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J Chest Surg 2022; 55(4): 274-276

Published online August 5, 2022 https://doi.org/10.5090/jcs.22.047

Copyright © Journal of Chest Surgery.

Allocation of Donor Lungs in Korea

Hye Ju Yeo, M.D., Ph.D.1,2

1Research Institute for Convergence of Biomedical Science and Technology and 2Division of Allergy, Pulmonary and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea

Correspondence to:Hye Ju Yeo
Tel 82-55-360-2120
Fax 82-55-360-2157
E-mail dugpwn@naver.com
ORCID
https://orcid.org/0000-0002-8403-5790

Received: July 4, 2022; Accepted: July 18, 2022

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

The expansion of indications for lung transplantation, the growth of the waiting list, and donor shortages are increasing the waiting list mortality rate in Korea. The current lung allocation system in Korea is based mainly on urgency, but outcomes should also be considered to avoid futile transplantation. This review describes the current status of, and issues with, the lung allocation system in Korea including donors, the waiting list, and transplant outcomes in the context of an aging society, in which the frequency of end-stage pulmonary disease is increasing.

Keywords: Lung transplantation, Waiting lists, Resource allocation, Donor, Survival

Lung transplantation is the only palliative treatment option for some patients with end-stage lung disease [1]. Since the first successful single lung transplantation was performed in 1996 in Korea, the number of transplants has been increasing annually, and 157 were performed in 2019 [2,3]. However, the number of patients on the waiting list for transplants also continues to increase. In 2019, 277 patients were on the waiting list for lung transplants, and there is a large gap between the demand for and availability of donor lungs. As a result, 82 candidates died while waiting for a transplant in 2019, representing a 7.9% increase from the previous year [2]. This gap is expected to further widen as the elderly population and number of patients with end-stage lung disease in need of lung transplantation increase [4]. Organ allocation systems are crucial for the fair and efficient distribution of donor lungs. This review describes the current lung allocation system in Korea, focusing on the major issues associated with donors, the waiting list, and transplant results.

Korea established the Korean Network for Organ Sharing in 2000. Since then, efforts have been made to distribute and manage organs fairly and efficiently according to the Internal Organs Transplant Act [5]. The current donor lung allocation system is based mainly on urgency, with additional points allocated according to region, blood type, wait time, previous donation history, and age [6]. Transplant candidates are classified as 0–4 according to urgency; a lower status indicates a higher priority. Status 0 corresponds to a hospitalized patient on a mechanical ventilator and/or extracorporeal membrane oxygenation (ECMO) due to respiratory failure. Status 1 is defined as the presence of 1 or more of the following: partial pressure of oxygen (PaO2) <55 mm Hg, as measured without oxygen administration; mean pulmonary arterial pressure >65 mm Hg or mean right atrial pressure >15 mm Hg; cardiac index <2 L/min/m2; partial pressure of carbon dioxide (PaCO2) ≥80 mm Hg; or hospitalization for >2 weeks with a high-flow nasal cannula (30 L, fraction of inspired oxygen ≥0.6). Status 2 is defined as the presence of one or more of the following: forced expiratory volume in 1 second (FEV1) <25%; PaO2 <60 mm Hg, as measured without supplemental oxygen; average right atrial blood pressure of 10–15 mm Hg; average pulmonary arterial pressure of 55–65 mm Hg; cardiac index <2–2.5 L/min/m2; 70 mm Hg≤ PaCO2 <80 mm Hg; or diffusing capacity of the lungs <30% on a pulmonary function test. Status 3 is defined as the presence of 1 or more of the following: requirement for a single lung transplant; emphysema, pulmonary hypertension, or diffuse interstitial lung disease; FEV1 <30%; or hospitalization more than three times for respiratory failure. Status 4 is the classification for all other patients.

The number of brain-dead donors in Korea steadily increased to 450 in 2019. However, only 13% of brain-dead donor lungs are used for lung transplantation [7,8]. Donor lungs can be injured by a proinflammatory cytokine or catecholamine surge after brain death. In addition, the lungs are vulnerable to parenchymal damage, such as pulmonary infection, aspiration, and pulmonary edema, after brain death in the intensive care unit [9]. Furthermore, many potential lung donors do not consent to lung donation, and the rate of lung donation remains lower in Korea than in other countries [10]. This is attributed to cultural factors and laws regarding organ donation [11]. Due to the shortage of donor lungs, attempts have been made to increase the donor pool worldwide, such as by extending the donor criteria and considering ex vivo lung perfusion (EVLP) and the use of donors after circulatory death (DCD). Currently, EVLP and DCD are not legal in Korea, and the use of marginal donors has increased by more than 50% [6,8]. EVLP is actively used in the United States and Canada to increase organ availability, and in some cases, organ quality is improved by using the prone position [12-14]. EVLP should be introduced to expand the pool of suitable donor lungs and reduce the average wait time of transplant candidates [15]. Similarly, permitting donations after cardiac death would increase the donor pool. Organ management centers should actively select and manage potential lung donors to maximize utilization of this valuable resource; an optimal donor management protocol and relaxation of the donor criteria are required.

A total of 1,671 patients were registered for lung transplantation from 2009 to 2020. Approximately half of these patients (46.1%) received transplants within 1 year of registration, while 31.8% died within 1 year without lung transplantation. The current system in Korea selects recipients based on urgency to decrease waiting list mortality. However, the waiting list mortality rate is still higher than in other countries (transplant rates/waiting list mortality: United States, 71.7%/14.4%; United Kingdom, 45%/17%; Japan, 37%/36.1%) [8-10]. Waiting list outcomes are affected by the donor pool, the efficiency of the allocation system, and the timing of registration. Status 0 patients are prioritized for transplants in urgency-based systems, and the proportion of highly urgent recipients has steadily increased. In Korea, most patients on the waiting list have interstitial pulmonary fibrosis (IPF) or another interstitial lung disease, and are at risk of rapid deterioration [6]. Therefore, registration and transplantation rates for highly urgent cases, such as those requiring ECMO, are high compared to other countries (e.g., <10% in the United States) [16]. In 2019, 68.6% of Korean transplant patients were status 0, and 38.5% underwent ECMO as a bridge to transplantation. Lung transplantation in Korea is still in the “learning phase,” and a lack of awareness among patients and/or their physicians about lung transplantation can delay registration. Therefore, there is a need to educate the general population and doctors regarding lung transplantation. Continuous improvements to the allocation system will also reduce waiting list mortality and ensure equal transplant opportunities.

The 1-year survival rate after transplantation has been steadily improving, and it reached 76.3% in 2019. The 1-year survival rate of transplantation for status 0 patients is 74.8%, and that for status 1 patients is 79.6%. The survival likelihood after transplantation is significantly affected by recipient age and urgency status at registration. The rate of lung transplantation in patients aged >65 years rose to 19.9% in 2019, of whom 61.3% were status 0 patients; most transplants in older patients were performed because of IPF (72%). The number of older patients with IPF undergoing transplants has also increased in the United States, but there have been no reports focusing on transplantation in patients with a highly urgent status, like those who receive transplants in Korea [17]. In particular, one-third of elderly patients were first registered for transplantation as status 0 patients. The main issue is that the referral of potential candidates to the transplant center is delayed.

In Korea, the 1-year survival rate for transplant patients aged ≥65 years was 67.7% in 2019, while the transplant survival rates of status 0 and 1 patients were 68.4% and 70%, respectively. Although the short-term survival rate is comparable to other age groups, older patients have relatively low intermediate- and long-term survival rates, and are at a high risk of post-transplant complications and morbidities [17]. Furthermore, pre-transplant evaluation is not possible for patients who are already in a highly urgent condition when registered, and the condition of these patients means that transplantation is likely to be futile [18]. Therefore, clinicians should recommend transplantation earlier to patients and their legal guardians.

Lung transplantation continues to develop in Korea. However, despite rapid technical advances, cultural factors have caused donor shortages, delayed registration of candidates, resulted in futile transplantations, and affected outcomes. Professionals involved in transplantation should work together to achieve a cultural shift; in the meantime, DCD and EVLP would help increase the donor pool.

Author contributions

All work was done by Hye Ju Yeo.

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Acknowledgments

I dedicate this thesis to Professor Hyo Chae Paik, who has devoted himself to the development of lung transplantation in Korea.

  1. Chambers DC, Cherikh WS, Harhay MO, et al. The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: thirty-sixth adult lung and heart-lung transplantation report-2019; focus theme: donor and recipient size match. J Heart Lung Transplant 2019;38:1042-55.
    Pubmed KoreaMed CrossRef
  2. Paik HC, Hwang JJ, Kim DH, Joung EK, Kim HK, Lee DY. The 10 years experience of lung transplantation. J Chest Surg 2006;39:822-7.
  3. The National Institute of Organ, Tissue and Blood Management. Annual report of the transplant 2019 [Internet]. Seoul: The National Institute of Organ, Tissue and Blood Management; 2020 [cited 2022 Jun 5].
    Available from: https://www.konos.go.kr/.
  4. Lee SH, Yeo Y, Kim TH, et al. Korean guidelines for diagnosis and management of interstitial lung diseases: part 2. Idiopathic pulmonary fibrosis. Tuberc Respir Dis (Seoul) 2019;82:102-17.
    Pubmed KoreaMed CrossRef
  5. Internal Organs Transplant Act, Act No. 17214 (Apr 7, 2020) [Internet]. Sejong: Korea Legislation Research Institute; 2020 [cited 2022 Jun 5].
    Available from: https://elaw.klri.re.kr/kor_service/lawView.do?hseq=54020&lang=ENG.
  6. Yeo HJ, Kim DH, Kim YS, Jeon D, Cho WH. Performance changes following the revision of organ allocation system of lung transplant: analysis of Korean Network for Organ Sharing data. J Korean Med Sci 2021;36:e79.
    Pubmed KoreaMed CrossRef
  7. Paik HC, Haam SJ, Lee DY, et al. Donor evaluation for lung transplantation in Korea. Transplant Proc 2012;44:870-4.
    Pubmed CrossRef
  8. Yeo HJ, Yoon SH, Lee SE, et al. Current status and future of lung donation in Korea. J Korean Med Sci 2017;32:1953-8.
    Pubmed KoreaMed CrossRef
  9. Chacon-Aponte AA, Duran-Vargas EA, Arevalo-Carrillo JA, et al. Brain-lung interaction: a vicious cycle in traumatic brain injury. Acute Crit Care 2022;37:35-44.
    Pubmed KoreaMed CrossRef
  10. Smith S, Trivedi JR, Fox M, Van Berkel VH. Donor lung utilization for transplantation in the United States. J Heart Lung Transplant 2020;39(4 Supplement):S374.
    CrossRef
  11. Nie JB, Jones DG. Confucianism and organ donation: moral duties from xiao (filial piety) to ren (humaneness). Med Health Care Philos 2019;22:583-91.
    Pubmed CrossRef
  12. Ahmad K, Pluhacek JL, Brown AW. Ex vivo lung perfusion: a review of current and future application in lung transplantation. Pulm Ther 2022;8:149-65.
    Pubmed KoreaMed CrossRef
  13. Son E, Jang J, Cho WH, Kim D, Yeo HJ. Successful lung transplantation after prone positioning in an ineligible donor: a case report. Gen Thorac Cardiovasc Surg 2021;69:1352-5.
    Pubmed KoreaMed CrossRef
  14. Marklin GF, O'Sullivan C, Dhar R. Ventilation in the prone position improves oxygenation and results in more lungs being transplanted from organ donors with hypoxemia and atelectasis. J Heart Lung Transplant 2021;40:120-7.
    Pubmed CrossRef
  15. Haam SJ, Paik HC, Lee DY, Kim DU, Kim NY. Ex vivo lung perfusion model in lung transplantation. J Korean Soc Transplant 2013;27:100-6.
    CrossRef
  16. Hayanga JW, Hayanga HK, Holmes SD, et al. Mechanical ventilation and extracorporeal membrane oxygenation as a bridge to lung transplantation: closing the gap. J Heart Lung Transplant 2019;38:1104-11.
    Pubmed CrossRef
  17. Courtwright A, Cantu E. Lung transplantation in elderly patients. J Thorac Dis 2017;9:3346-51.
    Pubmed KoreaMed CrossRef
  18. Yu WS, Kim SY, Kim YT, et al. Characteristics of lung allocation and outcomes of lung transplant according to the Korean urgency status. Yonsei Med J 2019;60:992-7.
    Pubmed KoreaMed CrossRef

Article

Collective of Current Reviews, Lectures

J Chest Surg 2022; 55(4): 274-276

Published online August 5, 2022 https://doi.org/10.5090/jcs.22.047

Copyright © Journal of Chest Surgery.

Allocation of Donor Lungs in Korea

Hye Ju Yeo, M.D., Ph.D.1,2

1Research Institute for Convergence of Biomedical Science and Technology and 2Division of Allergy, Pulmonary and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea

Correspondence to:Hye Ju Yeo
Tel 82-55-360-2120
Fax 82-55-360-2157
E-mail dugpwn@naver.com
ORCID
https://orcid.org/0000-0002-8403-5790

Received: July 4, 2022; Accepted: July 18, 2022

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

The expansion of indications for lung transplantation, the growth of the waiting list, and donor shortages are increasing the waiting list mortality rate in Korea. The current lung allocation system in Korea is based mainly on urgency, but outcomes should also be considered to avoid futile transplantation. This review describes the current status of, and issues with, the lung allocation system in Korea including donors, the waiting list, and transplant outcomes in the context of an aging society, in which the frequency of end-stage pulmonary disease is increasing.

Keywords: Lung transplantation, Waiting lists, Resource allocation, Donor, Survival

Introduction

Lung transplantation is the only palliative treatment option for some patients with end-stage lung disease [1]. Since the first successful single lung transplantation was performed in 1996 in Korea, the number of transplants has been increasing annually, and 157 were performed in 2019 [2,3]. However, the number of patients on the waiting list for transplants also continues to increase. In 2019, 277 patients were on the waiting list for lung transplants, and there is a large gap between the demand for and availability of donor lungs. As a result, 82 candidates died while waiting for a transplant in 2019, representing a 7.9% increase from the previous year [2]. This gap is expected to further widen as the elderly population and number of patients with end-stage lung disease in need of lung transplantation increase [4]. Organ allocation systems are crucial for the fair and efficient distribution of donor lungs. This review describes the current lung allocation system in Korea, focusing on the major issues associated with donors, the waiting list, and transplant results.

Current Korean lung allocation system

Korea established the Korean Network for Organ Sharing in 2000. Since then, efforts have been made to distribute and manage organs fairly and efficiently according to the Internal Organs Transplant Act [5]. The current donor lung allocation system is based mainly on urgency, with additional points allocated according to region, blood type, wait time, previous donation history, and age [6]. Transplant candidates are classified as 0–4 according to urgency; a lower status indicates a higher priority. Status 0 corresponds to a hospitalized patient on a mechanical ventilator and/or extracorporeal membrane oxygenation (ECMO) due to respiratory failure. Status 1 is defined as the presence of 1 or more of the following: partial pressure of oxygen (PaO2) <55 mm Hg, as measured without oxygen administration; mean pulmonary arterial pressure >65 mm Hg or mean right atrial pressure >15 mm Hg; cardiac index <2 L/min/m2; partial pressure of carbon dioxide (PaCO2) ≥80 mm Hg; or hospitalization for >2 weeks with a high-flow nasal cannula (30 L, fraction of inspired oxygen ≥0.6). Status 2 is defined as the presence of one or more of the following: forced expiratory volume in 1 second (FEV1) <25%; PaO2 <60 mm Hg, as measured without supplemental oxygen; average right atrial blood pressure of 10–15 mm Hg; average pulmonary arterial pressure of 55–65 mm Hg; cardiac index <2–2.5 L/min/m2; 70 mm Hg≤ PaCO2 <80 mm Hg; or diffusing capacity of the lungs <30% on a pulmonary function test. Status 3 is defined as the presence of 1 or more of the following: requirement for a single lung transplant; emphysema, pulmonary hypertension, or diffuse interstitial lung disease; FEV1 <30%; or hospitalization more than three times for respiratory failure. Status 4 is the classification for all other patients.

Donor shortages and increased use of marginal donors

The number of brain-dead donors in Korea steadily increased to 450 in 2019. However, only 13% of brain-dead donor lungs are used for lung transplantation [7,8]. Donor lungs can be injured by a proinflammatory cytokine or catecholamine surge after brain death. In addition, the lungs are vulnerable to parenchymal damage, such as pulmonary infection, aspiration, and pulmonary edema, after brain death in the intensive care unit [9]. Furthermore, many potential lung donors do not consent to lung donation, and the rate of lung donation remains lower in Korea than in other countries [10]. This is attributed to cultural factors and laws regarding organ donation [11]. Due to the shortage of donor lungs, attempts have been made to increase the donor pool worldwide, such as by extending the donor criteria and considering ex vivo lung perfusion (EVLP) and the use of donors after circulatory death (DCD). Currently, EVLP and DCD are not legal in Korea, and the use of marginal donors has increased by more than 50% [6,8]. EVLP is actively used in the United States and Canada to increase organ availability, and in some cases, organ quality is improved by using the prone position [12-14]. EVLP should be introduced to expand the pool of suitable donor lungs and reduce the average wait time of transplant candidates [15]. Similarly, permitting donations after cardiac death would increase the donor pool. Organ management centers should actively select and manage potential lung donors to maximize utilization of this valuable resource; an optimal donor management protocol and relaxation of the donor criteria are required.

Waiting list outcomes

A total of 1,671 patients were registered for lung transplantation from 2009 to 2020. Approximately half of these patients (46.1%) received transplants within 1 year of registration, while 31.8% died within 1 year without lung transplantation. The current system in Korea selects recipients based on urgency to decrease waiting list mortality. However, the waiting list mortality rate is still higher than in other countries (transplant rates/waiting list mortality: United States, 71.7%/14.4%; United Kingdom, 45%/17%; Japan, 37%/36.1%) [8-10]. Waiting list outcomes are affected by the donor pool, the efficiency of the allocation system, and the timing of registration. Status 0 patients are prioritized for transplants in urgency-based systems, and the proportion of highly urgent recipients has steadily increased. In Korea, most patients on the waiting list have interstitial pulmonary fibrosis (IPF) or another interstitial lung disease, and are at risk of rapid deterioration [6]. Therefore, registration and transplantation rates for highly urgent cases, such as those requiring ECMO, are high compared to other countries (e.g., <10% in the United States) [16]. In 2019, 68.6% of Korean transplant patients were status 0, and 38.5% underwent ECMO as a bridge to transplantation. Lung transplantation in Korea is still in the “learning phase,” and a lack of awareness among patients and/or their physicians about lung transplantation can delay registration. Therefore, there is a need to educate the general population and doctors regarding lung transplantation. Continuous improvements to the allocation system will also reduce waiting list mortality and ensure equal transplant opportunities.

Transplant outcomes

The 1-year survival rate after transplantation has been steadily improving, and it reached 76.3% in 2019. The 1-year survival rate of transplantation for status 0 patients is 74.8%, and that for status 1 patients is 79.6%. The survival likelihood after transplantation is significantly affected by recipient age and urgency status at registration. The rate of lung transplantation in patients aged >65 years rose to 19.9% in 2019, of whom 61.3% were status 0 patients; most transplants in older patients were performed because of IPF (72%). The number of older patients with IPF undergoing transplants has also increased in the United States, but there have been no reports focusing on transplantation in patients with a highly urgent status, like those who receive transplants in Korea [17]. In particular, one-third of elderly patients were first registered for transplantation as status 0 patients. The main issue is that the referral of potential candidates to the transplant center is delayed.

In Korea, the 1-year survival rate for transplant patients aged ≥65 years was 67.7% in 2019, while the transplant survival rates of status 0 and 1 patients were 68.4% and 70%, respectively. Although the short-term survival rate is comparable to other age groups, older patients have relatively low intermediate- and long-term survival rates, and are at a high risk of post-transplant complications and morbidities [17]. Furthermore, pre-transplant evaluation is not possible for patients who are already in a highly urgent condition when registered, and the condition of these patients means that transplantation is likely to be futile [18]. Therefore, clinicians should recommend transplantation earlier to patients and their legal guardians.

Conclusion

Lung transplantation continues to develop in Korea. However, despite rapid technical advances, cultural factors have caused donor shortages, delayed registration of candidates, resulted in futile transplantations, and affected outcomes. Professionals involved in transplantation should work together to achieve a cultural shift; in the meantime, DCD and EVLP would help increase the donor pool.

Author contributions

All work was done by Hye Ju Yeo.

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Acknowledgments

I dedicate this thesis to Professor Hyo Chae Paik, who has devoted himself to the development of lung transplantation in Korea.

There is no Figure.

There is no Table.

References

  1. Chambers DC, Cherikh WS, Harhay MO, et al. The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: thirty-sixth adult lung and heart-lung transplantation report-2019; focus theme: donor and recipient size match. J Heart Lung Transplant 2019;38:1042-55.
    Pubmed KoreaMed CrossRef
  2. Paik HC, Hwang JJ, Kim DH, Joung EK, Kim HK, Lee DY. The 10 years experience of lung transplantation. J Chest Surg 2006;39:822-7.
  3. The National Institute of Organ, Tissue and Blood Management. Annual report of the transplant 2019 [Internet]. Seoul: The National Institute of Organ, Tissue and Blood Management; 2020 [cited 2022 Jun 5]. Available from: https://www.konos.go.kr/.
  4. Lee SH, Yeo Y, Kim TH, et al. Korean guidelines for diagnosis and management of interstitial lung diseases: part 2. Idiopathic pulmonary fibrosis. Tuberc Respir Dis (Seoul) 2019;82:102-17.
    Pubmed KoreaMed CrossRef
  5. Internal Organs Transplant Act, Act No. 17214 (Apr 7, 2020) [Internet]. Sejong: Korea Legislation Research Institute; 2020 [cited 2022 Jun 5]. Available from: https://elaw.klri.re.kr/kor_service/lawView.do?hseq=54020&lang=ENG.
  6. Yeo HJ, Kim DH, Kim YS, Jeon D, Cho WH. Performance changes following the revision of organ allocation system of lung transplant: analysis of Korean Network for Organ Sharing data. J Korean Med Sci 2021;36:e79.
    Pubmed KoreaMed CrossRef
  7. Paik HC, Haam SJ, Lee DY, et al. Donor evaluation for lung transplantation in Korea. Transplant Proc 2012;44:870-4.
    Pubmed CrossRef
  8. Yeo HJ, Yoon SH, Lee SE, et al. Current status and future of lung donation in Korea. J Korean Med Sci 2017;32:1953-8.
    Pubmed KoreaMed CrossRef
  9. Chacon-Aponte AA, Duran-Vargas EA, Arevalo-Carrillo JA, et al. Brain-lung interaction: a vicious cycle in traumatic brain injury. Acute Crit Care 2022;37:35-44.
    Pubmed KoreaMed CrossRef
  10. Smith S, Trivedi JR, Fox M, Van Berkel VH. Donor lung utilization for transplantation in the United States. J Heart Lung Transplant 2020;39(4 Supplement):S374.
    CrossRef
  11. Nie JB, Jones DG. Confucianism and organ donation: moral duties from xiao (filial piety) to ren (humaneness). Med Health Care Philos 2019;22:583-91.
    Pubmed CrossRef
  12. Ahmad K, Pluhacek JL, Brown AW. Ex vivo lung perfusion: a review of current and future application in lung transplantation. Pulm Ther 2022;8:149-65.
    Pubmed KoreaMed CrossRef
  13. Son E, Jang J, Cho WH, Kim D, Yeo HJ. Successful lung transplantation after prone positioning in an ineligible donor: a case report. Gen Thorac Cardiovasc Surg 2021;69:1352-5.
    Pubmed KoreaMed CrossRef
  14. Marklin GF, O'Sullivan C, Dhar R. Ventilation in the prone position improves oxygenation and results in more lungs being transplanted from organ donors with hypoxemia and atelectasis. J Heart Lung Transplant 2021;40:120-7.
    Pubmed CrossRef
  15. Haam SJ, Paik HC, Lee DY, Kim DU, Kim NY. Ex vivo lung perfusion model in lung transplantation. J Korean Soc Transplant 2013;27:100-6.
    CrossRef
  16. Hayanga JW, Hayanga HK, Holmes SD, et al. Mechanical ventilation and extracorporeal membrane oxygenation as a bridge to lung transplantation: closing the gap. J Heart Lung Transplant 2019;38:1104-11.
    Pubmed CrossRef
  17. Courtwright A, Cantu E. Lung transplantation in elderly patients. J Thorac Dis 2017;9:3346-51.
    Pubmed KoreaMed CrossRef
  18. Yu WS, Kim SY, Kim YT, et al. Characteristics of lung allocation and outcomes of lung transplant according to the Korean urgency status. Yonsei Med J 2019;60:992-7.
    Pubmed KoreaMed CrossRef

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