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Imamura Y, Nakajima D, Kanou T, Shintani Y, Sugimoto S, Toyooka S, Hoshikawa Y, Matsumoto K, Nagayasu T, Suzuki H, Maeda S, Chida M, Shiraishi T, Sato T, Sato M, Nakajima J, Oishi H, Okada Y, Date H. Effect of revised organ transplant law in Japan on lung transplantation. Surg Today 2024:10.1007/s00595-024-02839-5. [PMID: 38619591 DOI: 10.1007/s00595-024-02839-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 02/25/2024] [Indexed: 04/16/2024]
Abstract
PURPOSE To investigate how revision of the organ transplant law in Japan affected lung transplantation in this country. METHODS Lung transplant candidates registered between January, 2000 and December, 2009 were designated as the pre-revision group (n = 396) and those registered between January, 2011 and December, 2020, as the post-revision group (n = 1326). Both groups were analyzed retrospectively using data collected by the Japanese Society of Lung and Heart-Lung Transplantation. RESULTS The number of patients who underwent brain-dead donor lung transplantation (BDLT) increased significantly after the law amendment (32.2 vs. 13.8%, p < 0.01). The median waiting time for BDLT was significantly reduced (708 days vs. 1163 days, p < 0.01) and the mortality rate while waiting for BDLT improved significantly after the law amendment (33.1 vs. 42.6%, p < 0.01). In the post-revision group, 18 pediatric patients underwent BDLT. The 5-year survival rates after BDLT were comparable between the groups (73.5% in the pre-revision group vs. 73.2% in the post-revision group, p = 0.32). CONCLUSIONS The organ transplant law revision shortened the waiting time for BDLT significantly and decreased the mortality rate while waiting for BDLT. The posttransplant outcomes in Japan remained favorable throughout the study period.
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Affiliation(s)
- Yoshito Imamura
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
- Department of Thoracic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Daisuke Nakajima
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan.
| | - Takashi Kanou
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yasushi Shintani
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Seiichiro Sugimoto
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shinichi Toyooka
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yasushi Hoshikawa
- Department of Thoracic Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Keitaro Matsumoto
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Takeshi Nagayasu
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Hidemi Suzuki
- Department of General Thoracic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Sumiko Maeda
- Department of General Thoracic Surgery, Dokkyo Medical University, Mibu, Japan
| | - Masayuki Chida
- Department of General Thoracic Surgery, Dokkyo Medical University, Mibu, Japan
| | - Takeshi Shiraishi
- Department of General Thoracic, Breast and Pediatric Surgery, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Toshihiko Sato
- Department of General Thoracic, Breast and Pediatric Surgery, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Masaaki Sato
- Department of Thoracic Surgery, The University of Tokyo, Tokyo, Japan
| | - Jun Nakajima
- Department of Thoracic Surgery, The University of Tokyo, Tokyo, Japan
| | - Hisashi Oishi
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Yoshinori Okada
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Hiroshi Date
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
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Date H. Living-donor lobar lung transplantation. J Heart Lung Transplant 2024; 43:162-168. [PMID: 37704161 DOI: 10.1016/j.healun.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 08/22/2023] [Accepted: 09/05/2023] [Indexed: 09/15/2023] Open
Abstract
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.
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Affiliation(s)
- Hiroshi Date
- The Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan.
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Tanaka S, Nakajima D, Sakamoto R, Oguma T, Kawaguchi A, Ohsumi A, Ohata K, Ueda S, Yamagishi H, Kayawake H, Yutaka Y, Yamada Y, Hamaji M, Hamada S, Tanizawa K, Handa T, Suga T, Baba S, Hiramatsu H, Ikeda T, Date H. Outcome and growth of lobar graft after pediatric living-donor lobar lung transplantation. J Heart Lung Transplant 2022; 42:660-668. [PMID: 36585287 DOI: 10.1016/j.healun.2022.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 11/24/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Living-donor lobar lung transplantation (LDLLT) remains a life-saving option for pediatric patients with respiratory failure. However, the long-term survival and post-transplant quality of adult lobar grafts transplanted into children are unknown. Therefore, this study aimed to evaluate the outcomes of pediatric LDLLT and post-transplant graft growth. METHODS We retrospectively reviewed the prospectively collected clinical data of 25 living-donor lung transplantations performed in 24 pediatric recipients aged ≤17 years. The annual pulmonary function test data and computed tomography scans of 12 recipients, followed up for >5 years without significant complications, were used to evaluate growth in height, graft function, and radiological changes. The Kaplan-Meier method and simple linear regression were performed for analysis. RESULTS Bilateral lower lobe transplantation was performed in 12 patients, unilateral lower lobe transplantation in 12, and bilateral middle lobe transplantation in 1. The median volumetric size matching at transplantation was 142% (range, 54%-457%). The 5- and 10-year overall survival rates were 87.7% and 75.1༅, respectively. Chronic lung allograft dysfunction occurred in 2 patients. During a median follow-up of 6 years, the median increases in height and vital capacity were 14.4% (range, 0.80%-43.5%) and 58.5% (range, 6.7%-322%), respectively. Graft weight was positively correlated with graft volume (r2=0.622, p<0.001) after the graft volume exceeded the original lobar volume in the donor. CONCLUSIONS This study shows that pediatric LDLLT offers satisfactory long-term survival, with the growth of mature adult lobes transplanted into growing children.
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Affiliation(s)
- Satona Tanaka
- Department of Thoracic Surgery, Kyoto University Hospital, Kyoto, Japan. https://twitter.com/https://twitter.com/t_satona
| | - Daisuke Nakajima
- Department of Thoracic Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Ryo Sakamoto
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tsuyoshi Oguma
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Atsushi Kawaguchi
- Center for Comprehensive Community Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Akihiro Ohsumi
- Department of Thoracic Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Keiji Ohata
- Department of Thoracic Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Satoshi Ueda
- Department of Thoracic Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Hiroya Yamagishi
- Department of Thoracic Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Hidenao Kayawake
- Department of Thoracic Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Yojiro Yutaka
- Department of Thoracic Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Yoshito Yamada
- Department of Thoracic Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Masatsugu Hamaji
- Department of Thoracic Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Satoshi Hamada
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Department of Advanced Medicine for Respiratory Failure, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kiminobu Tanizawa
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tomohiro Handa
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Department of Advanced Medicine for Respiratory Failure, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takenori Suga
- Department of Pediatrics, Kyoto University Hospital, Kyoto, Japan
| | - Shiro Baba
- Department of Pediatrics, Kyoto University Hospital, Kyoto, Japan
| | | | - Tadashi Ikeda
- Department of Cardiovascular Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Hiroshi Date
- Department of Thoracic Surgery, Kyoto University Hospital, Kyoto, Japan.
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Living-donor Segmental Lung Transplantation for Pediatric Patients. J Thorac Cardiovasc Surg 2022; 165:2193-2201. [PMID: 36088146 DOI: 10.1016/j.jtcvs.2022.07.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/26/2022] [Accepted: 07/02/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The preset study evaluated the outcome of living-donor segmental lung transplantation for pediatric patients. METHODS Between August 2009 and May 2021, we performed living-donor segmental lung transplantation in 6 critically ill pediatric patients, including 1 patient on a ventilator alone and another patient on a ventilator and extracorporeal membrane oxygenation (ECMO). There were 4 male and 2 female patients, with a median age of 7 years (range, 4-15 years) and a median height of 112.7 cm (range, 95-125.2 cm). The diagnoses included complications of allogeneic hematopoietic stem cell transplantation (n = 4) and pulmonary fibrosis (n = 2). All patients received bilateral lung transplantation under cardiopulmonary bypass. A basal segment and a lower lobe were implanted in 3 patients, and a basal segment and an S6 segment were implanted in the other 3 patients. In 2 patients, the right S6 segmental graft was horizontally rotated 180° and implanted as the left lung. RESULTS Among the 9 segmental grafts implanted, 7 functioned well after reperfusion. Two rotated S6 segmental grafts became congestive, with 1 requiring graft extraction and the other venous repair, which was successful. There was 1 hospital death (14 days) due to sepsis and 1 late death (9 years) due to leukoencephalopathy. The remaining 4 patients are currently alive at 9 months, 10 months, 1.3 years, and 1.9 years. CONCLUSIONS Living-donor segmental lung transplantation was a technically difficult but feasible procedure with acceptable outcomes for small pediatric patients with chest cavities that were too small for adult lower lobe implantation.
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Nakajima D, Date H. Living-donor lobar lung transplantation. J Thorac Dis 2022; 13:6594-6601. [PMID: 34992838 PMCID: PMC8662478 DOI: 10.21037/jtd-2021-07] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 01/27/2021] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Daisuke Nakajima
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiroshi Date
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Pediatric Living Lung Donor Transplant Candidates: Psychiatric Status of Utilized and Non-Utilized Donors. J Clin Psychol Med Settings 2021; 29:62-70. [PMID: 33881658 DOI: 10.1007/s10880-021-09777-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2021] [Indexed: 10/21/2022]
Abstract
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).
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Surgical Strategy for Lung Transplantation in Adults With Small Chests: Lobar Transplant Versus a Pediatric Donor. Transplantation 2017; 100:2693-2698. [PMID: 26760568 DOI: 10.1097/tp.0000000000001048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Adult lung transplant recipients with small chests have traditionally received lungs from pediatric donors, placing an additional strain on the already restricted pediatric donor pool. Performing lobar lung transplantation (LLT) can circumvent issues with donor-recipient size mismatch; however, LLT imparts additional risks. Here, we review our experience using LLT and standard lung transplantation using a pediatric donor (PDLT) for adults with small chests. METHODS We retrospectively reviewed consecutive patients with end-stage lung disease and a height of 65 inches or less who underwent LLT (n = 15) or PDLT (n = 15) between 2006 and 2012 at our institution, a high-volume lung transplant center. RESULTS Lobar lung transplantation recipients were older (54 ± 10 vs 48 ± 8 years) and had higher pulmonary pressure (57 ± 11 vs 52 ± 27 mmHg) and higher lung allocation scores (70 ± 9 vs 51 ± 8) than PDLT recipients (all P < 0.05). Mean waiting time was 62 days for PDLT and 9 days for LLT. Postoperatively, the incidence of severe primary graft dysfunction and the incidence of acute renal insufficiency were higher, and the mean intensive care unit stay was longer in the LLT group, but the incidence of bronchial anastomotic complications was higher in the PDLT group because of significant size discrepancy in the main bronchus (P < 0.05). Interestingly, long-term functional outcomes and survival rates were similar between the groups. CONCLUSIONS Both LLT and PDLT are viable surgical options for adult patients with small chests. Because of the potential impact on posttransplant outcomes, the technical complexity of transplantation, decisions regarding the best surgical approach should be made by experienced surgeons.
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Walters DM, Krupnick AS. Necessity is the mother of invention: Alternative techniques in living-related lobar transplantation come to the mainstream. J Thorac Cardiovasc Surg 2016; 153:487. [PMID: 27939496 DOI: 10.1016/j.jtcvs.2016.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 11/02/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Dustin M Walters
- University of Virginia Lung Transplant Program, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Alexander Sasha Krupnick
- University of Virginia Lung Transplant Program, Department of Surgery, University of Virginia, Charlottesville, Va.
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Braverman JM. Increasing the Quantity of Lungs for Transplantation Using High-Frequency Chest Wall Oscillation: A Proposal. Prog Transplant 2016; 12:266-74. [PMID: 12593065 DOI: 10.1177/152692480201200406] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The use of chest physiotherapy in donor patient management occupies an established place in most lung procurement protocols. Although its merits remain controversial and uncorroborated by direct data, some studies support the efficacy of chest physiotherapy in a variety of pulmonary patient populations. Comparative studies have shown that an airway clearance technology utilizing high-frequency chest wall oscillation clears pulmonary secretions as well as or better than chest physiotherapy, but has few of its contraindications and disadvantages. The implementation of high-frequency chest wall oscillation as part of the donor lung procurement protocol may increase rates of successful lung recovery by providing effective clearance of obstructing pulmonary secretions containing destructive by-products of inflammation and entrapped pathogens. High-frequency chest wall oscillation may also improve arterial blood gas values, a critical factor in increasing lung procurement rates. Although speculative, the benefits of high-frequency chest wall oscillation on donor lungs might improve perfusion and oxygenation of other organs for possible transplantation.
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Horn MV, Schenkel FA, Woo MS, Starnes VA. Pediatric Recipients of Living Donor Lobar Lung Transplants: Postoperative Care. Prog Transplant 2016. [DOI: 10.1177/152692480201200202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Bilateral living donor lobar lung transplantation is a treatment option for selected children and adults with end-stage lung disease. Careful donor evaluation, skilled intraoperative management and surgical technique, and diligent immediate postoperative care and follow-up all contribute to better outcomes. Although medical management of whole lung transplant recipients in the immediate postoperative period is similar to that of lobar lung transplant recipients, there are specific differences. Anatomical distinctions, such as the entire cardiac output flowing to 2 lobes instead of 5, and thoracic space issues with simultaneous mechanical ventilation and chest tube suction, contribute to these differences. Early postoperative care, including initial postoperative stabilization, ventilation, fluid management, rejection/infection surveillance and prophylaxis, and beginning rehabilitation, can be adapted to ensure successful outcomes in these patients.
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Affiliation(s)
- Monica V. Horn
- Childrens Hospital Los Angeles, Calif (MVH, MSW, VAS), USC University Hospital, Los Angeles (FAS), Keck School of Medicine, University of Southern California, Los Angeles (MSW, VAS)
| | - Felicia A. Schenkel
- Childrens Hospital Los Angeles, Calif (MVH, MSW, VAS), USC University Hospital, Los Angeles (FAS), Keck School of Medicine, University of Southern California, Los Angeles (MSW, VAS)
| | - Marlyn S. Woo
- Childrens Hospital Los Angeles, Calif (MVH, MSW, VAS), USC University Hospital, Los Angeles (FAS), Keck School of Medicine, University of Southern California, Los Angeles (MSW, VAS)
| | - Vaughn A. Starnes
- Childrens Hospital Los Angeles, Calif (MVH, MSW, VAS), USC University Hospital, Los Angeles (FAS), Keck School of Medicine, University of Southern California, Los Angeles (MSW, VAS)
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Abstract
PURPOSE OF REVIEW Lung transplantation for infants and children is an accepted but rarely exercised option for the treatment of end-stage lung disease, with outcomes equivalent to those for adults. However, widespread misconceptions regarding pediatric outcomes often confound timely and appropriate referral to specialty centers. We present the updated information for primary pediatricians to utilize when counseling families with children confronted by progressive end-stage pulmonary or cardiovascular disease. RECENT FINDINGS We provide general guidelines to consider for referral, and discuss allocation of organs in children, information regarding standard treatment protocols, and survival outcomes. SUMMARY Lung transplantation is a worthwhile treatment option to consider in children with end-stage lung disease. The treatment is complex, but lung transplant provides substantial survival benefit and markedly improved quality of life for children and their families. This timely review provides comprehensive information for pediatricians who are considering options for treatment of children with end-stage lung disease.
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Affiliation(s)
- Carol Conrad
- aDivision of Pediatric Pulmonary Medicine bDivision of Critical Care, Department of Pediatrics, Center for Excellence in Pulmonary Biology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Stanford, California, USA
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Scully BB, Zafar F, Schecter MG, Rossano JW, Mallory GB, Heinle JS, Morales DL. Lung Retransplantation in Children: Appropriate When Selectively Applied. Ann Thorac Surg 2011; 91:574-9. [DOI: 10.1016/j.athoracsur.2010.09.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2010] [Revised: 09/01/2010] [Accepted: 09/07/2010] [Indexed: 11/28/2022]
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Souilamas R, Souilamas J, Saueressig M, Pison C, Briot R. [How to increase availability of grafts in lung transplantion: ex vivo lung reconditioning - cardiac death donors - high emergency list]. REVUE DE PNEUMOLOGIE CLINIQUE 2010; 67:50-56. [PMID: 21353972 DOI: 10.1016/j.pneumo.2010.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2010] [Accepted: 12/27/2010] [Indexed: 05/30/2023]
Abstract
Lung transplantation has become an established treatment for end-stage pulmonary failure refractory to medical management. However, the scarcity of lung grafts and the growing number of candidates has led to an increase in deaths among patients on waiting lists. Despite improvements in donor management, organ preservation, and the use of marginal and cardiac death donors, only about 20% of candidate lungs are currently being transplanted. A new ex vivo "reconditioning" technique is opening up new perspectives. Indeed, a significant number of rejected lungs can now be retrieved and transplanted with acceptable results. Given the longer storage times provided by this technique, transplantation can be programmed, with better surgical efficiency. A new mobile organ-care machine is currently under evaluation. In near future, a pilot laboratory will be created and dedicated to ex vivo reconditionning of all lung grafts before transplantation and grafts will be sent to lung transplant centers after immunologic cross-matching.
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Affiliation(s)
- R Souilamas
- Chirurgie thoracique, hôpital européen Georges-Pompidou (HEGP), 20, rue Leblanc, 75015 Paris, France.
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15
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Favorable outcomes after living-donor lobar lung transplantation in ventilator-dependent patients. Surg Today 2008; 38:1078-82. [DOI: 10.1007/s00595-008-3781-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2008] [Accepted: 03/09/2008] [Indexed: 01/10/2023]
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Schecter MG, Elidemir O, Heinle JS, McKenzie ED, Mallory GB. Pediatric lung transplantation: a therapy in its adolescence. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2008; 11:74-79. [PMID: 18396229 DOI: 10.1053/j.pcsu.2007.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Pediatric lung transplant was born at the University of Toronto as an extension of the pioneering work of Cooper and Patterson in adult lung transplant in the 1980s. Through the 1990s, the field of pediatric lung transplantation grew with clinical outcomes in the largest centers being comparable to those in adult lung transplantation. For children and adults, the largest obstacle to long-term survival remains chronic allograft rejection secondary to the development of bronchiolitis obliterans, for which little advancement has been made in prevention or treatment. While transplantation has become accepted therapy for end-stage lung disease in adults, pediatric lung transplant has been less widely embraced for multiple reasons, such as adolescent non-compliance and the investment required in developing freestanding pediatric lung transplant centers. Another factor limiting pediatric lung transplant has been the paucity of suitable donor lungs. In 2002, Texas Children's Hospital and the Baylor College of Medicine successfully collaborated in developing an active and successful pediatric lung transplant program. Through our own work and an international collaborative of pediatric transplant pulmonologists and surgeons, we are hoping to move the field of pediatric lung transplant out of its "adolescence" into adulthood.
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Affiliation(s)
- Marc G Schecter
- Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA.
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Lung Transplantation. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Morton JM, Malouf MA, Plit ML, Spratt PM, Glanville AR. Successful lung transplantation for adolescents at a hospital for adults. Med J Aust 2007; 187:278-82. [PMID: 17767432 DOI: 10.5694/j.1326-5377.2007.tb01243.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2006] [Accepted: 06/21/2007] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To describe the results of lung transplantation (LTx) in adolescents at a hospital for adults. DESIGN AND SETTING Prospective cohort study set in an LTx unit at an adult tertiary referral hospital from 1991 to 2006. PATIENTS 37 consecutive adolescent lung transplant recipients including 13 males and 24 females (mean age, 16.7+/-2.0 [SD] years; range 12-19 years) who received heart-lung (six patients) or bilateral LTx (31 patients) for cystic fibrosis (29), congenital heart disease (four), acute respiratory failure (two), or another disorder (two). Two patients were transplanted after invasive ventilation, five after non-invasive ventilation and two after extracorporeal membrane oxygenation. MAIN OUTCOME MEASURES Overall survival compared with an adult cohort; survival free of bronchiolitis obliterans syndrome (BOS); overall and BOS-free survival in those transplanted before and after January 2000. RESULTS Mean waiting time was 273 days (range, 5-964 days; median, 163 days), mean donor age was 28 years (range, 9-53 years). Median inpatient stay was 11 days (range, 7-94 days). Mean follow-up was 1540+/-1357 days (range, 35-5163 days). The 5-year survival rate for the 16 patients transplanted before January 2000 was 38%, versus 74% for the 21 transplanted since January 2000 (P=0.05; Mantel-Cox). Overall, 18 of 35 evaluable patients developed BOS. Only BOS was associated with an increased mortality risk (P<0.01). CONCLUSION LTx may be performed successfully in adolescents at a hospital for adults.
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Affiliation(s)
- Judith M Morton
- Respiratory and Sleep Medicine, Monash Medical Centre, Melbourne, VIC, Australia
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20
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Yamane M, Date H, Okazaki M, Toyooka S, Aoe M, Sano Y. Long-term Improvement in Pulmonary Function After Living Donor Lobar Lung Transplantation. J Heart Lung Transplant 2007; 26:687-92. [PMID: 17613398 DOI: 10.1016/j.healun.2007.04.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2006] [Revised: 02/13/2007] [Accepted: 04/13/2007] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND As an alternative to cadaveric transplantation, living donor lobar lung transplantation (LDLLT) has been applied in critical patients with end-stage pulmonary disease because of the mismatch between the supply and demand of lungs for transplantation. However, it is unclear whether two pulmonary lobes can provide adequate long-term pulmonary function and satisfactory clinical outcome in recipients. METHODS Between October 1998 and September 2004, 28 females and 3 males, including 5 children, underwent LDLLT at Okayama University Hospital. Their mean age was 31.8 years, and the mean observation period was 53.8 months. One patient who underwent single-lung transplantation and another who died peri-operatively were excluded from further analyses. RESULTS The most common indication for transplantation was pulmonary arterial hypertension (32.3%). The overall survival rate was 93.6%. Seven recipients (22.6%) developed bronchiolitis obliterans syndrome after LDLLT. The mean percent predicted forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) improved between 12 and 24 months after transplantation (71.8 +/- 12.9% and 65.8 +/- 17.2% at 12 months vs 77.4 +/- 16.6% and 72.8 +/- 14.6% at 24 months; p < 0.005 and p < 0.05, respectively). The actual recipient FVC ultimately reached 123.0% of the estimated graft FVC of two donor lobes (calculated based on the donor FVC and number of segments implanted) at 36 months after LDLLT. CONCLUSIONS Although LDLLT may be associated with the limitation of size mismatch, it holds promise for providing well-functioning pulmonary lobar grafts to critically ill patients with poor life expectancy.
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Affiliation(s)
- Masaomi Yamane
- Department of Cancer and Thoracic Surgery (Surgery II), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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21
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Abstract
Living donor lobar lung transplantation (LDLLT) was developed in order to mitigate the growing competition for deceased donor (DD) lungs and resultant increase in waiting list mortality. Because each of the two donor lobes serves as an entire lung for the recipient, donors who are taller than the recipient are preferred. Therefore LDLLT is particularly well suited for pediatric recipients for whom adults serve as donors. Although long-term outcomes after LDLLT reported by the Organ Procurement and Transplantation Network (OPTN) are worse compared with DD recipients, overall pediatric outcomes as well as single center reports from the most experienced programs are more promising. Particularly encouraging are the findings that bronchiolitis obliterans (OB) is less frequent or less severe in LDLLT recipients in comparison to DD recipients. Moreover, outcomes may be improved by careful selection of donors to ensure adequately sized donor lobes and minimization of infectious risks. Although no donor deaths have been reported, there is a moderate risk of significant short-term complications. Long-term follow-up has not been reported. The use of LDLLT has decreased in recent years, and the recent change by the OPTN to an urgency/benefit allocation system for DD lungs in patients 12 yr and older may further reduce the demand. Nonetheless, we anticipate that LDLLT will continue to be utilized in select circumstances, particularly in children under 12 where access to DD organs remains challenging.
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Affiliation(s)
- Stuart C Sweet
- Department of Pediatrics, Washington University in St Louis, MO, USA.
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22
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Kozower BD, Sweet SC, de la Morena M, Schuler P, Guthrie TJ, Patterson GA, Gandhi SK, Huddleston CB. Living donor lobar grafts improve pediatric lung retransplantation survival. J Thorac Cardiovasc Surg 2006; 131:1142-7. [PMID: 16678602 DOI: 10.1016/j.jtcvs.2005.08.074] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2005] [Revised: 08/23/2005] [Accepted: 08/30/2005] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Lung retransplantation is a controversial practice due to increased morbidity and mortality and the scarcity of available donor organs. Living donor lobar lung transplantation increases the number of available donor organs and facilitates a more organized procedure than traditional cadaveric donation for this complex reoperation. The purpose of this study was to evaluate our experience with pediatric lung retransplantation and to compare the outcomes of living donor lobar lung transplantation with cadaveric donation. METHODS Retrospective review of a prospectively collected database identified 39 children who underwent lung retransplantation from 1991 to 2004. Retransplantation was performed with living donor lobar lung transplantation in 13 patients and cadaveric donation in 26 patients. Short- and long-term outcomes were compared between the 2 groups. RESULTS Perioperative mortality was 1/13 (7.7%) in the patients who had living donor lobar lung transplantation versus 11/26 (42.3%) in the cadaveric donation group (P = .03). Five-year survival for living donor lobar lung transplantation and cadaveric donation was 40.4% and 29.7%, respectively (P = .27). Both groups had a significant improvement in their forced expiratory volume in 1 second 6 months after retransplantation (P < .001). Multivariate analysis identified the use of cadaveric donation (relative risk = 6.16, P = .001) and early graft dysfunction (relative risk = 6.19, P = .001) as the major independent predictors of decreased survival following retransplantation. CONCLUSIONS Living donor lobar lung transplantation reduces perioperative mortality and is an independent predictor of improved survival following pediatric lung retransplantation. This strategy offers significant benefit for this high-risk group and preserves the limited supply of donor lungs for other children at risk of dying while waiting for lung transplantation.
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Affiliation(s)
- Benjamin D Kozower
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO 63110 , USA
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23
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Oto T, Date H, Hayama M, Ando A, Shimizu N. Peripheral Lung Volume Reduction Improved Early Graft Function in Severe Size Mismatched Living Donor Lobar Lung Transplantation. Transplant Proc 2005; 37:4515-21. [PMID: 16387158 DOI: 10.1016/j.transproceed.2005.10.119] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Lung transplantation from adults to infants or small children is still challenging because of concerns related to size disparity. Peripheral lung volume reduction for size disparity in cadaveric donor lung transplantation has been widely performed; however, little is known about the efficacy and the functional outcomes of downsizing the implanted lobes for severe size disparity in living donor lobar lung transplantation. METHODS Thirteen size-mismatched (donor/recipient lung volume ratio > 2.82) bilateral living donor lobar lung transplants were performed with (reduction group, n = 6) or without (no-reduction group, n = 7) peripheral lung volume reduction. RESULTS On spontaneous respiration, PaO2 in the reduction group was significantly higher than that in the no-reduction group (P < .01) and PaCO2 in the reduction group was significantly lower than that in the no-reduction group (P < .001). Pulmonary vascular resistance in the reduction group remained significantly lower than that in the no-reduction group throughout the assessment periods after chest closure (P < .05). Peak airway pressure in the no-reduction group increased significantly at the time of chest closure (P < .001) and remained significantly higher than that in the reduction group throughout the assessment period on mechanical ventilation (P < .01). The percentage of weight reduced from implanted grafts significantly correlated with donor/recipient lung volume ratio (r = 0.82, P < .05). CONCLUSIONS Peripheral lung volume reduction is useful to improve early graft function in severe size mismatched experimental living donor lobar lung transplantation. The technique might allow for further flexibility in donor size and for increasing the donor pool for small recipients.
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Affiliation(s)
- T Oto
- Department of Cancer and Thoracic Surgery, Okayama University School of Medicine, Okayama, Japan.
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24
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Wilkes DS, Egan TM, Reynolds HY. Lung transplantation: opportunities for research and clinical advancement. Am J Respir Crit Care Med 2005; 172:944-55. [PMID: 16020804 PMCID: PMC2718411 DOI: 10.1164/rccm.200501-098ws] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Lung transplantation is the only definitive therapy for many forms of end-stage lung diseases. However, the success of lung transplantation is limited by many factors: (1) Too few lungs available for transplantation due to limited donors or injury to the donor lung; (2) current methods of preservation of excised lungs do not allow extended periods of time between procurement and implantation; (3) acute graft failure is more common with lungs than other solid organs, thus contributing to poorer short-term survival after lung transplant compared with that for recipients of other organs; (4) lung transplant recipients are particularly vulnerable to pulmonary infections; and (5) chronic allograft dysfunction, manifest by bronchiolitis obliterans syndrome, is frequent and limits long-term survival. Scientific advances may provide significant improvements in the outcome of lung transplantation. The National Heart, Lung, and Blood Institute convened a working group of investigators on June 14-15, 2004, in Bethesda, Maryland, to identify opportunities for scientific advancement in lung transplantation, including basic and clinical research. This workshop provides a framework to identify critical issues related to clinical lung transplantation, and to delineate important areas for productive scientific investigation.
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Affiliation(s)
- David S Wilkes
- Indiana University School of Medicine, Indianapolis, Indiana, USA
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25
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Hoffman JA, Weinberg KI, Azen CG, Horn MV, Dukes L, Starnes VA, Woo MS. Human leukocyte antigen-DR expression on peripheral blood monocytes and the risk of pneumonia in pediatric lung transplant recipients. Transpl Infect Dis 2005; 6:147-55. [PMID: 15762932 DOI: 10.1111/j.1399-3062.2004.00069.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pneumonia is the leading cause of morbidity and mortality after living lobar lung transplantation (LT). Low levels of human leukocyte antigen-DR (HLA-DR) expression on peripheral blood monocytes, have been demonstrated to correlate with risk of infection in surgical, trauma, and adult transplant patients. In addition, interleukin (IL)-10 has been shown to be a negative regulator of HLA-DR expression. This study investigates whether HLA-DR expression and serum IL-10 levels correlate with the development of pneumonia after pediatric LT. METHODS Thirteen LT recipients were prospectively monitored with blood samples obtained pre-LT (baseline) and post-LT weeks 1-4. Mean fluorescence intensity (MFI) of HLA-DR on CD14+ monocytes was measured by flow cytometry. IL-10 levels were determined by ELISA from frozen serum collected at the same time points as monocyte HLA-DR expression. Correlates of pneumonia were abstracted from the medical record. RESULTS Monocyte HLA-DR expression declined in 11 of 13 patients in the first week post-LT. Two patients without an initial decline and four others whose HLA-DR expression recovered by week 2 post-LT, did not develop pneumonia or other infection or rejection. Pneumonia was observed in seven patients, six of whom failed to recover their monocyte HLA-DR expression by 2 weeks post-LT. Six of seven patients with pneumonia recovered, and one patient died of aspergillosis. During weeks 1-4, a statistically significant difference was seen in the profile of mean monocyte HLA-DR expression levels, analyzed as percent of baseline, between the patients with and without pneumonia (P=0.002). The greatest difference between groups over time was seen from post-LT weeks 1-2 (P=0.003). In addition, when comparing the values at each week, a significant difference was seen between the two groups at post-LT week 2 (P=0.006) and week 4 (P=0.05). Analysis of IL-10 concentrations revealed that the overall difference between the groups (patients with and without pneumonia) was statistically significant (P=0.014), with a paradoxical positive correlation between HLA-DR expression at post-LT week 4 and IL-10 concentrations. CONCLUSIONS Persistent low monocyte HLA-DR expression was associated with the risk of post-LT pneumonia in these patients. This measurement may be useful for monitoring risk of infection and stratifying patients into higher and lower risk groups. Increased IL-10 levels may be protective for infection in this group of patients. At present it is unknown whether the predictive power of HLA-DR expression is indicative of a global defect in monocytic function or a specific abnormality.
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Affiliation(s)
- J A Hoffman
- Department of Pediatrics, Division of Infectious Diseases, Childrens Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California 90027, USA.
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Abstract
PURPOSE OF REVIEW Until recently, the diagnosis of idiopathic pulmonary arterial hypertension was virtually a death sentence, particularly for children. Although there is no cure for idiopathic pulmonary arterial hypertension, recent medical advances have dramatically changed the course of this disease in children. A review of some of the latest medical advances will provide the reader with a better understanding of the most current treatment options for children with idiopathic pulmonary arterial hypertension. RECENT FINDINGS The literature reviewed demonstrate sustained clinical and hemodynamic improvement in children with various types of pulmonary arterial hypertension as well as increased survival in patients with idiopathic pulmonary arterial hypertension using current treatment strategies. SUMMARY This article will provide an overview of how the current diagnostic and treatment strategies of idiopathic pulmonary arterial hypertension in children have advanced over the last several years and how this impacts on clinical practice.
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Affiliation(s)
- Erika Berman Rosenzweig
- Department of Pediatrics, Columbia University College of Physicians & Surgeons, New York, New York 10032, USA
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27
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Veeken C, Palmer SM, Davis RD, Grichnik KP. Living-related lobar lung transplantation. J Cardiothorac Vasc Anesth 2005; 18:506-11. [PMID: 15365937 DOI: 10.1053/j.jvca.2004.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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28
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Bowdish ME, Pessotto R, Barbers RG, Schenkel FA, Starnes VA, Barr ML. Long-term Pulmonary Function After Living-donor Lobar Lung Transplantation in Adults. Ann Thorac Surg 2005; 79:418-25. [PMID: 15680807 DOI: 10.1016/j.athoracsur.2004.07.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2004] [Indexed: 10/25/2022]
Abstract
BACKGROUND Living-donor lobar lung transplantation was developed as an alternative to cadaveric transplantation. However, whether two pulmonary lobes provide comparable intermediate and long-term pulmonary function to full-sized bilateral cadaveric grafts in adults is unknown. METHODS An analysis of the pulmonary functions of 59 bilateral lobar and 43 bilateral cadaveric adult lung transplant recipients who survived more than 3 months after transplantation was performed. RESULTS Mean follow-up was 3.8 +/- 2.8 years. In lobar recipients, mean percent predicted forced vital capacity and forced expiratory volume in 1 second improved between 1 and 6 months after transplantation (42.5% +/- 13.4% and 46.9% +/- 14.0% at 1 month versus 63.6% +/- 14.1% and 64.5% +/- 13.7% at 6 months; p < 0.001 and <0.001, respectively). In cadaveric recipients, mean percent predicted forced vital capacity improved after transplantation (54.3% +/- 14.5% at 1 month versus 74.2% +/- 21.3% at 12 months; p < 0.01). As compared with the cadaveric group, mean percent predicted forced vital capacity and forced expiratory volume in 1 second were lower 1 and 3 months after transplantation in the lobar recipients (p = 0.001 at both times); however, by 6 months after transplantation, these values were comparable and remained so throughout the follow-up period. In a subset of lobar and cadaveric recipients, maximal exercise, heart rate, peak oxygen consumption, anaerobic oxygen consumption threshold, and ability to maintain oxygen saturation were also comparable. CONCLUSIONS In those adult recipients surviving more than 3 months after transplantation, lobar lung transplantation provides comparable intermediate and long-term pulmonary function and exercise capacity to bilateral cadaveric lung transplantation.
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Affiliation(s)
- Michael E Bowdish
- Department of Cardiothoracic Surgery, University of Southern California Keck School of Medicine, Los Angeles, California 90033, USA
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29
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Zweers N, Petersen AH, van der Hoeven JAB, de Haan A, Ploeg RJ, de Leij LFMH, Prop J. Donor brain death aggravates chronic rejection after lung transplantation in rats. Transplantation 2004; 78:1251-8. [PMID: 15548960 DOI: 10.1097/01.tp.0000142679.45418.96] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Many recipients of lung transplants from brain-dead donors develop bronchiolitis obliterans, a manifestation of chronic rejection. It has been shown that brain death increases inflammatory mediators and accelerates acute rejection in kidney, liver, and heart transplants. In this study, the authors investigated the hypothesis that brain death increases inflammatory mediators in the donor lung and subsequently aggravates chronic rejection of the lungs after transplantation in rats. METHODS Brain death was induced in F344 rats by inflation of a subdurally placed balloon catheter. After 6 hr, donor lungs were assessed for influx of leukocytes, expression of cell adhesion molecules, and cytokine mRNA expression. For assessment of the lung after transplantation, lungs from brain-dead F344 rats were transplanted into WKY rats. Lung function after transplantation was monitored by chest radiographs during an observation period of 100 days. At the end of this period, the lungs were histologically examined; also, cytokine mRNA expression was measured. Lungs from ventilated living donors and living donors served as controls. RESULTS After 6 hr of brain death, influx of polymorphonuclear cells and macrophages and expression of vascular cell adhesion molecule-1 in the donor lungs was increased. After transplantation at postoperative day 100, the lung function was significantly decreased compared with allografts from living donors. In the lung allografts from brain-dead donors, histologic symptoms of chronic rejection were obvious, including severe intimal hyperplasia but without bronchiolitis obliterans. Interleukin-2 mRNA was significantly increased in allografts from brain-dead donors compared with living donors. CONCLUSIONS This study shows that brain death induces an inflammatory response in the donor lung and subsequently aggravates chronic rejection after transplantation. This may explain the clinical difference in long-term function between lungs from cadaveric donors and living donors.
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Affiliation(s)
- Noëlle Zweers
- Department of Pathology and Laboratory Medicine, Medical Biology Section, University Hospital Groningen, Groningen, The Netherlands
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30
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Abstract
Anesthetic challenges regarding lung transplantation are related to the expanded spectrum of diseases for which lung transplantation is offered and to the interval changes in health status likely to occur as patients wait longer for an organ to become available. Particular attention to avoiding or reducing the impact of increases in pulmonary vascular resistance and right heart failure are important and may necessitate cardiopulmonary bypass. Intraoperative and postoperative ventilator management should account for differences in pulmonary compliance after the new lung is implanted. Minimizing intravenous fluids without compromising end organ perfusion may avoid or reduce postoperative respiratory insufficiency.
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Affiliation(s)
- Andrew L Rosenberg
- Department of Anesthesiology, University of Michigan Medical Center, Ann Arbor, MI 48109-0048, USA.
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31
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Van Raemdonck DEM, Rega FR, Neyrinck AP, Jannis N, Verleden GM, Lerut TE. Non-heart-beating donors. Semin Thorac Cardiovasc Surg 2004; 16:309-21. [PMID: 15635535 DOI: 10.1053/j.semtcvs.2004.09.014] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The widespread application of lung transplantation is limited by the shortage of suitable donor organs resulting in longer waiting times for listed patients with a substantial risk of dying before transplantation. To overcome this critical organ shortage, some transplant programs have now begun to explore the use of lungs from circulation-arrested donors, so called non-heart-beating donors (NHBDs). This review outlines the different categories of NHBDs, the relevant published experimental data that support the use of lungs coming from these donors and the clinical experience worldwide so far. Techniques for NHBD lung preservation and pretransplant functional assessment are reviewed. Ethical issues involved in transplanting lungs from asystolic donors are discussed.
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Affiliation(s)
- Dirk E M Van Raemdonck
- Thoracic Surgical Research Unit, Center for Experimental Surgery and Anaesthesiology, Catholic University, Leuven, Belgium.
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Date H, Aoe M, Sano Y, Nagahiro I, Miyaji K, Goto K, Kawada M, Sano S, Shimizu N. Improved survival after living-donor lobar lung transplantation. J Thorac Cardiovasc Surg 2004; 128:933-40. [PMID: 15573079 DOI: 10.1016/j.jtcvs.2004.07.032] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Survival after living-donor lobar lung transplantation has been reported to be similar to that after cadaveric lung transplantation. The purpose of this study was to summarize our 5-year experience of living-donor lobar lung transplantation for critically ill patients. METHODS Between October 1998 and April 2004, we performed living-donor lobar lung transplantation in 30 critically ill patients with various lung diseases, including 5 (17%) patients on a ventilator. Mean age was 30.4 years (range, 8-55 years). Postoperative management included slow weaning from a ventilator, relatively low-dose immunosuppressants, and careful rejection monitoring on the basis of radiographic and clinical findings without transbronchial lung biopsy. RESULTS The average duration of mechanical ventilation was 15.4 days, intensive care unit stay was 23.5 days, and hospital stay was 64.6 days. Clinically judged acute rejection occurred at an average rate of 1.5 episodes per patient, but infection occurred in only one patient during the first month. In spite of the complicated postoperative course, all patients were discharged without oxygen inhalation. Four patients had unilateral bronchiolitis obliterans syndrome, but the decrease in their forced expiratory volume in 1 second values stopped within 9 months. All 30 recipients are currently alive, with a follow-up period of 1 to 66 months. All donors have returned to their previous lifestyles. CONCLUSIONS Living-donor lobar lung transplantation can be applied to both pediatric and adult patients with very limited life expectancies. It might provide better survival than conventional cadaveric lung transplantation.
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Affiliation(s)
- Hiroshi Date
- Departments of Cancer and Thoracic Surgery, Okayama University Graduate School of Medicine and Dentistry, 2-5-1 Shikata-cho, Okayama 700-8558, Japan.
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Bowdish ME, Barr ML, Schenkel FA, Woo MS, Bremner RM, Horn MV, Baker CJ, Barbers RG, Wells WJ, Starnes VA. A decade of living lobar lung transplantation: perioperative complications after 253 donor lobectomies. Am J Transplant 2004; 4:1283-8. [PMID: 15268729 DOI: 10.1111/j.1600-6143.2004.00514.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Living lobar lung transplantation places two donors at risk for each recipient. We examined the perioperative outcomes associated with the 253 donor lobectomies performed at our institution during our first decade of living lobar lung transplantation. There have been no perioperative or long-term deaths. 80.2% of donors (n = 203) had no perioperative complications, while fifty (19.8%) had one or more complication. The incidence of intraoperative complications was 3.6%. Complications requiring reoperation occurred in 3.2% of donors. 15.0% of donors had other perioperative complications; the most serious were two donors who developed pulmonary artery thrombosis, while the most common was the need for an additional thoracostomy tube or a thoracostomy tube for >/=14 d for persistent air leaks and/or drainage. Right-sided donors were more likely to have a perioperative complication than left-sided donors (odd ratio 2.02, p = 0.04), probably secondary to right lower and middle lobe anatomy. This experience has shown donor lobectomy to be associated with a relatively low morbidity and no mortality, and is important if this procedure is to be considered an option at more pulmonary transplant centers, given continued organ shortages and differences in philosophical and ethical acceptance of live
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Affiliation(s)
- Michael E Bowdish
- Department of Cardiothoracic Surgery, University of Southern California Keck School of Medicine and Childrens Hospital Los Angeles, Los Angeles, CA, USA
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Abstract
Pulmonary arterial hypertension is a serious progressive condition with a poor prognosis if not identified and treated early. Because the symptoms are nonspecific and the physical findings can be subtle, the disease is often diagnosed in its later stages. Remarkable progress has been made in the field of pulmonary arterial hypertension over the past several decades. The pathology is now better defined, and significant advances have occurred in understanding the pathobiologic mechanisms. Risk factors have been identified, and the genetics have been characterized. Advances in technology allow earlier diagnosis as well as better assessment of disease severity. Therapeutic modalities such as new drugs, e.g., epoprostenol, treprostinil, and bosentan, and surgical/interventional options, e.g., transplantation and atrial septostomy, which were unavailable several decades ago, have had a significant impact on prognosis and outcome. Thus, despite our inability to cure pulmonary arterial hypertension, advances in medical treatments over the past two decades have resulted in significant improvement in outcomes for children with various forms of pulmonary arterial hypertension. This report is a review the current state of the art for pulmonary arterial hypertension in 2004, with an emphasis on childhood pulmonary arterial hypertension and specific recommendations for current practice and future directions.
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Affiliation(s)
- Erika Berman Rosenzweig
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York 10027, USA.
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35
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Fisher AJ, Donnelly SC, Pritchard G, Dark JH, Corris PA. Objective assessment of criteria for selection of donor lungs suitable for transplantation. Thorax 2004; 59:434-7. [PMID: 15115876 PMCID: PMC1747005 DOI: 10.1136/thx.2003.007542] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Donor organ shortage severely limits lung transplantation as a therapeutic option, yet many potential donor lungs are deemed unsuitable by clinical selection criteria. METHODS Of 39 consecutive potential donor lungs, 14 were accepted and 25 excluded by clinical selection criteria. All were evaluated prospectively by clinical assessment, bronchoscopy, and bronchoalveolar lavage (BAL) to evaluate objectively the discrimination of pulmonary infection and injury. RESULTS Accepted donors were significantly younger than those excluded (mean (SD) age 36.7 (15.3) years v 49.5 (13.2) years; p = 0.009, unpaired t test) and were more likely to have suffered traumatic brain death (50% v 20%; p = 0.07, Fisher's exact test). Oxygenation (PaO(2):FiO(2)) was higher in accepted donors than in excluded donors (median (range) 63.2 (48-82.5) kPa v 43.1 (7.7-71.7) kPa; p = 0.0001, Mann-Whitney test). Positive formal BAL culture was more frequent in accepted donors (75%) than in those excluded (43%; p = 0.1, Fisher's exact test). There was no significant difference in the percentage and concentration of neutrophils in BAL fluid between accepted and excluded donors (median (range) 37.9 (0-96.9)% and 44.6 (0-1190)x10(3)/ml v 36 (1-98.1)% and 46 (0.2-1457)x10(3)/ml), nor in the BAL fluid concentration of tumour necrosis factor-alpha (140 (0-340) pg/ml v 160 (0-760) pg/ml) or interleukin 8 (810 (33-17 600) pg/ml v 540 (0-15 110) pg/ml). CONCLUSION Current selection criteria are poor discriminators of pulmonary injury and infection and lead to the exclusion of potentially usable donor lungs.
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Affiliation(s)
- A J Fisher
- Department of Cardiopulmonary Transplantation and Immunobiology and Transplantation Research Group, University of Newcastle upon Tyne, Freeman Hospital, High Heaton, Newcastle upon Tyne NE7 7DN, UK
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Date H, Aoe M, Nagahiro I, Sano Y, Matsubara H, Goto K, Kawada M, Shimizu N. How to predict forced vital capacity after living-donor lobar-lung transplantation. J Heart Lung Transplant 2004; 23:547-51. [PMID: 15135369 DOI: 10.1016/j.healun.2003.07.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2003] [Accepted: 07/03/2003] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Living-donor lobar-lung transplantation (LDLLT) has evolved from a rarely performed experimental procedure to an accepted therapy for selected patients who are unlikely to survive the long wait for cadaveric lungs. However, a convincing study has not been performed that shows the effects of small grafts and of pre-operative variables in predicting functional outcome of recipients after LDLLT. METHODS From October 1998 to March 2002, 2 male and 11 female patients underwent LDLLT. Mean age was 27.3 years (range, 8-53 years). Diagnoses included primary pulmonary hypertension (n = 5), idiopathic interstitial pneumonia (n = 2), bronchiolitis obliterans (n = 2), bronchiectasis (n = 2), lymphangioleiomyomatosis (n = 1), and cystic fibrosis (n = 1). Donors included 12 men and 14 women with a mean age of 40 years. Given that the right lower lobe consists of 5 segments, the left lower lobe of 4, and the whole lung of 19, we estimated the graft forced vital capacity (FVC) based on the donor's measured FVC and compared this with the recipient's FVC measured after LDLLT. RESULTS Currently, all patients are alive, with a mean follow-up of 22.2 months (range, 10-51 months). The recipients' FVC measured at 6 months (1,813 +/- 86 ml) correlated well with the graft FVC (1,803 +/- 70 ml), estimated based on the donors' measured FVC (r = 0.802, p = 0.00098). CONCLUSIONS Recipient FVC after LDLLT can be predicted by measuring donor FVC before surgery regardless of the diagnosis of the recipient.
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Affiliation(s)
- Hiroshi Date
- Cancer and Thoracic Surgery Okayama University Graduate School of Medicine and Dentistry, Okayama, Japan
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Coloni GF, Venuta F, Ciccone AM, Rendina EA, De Giacomo T, Filice MJ, Diso D, Anile M, Andreetti C, Aratari MT, Mercadante E, Moretti M, Ibrahim M. Lung transplantation for cystic fibrosis. Transplant Proc 2004; 36:648-50. [PMID: 15110621 DOI: 10.1016/j.transproceed.2004.03.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Lung transplantation is a robust therapeutic option to treat patients with cystic fibrosis. PATIENTS AND METHODS Since 1996, 109 patients with cystic fibrosis were accepted onto our waiting list with 58 bilateral sequential lung transplants performed in 56 patients and two patients retransplanted for obliterative bronchiolitis syndrome. RESULTS Preoperative mean FEV(1) was 0.64 L/s, mean PaO(2) with supplemental oxygen was 56 mm Hg, and the mean 6-minute walking test was 320 m. Transplantation was performed through a "clam shell incision" in the first 29 patients and via bilateral anterolateral thoracotomies without sternal division in the remaining patients. Cardiopulmonary bypass was required in 14 patients. In 21 patients the donor lungs had to be trimmed by wedge resections with mechanical staplers and bovine pericardium buttressing to fit the recipient chest size. Eleven patients were extubated in the operating room immediately after the procedure. Hospital mortality of 13.8% was related to infection (n = 5), primary graft failure (n = 2), and myocardial infarction (n = 1). Acute rejection episodes occurred 1.6 times per patient/year; lower respiratory tract infections occurred 1.4 times per patient in the first year after transplantation. The mean FEV(1) increased to 82% at 1 year after operation. The 5-year survival rate was 61%. A cyclosporine-based immunosuppressive regimen was initially employed in all patients; 24 were subsequently switched to tacrolimus because of central nervous system toxicity, cyclosporine-related myopathy, or renal failure, obliterative bronchiolitis syndrome, gingival hyperplasia, or hypertrichosis. Ten patients were subsequently switched to sirolimus. Freedom from bronchiolitis obliterans at 5 years was 60%. CONCLUSIONS Our results confirm that bilateral sequential lung transplantation is a robust therapeutic option for patients with cystic fibrosis.
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Affiliation(s)
- G F Coloni
- UO Chirurgia Toracica, II Clinica Chirurgica, Università La Sapienza, Rome, Italy
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Woo MS. Living related donors. Pediatr Pulmonol 2004; 26:114-5. [PMID: 15029620 DOI: 10.1002/ppul.70074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Marlyn S Woo
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, USA.
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Starnes VA, Bowdish ME, Woo MS, Barbers RG, Schenkel FA, Horn MV, Pessotto R, Sievers EM, Baker CJ, Cohen RG, Bremner RM, Wells WJ, Barr ML. A decade of living lobar lung transplantation: recipient outcomes. J Thorac Cardiovasc Surg 2004; 127:114-22. [PMID: 14752421 DOI: 10.1016/j.jtcvs.2003.07.042] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Living lobar lung transplantation was developed as a procedure for patients considered too ill to await cadaveric transplantation. METHODS One hundred twenty-eight living lobar lung transplantations were performed in 123 patients between 1993 and 2003. Eighty-four patients were adults (age, 27 +/- 7.7 years), and 39 were pediatric patients (age, 13.9 +/- 2.9 years). RESULTS The primary indication for transplantation was cystic fibrosis (84%). At the time of transplantation, 67.5% of patients were hospitalized, and 17.9% were intubated. One-, 3-, and 5-year actuarial survival among living lobar recipients was 70%, 54%, and 45%, respectively. There was no difference in actuarial survival between adult and pediatric living lobar recipients (P =.65). There were 63 deaths among living lobar recipients, with infection being the predominant cause (53.4%), followed by obliterative bronchiolitis (12.7%) and primary graft dysfunction (7.9%). The overall incidence of acute rejection was 0.8 episodes per patient. Seventy-eight percent of rejection episodes were unilateral. Age, sex, indication, donor relationship, preoperative hospitalization status, use of preoperative steroids, and HLA-A, HLA-B, and HLA-DR typing did not influence survival. However, patients on ventilators preoperatively had significantly worse outcomes (odds ratio, 3.06, P =.03; Kaplan-Meier P =.002), and those undergoing retransplantation had an increased risk of death (odds ratio, 2.50). CONCLUSION These results support the continued use of living lobar lung transplantation in patients deemed unable to await a cadaveric transplantation. We consider patients undergoing retransplantations and intubated patients to be at significantly high risk because of the poor outcomes in these populations.
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Affiliation(s)
- Vaughn A Starnes
- University of Southern California Keck School of Medicine and Childrens Hospital Los Angeles, 90033, USA
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Abstract
Living-donor lobar lung transplantation is an alternative to conventional cadaveric lung transplantation for both pediatric and adult patients. In 16 patients, postoperative immunosuppression included cyclosporine, azathioprine, and corticosteroids. Cyclosporine delivery began during the first few postoperative hours via a nasal feeding tube inserted to the proximal jejunum. The dosage was adjusted to maintain trough levels in the target range of 250 to 350 ng/dL during the first 3 months; however, it was often reduced when renal dysfunction was suspected. We judged acute rejection on the basis of radiographic and clinical findings without lung biopsy. During the first month, 15 of 16 patients experienced at least one episode of acute rejection with an average of 1.7 episodes/patient. Cyclosporine was switched to tacrolimus in four patients (25%) due to repeated episodes of acute rejection. No patients experienced infectious complications during the first months. All 16 patients are currently alive with a follow-up period of 3 to 59 months. Three patients (19%) have developed unilateral bronchiolitis obliterans. Cyclosporine-based immunosuppression can be safely given to the recipients of LDLLT without significant adverse effects but the incidence of acute rejection is relatively high. The optimal long-term immunosuppressive regimen remains to be established.
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Affiliation(s)
- H Date
- Department of Cancer and Thoracic Surgery, Okayama University Graduate School of Medicine and Dentistry, Okayama, Japan.
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Abstract
In the past 15 years there have been more than 1200 pediatric lung and heart-lung transplants worldwide. This article regarding the current status of pediatric lung transplantation describes indications, outcomes, and complications, with particular emphasis on issues specific to pediatrics, including growth. Information useful to the pediatrician and pediatric pulmonologist is also included. Issues important to the future are reviewed.
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Affiliation(s)
- Stuart C Sweet
- Pediatric Lung Transplant Program, Division of Allergy and Pulmonary Medicine, Department of Pediatrics, St. Louis Children's Hospital at Washington University School of Medicine, St. Louis, MO 63110, USA.
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Abstract
The demand for donor lungs currently exceeds the supply of suitable grafts by a significant margin. Legal backgrounds and organizational and logistic issues are of major impact on the available donor pool. Re-evaluation of the donor criteria currently in use and new, innovative approaches such as living donor lung transplantation and non-heart-beating donation will hopefully contribute to improve this situation and reduce waiting time and waiting list mortality.
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Affiliation(s)
- Clemens Aigner
- Department of Cardiothoracic Surgery, University of Vienna, Währinger Gürtel 18-20: A - 1090 Vienna, Austria
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Date H, Aoe M, Nagahiro I, Sano Y, Andou A, Matsubara H, Goto K, Tedoriya T, Shimizu N. Living-donor lobar lung transplantation for various lung diseases. J Thorac Cardiovasc Surg 2003; 126:476-81. [PMID: 12928647 DOI: 10.1016/s0022-5223(03)00235-6] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE We report on our early experience in living-donor lobar lung transplantation for patients with various lung diseases including restrictive, obstructive, septic, and hypertensive lung diseases. METHODS From October 1998 to March 2002, living-donor lobar lung transplantation was performed in 14 patients with end-stage lung diseases. There were 11 female patients and 3 male patients, with ages ranging from 8 to 53 years, including 4 children and 10 adults. Diagnoses included primary pulmonary hypertension (n = 6), idiopathic interstitial pneumonia (n = 2), bronchiolitis obliterans (n = 2), bronchiectasis (n = 2), lymphangioleiomyomatosis (n = 1), and cystic fibrosis (n = 1). Bilateral living-donor lobar lung transplantation was performed in 13 patients and right single living-donor lobar lung transplantation was performed for a 10-year-old boy with primary pulmonary hypertension. RESULTS All the 14 patients are currently alive with a follow-up period of 4 to 45 months. Although their forced vital capacity (1327 +/- 78 mL, 50.2% of predicted) was limited at discharge, arterial oxygen tension on room air (98.5 +/- 1.8 mm Hg) and systolic pulmonary artery pressure (24.8 +/- 1.6 mm Hg) were excellent. Forced vital capacity improved gradually and reached 1894 +/- 99 mL, 67.4% of predicted, at 1 year. All donors have returned to their previous lifestyles. CONCLUSIONS Living-donor lobar lung transplantation can be applied to restrictive, obstructive, septic, and hypertensive lung diseases. This type of procedure can be an alternative to conventional cadaveric lung transplantation for both pediatric and adult patients who would die soon otherwise.
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Affiliation(s)
- Hiroshi Date
- Department of Cancer and Thoracic Surgery (Surgery II), Okayama University Graduate School of Medicine and Dentistry, 251 Shikata-Cho, Okayama 700-8558, Japan.
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Abstract
Although cadaveric transplantation remains the preferred option for patients who have end-stage lung disease, living lobar transplantation provides organ availability that can be life saving in severely ill pediatric and adult patients who will either die or become unsuitable recipients before a cadaveric organ becomes available. In addition, living lobar transplantation provides acceptable long-term survival when compared with recipients of cadaveric grafts; however, because this procedure presents risks to two healthy donors, appropriate recipient and donor selection and timing of transplantation are critical to minimize the morbidity to the donor and maximize the chance of a successful outcome in the recipient. The results of the authors' experience have demonstrated that the donor procedure is safe, well tolerated physiologically, and that the great majority of donors are extremely satisfied with their decision to donate. Although there have been no deaths in the donor cohort, a risk of death between 0.5% to 1% should be quoted pending further data. These encouraging results are important if this procedure is to be considered as an option at more pulmonary transplant centers in view of the institutional, regional, and intra- and international differences in the philosophical and ethical acceptance of the use of live organ donors for transplantation.
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Affiliation(s)
- Michael E Bowdish
- Department of Cardiothoracic Surgery, University of Southern California, Keck School of Medicine, 1510 San Pablo Street, Suite 415, Los Angeles, CA 90033, USA
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Braverman JM. Increasing the quantity of lungs for transplantation using high-frequency chest wall oscillation: a proposal. Prog Transplant 2002. [PMID: 12593065 DOI: 10.7182/prtr.12.4.l66540265q64067j] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The use of chest physiotherapy in donor patient management occupies an established place in most lung procurement protocols. Although its merits remain controversial and uncorroborated by direct data, some studies support the efficacy of chest physiotherapy in a variety of pulmonary patient populations. Comparative studies have shown that an airway clearance technology utilizing high-frequency chest wall oscillation clears pulmonary secretions as well as or better than chest physiotherapy, but has few of its contraindications and disadvantages. The implementation of high-frequency chest wall oscillation as part of the donor lung procurement protocol may increase rates of successful lung recovery by providing effective clearance of obstructing pulmonary secretions containing destructive by-products of inflammation and entrapped pathogens. High-frequency chest wall oscillation may also improve arterial blood gas values, a critical factor in increasing lung procurement rates. Although speculative, the benefits of high-frequency chest wall oscillation on donor lungs might improve perfusion and oxygenation of other organs for possible transplantation.
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Horn MV, Schenkel FA, Woo MS, Starnes VA. Pediatric recipients of living donor lobar lung transplants: postoperative care. Prog Transplant 2002; 12:81-5. [PMID: 12123177 DOI: 10.7182/prtr.12.2.w2017822x4761040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Bilateral living donor lobar lung transplantation is a treatment option for selected children and adults with end-stage lung disease. Careful donor evaluation, skilled intraoperative management and surgical technique, and diligent immediate postoperative care and follow-up all contribute to better outcomes. Although medical management of whole lung transplant recipients in the immediate postoperative period is similar to that of lobar lung transplant recipients, there are specific differences. Anatomical distinctions, such as the entire cardiac output flowing to 2 lobes instead of 5, and thoracic space issues with simultaneous mechanical ventilation and chest tube suction, contribute to these differences. Early postoperative care, including initial postoperative stabilization, ventilation, fluid management, rejection/infection surveillance and prophylaxis, and beginning rehabilitation, can be adapted to ensure successful outcomes in these patients.
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Logistics of the procurement procedure. Curr Opin Organ Transplant 2002. [DOI: 10.1097/00075200-200203000-00014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fujita T, Date H, Ueda K, Nagahiro I, Aoe M, Andou A, Shimizu N. Experimental study on size matching in a canine living-donor lobar lung transplant model. J Thorac Cardiovasc Surg 2002; 123:104-9. [PMID: 11782763 DOI: 10.1067/mtc.2002.117280] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE In an effort to address the donor-shortage issue, living-donor lobar lung transplants have been performed with satisfactory results. The use of small grafts is potentially problematic because it could cause high pulmonary artery pressure, resulting in lung edema. The purpose of this study was to evaluate the effect of small grafts on early pulmonary function and to identify the predictor for acceptable size discrepancy. METHODS Seventeen pairs of mongrel dogs with various donor-recipient sizes were used. Body weight, height, chest circumference, and lung weight were measured as size parameters. Right middle, lower, and cardiac lobes were implanted as a right lung of the recipient and the left lower lobe was implanted as a left lung without use of cardiopulmonary bypass. Pulmonary function of the recipient was measured for 6 hours after reperfusion. RESULTS A significant negative correlation was found between donor/recipient body-weight ratio and mean pulmonary artery pressure at 1 hour (r = -0.594, P =.025). A significant correlation was found between donor/recipient body-weight ratio and PaO(2) at 6 hours (r = 0.704; P =.007). There was no significant correlation between the other 3 size parameters and postoperative pulmonary function. All 8 recipients with a donor/recipient body-weight ratio of 1.2 or greater survived the 6-hour assessment period, and their PaO(2) exceeded 500 mm Hg at 6 hours. CONCLUSIONS Donor/recipient weight ratio is an important predictor of early pulmonary function in a canine living-donor lobar lung transplant model.
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Affiliation(s)
- Takashi Fujita
- Department of Surgery II, Okayama University School of Medicine, Okayama, Japan
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Matsumura Y, Okada Y, Shimada K, Sado T, Kondo T. Clinical lung transplantation in Japan: Current status and future trends. Allergol Int 2002. [DOI: 10.1046/j.1440-1592.2002.00240.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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