Combined Liver and Lung Transplantation With Extended Normothermic Lung Preservation in a Patient With End-Stage Emphysema Complicated by Drug-Induced Acute Liver Failure

Abstract

Isolated lung transplantation (LuTx) and liver transplantation are established treatments for irreversible lung and liver failure. Combined liver and lung transplantation (cLiLuTx) is a less common, but approved therapy of combined organ failure, mostly applied in patients suffering from progressive cystic fibrosis and advanced liver disease. We report a patient who was listed for LuTx due to end‐stage chronic obstructive pulmonary disease and who developed drug‐induced acute hepatic failure. The only therapeutic option was hyper‐urgent cLiLuTx. To correct the poor coagulation in order to reduce the per‐operative risk of bleeding, the liver was transplanted first. In anticipation of the longer lung preservation time, cold flushed lungs were preserved on a portable lung perfusion device for ex vivo normothermic perfusion for 11 h 15 min, transplanted sequentially off‐pump, and reperfused after a total ex vivo time of 13 h 32 min and 16 h for the first and second lung, respectively. Ten months later, the patient is doing well and no rejection occurred. Normothermic ex vivo lung perfusion may help to prolong preservation time, facilitating long‐distance transport and combined organ transplantation.

Prolonged EVLP Using OCS Lung

“…4,6 Ceulemans and colleagues perfused human lungs up to 11H on OCS for a successful combined lung-liver transplant. 7 The FDA-approval EXPAND trial, which makes use of OCS for extended-criteria donors, is currently enrolling human subjects with an EVLP interval limit of 12H. 8,9 …”

Evaluating acellular versus cellular perfusate composition during prolongedex vivolung perfusion after initial cold ischaemia for 24 hours

“…Whereas EVLP was developed by Steen et al . for the purpose of organ assessment especially from DCD donors and thus tended to be of short duration at the beginning of its clinical application, current perfusion times range from 4 to 11 h , opening up the field for reconditioning and treatment of marginal lung grafts. Centres in which the technique of EVLP was introduced have experienced an increase in transplantation rates by 15–30% .…”

Combined liver-thoracic transplantation: single-center experience with introduction of the‘Liver-first’principle

“…The most common example for cLiHTx is cardiomyopathy leading to cardiac cirrhosis, and for cLiLu(H)Tx, the most frequent condition is hepatic cirrhosis evolving to portopulmonary hypertension. A third option is a primary disease of both organs, like the patient in our series who was listed for end‐stage lung failure (COPD) and developed drug‐induced acute liver failure , as well as the two cases of epithelioid hemangio‐endothelioma previously reported by our group for the first time .…”

“…To decrease the risk of bleeding during LuTx, the liver was transplanted first. Due to an anticipated longer lung preservation time, the lungs were normothermically perfused and oxygenated as previously reported . Based on this successful clinical experience, and the potential benefits of this liver‐first principle , we opted for the same transplant sequence (liver first, lung second) in two other cLiLuTx.…”