Lung donor shortage – how to overcome it?

Lung transplantation (LTx) has undergone dramatic development throughout the last years. Today it has become standard treatment of end stage respiratory failure. Based on recent data from the International Society of Heart and Lung Transplantation (ISHLT), almost 4000 procedures are performed worldwide on a yearly basis. However, despite the continuing increase in numbers, there remains a significant gap between the demand and availability of organs. Indeed, based on prognoses of the expected incidence of respiratory diseases, this discrepancy is likely to increase even further. As a result, there is significant mortality on current waiting lists, differing between countries and centers , but up to 16% and more per year for some diagnoses. One key element affecting this process remains the relatively low utilization of organs, with retrieval rates of a maximum of 28% for the " Eurotransplant " zone and only 20% for the USA and UK [1–5]. While the question of safe utilization of the existing donor pool remains open, as does the question of what a transplantable or extended donor organ actually is, we have seen several successful attempts made over the last decade aimed at increasing the organ utilization rate. The first one was the introduction of specialized, adequate donor management during the period between brain stem death (BSD) and organ retrieval. This may have a pivotal role, as it is well known that pathological changes following BSD may have a substantial, detrimental effect on lung function. As a result, numerous guidelines have been published about organ donor management, including the recently introduced UK guidelines: Donor Optimization Extended Care Bundle [6]. This clear and schematic document provides general and organ specific goals of therapy along with advice how to achieve them. It is our experience that the introduction of this protocol resulted in more focused donor management by local intensive care staff. Also, their cooperation with specialist teams dedicated to cardiotho-racic donor management provided by transplant centers is, as a result, more open and effective. Proper, pulmonary artery catheter guided therapy is another element. Rational fluid administration, vasopressor and inotropic support to control hemodynamic instability along with steroids to reduce systemic inflammatory responses are important factors in stabilizing and optimizing donors, mitigating the effects of BSD and thus increasing the utilization of organs. Other less difficult maneuvers such as the introduction of lung protective ventilation, patient positioning including upper body elevation and undulating lateral positioning, lung physiotherapy …