Living-donor lobar lung transplantation

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 braindead 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 lobesparing and/or right-to-left inverted transplantation have been performed for undersized grafts, while singlelobe transplantation has been employed with or without contralateral pneumonectomy and/or delayed chest closure for oversized grafts.

Donor's long‐term quality of life following living‐donor lobar lung transplantation

“…However, because of the expanded utilization of the lung allocation scoring system and expanded donation after circulatory death, 4,5 LDLLT is currently rarely performed in the United States and is only performed in a few other countries 6,7 . However, in Japan, LDLLT remains a practical option and has been performed in one‐third of lung transplantation procedures since the 1990s instead of deceased donor lung transplantation 8,9 . This finding is partly because deceased lung donors are scarce, resulting in high waiting list‐related mortality 10,11 …”

A Breath of Fresh Air - Lung Transplantation Has Come of Age

“…As with DBD and DCD donation, CLAD remains a significant barrier to long term survival in LDLLT. Date and colleagues reported the majority of their LDLLT recipients experienced unilateral CLAD however shown to develop later in postoperative period, proving the possible protective effect of using 2 donors for a single recipient [34,36,37]. In their most recent study, long-term survival after LDLLT was reported to be 73.3% at 15 years, with 5-year survival following diagnosis of CLAD still promising at 66.9% [36].…”

“…Starnes and his colleagues at the University of Southern California (USC) in 1993, first reported the use of living-donor lobar lung transplantation (LDLLT) in extremely ill patients with a high risk of short-term waitlist mortality [32]. In LDLLT, with the use of 3 transplant teams, right and left lower lobes are resected from 2 healthy donors and implanted in recipient in place of the whole right and left lung, respectively [33,34]. Intermediate results proved promising in terms of functional outcome and survival [32].…”

“…However, in Japan, experience with LDLLT provides a reasonable option in hopes of equating supply and demand, for DCD has yet to be approved and median waitlist times are greater than 24 months [36]. In fact, Kyoto University reported by the end of 2019 of the 760 lung transplantations performed, 234 were LDLLT (30.8%) [34]. The authors reported 5-and 10-year survival rates after LDLLT of 79% and 64.6% respectively, comparable to that of their cadaveric lung transplant 5-and 10-year survival rates of 65.7% and 60.3% respectively [34].…”

“…In fact, Kyoto University reported by the end of 2019 of the 760 lung transplantations performed, 234 were LDLLT (30.8%) [34]. The authors reported 5-and 10-year survival rates after LDLLT of 79% and 64.6% respectively, comparable to that of their cadaveric lung transplant 5-and 10-year survival rates of 65.7% and 60.3% respectively [34]. These results can likely be attributed to living-donor lobar grafts being healthier non-injured grafts with significantly shorter ischemic times compared to conventional cadaveric transplantation.…”