Rekonditionering av lungor en resa från laboratoriet till kliniken Trygve Sjöberg, docent Avd för thoraxkirurgi Universitetssjukhuset Lund
Kliniskt problem: Endast 6 timmars preservationstid Orsak: Suboptimal preservationsmetod/lösning
Säker 24-timmars preservation med Perfadex
Kallt blod - en utmärkt preservationslösning Lungdonation från hjärtdöda Okänd lungfunktion!
THE LANCET Volume 357, Number 9259 Transplantation of lungs from a non-heart-beating donor Stig Steen, Trygve Sjöberg, Leif Pierre, Qiuming Liao, Leif Eriksson, Lars Algotsson --------------------------------------------------------------------------------------------------------------------- Heart-Lung Division, University Hospital of Lund, S-22185 Lund, Sweden (Prof S Steen MD, T Sjöberg PhD, L Pierre BSc, Q Liao MD, L Eriksson MD, L Algotsson MD) --------------------------------------------------------------------------------------------------------------------- Background In animals, we have previously done successful lung transplantations using organs from non-heart-beating donors. We have also developed an ex-vivo system of assessing the function of such organs before transplantation. The next stage was to try the technique in human beings. Bearing in mind the sensitive ethical issues involved, our first aim was to find out what procedures would be acceptable, and to use the results to guide a clinical lung transplantation from a non-heart-beating donor. Methods The ethical acceptability of the study was gauged from the results of a broad information programme directed at the general public in Sweden, and from discussions with professionals including doctors, nurses, hospital chaplains, and judges. The donor was a patient dying of acute myocardial infarction in a cardiac intensive-care unit after failed cardiopulmonary resuscitation. The next of kin gave permission to cool the lungs within the intact body, and intrapleural cooling was started 65 min after death. Blood samples were sent for virological testing and cross matching. The next of kin then had time to be alone with the deceased. After 3 h, the body was transported to the operating theatre and the heart-lung block removed. The lungs were assessed ex vivo, and the body was transported to the pathology department for necropsy. Results No contraindications to transplantation were found, and the right lung was transplanted successfully into a 54-year-old woman with chronic obstructive pulmonary disease. The donor lung showed excellent function only 5 min after reperfusion and ventilation, and during the first 5 months of follow-up, the function of the transplanted lung has been good. Interpretation About half the deaths in Sweden are caused by cardiac and cerebrovascular disease. This group could be a potential source of lung donors. When all hospitals and ambulance personnel in Sweden have received training in non-heart-beating lung donation, we hope that there will be enough donor lungs of good quality for all patients needing a lung transplant. Lancet 2001; 357: 825-29
Donation efter hjärndöd - Ca 80 % av donerade lungor kasseras
Kriterier för acceptabla lungor vid donation 100% O 2 5 PEEP 5 minuter PaO 2 40 kpa
Ödembildning i lungorna
Blodgasvärden (PaO 2 ) vid erbjudandet och efter rekonditionering kpa 70 60 50 40 30 20 10 0 Vid erbjudandet Vid erbjudandet Efter rekonditionering Efter rekonditioneringen 1 2 3 4 5 6 7
Den första kliniska transplantationen med initialt kasserade lungor som rekonditionerades gjordes i Lund den 22 maj 2005
Hjärndöd donator Trafikolycka Man, 19 år, 190 cm, 70 kg, ORh- Huvud och bröstskador Pågående blödningar i luftvägarna Röntgen visar lungskador P a O 2 = 9 kpa Samtliga transplantationscentra avböjer erbjudandet
PaO 2 : 9 kpa 52 kpa
Topical ECMO (extra corporeal membrane oxygenation)
Dubbellungtransplantation med initialt kasserade och rekonditionerade lungor
Double lung transplantation 5/6-06 24/3-07, n=6 PaO 2 i donatorn PaO 2 efter rekond. 1 28.7 68.7 2 18.2 79.5 3 19.7 68.6 4 11.5 52.3 5 22.4 76.1 6 22.8 51.6
Patient Double lung transplantation 5/6-06 24/3-07, n=6 Diagnosis Survival 3 months 6 months 26/10-08 1 54 COPD + + + 2 53 Pulm fibr + + + 3 55 COPD + + + 4 64 COPD + + 11 months rejection 5 35 Cystic fibr + + + 6 63 COPD + 95d, sepsis
Double lung transplantation 5/6-06 24/3-07, n=6 Six-minute walking test after transplantation. 6 min walking test Recipient: 1 2 3 4 5 6 Median 3 months 329 330 410 371 476-371 6 months 468 359 578 323 565-468 12 months 378 380 546-576 - 463
Double lung transplantation 5/6-06 24/3-07, n=6 FEV1 after transplantation. FEV1 (L) Recipient: 1 2 3 4 5 6 Median 3 months 2.1 1.8 2.6 1.6 1.5-1.8 6 months 2.1 2.0 2.6 1.8 1.6-2.0 12 months 2.2 2.2 2.6-2.1-2.2
Framtiden
Donation efter hjärndöd - 10-30 per miljon/år - Idag accepteras 20% för transplantation - Efter rekonditioning 50%? Donation efter hjärtdöd - 1000 per miljon/år?
Steen et al. Resuscitation 2002;55:285-99
USA TODAY May 8, 2008
March 2007
Donation efter hjärtdöd
Lancet 2001;357:825-829