DONOR CRITERIA AND EVALUATION

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The single most important limitation to organ transplantation today is donor availability. Once that hurdle is surmounted, the issues of cost–benefit and societal fiscal responsibility will limit transplantation. Until such a time, transplantation and, particularly, lung transplantation will be constrained by a limited donor pool and the attendant obligation of transplant centers to insure that that precious resource is used optimally. Such restraint is reflected in the progressive re-evaluation and liberalization of donor acceptance criteria; the advent of cadaveric and living, related lobar lung transplantation, and the extremely strict criteria for evaluation and acceptance of lung transplant recipients (there are 10 times as many patients listed for renal transplantation as for lung transplantation, in spite of the facts that there is an alternative to transplantation in kidney disease and lung disease is one of the most common causes of death in North America).

The United States has enacted legislation to facilitate organ donation. The Uniform Anatomical Gift Act of 1968 granted legal authority to competent adults and their next-of-kin to donate their organs after death. The Joint Commission on Aging and Health Organization and the Health Care Financing Administration require physicians to offer the possibility of organ or tissue donation to next-of-kin following the declaration of brain death. In spite of that, an appreciable impact on organ donation relative to other countries lacking such legislation has yet to be realized.

Estimates of the potential organ donor pool vary from 29 to 59 donors per 1 million population2, 7, 11; the actual donor yield is considerably less than that, and only 20% of donated organs are suitable for pulmonary transplantation based on current criteria. United Network for Organ Sharing (UNOS) data1 indicating the most common causes of death of organ donors are presented in Table 1. Head trauma (which accounts for 54% of all lung donors1) is frequently associated with aspiration of gastric contents and the requirement for prolonged mechanical ventilation. The sequelae of major central nervous system insults commonly include disturbances in fluid balance, consumptive coagulopathy, and, occasionally, neurogenic pulmonary edema. All of those causes and consequences of brain death impact upon the integrity of the lung and its potential utility for transplantation.

The following sections discuss existing and expanding criteria for the evaluation and use of donated organs for lung transplantation.

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DECLARATION OF BRAIN DEATH

Brain death is defined as the complete and irreversible loss of all brain and brainstem function. Lack of cerebral responses and brainstem—mediated reflexes, as well as absolute apnea, occur with brain death. The standard definition of brain death is derived from many sources, including the report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death,3 the National Institutes of Health Collaborative Study (1977), and The President's Commission for the

GENERAL ISSUES OF DONOR ACCEPTANCE

Numerous issues determine the general acceptability of a donor for solid organ transplantation. Many of them have been regulated by UNOS and some are left to the discretion of the individual transplant center.

A social and medical history and physical examination are obtained on each donor. All potential donors, regardless of history, are tested for hepatitis B surface antigen, the antibody to human immunodeficiency virus (HIV)-1 (in many centers the more sensitive polymerase chain reaction

LUNG DONOR-SPECIFIC ISSUES FOR ACCEPTANCE

Historically, lung transplantation carried sufficiently high risks that it was limited to ideal recipients and perfect donors. As lung transplantation has improved and the waiting list of potential lung transplant recipients has expanded, the definition of the acceptable donor has been liberalized.

Current generally accepted donor criteria for lung transplantation are listed in Table 4. Although appearing eminently reasonable, it is important to recognize that the listed standard criteria

DONOR–RECIPIENT MATCHING ISSUES

ABO compatibility is considered necessary for successful thoracic organ transplantation, although data exist in liver transplantation demonstrating good results from the use of ABO-incompatible donors. In cardiac transplantation, transgression of blood-group compatibility has resulted in hyperacute rejection, primary graft nonfunction, and an increased incidence of delayed graft failure. A comparison in heart transplant recipients of histologic features of acute rejection in ABO-identical

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    Bull Eur Physiopath Respir

    (1982)
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    Address reprint requests to Adaani E. Frost, MD, Baylor College of Medicine, Sm 1237, 6550 Fannin, The Methodist Hospital, Houston, TX 77030

    *

    From the Department of Medicine, Baylor College of Medicine, The Methodist Hospital, Houston, Texas

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