Prognostic factors influencing survival rates in children following lung transplantation.

OBJECTIVES: To assess the results of lung transplantation (LT) in children under 17 years of age and identify factors affecting long-term survival. METHODS: A retrospective review was performed of 37 patients (<17 years) who had received a lung transplant between 1996 and 2007. Morbidity, mortality, and survival were analyzed by the Kaplan-Meier method and the log-rank test. RESULTS: There were 37 LTs: 30 bilateral, four lobar, two liver-lung, one unilateral. Indications for transplantation were: cystic fibrosis (n = 30), pulmonary fibrosis (n = 1), bronchiectasis (n = 1), Kartagener's syndrome (n = 1), bronchiolitis obliterans (n = 3), and pulmonary fibrosis due to radiotherapy-chemotherapy (n = 1). The intubation time and oxygenation index of donors were 49 +/- 36 hours and 455 +/- 83.5 mm Hg, respectively. Seventeen patients needed extracorporeal circulation (ECC) and 13 were coded as priorities. High blood pressure and renal failure were the most frequent complications. Overall survival rates were 65.7%, 59.4%, 56.1%, 44.5%, and 39.6% at 1, 2, 3, 5, and 10 years, respectively. Need for ECC (P = .001), surgical complications (P = .037), oxygenation index <450 mm Hg (P = .005), OLT in priority code (P = .04), and age of donor >16 years (P = .005) were associated with poor survival. CONCLUSIONS: LT is an appropriate procedure for certain types of end-stage pediatric pulmonary pathologies, achieving acceptable long-term survival rates. When the procedure is carried out under a surgical priority code, it is associated with a high rate of perioperative morbidity and mortality and poorer long-term survival. Other factors that have a negative influence on survival include the need for ECC, surgical complications, an oxygenation index <450 mm Hg, and donor age >16 years.

Experience of the Reina Sofia Hospital in lung transplantation from donors older than forty years.

INTRODUCTION: The shortage of suitable donors for lung transplantation (LT) has led to liberalization of criteria for donor selection. This study evaluated the outcomes of LT among a subset of patients receiving organs from standard donors older than 40 years of age. METHODS: We distributed patients who underwent LTs performed between 1993 and 2007 into 2 groups: Group A, donors younger than 40 years; and Group B, donors 40 years of age or older. We compared donor and recipient preoperative, operative, and recipient postoperative factors by univariate analyses. RESULTS: We reviewed 255 consecutive LT patients: Group A, 198 patients (78%); and Group B, 57 patients (22%). Donors from Group A showed longer intubation times (43 hours vs 34 hours; P = .026) and a better PaO2/FiO2 ratio (477 vs 454 mm Hg; P = .020), with no differences in other donor variables. Among patients dying of primary graft failure, 20% were from Group B versus 5.6% from Group A (P = .04). There were no differences in mortality or other postoperative variables. Survival rates did not differ between groups (70%, 62%, 52%, and 45% in Group A vs 60%, 45%, 45%, and 20% in Group B at 1, 3, 5, and 10 years, respectively; P = .13). CONCLUSION: The use of ideal donors older than 40 years of age might be related to a higher incidence of primary graft failure. However, long-term survival is similar to that of recipients from younger donors.

Urgency-code lung transplantation for cystic fibrosis: experience and results.

Lung transplantation (LT) under urgency-code mechanical ventilation (UCMV) has been identified in the International Society for Heart and Lung Transplantation (ISHLT) Registry as a negative prognostic factor increasing the likelihood of mortality. The objective of this study was to review our experience of UCLT for with cystic fibrosis (CF) patients compared with elective LT (ELT). From October 1993 to October 2007, we performed 259 consecutive LTs in 250 patients, of whom 78 (31.20%) had CF. Our study group comprised CF patients who received UCLT (n = 23). The type of LT in the UCLT group was as follows: bipulmonary (18), left unipulmonary (2), and bilobar transplantation from cadavers (3). The UCLT group more often required cardiopulmonary bypass (CB) (P = .025), pulmonary tailoring (P = .030), and longer periods of pulmonary ischemia (P = .066) than the ELT group. We noticed a greater number of cases of pneumonia during the first postoperative month in the UCLT group. However, incidence of surgical complications, early and perioperative mortality, and episodes of acute and chronic rejection (bronchiolitis obliterans syndrome) did not differ between the groups. Survival rates at 1, 3, 5, and 10 years were 73.66%, 63.74%, 42.49%, and 42.49%, respectively, in the UCLT group (mean, 1927 [SE = 366] days) and 75.95%, 71.32%, 63.37%, and 63.37% in the ELT group (mean, 2946 [SE = 281] days; P = .3417). In our experience, UCLT in patients with CF is fully justified. Careful selection of such cases permits acceptable long-term survival rates to be achieved with no increase in early or perioperative mortality.

Results of lung transplantation in patients with chronic obstructive pulmonary disease.

OBJECTIVE: The objective of this study was to evaluate the results and survival rates of patients who underwent lung transplantation (LT) to treat chronic obstructive pulmonary disease (COPD). METHODOLOGY: We performed a retrospective analysis of 63 patients with COPD who underwent LT between 1996 and 2007. Our statistical analysis was based on descriptive statistics and survival analysis (Kaplan-Meier and log-rank test). RESULTS: Sixty-three LTs were performed in 53 male and 10 female patients with COPD. Twenty-eight LTs were unipulmonary and 35 were bipulmonary. Four cases required extracorporeal circulation. Surgical complications arose in 18 cases. There were 3 cases of intraoperative death as a result of cardiac failure. The most frequent long-term complications were hypertension (39.7%), renal failure (42.9%), and neoplasms (20.6%). Overall survival times (mean, 2553 days) were 75.9%, 74.15%, 65.67%, 55.87%, and 42.05% at 1, 2, 3, 5, and 10 years, respectively. No differences were observed in survival according to the following: donor age >30 years (P = 8), type of transplantation (unilateral vs bilateral; P = .57), donor intubation time >48 hours (P = .2), or donor oxygenation index <450 mm Hg (P = .3). CONCLUSIONS: No differences were observed in survival according to the type of transplantation (unilateral vs bilateral), which suggests that unipulmonary transplantation is a reasonable option, given that this procedure reduces both the ischemia time compared with bilateral transplantation and the surgery time, as well as offering more efficient use of donor organs.

Results of lung transplantation in patients with cystic fibrosis.

Lung transplantation (LT) is the only available option for patients with cystic fibrosis (CF) with end-stage lung disease. We reviewed our experience with LT in patients with end-stage CF (CFLT) to identify variables associated with survival and to compare the results with other indications for LT (OILT). Between October 1993 and October 2007, we performed 259 consecutive LTs in 250 patients for treatment of various end-stage pulmonary conditions. The indications for LT were CF in 78 patients idiopathic pulmonary fibrosis in 76, COPD in 64, bronchiectasis in 11, alfa-1-antitrypsin deficit in 5, primary pulmonary hypertension in 4, bronchiolitis obliterans syndrome in 4, and other indications in 11. Our study group comprised 78 patients with CF (30.11%) (CFLT). We observed significant differences in the actuarial survival between the CFLT and OILT groups. Perioperative mortality and the incidence of bronchiolitis obliterans syndrome were comparable in both groups. We found that in patients with CF, LT performed under urgency code (mechanical ventilation) showed no significant difference from LT performed electively insofar as long-term survival, early death, or perioperative death. The functional results in the CFLT group were excellent. We observed significant improvement in PaO(2), PaCO(2), forced vital capacity, and forced expiratory volume in the first second of expiration at 6, 12, and 36 months compared with the pretransplantation baseline values.

Combined lung and liver transplantation-University Hospital Reina Sofia experience: two case reports.

OBJECTIVE: To analyze the results of combined lung and liver transplantation. METHODS: We performed two combined lung and liver transplantations for patients with cystic fibrosis with chronic respiratory failure accompanied by advanced liver disease. In each case, all thoracic and abdominal organs were obtained from a single donor by means of standard harvest techniques. In the recipient, a two-stage procedure was adopted with completion of the bilateral lung transplantation before the liver operation. Immunosuppression consisted of three-drug therapy used for isolated lung transplantation. RESULTS: The patients were both boys of 13 and 15 years old. Episodes of acute pulmonary rejection were successfully treated with intravenous steroids. Neither lung disorder was associated with a liver rejection episode. Airway complications that occurred in both cases were managed endoscopically. CONCLUSION: Combined transplantation of lung and liver is a feasible and therapeutically effective procedure for patients with cystic fibrosis complicated by advanced liver disease. Herein we have described our experience in two of the only three cases of combined liver and lung transplantation performed in Spain to date. Patient and graft survivals were comparable to isolated liver or isolated bilateral lung transplantations.

Pediatric lung transplantation.

INTRODUCTION: Pediatric lung transplantation (LT) was started in Spain in 1996 at our institution. We compare the results of pediatric LT with those in adult patients. METHODS: A retrospective review of LT patients from 1993 to 2003 included demographic donor and recipient data, pulmonary function, gas exchange parameters, complications, episodes of rejection and pneumonia, as well as survival. Patients were divided into 2 groups: pediatric (<16 years) and adult (>16 years) LT patients. RESULTS: Of 165 LTs performed, 23 recipients were pediatric patients (10 boys, 13 girls; mean age, 11.9 +/- 2.9 years [range, 5-16 years]). The indications were cystic fibrosis (n = 21), pulmonary fibrosis (n = 1), and Kartagener syndrome (n = 1). The actuarial survival rate was 73%, 67%, and 62% at 1, 3, and 8 years post-LT in children, versus 67%, 56%, and 41% at 1, 3, and 8 years post-LT in adult patients (P = NS). Of the pediatric patients, 35% required mechanical ventilation preoperatively (P < .001). Pediatric patients showed a higher incidence of pneumonia (P < .01) and acute rejection episodes (P = .02) during the first month post-LT, and longer stays in the intensive care unit (P = .02). Pediatric patients displayed more immunosuppression-related adverse effects: diabetes (P = .04), neuropathy (P < .01), and hirsutism (P < .001). In children, arterial oxygen tension improved, from 51 mm Hg pre-LT to 93 mm Hg at 5 years post-LT. Forced expiratory volume in 1 second improved from 28% pre-LT to 84% at 5 years post-LT. CONCLUSION: In children, LT is a high-risk procedure because of the critical status of these patients. However, the results of pediatric LT are similar to those in adults, but with better long-term survival.

Long-term results of lung transplantation for emphysema.

INTRODUCTION: We sought to assess the differences between lung transplantation (LT) to treat emphysema, versus other pulmonary diseases. METHODS: This retrospective review of lung transplantations (LTs) performed from October 1993 to September 2003, included donor and recipient demographic data, pulmonary function, oxygenation, postoperative complications, incidence of rejection and pneumonia, and survival. RESULTS: Of 159 LTs performed the 39 transplanted to treat emphysema (24.4%), were in 33 men and 6 women of age 50.9 +/- 8.7 years (men, 25 to 65 years). There were differences between the emphysema vs other groups in terms of age (P < .001), gender (P = .001), need for bypass (P = .004), and immediate posttransplantation oxygenation index (P = .001). Perioperative mortality tended to be lower among patients with emphysema (2.7% vs 10.8%; P = .131). The incidences of complications and acute rejections was similar. Forced vital capacity, forced expiratory volume in 1 second, arterial oxygen tension, and arterial carbon dioxide tension improved significantly post-Tx. Actuarial survivals were 82%, 68%, and 63%, respectively, at 1, 3, and 7 years posttransplantation for emphysema patients vs 60%, 53%, and 42%, respectively, at 1, 3, and 7 years posttransplantation for non-emphysema patients (P = .049). CONCLUSION: Lung transplantation in patients with emphysema offers good long-term survival, with significant improvement in functional status and low morbidity. The older age of emphysema patients was not associated with a higher incidence of postoperative complications.

Analysis of lung transplant recipients surviving beyond 5 years.

INTRODUCTION: We started lung transplantation (LT) in October 1993 and review the status of recipients who have survived beyond 5 years. METHODS: A retrospective review of patients undergoing LT from October 1993 to October 1998 included pulmonary function data, incidence of bronchiolitis obliterans syndrome (BOS), functional status, and survival. RESULTS: Of 73 transplantations 41 (56%) patients have survived beyond 5 years (study group), including 23 men and 18 women of age 33.2 +/- 15.6 years. Indications for LT were as follows: cystic fibrosis (n = 16), emphysema (n = 13), pulmonary fibrosis (n = 8), and other (n = 4). Actuarial survival at 5, 7, and 9 years was 56%, 53%, and 43%, respectively. Freedom from BOS was 63%, 56%, and 50% at 5, 7, and 9 years, respectively. The median percent predicted FEV1 was 67%, 56%, and 56%, respectively. Also, 79% of recipients had no limitations in their daily activities; 65% were active and working. Only 5% of patients showed some degree of limitation at 5 years posttransplantation. When survivors beyond 5 years were compared with nonsurvivors beyond 5 years, differences were observed: nonsurvivors more frequently required bypass (P = .01), experienced longer postoperative intubation times (P = .01), and exhibited lower PaO2 at 12 months posttransplantation (P < .01). CONCLUSION: Our data show good survival rates among patients surviving beyond 5 years after LT, with a moderate incidence of BOS at 9 years posttransplantation. Despite the incidence of BOS, these patients have good pulmonary function and activity status.

Pulmonary tailoring and lobar transplantation to overcome size disparities in lung transplantation.

Size matching between donors and recipients represents one of the organ distribution criteria widely accepted by lung transplant teams. However, in some cases it is not possible to allocate a donor to the corresponding size-compatible recipient. To avoid possible complications derived from the implantation of oversized lungs into smaller recipients, surgical procedures such as pulmonary tailoring and lobar transplantation have been advocated. We review our experience in 13 patients undergoing volume reduction of the lung graft at the time of transplantation, either by nonanatomical lung volume reduction or by lobar transplantation. There were no significant differences between lung-downsized patients and standard lung transplantation patients in terms of donor characteristics, surgical and postoperative complications, functional outcome, and survival. We conclude that downsizing the lung graft either by nonanatomical resection or lobar transplantation is safe and reliable to overcome size disparities between donor and recipients, with no additional morbidity and with similar early and midterm outcomes to those in standard lung transplants.

Evolution and Risk Factors for Early Mortality After Lung Transplantation for Idiopathic Pulmonary Fibrosis: An Experience of 20 Years.

High early mortality after lung transplantation (LT) for idiopathic pulmonary fibrosis (IPF) is still not well controlled, and some aspects remain debated. The aim of this study was to evaluate our experience to identify factors that might improve the early outcomes. Among the 427 patients transplanted from October 1993 to December 2014, 117 IPF patients underwent LT at our department. There was an increasing age of transplant recipients, and the overall early (1-mo_ mortality was 25/117 (21.4%) with a progressive decrease over the years. Logistic regression analysis for early mortality was performed, and multivariate analysis identified recipient age <55 years (P = .042; odds ratio [OR], 2.98), single-lung transplants (P = .001; OR, 5.226), and previous corticosteroid treatment (P = .05; OR, 5.128) as independent risk factors for development of early mortality. In conclusion, despite the increasing age of transplant recipients, we observed a decrease in mortality to almost one-half compared with our initial results. According to our results, the mortality risk in patients <55 years old is independent from the type of transplant (single or double), being higher with a single transplant. In addition, corticosteroid treatment should be reduced to achieve lower early mortality.

Prediction of early bronchopleural fistula after pneumonectomy: a multivariate analysis.

BACKGROUND: The aim of this study was to determine independent risk factors for early bronchopleural fistula (BPF) after pneumonectomy and to assess the efficacy of bronchial coverage in preventing this complication. METHODS: We reviewed 242 consecutive patients undergoing pneumonectomy for lung cancer. The bronchial stump was covered with autologous tissue in 178 patients (74%). Perioperative data were recorded to identify risk factors of BPF by univariate and multivariate analyses. RESULTS: Overall morbidity and mortality rates were 59% and 5.4%, respectively. The incidence of BPF was 5.4%. By univariate analysis, patients with chronic obstructive pulmonary disease (COPD; p = 0.017), hyperglycemia (p = 0.003), hypoalbuminemia (p = 0.017), previous steroid therapy (p < 0.001), poor predicted postpneumonectomy forced expiratory volume in 1 second (FEV1; p = 0.012), long bronchial stumps (p < 0.001), and mechanical ventilation (p = 0.015), were related with higher risk of BPF. In the multiple logistic regression model, the independent risk factors of BPF were the bronchial stump coverage and length, side of pneumonectomy, predicted postpneumonectomy FEV1, COPD, and mechanical ventilation. CONCLUSIONS: Bronchial stump coverage is highly recommended in all cases to minimize the risks of BPF. A shorter length of the bronchial stump and early extubation may prevent the development of BPF. Careful attention must be paid to those patients with COPD and poor predicted postpneumonectomy FEV1.

Lung transplants with tacrolimus and mycophenolate mofetil: a review.

Traditionally, immunosuppressive maintenance therapy in solid organ transplantation has consisted of cyclosporine (CsA), azathioprine, and prednisone. However, lung transplant recipients are far more frequently affected by acute rejection, especially during the first 6 months after the transplantation, than patients with other transplanted organs. Further, they display a greater risk for chronic transplant dysfunction and ultimate graft loss. Bronchiolitis obliterans syndrome (BOS) is the major cause of morbidity and mortality among long-term survivors after lung transplantation. Acute pulmonary allograft rejection has been identified as the major risk factor for the development of BOS. Based on favourable results in kidney, liver, and heart transplantation, tacrolimus and mycophenolate mofetil have been used as primary prophylaxis and as rescue therapy for recurrent or persistent acute rejection and BOS. A secondary indication is CsA toxicity. This review focuses on reported results of the combination of tacrolimus and mycophenolate mofetil in lung transplantation. These new immunosuppressive drugs have markedly improved the efficacy profiles without additional detrimental toxicities, and appear to be a safe alternative to CsA and azathioprine in patients following lung transplantation. However, at present, BOS is not influenced by these new drugs. The optimal long-term immunosuppressive regimen remains to be established.

[Simultaneaous bilateral pulmonary metastasectomy of carcinoma of the sweat glands]. / Metastasectomía pulmonar bilateral simultánea de un carcinoma de glándulas sudoríparas.

A 51-year-old woman with carcinoma of the right axillary sweat glands was treated by radical surgery and radiotherapy. Six years later she developed multiple bilateral lung metastases. Nine nodes were resected from both lungs using a clamshell approach (bilateral transsternal, anterolateral thoracotomy). After surgery, the patient received 6 cycles of adjuvant chemotherapy with cisplatin and 5-fluoruracil. Three years after treatment, no intrathoracic recurrences had occurred and the patient was asymptomatic, with good quality of life.

[Spontaneous, massive primary pneumothorax in both lungs]. / Neumotórax espontáneo primario masivo bilateral simultáneo.

Primary spontaneous pneumothorax in both lungs simultaneously is rare. We report the case of a 22-year-old man with no relevant medical history who came to the emergency room in critical condition after suffering simultaneous massive pneumothorax in both lungs. After a pleural drain was inserted in each hemithorax, elective surgery was prescribed because of the bilaterality and severity of the pneumothorax. Sequential video thoracoscopic surgery was performed in a single session, during which small blebs were identified at both lung vertices. The blebs were resected and pleural abrasion performed. Postoperative recovery was unremarkable. The patient was discharged four days after surgery. Five years later, the patient was asymptomatic, having experienced no recurrences.

Lung volume reduction surgery after lung transplantation for emphysema-chronic obstructive pulmonary disease.

Lung Volume Reduction Surgery (LVRS) has become a palliative treatment for patients with advanced emphysema and disabling dyspnea. After single lung transplantation in chronic obstructive pulmonary disease, LVRS may be indicated to improve graft dysfunction caused by native lung hyperinflation compressing the grafted lung. This common complication is the subject of our study, which showed LVRS to be helpful to manage this situation. We performed an observational retrospective and descriptive study using the data of 293 patients transplanted in our center between January 1996 and October 2011. Some of the patients who underwent a single lung transplantation developed native lung hyperinflation years after the transplantation, interfering with respiratory function due to graft compression.

Lung cancer in patients with lung transplants.

OBJECTIVE: The aim of our study was to describe the incidence of lung cancer in patients after lung transplantation (LT). MATERIALS AND METHODS: We performed an observational, retrospective, descriptive study based on data from 340 patients undergoing lung transplantation between October 1993 and December 2010. We collected data about the donors, recipients, intra- and postoperative periods, and survivals. RESULTS: We identified 9 (2.6%) patients who developed lung cancer after LT. Their average age was 56 ± 9.3 years (range, 18-63). All cases were men with 8/9 (88.8%) having received a single lung transplant. All cancers developed in the native lung. The indications for transplantation were: emphysema type chronic obstructive pulmonary disease (COPD; n = 5), idiopathic pulmonary fibrosis (n = 3), or cystic fibrosis (n = 1); 77% of them were former smokers. All of the COPD patient were affected. The interval from transplantation to diagnosis was 53.3 ± 12 months (range 24-86). Survival after cancer diagnosis was 49.3 ± 6.3 (range = 0-180) months. CONCLUSIONS: LT was associated with a relatively high incidence of lung cancer, particularly in the native lung. In our series, lung cancer was related more to patients with emphysema-type COPD and a history of smoking. We believe that these patients should be closely followed to establish the diagnosis and apply early treatment.

Postoperative complications in the intensive care unit following lung transplantation in adults: results in University Hospital Reina Sofia.

The postoperative period following lung transplantation remains critical because of several complications. Infection, primary graft failure, acute rejection, and surgical complications are risk factors for mortality and morbidity. The recognition and early treatment of these complications is important to optimize outcomes. This article provides an overview of postoperative complications observed in our center during the last year. We were particularly interested in the influence of variables, such as inotrope usage and Acute Physiology and Chronic Health Evaluation (APACHE II) score, a well-known, and validated mortality prediction model for general intensive care unit (ICU) patients only infrequently reported in the transplantation literature. High APACHE II scores were significantly associated with prolonged mechanical ventilation (P = 0.041) and a tracheostomy requirement (P = .035). The factors significantly associated with an early postoperative death were older donor age (P = .005), prolonged donor ICU period (P = .004), need for cardiopulmonary bypass (CB; P = .005), and high inotrope requirements in the ICU (P = .034). CB data were biased because we selected the worst case patients. Donor age and high inotrope requirements in the ICU have been reported previously to be prognostic factors for poor graft function. We believe that control of these variables may improve outcomes.

Results of lung transplantation in idiopathic pulmonary fibrosis patients.

Lung transplantation (OLT) remains the only available therapy for patients with end-stage idiopathic pulmonary fibrosis (IPF). The objective of this study was to review our experience of OLT for end-stage IPF (IPFLT) patients, seeking to identify variables associated with survival for comparison with outcomes of other indications for LT (OILT). From October 1993 to December 2009, we performed 310 consecutive OLT in 301 patients for treatment of various end-stage pulmonary conditions. The indications for OLT were: IPF (n=89, 30.5%) chronic obstructive pulmonary disease (n=82), cystic fibrosis (n=80), bronchiectasis (n=12), alfa-1-antitrypsin deficit (n=6), primary pulmonary hypertension (n=4), bronchiolitis obliterans (n=4), other conditions (n=15). We observed significant differences in the actuarial survival between the IPFLT and the OILT groups particularly at the expense of worse perioperative 30-day and early 1-year mortality in the IPFLT group. Upon univariate and multivariate analyses, the need for cardiopulmonary bypass, previous recipient ventilator dependence, and donor age>50 years were all associated with poorer survival rates among IPF patients. In our experience, survival did not differ between patients who underwent a single versus a bilateral sequential lung transplant (BSLT); however, BSLT cases were associated with short-term damage but long-term survival. The functional results in the IPFLT group were excellent. We observed significant improvements in the values of arterial oxygen pressure (PaO2), arterial carbon dioxide pressure (PaCO2), forced vital capacity (FVC%) and forced expiratory volume in 1 second (FEV1%) at 6, 12, and 36 months compared to their pretransplant baseline results.

Experience of the Reina Sofia hospital in lobar lung transplantation.

The number of patients awaiting lung transplantation has steadily increased over the past decade, but the number of donors has remained relatively stable. Owing to the increasing scarcity of donor lungs, especially for pediatric and small adult recipients, advanced operative strategies for the use of larger grafts for smaller recipients have been developed. Size matching between donors and recipients represents one of the organ distribution criteria widely accepted by lung transplantation teams. However, in some cases it is not possible to allocate a donor to the corresponding size-compatible recipient. To avoid possible complications derived from the implantation of oversized lungs into smaller recipients, various methods of downsizing are applied for cadaveric donor lungs, such as lobar transplantation. We review our experience in 6 patients undergoing volume reduction of the lung graft by lobar resection at the time of transplantation. Graft volume reduction by anatomic resection (lobar transplantation) is a reliable and safe procedure to overcome size disparities between the donor and the recipient of a lung transplant, and thus to maximize the number of donors.