate of every with low donation rates (Germany and the Nether- reported lung donor. Lung donor yield can be improved lands) are higher compared to those in countries with by increased utilization of extended-criteria donors. high donation rates (Austria and Belgium): 12% vs. This percentage of used extended-criteria donors varies 7% at 1 year [1]. widely across centers ranging from 24% to 77% of the Because of the large discrepancies among the Euro- total transplant volume [2]. transplant countries, Dutch members of parliament 14 12 10 8 6 4 2 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Austria Belgium Germany Netherlands Figure 1 Donation rates per million population of used diseased donor lungs, by year, by donor country. 2 Transplant International 2020; ª 2020 Eurotransplant International Foundation. Transplant International published by John Wiley & Sons Ltd on behalf of Steunstichting ESOT. Donor lung quality and survival in the LAS era have asked for a change in legislation. The proposal Table 1. The Eurotransplant lung donor score. for change toward an opting-out scheme was success- fully passed in 2018, and the new organ donor law Factor Points will be implemented July 1, 2020 [4]. Parliamentary Donor age (year) discussions in Germany have just started, and the <45 1 authors hope that with additional insight gained by 45–54 1 – the current study, Germany will, as the last country 55 59 2 60+ 3 in Eurotransplant, also adopt the opting-out system. Donor history In May 2005, the Lung Allocation Score (LAS) was Compromised* 4 implemented in the United States. This allocation sys- Uncompromised 1 tem replaced a scheme based solely on waiting time. Smoking history There were three objectives: reduce the number of Yes 2 No 1 deaths on the lung transplant waiting list; increase the NA 1 survival benefit for lung recipients; and ensure the Chest X-ray efficient and equitable allocation of lungs to transplant Clear 1 candidates [5]. Germany was the first country to Edema 1 adopt the LAS as national allocation policy on Decem- Shadow 2 ber 10, 2011; the Netherlands followed on April 22, Atelectasis 1 Consolidation 2 2014 [6]. NA 1 The aim of this study was to investigate whether Bronchoscopy there is an impact of donation rates on the quality of Clear 1 lungs used for transplantation and whether donor lung Non purulent 1 quality affects post-transplant outcome in the current Purulent 2 Inflammation 3 LAS era. Visualized tumor 5 NA 1 Patients and methods PO2/FiO2 (mmHg) >450 1 351–450 1 Definitions 301–350 2 ≤300 3 The lung donor score (LDS) is a Eurotransplant adap- NA 2 tation of the Oto score [7,8], where the ideal donor has a LDS value of 6. This LDS is an instrument to gauge *The donor history is compromised in case of a malignancy, donor quality based on six preprocurement variables: sepsis, drug abuse, meningitis, or a positive virology (HBsAg, HBcAb, and HCVAb) was registered. general and smoking history, age, arterial blood gases, chest X-ray, and bronchoscopic findings (Table 1). The LDS of six points is equivalent to the ISHLT definition