The First Experience of Ex-Vivo Lung Perfusion (EVLP) in Iran: An Effective Method to Increase Suitable Lung for Transplantation.

BACKGROUND: Although lung transplantation is a well-accepted treatment for end-stage lung diseases patients, only 15%-20% of the brain-dead donors' lungs are usable for transplantation. This results in high mortality of candidates on waiting lists. Ex-vivo lung perfusion (EVLP) is a novel method for better evaluation of a potential lung for transplantation. OBJECTIVE: To report the first experience of EVLP in Iran. METHODS: The study included a pig in Vienna Medical University, Vienna, Austria, and 4 humans in Masih Daneshvari Hospital, Tehran, Iran. All brain-dead donors from 2013 to 2015 in Tehran were evaluated for EVLP. Donors without signs of severe chest trauma or pneumonia, with poor oxygenation were included. RESULTS: An increasing trend in difference between the pulmonary arterial pO2 and left atrial pO2, an increasing pattern in dynamic lung compliance, and a decreasing trend in the pulmonary vascular resistance, were observed. CONCLUSION: The initial experience of EVLP in Iran was successful in terms of important/critical parameters. The results emphasize on some important considerations such as precisely following standard lung harvesting and monitoring temperature and pressure. EVLP technique may not be a cost-effective option for low-income countries at first glance. However, because this is the only therapeutic treatment for end-stage lung disease, it is advisable to continue working on this method to find alternatives with lesser costs.

Efficacy of recruitment maneuver for improving the brain dead marginal lungs to ideal.

BACKGROUND: Because of the shortage of lungs for transplantation, finding the suitable lungs in brain-dead donors is an important issue. Recruitment maneuver is a strategy aimed at re-expanding collapsed and edematous lung tissue. The aim of this study was to assess the efficacy of this maneuver on improving marginal lungs for transplantation. METHODS: From 127 brain-dead potential donor which were evaluated for lung donation in Masih Daneshvari Organ Procurement Unit of Tehran, Iran, 31 (25%) had marginal lungs for transplantation. These donors had normal chest X ray or bilateral infiltration and had PaO2 200-300 mm Hg with FIO2 100%. The recruitment maneuver was performed and arterial blood gas was obtained before and after maneuver. The maneuver lasts for 2 hours with continuous check of O2 saturation and patient's hemodynamic during. Finally, patients with normal bronchoscopy and PaO2/FIO2 >300 mm Hg were considered good candidates for lung transplantation. The frequency (%) and mean ± SD were used for description of variables and the Wilcoxon test was used for comparison between pre- and post-maneuver PaO2 with FIO2 100%. RESULTS: The mean ± SD of PaO2/FIO2 with 100% FIO2 of patients before and after recruitment were 239 ± 62 and 269 ± 91, respectively. Recruitment maneuver could convert 10 marginal lungs (32%) to appropriate ones (PaO2 > 300) and finally 8 lungs were transplanted. CONCLUSIONS: Findings of this study showed that recruitment maneuver could convert inappropriate lungs to appropriate ones in one third of brain-dead patients who had marginal lung condition. So, it is recommended that this maneuver is considered in the assessment protocol of lungs for donation.

The first hand transplantation in iran.

Nowadays, hand transplantation is a very challenging procedure for surgeons and researchers worldwide. Despite many problems that may occur after this surgery, some centers continue to practice this highly sophisticated procedure. Herein, we report on a 38-year-old man who received hand transplant from a 24-year-old brain-dead man. This patient had lost his right hand from the lower one-third of forearm six years before after a trauma from a mincing machine. Team members organized pre-operative research, cadaver dissection, legal consultation, religious permission and discussion to patient. This procedure was done by 15 Khordad Plastic Surgery Transplant team on February 27, 2013 for the first time in Iran.

Causes of family refusal for organ donation.

INTRODUCTION: Family refusal represents a barrier for organ donation together with other cultural and religious factors possible ignorance and clinical obstacles. METHODS: We performed this retrospective study by phone employing our organ procurement unit database, using a list of families of potential organ donors who had refused organ donation. RESULTS: In 2009, 146 potential organ donor families refused donation. We contacted 81 families. The main reason expressed by there families to justify the refusal to donate the deceased's organs was denial and rejection of brain-death criteria (44.4%). Other causes were believing in a miracle (13.6%); fear about organ trade and unknown organ destination (9.9%); religious beliefs (8.6%); insecutrity about the brain-death diagnosis (6.2%); unstable family mood (6.2%); unknown donor wishes about donation (4.9%); belief in body integrity after death (3.7%); and fear of objection by other family members (2.5%). CONCLUSION: Our findings showed several reasons for family refusal for organ donation; among the main cause is poor acceptance of brain death. It seems that increasing the knowledge of people about brain death and organizing strategies to confirm brain death for families are necessary to meet the organ shortage.

Attitudes toward organ donation: a survey on Iranian teachers.

BACKGROUND: Organs from brain dead patients are the main source for transplantation. However, in most societies, including Iran, the family consent rate for organ donation is low necessitating improvements in public knowledge. Because teachers' knowledge has an important role to educate the next generations, this study assessed their knowledge and attitudes about brain death and organ donation. METHODS: The present cross-sectional study included, 93 teachers selected from eight schools in Tehran, Iran, in 2009. We used a standardized questionnaire containing items which inquired about knowledge and attitudes of the participants regarding brain death and organ donation. RESULTS: The mean age of the participants was 37 years and 48 (52%) were males. Eighty-seven (94%) of them had heard or read about organ donation, among whom 91% favored organ donation. The main sources of their information were television, radio, and newspapers. Sixty-five (70%) were willing to donate their own organs after death. Those with lower organ donation desire were in contact with a small number of patients who have chronic diseases, had less trust in organ donation networks and brain death diagnostic tools, expressed less desire to receive an organ, and had a low record of blood donation (P<0.05). CONCLUSION: Our findings show that although most teachers had heard or read about brain death and organ donation, and approved of organ donation after death, a lack of exposure to patients with chronic diseases and a distrust of organ donation networks were greater among teachers with a lower desire to participate in this effort. Therefore, building trust in brain death diagnostic systems is necessary together with relevant educational programs.

Microbial pattern of bronchoalveolar lavage in brain dead donors.

BACKGROUND: We assessed bronchoalveolar lavage (BAL) cultures of brain dead donors seeking to achieve better donor management and decrease transplant complications. Determining the most common source of some postoperative infections causing morbidity and mortality among lung recipients would help to reach this goal. MATERIALS AND METHODS: This prospective study was performed on 80 brain dead donors from August 2008 to August 2009. Donors with partial pressure of arterial O2 to the fraction of inspired O2 (PaO2/FIO2)>300 mm Hg and a normal chest x-ray underwent bronchoscopy to obtain a BAL. FINDINGS: The mean donor age was 30±14 years and 50 (63%) were males with 21 (26%) showing a positive history for smoking and 32 (40%) with turbid tracheal secretions. Chest x-ray was abnormal in 49 (61%). Positive culture BAL results were observed among 30 (38%) patients: there were 17 (90%) bacterial and 6 (22%) fungal. Finally, 16 donors (20%) were considered suitable lung donors, allowing 10 lung transplantations. CONCLUSION: Only 20% of donors had acceptable lungs for transplantation. The high rates of positive bacterial and fungal BAL cultures in donors suggest the need for more aggressive critical care management and antibiotic therapy which may be beneficial to prevent future infections in recipients. Further prospective studies are needed to assess the correlation between donor BAL results and posttransplant morbidity and mortality.

Survival of Iranian patients on lung transplant waiting list: is there any difference?

OBJECTIVE: Lung transplantation is the last treatment option for end-stage pulmonary diseases. Reviewing the characteristics of patients on the lung transplant waiting list is a helpful way to evaluate and prioritize the patients in need of special care. Because we have no information about mortality on the lung transplantation waiting list in Iran, the aim of this study was to evaluate the characteristics and survival rates of these patients. METHODS: The file of lung transplant candidates listed between 2005 and 2010 were evaluated for patient demographic data, type of disorder, waiting list time, and outcomes of death, transplantation, or alive. RESULTS: The 131 patients on our list in this period revealed a mean age of 37±14 years with 86 (66%) males. The most common disorder among waiting list patients was pulmonary fibrosis (n=52; 40%). Among the 17 (13%) patients who were transplanted, most (35%) suffered from pulmonary fibrosis. The mean waiting time to transplantation was 17.2±11.8 months. Twenty-two patients (7%) died while on the waiting list. The mortality rate was unexpectedly highest among cystic fibrosis patients and then those with bronchiectasis. The mean survival time for all non-transplant patients based on the Kaplan-Meier method was 27.4 months and their 2-year survival rate was 74% based on life tables. CONCLUSION: Although pulmonary fibrosis patients show the poorest survival on lung transplant waiting lists, in other countries, patients with cystic fibrosis and bronchiectasis displayed the worst survival on the Iranian list probably due to their poor rehabilitation and sputum evacuation. We concluded that it is necessary for every center to evaluate the characteristics of its patient cohort to match the activity according to the needs.

Concomitant cryptococcosis and burkholderia infection in an asymptomatic lung transplant patient with cystic fibrosis.

Concomitant pulmonary infections with Cryptococcus neoformans and Burkholderia cepacia in lung transplant recipients are very rare and create unique diagnostic and therapeutic dilemmas. Herein, we present a double lung transplant patient with cystic fibrosis who was found to have coinfection with these two rare organisms, though he was completely asymptomatic.

Attitudes of medical students about brain death and organ donation.

INTRODUCTION: There have been publications on the attitudes of the general Iranian population and health care personnel about brain death and organ donation; however, there is little information about such attitudes of medical students. In 2006, a survey was conducted in Tehran about the attitudes of medical students in a hospital with a transplantation program. MATERIAL AND METHODS: The general population, health care personnel, and medical students were surveyed, and data were extracted from interviews with 41 medical students. The survey included 35 items about attitudes toward brain death and organ transplantation. RESULTS: Nine students (22.0%) had ever seen a transplant recipient, and 7 (17.1%) had ever seen a brain-dead patient. Thirty-four students (82.9%) agreed with organ donation after brain death. Six students (14.6%) had received information through university lectures, and 40 (97.5%) perceived a need for further information about organ donation and brain death in the university curriculum. Nine students (22.0%) had an organ donor card. CONCLUSION: Most Iranian medical students have neither been exposed to brain death or organ recipients nor received appropriate information about organ donation and transplantation.

Issuing donor cards in a single center in Iran: results of the first 3 years.

INTRODUCTION: Issuing an organ donation card has become a goal for procurement units to solve the organ shortage. The number of issued cards is an index of the attitudes or even actions of communities toward brain-dead donations. In the present study, we have reported the characteristics of issuing organ donation cards in a single organ procurement unit in Iran. MATERIALS AND METHODS: This retrospective study used an organ donation willingness database for 3 years after launching the unit. We used the registration data of the first 3 years of its activity from August 1, 2005, to July 31, 2008. For each organ donation volunteer, we extracted demographic data, organs to be donated, and source of their knowledge about the organ donation card system. RESULTS: During the study period, donor cards were issued to 172,290 volunteers; a monthly mean of 4785 registries. Among the total volunteers, 54.2% were females: with 50.7% between 21 to 30 years, 35.2% with an educational level less than a high school diploma, and 35.7% introduced by their friends. The volunteers were more willing to donate heart, kidney, liver, lung, and tissue donations, respectively. Out of the total number of volunteers, 94.1% were willing to donate all organs. An increasing trend was seen in the donation cards issued during the study period. CONCLUSION: Following 3 years of activity, a single center has issued nearly 200,000 cards. The rate at which organ donor cards are issued is increasing, which puts emphasis on establishment of funding for other organ procurement units. This information may be useful to program the field of brain-dead donations in this country.

Age and sex predict PaO2/FiO2 ratio in brain-dead donor lungs.

OBJECTIVES: To define the prevalence of various ranges of the ratio of partial arterial oxygen tension to fraction of inspired oxygen (Pao(2)/Fio(2)) and to determine correlative and predictive variables of donor lung Pao(2)/Fio(2). MATERIAL AND METHODS: From the brain death database of Masih Daneshvari Hospital Organ Procurement Center, we extracted demographic data, cause of injury, patient clinical condition, and laboratory findings as independent data. Donor lung suitability was determined with an oxygen challenge test, with results of 400 mm Hg considered ideal; 300 to 399 mm Hg, good; 200 to 299 mm Hg, borderline; and less than 200 mm Hg, not acceptable. RESULTS: Using the Pao(2)/Fio(2) cutoff points, 6.7% of donor lungs were considered ideal; 26.7%, good; 40%, borderline; and 26.7%, unacceptable. Mean (SD; range) Pao(2)/Fio(2) was 266.6 (85.6; 110-460). The Pao(2)/Fio(2) was significantly correlated with age (r = -0.35; P = .02). After entering the study variables into a linear regression model, age (-2.3; P = .008) and sex (51.5; P = .04) were significant predictors of donor lung suitability (R(2) = 0.95; P < .001). CONCLUSION: Results of oxygen challenge tests demonstrated better suitability of lungs from male and younger brain-dead donors. This finding is independent of other variables including cause of brain death and clinical and paraclinical data.

Organ retrieval from brain-dead patients by a single organ procurement center in Iran.

INTRODUCTION: The majority of transplantations depend solely on cadaveric organs. In recent years, special focus has been directed toward brain-dead patients in Iran, but it seems that there is limited information regarding the characteristics of cadaveric organ donation in our country. MATERIALS AND METHODS: This is a retrospective analysis of data of our Organ Procurement Unit (OPU), which is one of the most active organ procurement units in Iran. We incorporated the data on all organ donations from brain-dead patients between 2004 and 2008 into the present study. Demographic characteristics of the patients along with data regarding brain death and organ donation were extracted from already registered data on patients. RESULTS: Among 93 brain-dead patients registered in the database of the OPU, organs were retrieved from 85% (n = 79). Out of the 14 patients from whom no organ was retrieved, the cause for this failure was death before donation in 85% (n = 12). The numbers of donated organs varied between zero and six (mean +/- standard deviation = 3.1 +/- 1.7). The most donated organs in terms of frequency and count were: right kidney (n = 68; 73.1%), left kidney (n = 67; 72%), liver (n = 63; 67.7%), heart (n = 40; 43%), pancreas (n = 5; 5.4%), and lung (n = 4; 4.3%). DISCUSSION: The overall organ retrieval rate from brain-dead patients by this OPU was comparable to that of developed countries; however, we still believe we can improve this rate/scale.

Lung donation and causes behind its failure: a single-center experience.

INTRODUCTION: Brain-dead patients are almost the only source of organs for lung transplantation, and lungs fall within the area of the least harvested organs. As a result, maintaining the highest possible harvest rate is a must for the lung transplantation system. In the present study, the harvest rate of lungs and also the causes of failure to donate the lungs is reported for brain-dead patients in our organ procurement unit. MATERIALS AND METHODS: After going through the brain-death database at our organ procurement unit between 2004 and 2008, we included all 93 brain deaths in this hospital. The lung donation rate was reviewed to examined the causes for failure to donate lungs. RESULTS: From the total brain-dead patients registered in the database, only 4 (4.6%) patients donated their lungs. The causes of failure to donate a lung were not suitable lungs among 78 (83.8%) because they had an unacceptable oxygen challenge test results (<300 mm Hg). Another 11 patients had acceptable oxygen challenge test results, but donation failed in their case as well due to most frequently to pulmonary aspiration. CONCLUSION: In this center, only a small percentage of lungs are appropriate for harvest in brain-dead patients, because many patients' lungs do not meet the criteria with unacceptable oxygen challenge test results. Patients with proper test results may fail to donate lungs due to pulmonary aspiration. More aggressive care of the patients may have an important role in keeping them in good condition and helping to preserve the organs for harvest. For this purpose, further training of intensive care unit staff and physicians are among the suggested steps to enhance the quality of care, which in turn can maximize the lung harvest rate.

Eight years of lung transplantation: experience of the National Research Institute of Tuberculosis and Lung Diseases.

BACKGROUND: Lung transplantation has evolved from an experimental procedure to a viable therapeutic option in many countries. In Iran, the first single-lung transplantation was performed in the year 2000, more than 3 decades after the first successful procedure in the world, and the first double-lung transplantation was performed in the year 2006. OBJECTIVE: To describe our 8-year experience in lung transplantation. PATIENTS AND METHODS: During 8 years, we performed 24 lung transplantation procedures. Underlying lung diseases were pulmonary fibrosis in 16 patients (66.6%); chronic obstructive pulmonary disease in 2 (8.3%); bronchiectasis in 5, including 2 patients with cystic fibrosis (20.8%), and alveolar microlithiasis in 1 (4.16%). Data for all patients were collected and analyzed. Procedures were carried out using standardized methods. The induction suppression regimen consisted of cyclosporine and methylprednisolone. Maintenance immunosuppression drugs were cyclosporine and mycophenolate mofetil, and tapering dosage of prednisolone. Patients were followed up with physical examinations, 3 times a week, as well as and cycle ergometry 3 times a week and spirometry and laboratory tests once a week and chest radiography per needed for up to 3 months posttransplantation. RESULTS: The longest survival time was 7.2 years, in a 60-year-old patient with idiopathic pulmonary fibrosis. Fourteen patients died, 8 as a result of hemodynamic instability and/or hemorrhage, 1 as a result of bone and fat emboli, 3 after cessation of drug and 2 of them after infection. CONCLUSION: Although lung transplantation is a complex procedure it can be performed in developing countries such as Iran.

Fat and bone marrow embolization in a donor as the cause of death in a lung recipient.

The cause of death in organ donors may have a great impact on organ recipient outcomes. Trauma is the prevailing cause of death among brain-dead patients in Iran and many other countries. Such patients may have many complications, among them vascular embolization with fat and other tissues. We have described herein a case of vascular embolization in a donor and its consequence on the recipient's outcome. The recipient was a 36-year-old woman with pulmonary fibrosis, who received a single lung transplant from a patient brain dead due to trauma. Donor had no obvious fractures; the oxygen challenge test was ideal. The harvested lung was normal upon bronchoscopy and it was clear on plain chest radiography. The day after lung transplantation, the recipient was extubated successfully with normal O(2) saturation. On computed tomography scan, there was a fixed infiltration at the base of the transplanted lung. On day 5 posttransplantation, the infiltrate expanded and the patient developed acute respiratory distress syndrome (ARDS). The patient's condition deteriorated rapidly and she expired on day 10 posttransplantation due to ARDS. The pathologic examination of the brain-dead patient, which was obtained from another patient's lung, was available after our recipient's death, showed massive vascular fat and bone marrow embolization. In the mentioned case, all criteria for lung harvest from the brain-dead patient were met. Looking for embolization is not among the criteria for lung transplantation if chest radiography is clear and O(2) challenge test is acceptable, but we observed a poor recipient outcome due to bone and fat embolization in the donor's lung. When transplanting from a traumatic patients, such complications should be kept in mind.

Pulmonary aspergillosis in solid organ transplant patients: a report from Iran.

BACKGROUND: Aspergillosis is one of the most important opportunistic infections after organ transplantation. Early diagnosis and initiation of appropriate antifungal therapy are key factors for better prognosis. METHODS: We reviewed the medical records of patients with solid organ transplantation with evidence of Aspergillus infections from December 2001 to January 2008, evaluating patient demographics, time of onset after transplantation, risk factors, radiologic appearance, diagnostic criteria, antifungal therapy, and outcome. RESULTS: We observed aspergillosis in 8 lung, 3 kidney, and 1 heart recipient, with overall mean age of 40.6 years. Seven cases of Aspergillus tracheobronchitis were diagnosed in lung transplant recipients, all of them in the first 6 months after transplantation. All patients responded to antifungal therapy and bronchoscopic debridement. We observed 5 cases of invasive pulmonary aspergillosis. Three patients survived in response to antifungal treatment. The two patients who died were treated with a combination of itraconazole and amphotericin B, whereas all cured patients had been treated with voriconazole alone or in combination with caspofungin. CONCLUSION: It seems that the prognosis of aspergillosis in solid organ recipients is improving with new treatment regimens, particularly if they are used in early stages of infection.

Spoligotyping of Mycobacterium tuberculosis in anthracotic bronchitis.

BACKGROUND: Mycobacterium tuberculosis infection has been shown to be associated with anthracotic bronchitis. However, the typical manifestation of infection is not usually present in infected patients, which raises the question of whether a particular strain of M. tuberculosis is associated with this group of patients. OBJECTIVE: To determine whether a particular strain of M. tuberculosis is associated with anthracotic bronchitis. DESIGN: We assessed the predominant space oligonucleotide (spoligotype) patterns of M. tuberculosis complex isolated from patients with anthracotic bronchitis and compared the results with tuberculosis (TB) subtype patterns in Iran and other countries. RESULTS: During a 7-month period (April--October 2006), we enrolled 87 patients (30 men and 57 women) with anthracotic bronchitis, 26% (n = 23) of whom had TB. Spoligotyping of M. tuberculosis among these 23 patients showed four distinct patterns: East-African-Indian (11, 47.8%) and Central-Asian (7, 30.4%), Haarlem I (4, 17.4%) and T-1 (1, 4.3%). When compared with spoligotype patterns of M. tuberculosis in Middle Eastern countries, including Iran, anthracotic bronchitis had similar patterns. CONCLUSION: Our results indicate that the atypical manifestations of TB in anthracotic patients are not caused by any particular subtypes of M. tuberculosis. We conclude that anthracotic bronchitis is actually an atypical presentation of tuberculous infection with common subtypes inside the bronchial mucosa.