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Sellers ZM, Assis DN, Paranjape SM, Sathe M, Bodewes F, Bowen M, Cipolli M, Debray D, Green N, Hughan KS, Hunt WR, Leey J, Ling SC, Morelli G, Peckham D, Pettit RS, Philbrick A, Stoll J, Vavrina K, Allen S, Goodwin T, Hempstead SE, Narkewicz MR. Cystic fibrosis screening, evaluation, and management of hepatobiliary disease consensus recommendations. Hepatology 2024; 79:1220-1238. [PMID: 37934656 PMCID: PMC11020118 DOI: 10.1097/hep.0000000000000646] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/11/2023] [Indexed: 11/09/2023]
Abstract
Cystic fibrosis (CF) may cause a spectrum of hepatobiliary complications, including portal hypertension, multilobular cirrhosis, and liver failure. Current guidelines on the detection and monitoring of hepatobiliary complications in CF were published in 1999. The CF Foundation assembled a committee to evaluate research advances and formulate revised guidelines for CF-associated liver disease. A committee of hepatologists, gastroenterologists, pulmonologists, pharmacists, nurses, dietitians, individuals with CF, and the parents of a child with CF devised "population, intervention, comparison, and outcome" questions regarding hepatobiliary disease in CF. PubMed literature searches were performed for each population, intervention, comparison, and outcome question. Recommendations were voted on with 80% agreement required to approve a recommendation. Public comment on initial recommendations was solicited prior to the formulation of final recommendations. Thirty-one population, intervention, comparison, and outcome questions were assembled, 6401 manuscripts were title screened for relevance, with 1053 manuscripts undergoing detailed full-text review. Seven recommendations were approved for screening, 13 for monitoring of existing disease, and 14 for treatment of CF-associated hepatobiliary involvement or advanced liver disease. One recommendation on liver biopsy did not meet the 80% threshold. One recommendation on screening ultrasound was revised and re-voted on. Through a multidisciplinary committee and public engagement, we have assembled updated recommendations and guidance on screening, monitoring, and treatment of CF-associated hepatobiliary involvement and advanced liver disease. While research gaps remain, we anticipate that these recommendations will lead to improvements in CF outcomes through earlier detection and increased evidence-based approaches to monitoring and treatment.
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Affiliation(s)
- Zachary M. Sellers
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, California, USA
| | - David N. Assis
- Department of Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
| | - Shruti M. Paranjape
- Division of Pediatric Pulmonology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Meghana Sathe
- Department of Pediatrics, Division of Pediatric Gastroenterology and Nutrition, UT Southwestern, Dallas, Texas, USA
| | - Frank Bodewes
- Department of Pediatric Gastroenterology, University Medical Center Groningen, Groningen, The Netherlands
| | - Melissa Bowen
- Department of Advanced Lung Disease and Lung Transplant, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Marco Cipolli
- Cystic Fibrosis Center, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Dominique Debray
- Pediatric Hepatology Unit, AP-HP, HôpitalNecker-Enfants malades, Paris, France
| | - Nicole Green
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Seattle Children’s Hospital and University of Washington, Seattle, Washington State, USA
| | - Kara S. Hughan
- Department of Pediatrics, Division of Pediatric Endocrinology and Metabolism, UPMC Children’s Hospital of Pittsburgh and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - William R. Hunt
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep, Emory University, Atlanta, Georgia, USA
| | - Julio Leey
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Florida, Gainesville, Florida, USA
| | - Simon C. Ling
- Department of Paediatrics, Division of Gastroenterology, Hepatology & Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Giuseppe Morelli
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Daniel Peckham
- Leeds Institute of Medical Research at St. James’s, University of Leeds, Leeds, UK
| | - Rebeca S. Pettit
- Riley Hospital for Children at IU Health, Indianapolis, Indiana, USA
| | - Alexander Philbrick
- Department of Specialty Pharmacy, Northwestern Medicine, Chicago, Illinois, USA
| | - Janis Stoll
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Washington University School of Medicine, St Louis, Missouri, USA
| | - Kay Vavrina
- University of Texas, Health Science Center, San Antonio, Texas, USA
| | - Stacy Allen
- CF Parent Community Advisor to Cystic Fibrosis Foundation, USA
| | - Tara Goodwin
- CF Parent Community Advisor to Cystic Fibrosis Foundation, USA
| | | | - Michael R. Narkewicz
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Digestive Health Institute, Children’s Hospital Colorado, University of Colorado School of, Aurora, Colorado, USA
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2
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Connor AA, Huang HJ, Mobley CM, Graviss EA, Nguyen DT, Goodarzi A, Saharia A, Yau S, Hobeika MJ, Suarez EE, Moaddab M, Brombosz EW, Moore LW, Yi SG, Gaber AO, Ghobrial RM. Progress in Combined Liver-lung Transplantation at a Single Center. Transplant Direct 2023; 9:e1482. [PMID: 37096152 PMCID: PMC10121433 DOI: 10.1097/txd.0000000000001482] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/03/2023] [Indexed: 04/26/2023] Open
Abstract
Combined liver-lung transplantation is an uncommon, although vital, procedure for patients with simultaneous end-stage lung and liver disease. The utility of lung-liver transplant has been questioned because of initial poor survival outcomes, particularly when compared with liver-alone transplant recipients. Methods A single-center, retrospective review of the medical records of 19 adult lung-liver transplant recipients was conducted, comparing early recipients (2009-2014) with a recent cohort (2015-2021). Patients were also compared with the center's single lung or liver transplant recipients. Results Recent lung-liver recipients were older (P = 0.004), had a higher body mass index (P = 0.03), and were less likely to have ascites (P = 0.02), reflecting changes in the etiologies of lung and liver disease. Liver cold ischemia time was longer in the modern cohort (P = 0.004), and patients had a longer posttransplant length of hospitalization (P = 0.048). Overall survival was not statistically different between the 2 eras studied (P = 0.61), although 1-y survival was higher in the more recent group (90.9% versus 62.5%). Overall survival after lung-liver transplant was equivalent to lung-alone recipients and was significantly lower than liver-alone recipients (5-y survival: 52%, 51%, and 75%, respectively). Lung-liver recipient mortality was primarily driven by deaths within 6 mo of transplant due to infection and sepsis. Graft failure was not significantly different (liver: P = 0.06; lung: P = 0.74). Conclusions The severity of illness in lung-liver recipients combined with the infrequency of the procedure supports its continued use. However, particular attention should be paid to patient selection, immunosuppression, and prophylaxis against infection to ensure proper utilization of scarce donor organs.
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Affiliation(s)
- Ashton A. Connor
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX
- Department of Surgery, Houston Methodist Hospital, Houston, TX
| | - Howard J. Huang
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX
- Department of Medicine, Houston Methodist Hospital, Houston, TX
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Constance M. Mobley
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX
- Department of Surgery, Houston Methodist Hospital, Houston, TX
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Edward A. Graviss
- Department of Surgery, Houston Methodist Hospital, Houston, TX
- Department of Medicine, Weill Cornell Medical College, New York, NY
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX
| | - Duc T. Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX
| | - Ahmad Goodarzi
- Department of Medicine, Houston Methodist Hospital, Houston, TX
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Ashish Saharia
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX
- Department of Surgery, Houston Methodist Hospital, Houston, TX
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Simon Yau
- Department of Medicine, Houston Methodist Hospital, Houston, TX
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Mark J. Hobeika
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX
- Department of Surgery, Houston Methodist Hospital, Houston, TX
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Erik E. Suarez
- Department of Medicine, Houston Methodist Hospital, Houston, TX
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Mozhgon Moaddab
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX
| | | | - Linda W. Moore
- Department of Surgery, Houston Methodist Hospital, Houston, TX
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Stephanie G. Yi
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX
- Department of Surgery, Houston Methodist Hospital, Houston, TX
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - A. Osama Gaber
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX
- Department of Surgery, Houston Methodist Hospital, Houston, TX
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Rafik Mark Ghobrial
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX
- Department of Surgery, Houston Methodist Hospital, Houston, TX
- Department of Medicine, Weill Cornell Medical College, New York, NY
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3
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Shamaa TM, Shamaa O, Crombez C, Konel JM, Kitajima T, Shimada S, Ivanics T, Mohamed A, Collins K, Nagai S, Yoshida A, Abouljoud M, Rizzari M. The use of normothermic liver preservation in combined liver and lung transplantation: A single-center experience. Am J Transplant 2022; 22:2261-2264. [PMID: 35384271 DOI: 10.1111/ajt.17053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 03/30/2022] [Accepted: 03/30/2022] [Indexed: 01/25/2023]
Abstract
Combined liver and lung transplantation (CLLT) is indicated in patients with both end-stage liver and lung disease. Ex-situ normothermic machine perfusion (NMP) has been previously used for extended normothermic lung preservation in CLLT. We aim to describe our single-center experience using ex-situ NMP for extended normothermic liver preservation in CLLT. Four CLLTs were performed from 2019 to 2020 with the lung transplanted first for all patients. Median ex-situ pump time for the liver was 413 min (IQR 400-424). Over a median follow-up of 15 months (IQR 14-19), all patients were alive and doing well. Normothermic extended liver preservation is a safe method to allow prolonged cold ischemia using normothermic perfusion of the liver during CLLT.
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Affiliation(s)
- Tayseer M Shamaa
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Omar Shamaa
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Catherine Crombez
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
| | | | - Toshihiro Kitajima
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Shingo Shimada
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Tommy Ivanics
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Adhnan Mohamed
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Kelly Collins
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Shunji Nagai
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Atsushi Yoshida
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Marwan Abouljoud
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Michael Rizzari
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
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4
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Urlik M, Latos M, Stącel T, Wystrychowski W, Joanna M, Nęcki M, Antończyk R, Badura J, Horynecka Z, Sekta S, Król B, Gawęda M, Pandel A, Zembala M, Ochman M, Król R. First in Poland Simultaneous Liver-Lung Transplantation With Liver-First Approach for Recipient Due to Cystic Fibrosis: A Case Report. Transplant Proc 2022; 54:1171-1176. [PMID: 35597673 DOI: 10.1016/j.transproceed.2022.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 02/18/2022] [Indexed: 10/18/2022]
Abstract
Cystic fibrosis is an autosomal progressive disease affecting the lung, pancreas, and liver. Some patients develop end-stage respiratory and liver failure. For such patients, combined lung-liver transplantation remains the only therapeutic option. In this article we present the first simultaneous lung-liver transplantation in Poland, as well as in Central and Eastern Europe, with detailed clinical history, surgical aspects, and postoperative course.
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Affiliation(s)
- Maciej Urlik
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Center for Heart Diseases in Zabrze, Medical University of Silesia, Katowice, Poland.
| | - Magdalena Latos
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Center for Heart Diseases in Zabrze, Medical University of Silesia, Katowice, Poland.
| | - Tomasz Stącel
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Center for Heart Diseases in Zabrze, Medical University of Silesia, Katowice, Poland.
| | - Wojciech Wystrychowski
- Department of General, Vascular and Transplant Surgery, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland.
| | - Musialik Joanna
- Department of General, Vascular and Transplant Surgery, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland.
| | - Mirosław Nęcki
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Center for Heart Diseases in Zabrze, Medical University of Silesia, Katowice, Poland.
| | - Remigiusz Antończyk
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Center for Heart Diseases in Zabrze, Medical University of Silesia, Katowice, Poland.
| | - Joanna Badura
- Department of General, Vascular and Transplant Surgery, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland.
| | - Zuzanna Horynecka
- Department of General, Vascular and Transplant Surgery, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland.
| | - Sylwia Sekta
- Department of General, Vascular and Transplant Surgery, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland.
| | - Bogumiła Król
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Center for Heart Diseases in Zabrze, Medical University of Silesia, Katowice, Poland.
| | - Martyna Gawęda
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Center for Heart Diseases in Zabrze, Medical University of Silesia, Katowice, Poland.
| | - Anastazja Pandel
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Center for Heart Diseases in Zabrze, Medical University of Silesia, Katowice, Poland.
| | - Marian Zembala
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Center for Heart Diseases in Zabrze, Medical University of Silesia, Katowice, Poland.
| | - Marek Ochman
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Center for Heart Diseases in Zabrze, Medical University of Silesia, Katowice, Poland.
| | - Robert Król
- Department of General, Vascular and Transplant Surgery, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland.
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5
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Consensus document for the selection of lung transplant candidates: An update from the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2021; 40:1349-1379. [PMID: 34419372 DOI: 10.1016/j.healun.2021.07.005] [Citation(s) in RCA: 295] [Impact Index Per Article: 98.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 07/14/2021] [Indexed: 02/06/2023] Open
Abstract
Tens of thousands of patients with advanced lung diseases may be eligible to be considered as potential candidates for lung transplant around the world each year. The timing of referral, evaluation, determination of candidacy, and listing of candidates continues to pose challenges and even ethical dilemmas. To address these challenges, the International Society for Heart and Lung Transplantation appointed an international group of members to review the literature, to consider recent advances in the management of advanced lung diseases, and to update prior consensus documents on the selection of lung transplant candidates. The purpose of this updated consensus document is to assist providers throughout the world who are caring for patients with pulmonary disease to identify potential candidates for lung transplant, to optimize the timing of the referral of these patients to lung transplant centers, and to provide transplant centers with a framework for evaluating and selecting candidates. In addition to addressing general considerations and providing disease specific recommendations for referral and listing, this updated consensus document includes an ethical framework, a recognition of the variability in acceptance of risk between transplant centers, and establishes a system to account for how a combination of risk factors may be taken into consideration in candidate selection for lung transplantation.
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6
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Bell PT, Carew A, Fiene A, Divithotawela C, Stuart KA, Hodgkinson P, Chambers DC, Hopkins PM. Combined Heart-Lung-Liver Transplantation for Patients With Cystic Fibrosis: The Australian Experience. Transplant Proc 2021; 53:2382-2389. [PMID: 34412912 DOI: 10.1016/j.transproceed.2021.07.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 07/19/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Combined multivisceral transplantation has emerged as a therapeutic option for a select patient cohort; however, clinical decision-making remains complex and controversial. The aim of this study was to examine patient characteristics, operative complications, and long-term outcomes of all patients who have undergone combined heart-lung-liver transplantation (HLLTx) in Australia. METHODS In this study, we performed a retrospective analysis of all adult patients who have undergone combined HLLTx in Australia to date. Recipient clinical characteristics, waitlist, and transplant outcomes are described. RESULTS Eight adult patients have received HLLTx at a single Australian transplant center. Recipients of HLLTx have typically been young (median age, 30.1 years; range, 24-37), underweight (median body mass index, 19.8 kg/m2; range, 16.2-30.4) patients with cystic fibrosis (n = 8, 100%) with severe airflow obstruction (median forced expiratory volume in the first second of expiration, 24% predicted; range, 17%-48%) accompanied by liver cirrhosis confirmed on histopathology (n = 8, 100%). Despite relative preservation of synthetic function and low model for end-stage liver disease scores (median, 8; range, 6-17), all recipients had complications of portal hypertension prior to transplantation, with many patients having suffered life-threatening variceal hemorrhage. In this cohort, HLLTx was associated with overall posttransplant survival of 87.5% at 30 days, 71.4% at 1 year, and 42.9% at 5 years. Listing for combined HLLTx was associated with prolonged waitlist times relative to bilateral sequential single-lung transplantation (median 556 vs 56 days, respectively), however waitlist mortality and/or delisting was comparable between groups. CONCLUSIONS Taken together, these findings highlight the opportunities and challenges facing combined (heart-) lung and liver transplantation in patients with multiorgan failure.
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Affiliation(s)
- P T Bell
- Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - A Carew
- Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - A Fiene
- Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Australia
| | - C Divithotawela
- Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Australia
| | - K A Stuart
- Queensland Liver Transplant Service, Princess Alexandra Hospital, Brisbane, Australia
| | - P Hodgkinson
- Queensland Liver Transplant Service, Princess Alexandra Hospital, Brisbane, Australia
| | - D C Chambers
- Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - P M Hopkins
- Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Australia.
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7
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Hyzny EJ, Chan EG, Morrell M, Harano T, Sanchez PG. A review of liver dysfunction in the lung transplant patient. Clin Transplant 2021; 35:e14344. [PMID: 33960530 DOI: 10.1111/ctr.14344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 04/09/2021] [Accepted: 04/26/2021] [Indexed: 12/11/2022]
Abstract
Liver dysfunction is an increasingly common finding in patients evaluated for lung transplantation. New or worsening dysfunction in the perioperative period, defined by presence of clinical ascites/encephalopathy, high model for end-stage liver disease (MELD) score, and/or independent diagnostic criteria, is associated with high short- and long-term mortality. Therefore, a thorough liver function assessment is necessary prior to listing for lung transplant. Unfortunately, identification and intraoperative monitoring remain the only options for prevention of disease progression with isolated lung transplantation. Combined lung and liver transplantation may provide an option for definitive long-term management in selecting patients with known liver disease at high risk for postoperative progression. However, experience with the combined operation is extremely limited and indications for combined lung and liver transplant remain unclear. Herein, we present a comprehensive literature review of patients with liver dysfunction undergoing lung transplantation with and without concurrent liver transplant in an effort to illuminate the risks, benefits, and clinical judgement surrounding decision to pursue combined lung-liver transplantation (CLLT). We also argue description of liver function is currently a weakness of the current lung allocation scoring system. Additional algorithms incorporating liver function may aid in risk stratification and decision to pursue combined transplantation.
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Affiliation(s)
- Eric J Hyzny
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ernest G Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Matthew Morrell
- Pulmonary, Allergy, and Critical Care Medicine Division, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Takashi Harano
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Pablo G Sanchez
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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8
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Aburahma K, Salman J, Engel B, Vondran FWR, Greer M, Boethig D, Siemeni T, Avsar M, Schwerk N, Müller C, Taubert R, Hoeper MM, Welte T, Wedemeyer HH, Richter N, Warnecke G, Tudorache I, Haverich A, Kuehn C, Grannas G, Ius F. Liver-first strategy for a combined lung and liver transplant in patients with cystic fibrosis. Eur J Cardiothorac Surg 2021; 60:822-830. [PMID: 33956976 DOI: 10.1093/ejcts/ezab164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 02/08/2021] [Accepted: 02/14/2021] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES A combined lung and liver transplant in patients with cystic fibrosis (CF) is an uncommon procedure. The goal of this study was to compare long-term outcomes between patients with CF who underwent either a combined lung-liver or a lung-only transplant. METHODS This is a retrospective single-centre study of patients with CF who underwent a lung transplant between January 2005 and May 2020. Since 2006, our preference for a combined lung-liver transplant was to transplant the liver first and then the lung. Outcomes were compared using the Kaplan-Meier analysis and the log-rank test. Median follow-up was 53 (23-97) months. RESULTS During the study period, among 357 patients with CF who underwent a lung transplant, 14 (4%) required a lung-liver transplant whereas 343 (96%) had a lung-only transplant. Lung cold ischaemic time was longer in the lung-liver transplant group, but no patient in this group showed primary graft dysfunction at 72 h after the transplant. Prevalence of anti-human leucocyte antigen donor-specific antibodies was 7.1% vs 13.7% in the lung-liver versus the lung-only transplant group (P = 0.42). At 5 years, lung graft survival (78% vs 69%) and freedom from chronic lung allograft dysfunction (79% vs 62%) did not differ between the lung-liver versus the lung-only groups (P = 0.45 and P = 0.55, respectively). Freedom from lung biopsy-confirmed rejection was significantly higher in patients undergoing a lung-liver transplant (91% vs 50%; P = 0.027). CONCLUSIONS A lung-liver transplant did not impair lung graft function. The lower prevalence of donor-specific antibodies and the better freedom from lung biopsy-confirmed rejection suggest tolerogenic effects of the liver graft.
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Affiliation(s)
- Khalil Aburahma
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jawad Salman
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Bastian Engel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Florian W R Vondran
- Department of General, Visceral, and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Mark Greer
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Dietmar Boethig
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Thierry Siemeni
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Murat Avsar
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Nicolaus Schwerk
- Department of Paediatrics, Hannover Medical School, Hannover, Germany
| | - Carsten Müller
- Department of Paediatrics, Hannover Medical School, Hannover, Germany
| | - Richard Taubert
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Hans H Wedemeyer
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Nicolas Richter
- Department of General, Visceral, and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Gregor Warnecke
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany.,Department of Cardiac Surgery, Heidelberg Medical School, Heidelberg, Germany
| | - Igor Tudorache
- Department of Cardiac Surgery, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Christian Kuehn
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Gerrit Grannas
- Department of General, Visceral, and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
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9
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Chahal D, Hussaini T, Farnell D, Nador R, Yoshida EM. Isolated Liver Rejection After Lung and Combined Kidney-Liver Transplantation: A Case Report. Transplant Proc 2021; 53:1333-1336. [PMID: 33750588 DOI: 10.1016/j.transproceed.2021.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 12/31/2020] [Accepted: 02/01/2021] [Indexed: 12/01/2022]
Abstract
Liver allografts are unique in solid organ transplantation as they are less susceptible to both acute and chronic rejection. Operational tolerance, defined as prolonged graft survival in the absence of immunosuppression, is also achieved more frequently with liver allografts. It is unknown if the presence of multiple allografts in the same individual, levels of immunosuppression, or the presence of cystic fibrosis (CF) impacts the livers ability to ward off rejection or achieve operational tolerance. We describe an unsensitized, ABO-compatible patient with CF who underwent double lung transplantation and several years later a combined liver-kidney transplant. He developed isolated late acute T-cell mediated rejection of his liver allograft despite a high level of immunosuppression (IS) required for his lung and kidney allografts. To our knowledge, this is the first case of isolated liver rejection in a patient with 3 separate organ allografts, or in a patient with CF, to be reported in the literature. This isolated liver rejection is out of keeping with typically accepted ideas about orthotopic liver tolerance.
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Affiliation(s)
- Daljeet Chahal
- Division of Gastroenterology, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Trana Hussaini
- Department of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - David Farnell
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Roland Nador
- Division of Respiratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric M Yoshida
- Division of Gastroenterology, University of British Columbia, Vancouver, British Columbia, Canada
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10
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Kovac D, Choe J, Liu E, Scheffert J, Hedvat J, Anamisis A, Salerno D, Lange N, Jennings DL. Immunosuppression considerations in simultaneous organ transplant. Pharmacotherapy 2021; 41:59-76. [PMID: 33325558 DOI: 10.1002/phar.2495] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/21/2020] [Accepted: 12/01/2020] [Indexed: 12/12/2022]
Abstract
Solid organ transplantation is a life-saving procedure for patients in the end stage of heart, lung, kidney, and liver failure. For patients with more than one failing organ, simultaneous organ transplantation has emerged as a viable treatment option. Immunosuppression strategies and outcomes for simultaneous organ transplant recipients have been reported, but often involve limited populations. Transplanting dual organs poses challenges in terms of balancing immunosuppression with immunologic risk and allograft damage from surgical complications. Furthermore, transplanting certain organs can impose considerations on the management of immunosuppression. For example, liver allografts may confer immunologic privilege and lower rates of rejection of other allografts. This review article evaluates immunosuppression strategies for simultaneous kidney-pancreas, liver-kidney, heart-kidney, heart-liver, heart-lung, lung-liver, and lung-kidney transplants. To date, no comprehensive review exists to address immunosuppressive strategies in simultaneous organ transplant populations. Our review summarizes the available literature and provides evidence-based recommendations regarding immunosuppression strategies in simultaneous organ transplant recipients.
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Affiliation(s)
- Danielle Kovac
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Jason Choe
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Esther Liu
- Department of Pharmacy, NewYork-Presbyterian Weill Cornell Medical Center, New York, New York, USA
| | - Jenna Scheffert
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Jessica Hedvat
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Anastasia Anamisis
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - David Salerno
- Department of Pharmacy, NewYork-Presbyterian Weill Cornell Medical Center, New York, New York, USA
| | - Nicholas Lange
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Douglas L Jennings
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA.,Division of Pharmacy Practice, Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, New York, New York, USA
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11
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Roquet G, Maury JM, Mabrut JY, Flamens C, Senechal A, Mornex JF, Tronc F. Combined Single Lung and Liver Transplantation in a Cystic Fibrosis Patient With Previous Contralateral Pneumonectomy: A Case Report. Transplant Proc 2020; 52:2820-2823. [PMID: 33010935 DOI: 10.1016/j.transproceed.2020.08.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 08/12/2020] [Indexed: 11/16/2022]
Abstract
Combined lung-liver transplantation is a rare life-saving procedure to treat concomitant end-stage lung and liver failure. In this report, we describe the first published case of single lung and liver transplantation in a cystic fibrosis patient who had previously undergone a pneumonectomy for the treatment of an infected and destroyed right lung. We detail the lung first, sequential transplant procedure and surgical difficulties due to mediastinal shift. Emergent intraoperative renal replacement therapy was carried out before liver transplantation to overcome pulmonary edema in the transplanted lung. After fluid balance equilibration, liver transplantation was performed in good conditions. The patient is currently alive with no signs of rejection 8 years after the procedure.
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Affiliation(s)
- Gaetane Roquet
- Department of Thoracic Surgery and Lung Transplantation, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Jean Michel Maury
- Department of Thoracic Surgery and Lung Transplantation, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Jean Yves Mabrut
- Department of General Surgery and Liver Transplantation, Hospices Civils de Lyon, Croix Rousse University Hospital, Claude-Bernard Lyon 1 University, Lyon, France
| | - Claire Flamens
- Department of Anesthesiology and Critical Care, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Agathe Senechal
- Department of Pneumology, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Jean François Mornex
- Department of Pneumology, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - François Tronc
- Department of Thoracic Surgery and Lung Transplantation, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France.
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12
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13
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A Propensity-matched Survival Analysis: Do Simultaneous Liver-lung Transplant Recipients Need a Liver? Transplantation 2020; 103:1675-1682. [PMID: 30444805 DOI: 10.1097/tp.0000000000002529] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND There is debate whether simultaneous lung-liver transplant (LLT) long-term outcomes warrant allocation of 2 organs to a single recipient. We hypothesized that LLT recipients would have improved posttransplant survival compared with matched single-organ lung recipients with an equivalent degree of liver dysfunction. METHODS The Organ Procurement and Transplant Network/United Network for Organ Sharing STAR file was queried for adult candidates for LLT and isolated lung transplantation from 2006 to 2016. Waitlist mortality and transplant odds were calculated for all candidates. Donor and recipient demographic characteristics were compiled and compared. The LLT recipients were matched 1:2 with a nearest neighbor method to single-organ lung recipients. Kaplan-Meier methods with log-rank test compared long-term survival between groups. Univariate regression was used to calculate the association of LLT and mortality within 6 months of transplant. A proportional hazards model was used to calculate risk-adjusted mortality after 6 months posttransplantation. RESULTS Thirty-eight LLT patients were matched to 75 single-organ lung recipients. After matching, no differences in baseline demographics or liver function were observed between cohorts. Length of stay was significantly longer in LLT recipients compared to isolated lung recipients (45.89 days vs 22.44 days, P < 0.001). There was no significant difference in survival probability between LLT and isolated lung transplant (1 y, 89.5% vs 86.7%; 5 y, 67.0% vs 64.6%; P = 0.20). CONCLUSIONS After matching for patient characteristics and level of liver dysfunction, survival in simultaneous LLT was comparable to isolated lung transplantation. Although this population is unique, the clinical picture prompting liver transplant is not clear. National guidelines to better elucidate patient selection are needed.
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14
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Impact and Implications following the November 2017 Emergency Change to the United States Lung Allocation Policy. Ann Am Thorac Soc 2020; 17:795-799. [PMID: 32068435 DOI: 10.1513/annalsats.201911-818ps] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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15
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Vazquez Guillamet R. Chronic Obstructive Pulmonary Disease and the Optimal Timing of Lung Transplantation. MEDICINA-LITHUANIA 2019; 55:medicina55100646. [PMID: 31561607 PMCID: PMC6843760 DOI: 10.3390/medicina55100646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 09/17/2019] [Accepted: 09/23/2019] [Indexed: 11/29/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) accounts for the largest proportion of respiratory deaths worldwide and was historically the leading indication for lung transplantation. The success of lung transplantation procedures is measured as survival benefit, calculated as survival with transplantation minus predicted survival without transplantation. In chronic obstructive pulmonary disease, it is difficult to show a clear and consistent survival benefit. Increasing knowledge of the risk factors, phenotypical heterogeneity, systemic manifestations, and their management helps improve our ability to select candidates and list those that will benefit the most from the procedure.
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Han JL, Beal EW, Mumtaz K, Washburn K, Black SM. Combined liver-lung transplantation: Indications, outcomes, current experience and ethical Issues. Transplant Rev (Orlando) 2019; 33:99-106. [DOI: 10.1016/j.trre.2018.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 11/14/2018] [Accepted: 11/15/2018] [Indexed: 01/29/2023]
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