ECD for lung transplantation

The short supply of donor organs has been one of the most critical problems in the area of lung transplantation (LTx), and this is especially serious in Japan. One approach to attempt to address this limitation is the use of extended criteria donor (ECD) lungs. The currently accepted criteria for suitable donor lungs (Table 7.1) were instituted in the mid-1980s during the early development of clinical LTx [1]. These criteria were chosen by early transplant physicians and surgeons based on prevailing knowledge of pulmonary physiology, but were not based upon strict scientific evidence [2]. Afterward the ever-increasing number of recipients on waiting lists compelled lung transplant doctors to consider the use of ECD lungs. Liberalization of the donor selection criteria has been gradually accepted worldwide since the mid-1990s [2]. A recent large registry study of more than ten thousand LTxs performed in the USA from 1999 to 2008 revealed that at least one variance from the criteria occurred in more than a half of transplants [3]. Although results have varied among studies, outcomes of LTx using ECD lungs have generally been acceptable [4-18]. However, proper judgment is still difficult if multiple factors are defined extended and if ECD lungs are used in high-risk recipients especially who are rapidly deteriorating on the waiting list. To properly assess and optimize ECD lungs in such circumstances, a new strategy utilizing normothermic ex vivo lung perfusion (EVLP) system has been developed, and the impact of the system on LTx has been explored in several high-flow transplant centers [19, 20]. In Japan, 124 LTxs from deceased donors have been successfully performed as of the end of 2012 [21]. These transplantations achieved a 5-year patient survival rate of 72.0 % and a 10-year survival of 57.3 % [21]. To maximize the lung utilization rate in multiorgan donors, Japan Organ Transplant Network has operated a system involving the partnership of well-trained transplant consultant doctors and local doctors in assessing donor lungs and providing intensive care to donors since 2002 [22]. These consultant doctors tirelessly performed bronchial toileting for donors and provided advice on respiratory therapy, mechanical ventilation, infection controls, and circulatory management of donors. Since such sustained efforts by the consultant doctors in cooperation with local doctors have been made to effectively utilize ECD lungs, the lungs were used for transplantation in more than 60 % of brain-dead donors [22]. This chapter reviews definition and assessment methods of ECD lungs, studies showing outcomes of LTx using ECDs, and progress in recent research regarding ECD lungs.