Living donor lobar grafts improve pediatric lung retransplantation survival

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.

Pediatric Living Lung Donor Transplant Candidates: Psychiatric Status of Utilized and Non-Utilized Donors

Living donor lung (lobar) transplantation has greatly decreased in the past decade due to the success of the lung allocation score (LAS) system, instituted in 2005 by the Organ Procurement and Transplantation Network (OPTN). Between 1993 and 2006, 460 living lung donor transplants were performed in the United States with 369 donations occurring at the University of Southern California and Washington University in St. Louis. These two centers accounted for over 80% of all living donor lung transplants between 1994 and 2006. All potential donors received a psychological/psychiatric evaluation as part of the donor selection process, which is standard practice in the United States, Europe, and Asia. Utilized and non-utilized lung donors were compared in terms of their psychiatric history and present status. Results indicated that 31% (N = 54) of the total sample had a lifetime prevalence of a psychiatric disorder, which is less than that the 46% lifetime rate for the general population (Kessler in Arch Gen Psychiatry 62:593-602, 2005). This study did find that psychiatric history or status was not exclusion factor for transplant surgery in either group. This observation about psychiatric issues in potential living lung donors should be useful to transplant centers who utilize adult live donors of any solid organ type for pediatric recipients and in Japan where live donor lung transplants still represent a significant proportion of lung transplants (Date in J Thorac Dis 8: S631-S636, 2016).

Living-related lung transplantation

Living-donor lobar lung transplantation (LDLLT) was developed to deal with the severe shortage of brain dead door for patients who would not survive the long waiting period. In standard LDLLT, right and left lower lobes removed from two healthy donors are implanted into a recipient after right and left pneumonectomies using cardiopulmonary bypass (CPB). The number of LDLLT has decreased in the USA due to the recent change in allocation system for cadaveric donor lungs. For the past several years, most of the reports on LDLLT have been from Japan, where the average waiting time for a cadaveric lung is exceeding 800 days. LDLLT has been performed both for adult and pediatric patients suffering from various end-stage lung diseases including restrictive, obstructive, vascular and infectious lung diseases. Since only two lobes are implanted, size matching is a very important issue. Functional size matching by measuring donor pulmonary function and anatomical size matching by three-dimensional computed tomography (3D-CT) volumetry are very useful. For oversize graft, we have employed several techniques, including single lobe transplantation, delayed chest closure, downsizing the graft, and middle lobe transplantation. In cases of undersize mismatch, native upper lobe sparing transplant or right-left inverted transplant was performed. The 5-, 10- and 15-year survivals were 80.8%, 72.6% and 61.7%, respectively. There was no difference in survival between standard LDLLT and non-standard LDLLT such as single, sparing and inverted transplant. All donors have been discharged without any restrictions. LDLLT is a viable option for very ill patients who would not survive a long waiting time for cadaveric lungs. We have successfully developed various surgical techniques to overcome size mismatching with favorable outcome.

Bronchoscopic procedures and lung biopsies in pediatric lung transplant recipients

Bronchoscopy remains a pivotal diagnostic and therapeutic intervention in pediatric patients undergoing lung transplantation (LTx). Whether performed as part of a surveillance protocol or if clinically indicated, fibre-optic bronchoscopy allows direct visualization of the transplanted allograft, and in particular, an assessment of the patency of the bronchial anastomosis (or tracheal anastomosis following heart-lung transplantation). Additionally, bronchoscopy facilitates differentiation of infective processes from rejection episodes through collection and subsequent assessment of bronchoalveolar lavage (BAL) and transbronchial biopsy (TBBx) samples. Indeed, the diagnostic criteria for the grading of acute cellular rejection is dependent upon the histopathological assessment of biopsy samples collected at the time of bronchoscopy. Typically, performed in an out-patient setting, bronchoscopy is generally a safe procedure, although complications related to hemorrhage and pneumothorax are occasionally seen. Airway complications, including stenosis, malacia, and dehiscence are diagnosed at bronchoscopy, and subsequent management including balloon dilatation, laser therapy and stent insertion can also be performed bronchoscopically. Finally, bronchoscopy has been and continues to be an important research tool allowing a better understanding of the immuno-biology of the lung allograft through the collection and analysis of collected BAL and TBBx samples. Whilst new investigational tools continue to evolve, the simple visualization and collection of samples within the lung allograft by bronchoscopy remains the gold standard in the evaluation of the lung allograft. This review describes the use and experience of bronchoscopy following lung transplantation in the pediatric setting.

Cystic fibrosis and the thoracic surgeon

Indications for thoracic surgery in patients with cystic fibrosis (CF) are principally represented by pleural diseases including pneumothorax, pleural effusion, and empyema and by parenchymal lung diseases including bronchiectasis, hemoptysis, and pulmonary abscess. Moreover, lung transplantation has proved a viable therapeutic option for progressive respiratory failure due to end-stage CF. Main surgical experiences in this setting are reviewed and discussed.

Update on paediatric lung transplantation

Lung transplantation is well-established in the treatment of end-stage lung disease in children. Our understanding of the problems associated with transplantation has increased rapidly over the past 25 years. Recent figures suggest this knowledge is starting to translate into improvements in management and survival. The common indications for lung transplantation in children, the process of assessment and the outcomes and complications of transplantation are reviewed. We discuss briefly some of the ethical issues relevant to lung transplantation and review strategies for the future. This information may help the respiratory paediatrician prepare potential candidates and their families for the process of assessment and help him or her anticipate common problems that may occur.

Bronchial healing after living-donor lobar lung transplantation

PURPOSE

To review the outcome of bronchial healing after living-donor lobar lung transplantation (LDLLT).

METHODS

We retrospectively analyzed 87 anastomoses in 45 consecutive patients who underwent LDLLT, and 14 anastomoses in 10 consecutive patients who underwent cadaveric lung transplantation (CLT), between October 1998 and September 2007. Bronchial anastomosis complications that required intervention were defined as "airway complications" (ACs).

RESULTS

There were no significant differences in the background characteristics of the LDLLT and CLT recipients. Airway complications developed in 2 (2.2%) of the 87 anastomoses in the LDLLT group and in 3 (21.4%) of the 14 anastomoses in the CLT group (P = 0.018). The donors of the LDLLT grafts were significantly younger than the donors of the CLT grafts (38.3 years vs 46.1 years, respectively; P = 0.013). The ischemic graft times in the LDLLT and CLT groups were 136.9 min and 413.7 min, respectively (P < 0.0001). The periods of pretransplant ventilation in the LDLLT and CLT groups were 0 days and 4.5 days, respectively (P = 0.0083).

CONCLUSION

Our study suggests that bronchial healing after LDLLT is acceptable.

Pre-transplant Mechanical Ventilation Increases Short-term Morbidity and Mortality in Pediatric Patients With Cystic Fibrosis

BACKGROUND

Patients with cystic fibrosis (CF) who are listed for lung transplantation may require mechanical ventilatory support before transplant. Although CF is a risk factor for poor outcomes in adults, no data currently exist pertaining to pre-transplant ventilatory support in children with CF.

METHODS

In a retrospective cohort study, we reviewed the medical records of 18 consecutive CF patients transplanted at St. Louis Children's Hospital (SLCH) who required mechanical ventilation before lung transplantation. Controls included patients transplanted at SLCH who were not mechanically ventilated before transplant and were matched for underlying diagnosis, gender, age, type of transplant (cadaveric vs living donor) and year of transplant.

RESULTS

Ventilated and non-ventilated patients were similar in their pre-transplant characteristics (weight, height and body mass index) and ischemic and bypass times. However, patients ventilated before transplantation had significantly worse immediate post-transplant outcomes, including early graft dysfunction (p = 0.012), prolonged mechanical ventilation (34.1 vs 5 days, p = 0.009), prolonged stay in the pediatric intensive care unit (35.4 vs 8.1 days, p = 0.01), longer time to hospital discharge (38.4 vs 21.3 days, p = 0.033), and worse 1-year mortality after transplant (221.6 vs 335.2 days, p = 0.021). Among ventilated patients, length of pre-transplant ventilation did not affect post-transplant outcomes (length of ventilation, p = 0.92; length of stay in the pediatric intensive care unit, p = 0.68; time to hospital discharge, p = 0.46; and 1-year mortality rate, p = 0.25).

CONCLUSIONS

This is the first report in pediatric patients with CF demonstrating that mechanical ventilation before lung transplant is a predictor of poor short-term outcomes, including 1-year-survival, after transplant. Length of pre-transplant ventilatory support does not appear to impact outcomes.