Living-donor lobar lung transplantation

Living-donor lobar lung transplantation (LDLLT) is indicated for critically ill patients who would not survive the waiting period in the case of severe brain-dead donor shortage. It is essential to confirm that potential donors are willing to donate without applying psychological pressure from others. In standard LDLLT, the right and left lower lobes donated by 2 healthy donors are implanted into the recipient under cardiopulmonary support. LDLLT can be applied to various lung diseases including restrictive, obstructive, infectious, and vascular lung diseases in both adult and pediatric patients if size matching is acceptable. Functional size matching by measuring donor pulmonary function and anatomical size matching by 3-dimensional computed tomography volumetry are very useful. When 2 donors with ideal size matching are not available, various transplant procedures, such as single lobe, segmental, recipient lobe-sparing, and inverted lobar transplants are valuable options. There seems to be immunological advantages in LDLLT as compared to cadaveric lung transplantation (CLT). Unilateral chronic allograft dysfunction is a unique manifestation after bilateral LDLLT, which may contribute to better prognosis. The growth of adult lung graft implanted into growing pediatric recipients is suggested by radiologic evaluation. Although only 2 lobes are implanted, postoperative pulmonary function is equivalent between LDLLT and CLT. The long-term outcome after LDLLT is similar to or better than that after CLT. The author has performed 164 LDLLTs resulting in 71.6% survival rate at 10 years. All living-donors returned to their previous life styles. Because of possible serious morbidity in donors, LDLLT should be applied only for critically ill patients.

Comparison of living-donor lobar lung transplantation and cadaveric lung transplantation for pulmonary hypertension

OBJECTIVES

Living-donor lobar lung transplantation (LDLLT) is a life-saving procedure for critically ill patients with various lung diseases, including pulmonary hypertension. However, there are concerns regarding the development of heart failure with pulmonary oedema after LDLLT in which only one or two lobes are implanted. This study aimed to compare the preoperative conditions and postoperative outcomes of LDLLT with those of cadaveric lung transplantation (CLT) in pulmonary hypertension patients.

METHODS

Between 2008 and 2021, 34 lung transplants for pulmonary hypertension, including 12 LDLLTs (five single and seven bilateral) and 22 bilateral CLTs, were performed. Preoperative variables and postoperative outcomes were retrospectively compared between the two procedures.

RESULTS

Based on the preoperative variables of less ambulatory ability (41.7% vs 100%, p < 0.001), a higher proportion of WHO class 4 (83.3% vs 18.2%, p < 0.001), and higher mean pulmonary artery pressure (74.4 mmHg vs 57.3 mmHg, p = 0.040), LDLLT patients were more debilitated than CLT patients. Nevertheless, hospital death was similar between the two groups (8.3% vs 9.1%, p > 0.99, respectively). Furthermore, the 5-year overall survival rate was similar between the two groups (90.0% vs 76.3%, p = 0.489).

CONCLUSIONS

Although LDLLT patients with pulmonary hypertension had worse preoperative conditions and received smaller grafts than CLT patients, LDLLT patients demonstrated similar perioperative outcomes and prognoses as CLT patients. LDLLT is a viable treatment option for patients with pulmonary hypertension.

Living-donor lobar lung transplantation

Living-donor lobar lung transplantation (LDLLT) has become an important life-saving option for patients with severe respiratory disorders, since it was developed by a group in the University of Southern California in 1993 and introduced in Japan in 1998 in order to address the current severe shortage of brain-dead donor organs. Although LDLLT candidates were basically limited to critically ill patients who would require hospitalization, the long-term use of steroids, and/or mechanical respiratory support prior to transplantation, LDLLT provided good post-transplant outcomes, comparable to brain-dead donor lung transplantation in the early and late phases. In Kyoto University, the 5- and 10-year survival rates after LDLLT were reported to be 79.0% and 64.6%, respectively. LDLLT should be performed under appropriate circumstances, considering the inherent risk to the living donor. In our transplant program, all living donors returned to their previous social lives without any major complications, and living-donor surgery was associated with a morbidity rate of <15%. Both functional and anatomical size matching were preoperatively performed between the living-donor lobar grafts and recipients. Precise size matching before surgery could provide a favorable pulmonary function and exercise capacity after LDLLT. Various transplant procedures have recently been developed in LDLLT in order to deal with the issue of graft size mismatching in recipients, and favorable post-transplant outcomes have been observed. Native upper lobe-sparing and/or right-to-left inverted transplantation have been performed for undersized grafts, while single-lobe transplantation has been employed with or without contralateral pneumonectomy and/or delayed chest closure for oversized grafts.

Twenty-year Follow-up of the First Bilateral Living-donor Lobar Lung Transplantation in Japan

Patients with end-stage lung disease can undergo living-donor lobar lung transplantation (LDLLT), with survival rates improving every year. We herein report the 20-year follow-up findings of the first patient who underwent LDLLT in Japan. A 24-year-old woman with primary ciliary dyskinesia became ventilator-dependent after severe respiratory failure and right-sided heart failure following repeated respiratory infections. In 1998, she underwent LDLLT and received her sister's right lower lobe and her mother's left lower lobe. Although the patient required 21 hospitalizations and developed unilateral bronchiolitis obliterans syndrome, she is in good physical condition and lives without restriction at 20 years after undergoing LDLLT.