Reply to Keshavamurthy et al.

Abstract

We thank you for your comment [1] on our paper: Lungs from donation after circulatory death donors: an alternative source to brain-dead donors? Mid-term results were obtained from a single institution [2]. Since the time when the analysis was done, we have performed another 18 donation after circulatory death (DCD) lung transplantations with excellent results, comparable with that published. We continue to believe that DCD lungs are a valuable source of organs and may contribute in shortening the recipients’ waiting time and decrease the waiting list mortality rate. Differing from the experience of Keshavamurthy et al., any manoeuvres that may potentially harm the patient before he/she becomes a donor, i.e. dies, are not allowed in the UK. Interference in any way with the process of dying after a withdrawal of treatment is prohibited. Thus, administration of heparin does not take place in our practice, and non-interference is important in the light of on-going discussions about ethical dilemmas surrounding donation after circulatory death [3]. We congratulate you on an extremely low rate of primary graft dysfunction (PGD) in your material; however, the rate observed in our data is similar to that reported by the others [4]. There were no statistically significant differences in the rate of PGD between heparinized donation after brain death and nonheparinized DCD donors except for a trend towards a higher rate in the DCD group on arrival to intensive care unit. The trend was not observed at any other point of observation and does not seem to influence other parameters of outcome: duration of mechanical ventilation, survival and freedom from bronchiolitis obliterans syndrome. Of course, we cannot be certain that the trend towards a lower PaO2/FiO2 ratio immediately after lung transplantation was related to the lack of donor heparinization prior to cardiac arrest, however, currently there is no clinical evidence that lungs form non-heparinized donors are inferior to those obtained from heparinized ones [5]. Heparinized or not, we agree with Keshavamurthy et al. that lungs from DCD donors should be considered as an excellent source of organs for transplantation. Implementation of this strategy in a great number of centres could decrease the waiting time for transplantation and reduce the mortality rate for patients on the active transplant waiting list.