Living lobar lung transplantation

Michael E Bowdish, Mark L Barr
Respiratory Care Clinics of North America 2004, 10 (4): 563-79
A constant awareness of the risk to the living donors must be maintained with any live-donor organ transplantation program, and comprehensive short- and long-term follow-up should be strongly encouraged to maintain the viability of these potentially life-saving programs. There has been no perioperative or long-term mortality following lobectomy for living lobar lung transplantation, and in the authors' series the perioperative risks associated with donor lobectomy are similar to those seen with standard lung resection. These risks might increase if the procedure were offered on an occasional basis and not within a well-established program. Further long-term outcome data, similar to data for live-donor renal and liver transplantation, are needed. Therefore, the authors still favor performing living lobar lung transplantation only for the patient with a clinically deteriorating condition. They believe that prospective donors should be informed of the morbidity associated with donor lobectomy and the potential for mortality, as well of potential recipient outcomes in regard to life expectancy and quality of life after transplantation. A major question regarding lobar lung transplantation that has been unanswered during the last decade has been defining when a potential recipient is too ill to justify placing two healthy donors at risk of donor lobectomy. Recipient age, gender, indication for primary transplant, prehospitalization status, preoperative steroid usage, relationship of donor to recipient, and the presence or absence of rejection episodes postoperatively do not seem to influence overall mortality. Patients receiving mechanical ventilation preoperatively and those undergoing retransplantation after either a previous cadaveric or lobar lung transplantation have significantly elevated odds ratios for postoperative death. The authors therefore recommend caution in these subgroups of patients. This experience is similar to the cadaveric experience in which intubated patients have higher I-year mortalities and patients undergoing retransplantation have decreased 3- and 5-year survival. A similar experience with a smaller number of lobar transplants has been reported by the Washington University group. Despite the high-risk patient population, this alternative procedure has been life saving in severely ill patients who would die or become unsuitable recipients before a cadaveric organ becomes available. Although cadaveric transplantation is preferable because of the risk to the donors, living lobar lung transplantation should continue to be used under properly selected circumstances. Although there have been no deaths in the donor cohort, a risk of death between 0.5% and 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 organs from live donors for transplantation.

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