Combined lung and liver transplantation: Analysis of a single‐center experience

Abstract

Patients with end-stage lung disease complicated by cirrhosis are not expected to survive lung transplantation alone. Such patients are potential candidates for combined lung-liver transplantation (CLLT), however few reports document the indications and outcomes after CLLT. This is a review of a large single-center CLLT series. Eight consecutive CLLT performed during 2009-2012 were retrospectively reviewed. One patient received a third simultaneous heart transplant. Mean age was 42.5 6 11.5 years. Pulmonary indications included cystic fibrosis (CF) (n 5 3), idiopathic pulmonary fibrosis (n 5 2), a1-antitrypsin deficiency (AATD) (n 5 1) and pulmonary hypertension (n 5 2). Liver indications were CF (n 5 3), hepatitis C (n 5 2), AATD (n 5 1), cryptogenic (n 5 1), and cardiac=congestive (n 5 1). Urgency was reflected by median lung allocation score (LAS) of 41 (36.0-89.0) and median predicted FEV1 of 25.7%. Median donor age was 25 (20-58) years with median cold ischemia times of 147 minutes and 6.1 hours for lung and liver, respectively. Overall patient survival at 30 days, 90 days and 1 year was 87.5%, 75.0% and 71.4% respectively. One patient had evidence of acute lung rejection, and no patients had liver allograft rejection. Early postoperative mortalities (90 days) were caused by sepsis in 2 recipients who exhibited the highest LAS of 69.9 and 89.0. The remaining recipients had a median LAS of 39.5 and 100% survival at 1-year. Median length of stay was 25 days (7-181). Complications requiring operative intervention included bile duct ischemia (n 5 1) and bile leak (n 5 1), ischemia of the bronchial anastomosis (n 5 1), and necrotizing pancreatitis with duodenal perforation (n 5 1). This series reflects a large single-center CLLT experience. Sepsis is the most common cause of death. The procedure should be considered for candidates with LAS < 50. Liver Transpl 20:46-53, 2014. V C 2013 AASLD.

Cystic Fibrosis Related Liver Disease—Another Black Box in Hepatology

“…With regard to portal hypertension, use of β-blockers is limited due to concomitant CF lung disease. Liver transplantation or combined liver-lung-transplantation [125,126,127] is a therapeutic option for advanced decompensated cirrhosis (falling albumin < 30 g/L, increasing coagulopathy not correctable by vitamin K, ascites, jaundice, intractable variceal bleeding, or encephalopathy) but also hepatopulmonary and portopulmonary syndrome, deteriorating pulmonary function (FEV1/FVC < 50) and severe malnutrition unresponsive to intensive nutritional support [8]. Although impaired pulmonary function is thought to negatively influence the outcome of liver transplantation in CF, several reports have demonstrated improvement of respiratory function and general condition after isolated liver transplantation [128].…”

Reframing the impact of combined heart-liver allocation on liver transplant wait-list candidates

“…In the United States, certain types of simultaneous multiorgan transplantation (MOT), including combined liver‐kidney and heart‐liver (H‐L) transplantation, have been increasingly practiced . This demand is attributable to several factors, including an aging population with congenital heart disease and congestive hepatopathy as well as an increased prevalence of chronic kidney disease in liver and heart transplant candidates .…”

“…In the United States, certain types of simultaneous multiorgan transplantation (MOT), including combined liver-kidney and heart-liver (H-L) transplantation, have been increasingly practiced. [1][2][3][4][5][6][7] This demand is attributable to several factors, including an aging population with congenital heart disease and congestive hepatopathy 6 as well as an increased prevalence of chronic kidney disease in liver and heart transplant candidates. [3][4][5][6] The need for the second organ may be for end-stage disease in the nonprimary organ necessitating a transplant independent of the primary organ (eg, a patient with decompensated cirrhosis on hemodialysis), or there may be end-stage disease in the nonprimary organ without overt clinical symptoms, but the organ is needed in order to optimize function of the primary organ (eg, end-stage heart failure with congestive hepatopathy and cirrhosis but preserved liver synthetic function).…”

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

“…Indications and results of the largest reported series on cLiThTx are summarized in Table . As in our experience, the most frequently reported indication for cLiThTx is a systemic disease, like familial amyloidosis involving both cardiopulmonary and hepatic systems for cLiHTx; and cystic fibrosis or alpha‐1‐antitrypsin deficiency for cLiLuTx.…”

“…In our experience, veno‐venous bypass (porto‐femoro‐axillary) was used during LiTx in all cases as it might support hemodynamic stability and reduce portal or retroperitoneal venous hypertension during caval and portal vein occlusion. The same reason was advocated in the series of Yi, Barabara, and Atluri . In contrast to our and Yi′s experience where cardiopulmonary bypass was not used for cLiLuTx, it was applied in this setting by several other centers: the group of Couetil described completion of the thoracic organ implantation with the use of cardiopulmonary bypass, after which the bypass was stopped, heparinization was reversed and LiTx could safely be performed .…”