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    "titulo" => "Increasing the number of valid lungs for transplantation&#58; a necessity"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Solid organ transplantation is currently a well-established management option for a range of diseases&#46; Lung transplantation in many cases proves life-saving&#44; and in some cases is indicated on a rescue basis&#8212;representing the only possible treatment option in end-stage respiratory failure&#46; Of all the solid organs amenable to transplantation&#44; the lungs represent one of the least frequent interventions&#44; because of their extreme fragility&#46; Mechanical ventilation &#8211; essential during the period in which the donor is admitted and up until brain death &#8211; and the risk of infection associated to ventilation both exert deleterious effects upon lungs amenable to transplantation&#46; In the year 2010 there were a total of 1502 organ donations in Spain&#44; of which only 323 &#40;21&#46;5&#37;&#41; represented potential lung donations&#46; In turn&#44; of these 323 organs&#44; only 201 reached the transplantation phase &#40;13&#46;3&#37; of the total donations that year&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The existing shortage of organs valid for transplantation&#44; and the consolidation of this kind of treatment as the only valid option for many patients&#44; have made it necessary to explore new possibilities among the so-called marginal or expanded criteria donors&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The obtainment of organs from donors after cardiac death or from non-heart beating donors&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and the harvesting of lungs from elderly patients&#44; are currently evaluated options that offer excellent results&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Among the usual criteria for discarding potential lung donors&#44; smoking&#44; radiological alterations and prolonged trachea intubation have been those most often transgressed by different surgical groups&#8212;with good clinical results&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> One of the most firmly remaining exclusion criteria is donor age&#8212;defined as 55 years&#44; maximum&#46; Mi&#241;ambres et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> studied the short&#44; middle and long term outcomes obtained with lungs from donors over age 55 years&#46; The results were seen to be good&#44; and the authors concluded that resorting to such donors undoubtedly represents a valid option for dealing with the existing organ shortage&#46; In their study&#44; involving 33 lung transplant recipients with adequately selected donors aged 55 years or older&#44; the survival data were found to be similar to those obtained with lungs from donors under 55 years of age&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">However&#44; the important loss of lungs potentially valid for transplantation purposes among non-marginal donors who die in Intensive Care Units has made it necessary to develop guides and recommendations aiming to minimize the damage caused by mechanical ventilation&#44; in an attempt to increase the number of available organs&#46; Previous studies have demonstrated the need and usefulness of applying protective measures in the brain death donor&#44; with a view to increase the number of valid lungs for transplantation&#46; Thus&#44; Mascia et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> and Noiseux et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> place special emphasis on the usefulness of protective ventilation and recruitment maneuvers&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In Spain in 2006&#44; the National Transplant Organization gathered a group of experts from different scientific societies with the purpose of developing a protocol for the maintenance of chest organ donors&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> This protocol has been introduced in most Departments of Intensive Care Medicine in the country&#44; and has made it possible to increase organ recovery and to expand the overall number of lung transplantations performed&#46; Undoubtedly&#44; protective ventilation following the current recommendations for the management of patients with acute respiratory distress syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and the use of recruitment maneuvers and apnea test in ventilator CPAP mode&#44; avoiding depressurization of the airway&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> have contributed to increase the number of valid lungs&#46; Other measures&#44; applied by different groups&#44; such as selective digestive decontamination for the prevention of ventilation associated pneumonia&#44; also may be effective in securing a larger number of organs&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a> Without doubt&#44; the cold ischemia time between organ explantation and implantation in the recipient plays a decisive role in the appearance of reperfusion damage&#46; Devices are being developed&#44; designed to maintain organ preservation with blood or preservation fluid&#44; in order to attenuate the deleterious effects of cold ischemia&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Additional measures&#44; such as adequate selection of the preservation fluid for maintaining the lungs during the cold ischemia phase&#44; might possibly improve the transplantation results&#44; and in future expand the inclusion criteria and thus the pool of valid organ donors&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> It remains to be determined whether procedures aiming to ensure even more meticulous hemodynamic management of the donor&#44; with monitorization of extravascular pulmonary water in order to keep it to a minimum&#44; are able to contribute to rescue a larger number of organs&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The experience of the transplant teams has made it possible to expand the theoretical limits for lung donation&#44; with the successful inclusion of donors above 55 years of age&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Careful evaluation of the donor&#44; with the application of strict protocols to harvest a single lung in patients with unilateral damage&#44; or in patients with pulmonary thromboembolism subjected to post-explantation pulmonary thromboembolectomy&#44; are a clear illustration of the need for valid organs for transplantation and of the efficacy of the transplant teams in dealing with a healthcare problem of exceptional relevance&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">There is no doubt as to the importance of establishing procedures for rescuing patients on the lung transplantation waiting list&#44; or of the key role played in this sense by the Departments of Intensive Care Medicine as the natural setting where brain death donors are maintained&#44; and as the reference for the development of specific procedures allowing us to increase the number of valid lung donors&#46;</p></span>"
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Editorial
Increasing the number of valid lungs for transplantation: a necessity
Incrementar el número de pulmones válidos para trasplante: una necesidad
F. del Rio Gallegos
Coordinación de Trasplantes, Hospital Clínico San Carlos, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Solid organ transplantation is currently a well-established management option for a range of diseases&#46; Lung transplantation in many cases proves life-saving&#44; and in some cases is indicated on a rescue basis&#8212;representing the only possible treatment option in end-stage respiratory failure&#46; Of all the solid organs amenable to transplantation&#44; the lungs represent one of the least frequent interventions&#44; because of their extreme fragility&#46; Mechanical ventilation &#8211; essential during the period in which the donor is admitted and up until brain death &#8211; and the risk of infection associated to ventilation both exert deleterious effects upon lungs amenable to transplantation&#46; In the year 2010 there were a total of 1502 organ donations in Spain&#44; of which only 323 &#40;21&#46;5&#37;&#41; represented potential lung donations&#46; In turn&#44; of these 323 organs&#44; only 201 reached the transplantation phase &#40;13&#46;3&#37; of the total donations that year&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The existing shortage of organs valid for transplantation&#44; and the consolidation of this kind of treatment as the only valid option for many patients&#44; have made it necessary to explore new possibilities among the so-called marginal or expanded criteria donors&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The obtainment of organs from donors after cardiac death or from non-heart beating donors&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and the harvesting of lungs from elderly patients&#44; are currently evaluated options that offer excellent results&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Among the usual criteria for discarding potential lung donors&#44; smoking&#44; radiological alterations and prolonged trachea intubation have been those most often transgressed by different surgical groups&#8212;with good clinical results&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> One of the most firmly remaining exclusion criteria is donor age&#8212;defined as 55 years&#44; maximum&#46; Mi&#241;ambres et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> studied the short&#44; middle and long term outcomes obtained with lungs from donors over age 55 years&#46; The results were seen to be good&#44; and the authors concluded that resorting to such donors undoubtedly represents a valid option for dealing with the existing organ shortage&#46; In their study&#44; involving 33 lung transplant recipients with adequately selected donors aged 55 years or older&#44; the survival data were found to be similar to those obtained with lungs from donors under 55 years of age&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">However&#44; the important loss of lungs potentially valid for transplantation purposes among non-marginal donors who die in Intensive Care Units has made it necessary to develop guides and recommendations aiming to minimize the damage caused by mechanical ventilation&#44; in an attempt to increase the number of available organs&#46; Previous studies have demonstrated the need and usefulness of applying protective measures in the brain death donor&#44; with a view to increase the number of valid lungs for transplantation&#46; Thus&#44; Mascia et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> and Noiseux et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> place special emphasis on the usefulness of protective ventilation and recruitment maneuvers&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In Spain in 2006&#44; the National Transplant Organization gathered a group of experts from different scientific societies with the purpose of developing a protocol for the maintenance of chest organ donors&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> This protocol has been introduced in most Departments of Intensive Care Medicine in the country&#44; and has made it possible to increase organ recovery and to expand the overall number of lung transplantations performed&#46; Undoubtedly&#44; protective ventilation following the current recommendations for the management of patients with acute respiratory distress syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and the use of recruitment maneuvers and apnea test in ventilator CPAP mode&#44; avoiding depressurization of the airway&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> have contributed to increase the number of valid lungs&#46; Other measures&#44; applied by different groups&#44; such as selective digestive decontamination for the prevention of ventilation associated pneumonia&#44; also may be effective in securing a larger number of organs&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a> Without doubt&#44; the cold ischemia time between organ explantation and implantation in the recipient plays a decisive role in the appearance of reperfusion damage&#46; Devices are being developed&#44; designed to maintain organ preservation with blood or preservation fluid&#44; in order to attenuate the deleterious effects of cold ischemia&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Additional measures&#44; such as adequate selection of the preservation fluid for maintaining the lungs during the cold ischemia phase&#44; might possibly improve the transplantation results&#44; and in future expand the inclusion criteria and thus the pool of valid organ donors&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> It remains to be determined whether procedures aiming to ensure even more meticulous hemodynamic management of the donor&#44; with monitorization of extravascular pulmonary water in order to keep it to a minimum&#44; are able to contribute to rescue a larger number of organs&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The experience of the transplant teams has made it possible to expand the theoretical limits for lung donation&#44; with the successful inclusion of donors above 55 years of age&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Careful evaluation of the donor&#44; with the application of strict protocols to harvest a single lung in patients with unilateral damage&#44; or in patients with pulmonary thromboembolism subjected to post-explantation pulmonary thromboembolectomy&#44; are a clear illustration of the need for valid organs for transplantation and of the efficacy of the transplant teams in dealing with a healthcare problem of exceptional relevance&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">There is no doubt as to the importance of establishing procedures for rescuing patients on the lung transplantation waiting list&#44; or of the key role played in this sense by the Departments of Intensive Care Medicine as the natural setting where brain death donors are maintained&#44; and as the reference for the development of specific procedures allowing us to increase the number of valid lung donors&#46;</p></span>"
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