P.M Schuler

Single center comparison of pediatric living donor lobar and cadaveric lung transplant

Abstract Living donor lobar transplant (LDLT) has been used to address the ongoing shortage of cadaveric lungs and unpredictable course of end-stage lung disease. Because LDLT involves putting two healthy patients at risk, we compared outcomes between cadaveric lung transplant and LDLT. From July 1994 to May 2002, 38 LDLTs were performed at this center. A cohort of cadaveric recipients, also transplanted here during that era, matched by age at transplant, sex and underlying disease was selected to serve as a controls. LDLT recipients were less stable at the time of transplant: more patients (12/38) in the LDLT cohort were mechanically ventilated compared to 2/38 in the controls. The average ischemic times were significantly shorter in the LDLT patients (1:32) compared to controls (4:46). One and 3 year survival for the LDLT recipients was 60 % and 48% compared to 89% and 58% for the control cohort. The difference in Kaplan-Meier survival curves was statistically significant (P=0.03). There was no difference in the incidence of acute rejection between the LDLT and control cohorts. Post-transplant FEV 1 and FVC were not significantly different. However, freedom from bronchiolitis obliterans syndrome (BOS) at 1 and 3 years was 92% and 85% compared to 75% and 53% in the cadaveric cohort (P=0.03). Not surprisingly, the causes of death in the LDLT population reflected this difference. Only 2/24 (8%) of deaths in the LDLT cohort were due to BOS compared to 8/18 (45%) of deaths in the control cohort. In contrast, 11/24 (46%) of deaths in the LDLT cohort were related to infection compared to 2/18 (11%) in the control population. Based on this comparison, we conclude that LDLT can be performed successfully in pediatric patients. Although the decreased incidence of BOS makes us optimistic about the long-term survival of LDLT recipients, efforts focusing on minimizing infectious complications are necessary to improve overall survival.

Lung transplantation in infancy

Abstract Purpose: Neonates and infants have an unusual spectrum of end stage pulmonary diseases distinguishing them from other patients undergoing bilateral lung transplant (BLT). This study was undertaken to review a single institutional experience with BLT in infants 1 year of age or less. Procedures: A retrospective review was performed of pediatric patients who underwent BLT between January 1990 and September 2002. Results: A total of 207 children under the age 18 years underwent primary BLT, 34 (16.4%) of which were infants. Major disease entities prompting BLT included pulmonary hypertension of varying etiologies (n=13), pulmonary alveolar proteinosis (n=11), and infantile interstitial pneumonitis (n=5). Prior to transplant, 10 patients were on ECMO and 27 were on mechanical ventilatory support. Median wait list time was 22 days (2–15 days), median age at transplant was 127 days (36 days–1 year) and median weight was 5.2 kg (3.2–11.8 kg). Median length of ventilatory support post-transplant was 16.5 days (2–89 days) and median hospital stay was 20 days (4–79 days). Hospital mortality of 24% (8/34). Acute rejection was rare with an average of only 0.2 episodes per patient despite routine surveillance biopsies. One and 5-year survivals were 70% and 53% respectively with a mean follow-up time of 4 years. Freedom from bronchiolitis obliterans (BO) at 1 and 5 years was 92% and 78% compared to 80% and 43% in the other 173 lung transplants performed during this interval (p=0.02). Two retransplants were performed both within 6 months of primary transplant, one of whom is a long-term survivor. Conclusions: Acceptable mortality and long term survival can be achieved in infants undergoing BLT. As incidence of BO is significantly decreased in this patient population, avoidance of factors contributing to early mortality should lead to long-term survival that supersedes that seen in older patients undergoing BLT.