Key Point

In patients with IPF and low life expectancy, living donor lobar lung transplantation significantly improved lung function and survival.

OKAYAMA, JAPAN—Most patients with idiopathic pulmonary fibrosis (IPF) who are waiting for donor lungs do not survive their wait, which can be as long as two years. With this fact in mind, living donor lobar lung transplantation (LDLLT) was pioneered at the University of Southern California as an alternative to cadaveric donor lung transplantation. To date, this procedure has been used almost exclusively in patients with cystic fibrosis. But then a team of Japanese researchers performed LDLLT in nine IPF patients who had very poor life expectancies. More than two years later, eight of these patients are alive and have had dramatic improvements in their respiratory function and mobility.¹

Because of the risk for complications during donor surgery, donors were restricted to immediate family members, second-degree relatives, and spouses of the patients. “In our institution, we accept only blood relatives within the second degree or spouses,” said Hiroshi Date, MD, Associate Professor in the Department of Cancer and Thoracic Surgery at Okayama University Graduate School of Medicine and Dentistry. “This is done for ethical reasons—mainly, the donor’s love for the recipient.” The procedure involved removing the native lungs and replacing them with the right and left lower lobes from lungs of living donors. After surgery, patients were kept intubated for at least three days to attain optimal expansion of the implanted lobes.

Fiberoptic bronchoscopy was performed every 12 hours to assess airway viability and suction any retained secretions. Intensive chest physiotherapy was performed every four hours, and bedside postoperative pulmonary rehabilitation was started as soon as possible. Patients received perioperative antibiotics, cyclosporine, azathioprine, and corticosteroids. Oral fluconazole was begun three weeks after transplantation, and ganciclovir was administered for the first three months postsurgery to prevent cytomegalovirus.

Three months after LDLLT, patients were permitted to return home. They were asked to keep a diary and record daily pulmonary function, digital oxygen saturation, body temperature, body weight, blood pressure, and heart rate. Full postoperative assessment was performed at six months, 12 months, and yearly thereafter.

DRAMATIC IMPROVEMENT

Prior to transplant, mean vital capacity was 0.9 L (31.2% of predicted). Three patients were too sick to undergo pulmonary function testing prior to transplant, so vital capacity measures from more than nine months prior were used. Systolic pulmonary artery pressure was 52 mm Hg. All nine patients required continuous oxygen and seven were completely bedridden. Mean Paco₂ was 53.7 mm Hg.

One patient died on day 16 from severe acute rejection. For the remaining eight, the mean duration of mechanical ventilation was 11.8 days, ICU stay was 18.6 days, and the mean duration of hospital stay was 60.2 days.

Histologic examinations performed on the excised lungs confirmed a diagnosis of advanced usual interstitial pneumonia in six patients and fibrotic nonspecific interstitial pneumonia in three.

At three months posttransplant, vital capacity was still limited, but arterial oxygen tension and systolic pulmonary arterial pressure were both excellent. Seven patients who could not walk before surgery had a six-minute walk distance of 342 meters. At one year, vital capacity was a mean of 71.4% of predicted. Radiographic changes were dramatic in all patients—showing fully expanded grafts that filled the chest cavity, with no dead space. All lobar donors had returned to their previous lifestyles.

“Patients with IPF have a very limited life expectancy if they do not receive lung transplantation.” Dr. Date explained. “They often die before cadaveric donor lungs are found. It is for this reason that LDLLT may be the only option for them. In addition, patients with IPF have small chest cavities, which makes them good candidates for lobar transplantation.”

Dr. Date added that if one considers only the recipient, LDLLT appears to be the better option compared to cadaveric donor lung transplantation. “However,” he pointed out, “because of the serious complications possible in donor lobectomy, cadaveric transplantation should be the first choice.”

For LDLLT, Dr. Date’s institution accepts only very sick individuals who would most likely die while waiting for cadaveric donor lungs. “Between 1998 and 2005, we have done 41 lung transplants (35 LDLLT and six cadaveric transplants). Thirty-three LDLLT recipients (94%) and five (83%) cadaveric lung recipients are currently alive after a mean follow-up period of 32 months (and a maximum of 84 months),” he reported.

—Gale Jurasek

Reference
1. Date H, Tanimoto Y, Goto K, et al. A new treatment strategy for advanced idiopathic interstitial pneumonia: living-donor lobar lung transplantation. Chest. 2005;128:1364-1370.

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