110: Living Lobar Lung Transplantation

Introduction

Living lobar lung transplantation was developed as an alternative to deceased donor lung transplantation because of the shortage of acceptable donor organs.^1,2 In living lobar lung transplantation, two healthy donors are selected—one to undergo removal of the right lower lobe and the other to undergo removal of the left lower lobe. These lobes then are implanted in the recipient in place of whole right and left lungs. This technique has proved to be beneficial to a group of patients who otherwise would have succumbed to disease while awaiting lungs from a conventional deceased donor.³

General Principles and Patient Selection

Living lobar lung transplant candidates should meet the standard criteria for deceased donor lung transplantation and be listed on the Organ Procurement and Transplantation Network lung transplantation waiting list.⁴ The expectation for potential recipients should be that they will either die before a deceased donor lung becomes available or become too ill to undergo any sort of organ transplant procedure. In the United States, cystic fibrosis has been the most common indication for living lobar lung transplantation. Other indications have included primary pulmonary arterial hypertension (PAH), pulmonary fibrosis, bronchopulmonary dysplasia, and obliterative bronchiolitis.² In Japan, which is the country where the second highest numbers of these cases have been performed and where cystic fibrosis is very rare, the most frequent indications have been PAH, obliterative bronchiolitis (including a subset of patients with prior hematopoietic stem cell transplantation), and interstitial pneumonia.⁵

The goals of donor selection are to identify donors with excellent health, adequate pulmonary reserve for lobar donation, an emotional attachment to the recipient, and a willingness to accept the risks of donation without coercion. Our criteria for donation also include age between 18 and 55 years, no history of thoracic procedures on the side to be donated, and excellent general health. Donors taller than the recipient are favored over donors of the same or lesser height because they have the potential to provide larger lobes. Initially, only the mother and father of the recipient were considered as donors; however, lobes from siblings, extended family members, and unrelated individuals who can demonstrate an emotional attachment to the recipient are also presently considered. A psychosocial interview is conducted. Potential donors are interviewed both separately and with the potential recipient's family to ascertain interpersonal dynamics. Elements of the interview include the motivation to donate, pain tolerance, feelings regarding donation should the recipient expire, and the ability of the potential donor to be separated from family and career obligations. Since an element of coercion always can exist between a potential donor and the recipient and/or the recipient's family, any potential donor who discloses that he or she feels any pressure to donate after careful consultation and explanation of the procedure is denied for unspecified reasons, thus preventing untoward feelings between the family, recipient, and potential donor.