Guidelines for Donor Lung Selection: Time for Revision?

摘要

PatientsFollow-UpSamplingVariance From Donor GuidelinesMultivariable ModelRisk-adjusted donor guidelines modelRisk-adjusted new donor modelValidationResultsDegree of Compliance With Current Donor GuidelinesEffect of Current Donor Guideline Variables and Variances on SurvivalNew Donor Factors and Impact on SurvivalValidationCommentPrincipal Findings: Degree of Compliance With Current Donor GuidelinesPrincipal Findings: Effect of Current Donor Guideline Variables and Variances on SurvivalOther Donor Factors and Impact on SurvivalStrengths and LimitationsConclusionDiscussionAppendix: Variables Considered in AnalysesRecipientDonorRecipient and Donor MismatchesReferencesFew data support current guidelines for donor selection in lung transplantation. We determined degree of compliance with current donor guidelines, effect of these and variances on survival, and other donor factors predicting survival.MethodsFrom July 1999 to June 2008, 10,333 primary transplants were performed in the US, with United Network for Organ Sharing data available for age, ABO type, chest radiograph, arterial difference in partial pressure of oxygen (Pao2) greater than 300 on 100% fraction of inspired oxygen, smoking, absence of aspiration/sepsis, and purulent secretions. Multivariable survival methods were used to determine relevance of these and new variables, adjusted for recipient risk factors.ResultsIn 56% of transplants, variance from at least one guideline was observed: chest radiograph, 41%; smoking, 21%; and Pao2, 18%; but rarely ABO compatibility (0.06%). Practice within guidelines was not associated with increased mortality. Common variances from guidelines; eg, Pao2/fraction of inspired oxygen down to 230, were not associated with increased mortality, but smoking (p = 0.02) was. New donor variables associated with increased mortality were diabetes (p = 0.001), presence of cytomegalovirus antibodies (p < 0.0001), recent smoking history (p = 0.02), African-American (p = 0.005), blood type A (p = 0.02), death other than from head trauma (p = 0.02), and gender (p = 0.02), race (p = 0.03), and size (p = 0.002) discordances.ConclusionsVariance from current donor guidelines for lung transplantation is frequent; analysis suggests that donor Pao2 ranges can be widened and a suspicious chest radiograph, evidence of sepsis, and purulent bronchial secretions ignored. Older age and smoking history appear to have a minor impact. New and possibly important factors identified suggest the need to better understand the impact of a wider range of donor variables on recipient outcomes.CTSNet classification:12Despite advances in lung transplantation (LTx), donor selection guidelines have remained largely unchanged since 1993, when the original guidelines were drafted [