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Right arrow Lung - transplantation

Ann Thorac Surg 2005;79:418-425
© 2005 The Society of Thoracic Surgeons

Original article: General thoracic

Long-term Pulmonary Function After Living-Donor Lobar Lung Transplantation in Adults

Michael E. Bowdish, MD, Renzo Pessotto, MD, Richard G. Barbers, MD, Felicia A. Schenkel, RN, Vaughn A. Starnes, MD, Mark L. Barr, MD*

Department of Cardiothoracic Surgery, University of Southern California Keck School of Medicine, Los Angeles, California

Accepted for publication July 6, 2004.

* Address reprint requests to Dr Barr, Department of Cardiothoracic Surgery, University of Southern California Keck School of Medicine, 1520 San Pablo St, Suite 4300, Los Angeles, CA 90033 (E-mail: mbarr{at}surgery.usc.edu).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
BACKGROUND: Living-donor lobar lung transplantation was developed as an alternative to cadaveric transplantation. However, whether two pulmonary lobes provide comparable intermediate and long-term pulmonary function to full-sized bilateral cadaveric grafts in adults is unknown.

METHODS: An analysis of the pulmonary functions of 59 bilateral lobar and 43 bilateral cadaveric adult lung transplant recipients who survived more than 3 months after transplantation was performed.

RESULTS: Mean follow-up was 3.8 ± 2.8 years. In lobar recipients, mean percent predicted forced vital capacity and forced expiratory volume in 1 second improved between 1 and 6 months after transplantation (42.5% ± 13.4% and 46.9% ± 14.0% at 1 month versus 63.6% ± 14.1% and 64.5% ± 13.7% at 6 months; p < 0.001 and <0.001, respectively). In cadaveric recipients, mean percent predicted forced vital capacity improved after transplantation (54.3% ± 14.5% at 1 month versus 74.2% ± 21.3% at 12 months; p < 0.01). As compared with the cadaveric group, mean percent predicted forced vital capacity and forced expiratory volume in 1 second were lower 1 and 3 months after transplantation in the lobar recipients (p = 0.001 at both times); however, by 6 months after transplantation, these values were comparable and remained so throughout the follow-up period. In a subset of lobar and cadaveric recipients, maximal exercise, heart rate, peak oxygen consumption, anaerobic oxygen consumption threshold, and ability to maintain oxygen saturation were also comparable.

CONCLUSIONS: In those adult recipients surviving more than 3 months after transplantation, lobar lung transplantation provides comparable intermediate and long-term pulmonary function and exercise capacity to bilateral cadaveric lung transplantation.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
The number of patients awaiting lung transplantation has steadily increased during the past decade owing to its acceptance as an established treatment modality for patients with end-stage lung disease [1]. Although demand has increased, the number of suitable cadaveric lung donors has remained relatively stable with virtually no increase since 1993 despite liberalizing the standard donor criteria and the use of older and more marginal donors [2]. These trends have led to a leveling off of the annual lung transplantation rate and a doubling of the median waiting time [1].

Living lobar lung transplantation was introduced in 1993 as an alternative to cadaveric lung transplantation for patients considered too ill to await a cadaveric organ [3]. With this technique 2 healthy donors are selected—one to undergo removal of the right lower lobe and the other, the left lower lobe. These lobes are then implanted in the recipient in place of whole right and left lungs, respectively.

Although perioperative and early functional outcomes and survival have been acceptable with this technique [3–11], there has been concern whether the relatively undersized bilateral lobar grafts would provide comparable pulmonary function to full-sized bilateral cadaveric grafts in adult recipients. The purpose of this study was to compare functional outcomes, in terms of pulmonary function and exercise studies, between adult recipients of living lobar and bilateral cadaveric allografts surviving more than 3 months after transplantation.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Acknowledgments
 References
 
Study Subjects and Design
Between January 1993 and September 2002, 125 adult patients (≥18 years of age) underwent bilateral lung transplantation at the University of Southern California. Seventy-nine patients underwent living-donor lobar lung transplantation, and 46 underwent bilateral cadaveric lung transplantation. Those lobar and cadaveric recipients surviving more than 3 months after transplantation constitute the cohort of patients for this analysis. Changes in pulmonary function with time in each group and a comparison of the lobar recipients to the cadaveric recipients at each time were analyzed.

Living Lobar and Bilateral Cadaveric Lung Transplantation
All patients fulfilled the criteria for cadaveric lung transplantation and were listed with the United Network for Organ Sharing. Living lobar lung transplantation recipients were selected primarily on the basis of a deteriorating clinical status with the expectation that a cadaveric donor would not become available in a suitable time frame. The process of living donor selection and the techniques of right and left donor lobectomy have been described previously [3–5, 11, 12]. Bilateral lobar and cadaveric lung transplant procedures were performed through a transverse thoracosternotomy with the use of cardiopulmonary bypass, using a running polypropylene suture for the bronchial anastomosis [3–5, 11, 13]. There were no differences in either the immunosuppressive or infection prophylaxis protocols in either the living lobar or bilateral cadaveric lung transplant groups. All patients received triple immunosuppressive therapy consisting of cyclosporine or tacrolimus, azathioprine or mycophenolate mofetil, and prednisone, without the use of prophylactic monoclonal or polyclonal antibodies [11]. All patients received standardized prophylaxis against candida, Pneumocystis carinii, and cytomegalovirus [11]. In addition, those patients with cystic fibrosis received antibiotic regimens on the basis of the results of perioperative cultures. Unique aspects of the perioperative management of the bilateral lobar recipient related to the lobar physiology, as well as donor management, have been previously described [11].

Postoperative Evaluation of Pulmonary Function
After transplantation, pulmonary function testing was performed in all patients to obtain the forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and mid-forced expiratory flow (FEF25 to 75) at 1 month, 3 months, 6 months, 1 year, and every year thereafter. Values were recorded as percent predicted based on recipient age, sex, and height [14].

Exercise Testing
Incremental symptom-limited maximal exercise testing was performed using a modified Bruce protocol. After an initial 5-minute resting period, the patients were exercised on a treadmill with incremental workloads (10 to 16 W/min). Data collected included maximum workload (watts), heart rate, and oxygen consumption at anaerobic threshold and peak exercise. Predicted values for exercise variables were as described for incremental exercise testing [15]. The anaerobic threshold was identified noninvasively according to standard criteria [16].

Statistical Analysis
Data are presented as the mean ± standard deviation. Dichotomous variables among the groups were compared using Fisher's exact test. Continuous variables between the two groups were compared using the unpaired Student's t test if the variance was equal or a Mann-Whitney test if the variance was unequal. In addition to examining intergroup differences in pulmonary function at each time, differences within each group as a function of time were also analyzed using a one-way analysis of variance. Kaplan-Meier survival curves for the two groups were compared with the log rank (Mantel-Haenszel) test. A p value less than or equal to 0.05 was considered statistically significant. GraphPad version 3.03 for Windows (GraphPad Software, Inc, San Diego, CA) was used for all statistical analysis.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Acknowledgments
 References
 
Overall Survival
Overall initial 3-month survival among all 125 recipients of bilateral lung transplantation at our institution during the study period was significantly lower in the lobar recipients as compared with recipients of bilateral cadaveric grafts. Twenty (25%) lobar recipients died in the first 3 months after transplantation, whereas only 3 (6.5%) died in the cadaveric group (p = 0.009). The 59 living lobar and 43 bilateral cadaveric lung transplant recipients surviving more than 3 months after transplantation constitute the subjects of the following analysis.

Demographics
Demographics, indications for transplantation, and preoperative characteristics for the two groups are listed in Table 1. The lobar recipients were significantly younger than the cadaveric recipients. Cystic fibrosis was the indication for transplantation in 95% of lobar recipients, whereas the indications in the cadaveric recipients were more diverse. Cadaveric recipients tended to be outpatients at the time of transplantation, whereas 73% of lobar recipients were hospitalized at the time of transplantation with 12% being ventilator dependent (as compared with only 1 cadaveric patient who was ventilator dependent and hospitalized at the time of transplantation).


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  		Table 1. Demographics, Indications for Transplantation, Preoperative, and Follow-Up Characteristics in Three-Month Survivors of Bilateral Cadaveric and Living Donor Lobar Lung Transplantation
 
Late Mortality in Three-Month Survivors of Living Lobar and Bilateral Cadaveric Lung Transplantation
The mean follow-up was similar between the two groups of lung transplant recipients (4.1 ± 2.9 years in the lobar recipients versus 3.5 ± 2.6 years in cadaveric recipients; p = 0.29). The primary cause of death was predominantly pneumonia or sepsis in both groups and no significant differences in cause of death were seen between the two groups (Table 2). There was no significant difference in overall survival between these two groups of patients surviving at least 3 months after either living lobar or cadaveric lung transplantation: conditional 1-, 3-, and 5-year actuarial survival was 83%, 81%, and 75% in cadaveric recipients and 83%, 64%, and 62% in lobar recipients (Fig 1; p = 0.32).


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  		Table 2. Causes of Death in Three-Month Survivors of Bilateral Cadaveric and Living Donor Lobar Lung Transplants
 


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  		Fig 1. Kaplan-Meier survival curves and number of patients at risk at each time for recipients of bilateral cadaveric ({blacktriangleup}) and living donor lobar ({blacksquare}) lung transplants surviving more than 3 months after transplantation. There was no difference in survival between these two groups (p = 0.32).

 
Analysis of Pulmonary Function Tests in Living Lobar and Bilateral Cadaveric Lung Transplant Recipients
As shown in Figure 2, mean percent predicted FVC and FEV1 were significantly lower at 1 and 3 months after transplantation in the lobar recipients as compared with the cadaver recipients; however, by 6 months after transplantation, there were no differences in these values between the groups. Mean percent predicted FEF25 to 75 was lower in the lobar group 1 month postoperatively as compared with the cadaveric group, but no difference was seen after this time.



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  		Fig 2. Pulmonary function tests with time in recipients of bilateral cadaveric ({blacktriangleup}) and living donor lobar ({blacksquare}) lung transplants surviving more than 3 months after transplantation. Sample size at each time is also shown. Values are shown as the mean ± standard deviation. (A) Percent predicted forced vital capacity (FVC) was significantly lower in the lobar group at 1 and 3 months after transplantation compared with the cadaveric group (*42.5% ± 13.4% and 50.0% ± 14.4% versus 54.3% ± 14.5% and 64.7% ± 18.7%; p = 0.0006 and p = 0.0004, respectively). Significant improvements in FVC occurred between 1 and 6 months in the lobar group (**42.5% ± 13.4% versus 63.6% ± 14.1%; p < 0.001) and between 1 and 12 months (***42.5% ± 13.4% versus 67.7% ± 16.6%; p < 0.01) in the cadaveric group. (B) Percent predicted forced expiratory volume in 1 second (FEV1) was significantly lower in the lobar group at 1 and 3 months after transplantation compared with the cadaveric group (*46.9% ± 14.0% and 52.9% ± 14.7% versus 64.5% ± 21.0% and 68.1% ± 24.4%; p = 0.0001 and p = 0.0031, respectively). Significant improvements in FEV1 occurred between 1 and 6 months in the lobar group (**46.9% ± 14.0% versus 64.5% ± 13.7%; p < 0.01), although no change with time occurred in the cadaveric group. (C) Percent predicted mid-expiratory flow (FEF25–75) was lower at 1 month after transplantation in the lobar group (*65.2% ± 27.7% versus 95.2% ± 51.0%; p < 0.006); however, no between-group differences were seen after this time. The mid-expiratory flow also did not change with time in either the lobar or cadaveric group.

 
Analysis of pulmonary function changes with time in the lobar group showed that significant improvements occurred in FVC and FEV1 between 1 and 6 months after transplantation (42.5% ± 13.4% and 46.9% ± 14.0% at 1 month versus 63.6% ± 14.1% and 64.5% ± 13.7% at 6 months; p < 0.001 and p < 0.001, respectively), but no changes occurred in FEF25 to 75 with time. Analysis of pulmonary function changes with time in the cadaveric group showed that only FVC improved after transplantation from 54.3% ± 14.5% to 74.2% ± 21.3% between 1 and 12 months (p < 0.01), but that no change with time occurred in FEV1 or FEF25 to 75.

To determine whether the improvement seen in pulmonary function in the lobar recipients by 6 months after transplantation (at which time the values became comparable to the cadaveric recipients) was related to the death of lobar lung transplant recipients with shorter survival and presumably worse pulmonary function, a subgroup analysis was conducted. In this cohort of lobar recipients surviving at least 3 months after transplantation, pulmonary function was compared between those surviving less than 2 years and those surviving at least 2 years after transplantation. As shown in Figure 3, FVC and FEV1 were similar in lobar recipients surviving less than or at least 2 years at 1, 3, and 6 months after transplantation. At 12 months, FVC and FEV1 were lower in those patients who survived less than 2 years (57.6% ± 16.3% and 59.6% ± 21.2% versus 70.8% ± 15.6% and 74.2% ± 15.2%; p = 0.03 and p = 0.03, respectively). No differences in FEF25 to 75 were detected in these two groups of patients. Forced vital capacity and FEV1 showed significant improvements between 1 and 6 months in those lobar recipients surviving at least 2 years, whereas only FVC improved in the same time period in those lobar recipients surviving less than 2 years.



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  		Fig 3. Comparison of pulmonary function tests with time in recipients of living donor lobar lung transplants surviving more than 3 months but less than 2 years after transplantation (<2 years survival; {blacksquare}) versus recipients surviving at least 2 years (≥2 years survival; {blacktriangleup}). Sample size at each time is also shown. Values are shown as the mean ± standard deviation. (A) Percent predicted forced vital capacity (FVC) was comparable in these two groups until 12 months after transplantation (*p = 0.03), when those surviving less than 2 years showed a decline compared with those surviving at least 2 years. Both groups showed significant improvements between 1 and 6 months after transplantation (**p < 0.05; ***p < 0.001). (B) Percent predicted forced expiratory volume in 1 second (FEV1) was comparable in these two groups until 12 months after transplantation (p = 0.03), when those surviving less than 2 years showed a decline compared with those surviving at least 2 years. There was no change with time in the less than 2 years group, while the at least 2 years group showed an improvement between 1 and 6 months after transplantation (**p < 0.001). (C) Percent predicted mid-expiratory flow (FEF25 to 75) was comparable in these two groups and did not change with time in either group.

 
A similar analysis was conducted with the bilateral cadaveric recipients to determine whether the improvement seen in pulmonary function in these recipients was related to the death of recipients with shorter survival and worse pulmonary function. Interestingly, those patients surviving less than 2 years in the cadaveric cohort did not demonstrate the same decline in FVC or FEV1 at 12 months after transplantation as seen in the lobar group (Fig 4).



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  		Fig 4. Comparison of pulmonary function tests with time in recipients of bilateral cadaveric lung transplants surviving more than 3 months but less than 2 years after transplantation (<2 years survival; {blacksquare}) versus recipients surviving at least 2 years (≥2 years survival; {blacktriangleup}). Sample size at each time point is also shown. There were no differences in mean percent predicted forced vital capacity (FVC; A), forced expiratory volume in 1 second (FEV1; B), or mid-expiratory flow (FEF25 to 75; C) between the less than 2 years or at least 2 years survival groups.

 
Exercise Capacity
Incremental, symptom-limited, maximal exercise testing was performed in a cohort of living lobar and bilateral cadaveric lung transplant recipients at a mean interval of 2.1 ± 0.8 years after transplantation as described in the Methods section. Lobar and cadaveric recipients reached similar maximum workloads at peak exercise, maximum heart rates, peak oxygen consumption, and oxygen consumption at anaerobic thresholds (Table 3). Oxygen saturation was well maintained in both the lobar and cadaveric recipients throughout the testing period.


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  		Table 3. Results of Exercise Testing in Recipients of Living Donor Lobar (n = 8) and Bilateral Cadaveric Lung Transplants (n = 9) at a Mean Interval of 2.1 ± 0.8 Years After Transplantationa
 
Freedom From Obliterative Bronchiolitis and Bronchiolitis Obliterans Syndrome
Freedom from obliterative bronchiolitis, diagnosed pathologically, or bronchiolitis obliterans syndrome, diagnosed by standard spirometric criteria [17], in these recipients at 1, 3, and 5 years was 98%, 85%, and 79% in the living lobar cohort, and 100%, 100%, and 78% in the bilateral cadaveric cohort. By Kaplan-Meier analysis, the actuarial freedom from obliterative bronchiolitis and bronchiolitis obliterans syndrome did not differ between these two groups of patients (Fig 5; p = 0.52).



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  		Fig 5. Freedom from obliterative bronchiolitis (OB) and bronchiolitis obliterans syndrome (BOS) in adult recipients surviving more than 3 months after either bilateral living donor lobar ({blacksquare}) or cadaveric ({blacktriangleup}) lung transplantation. There was no difference between these two groups (p = 0.52).

 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Acknowledgments
 References
 
Although demand for clinical lung transplantation has increased during the last decade, the availability of cadaveric donors has failed to increase to the same degree despite liberalizing the donor criteria and the use of older, more marginal donors [1, 2]. In response to the cadaveric lung donor shortage, living donor lobar lung transplantation was introduced in 1993 [3]. With this technique, right and left lower lobes from a pair of adult donors are transplanted into adult or pediatric recipients in place of the entire right and left lungs. As opposed to bilateral cadaveric lung transplantation, this creates the unique physiologic situation whereby respiratory function is entirely dependent on the two relatively undersized pulmonary lobes.

In our intermediate report in 1996, we demonstrated that postoperative pulmonary function testing in 27 adult and 10 pediatric lobar lung transplant recipients generally showed a steady improvement that plateaued by postoperative month 9 to 12. In 15 of those patients with at least 1 year of follow-up at that time, mean FVC, FEV1, and FEF25 to 75 were 72%, 73%, and 92% predicted, respectively [4]. A separate analysis of 8 patients (3 adults, 5 pediatric) who underwent living donor lobar lung transplantation for indications other than cystic fibrosis again showed a gradual progressive improvement in pulmonary function that tended to plateau by postoperative month 9 to 12. In the 5 of these patients with at least 1 year follow-up at the time of the report, mean FVC, FEV1, and FEF25 to 75 were 80.6%, 75.6%, and 64% predicted, respectively [5]. These results are similar to those reported in bilateral cadaveric transplantation, which have shown improvements in FEV1, FVC, and diffusing capacity for the first 6 to 12 months after transplantation, after which time lung function tends to decline at a variable rate and is highly influenced by the presence or absence of complications [18–20].

Although the flow values seen previously with lobar transplantation seem acceptable and comparable to reports of bilateral cadaveric lung transplantation, a direct comparison of the short-term and long-term pulmonary function in adult bilateral cadaveric and living donor lobar lung transplantation has not been reported. The purpose of this study was therefore to evaluate and compare the pulmonary function of adult living donor lobar and bilateral cadaveric lung transplant recipients who survived at least 3 months after transplantation.

Patients receiving lobar grafts were significantly younger than the cadaveric recipients. This is consistent with the large percentage of patients with cystic fibrosis in this group of patients. Despite excluding lung transplant recipients expiring within 3 months of transplantation, and consistent with our previous reports [3–5, 7, 8], the lobar recipients were significantly sicker then the cadaveric cohort as demonstrated by the large percentage of lobar recipients hospitalized or ventilator dependent at the time of transplantation. Although the cause of death and preoperative characteristics of the recipients who expired in the first 3 months after transplantation are not included in this analysis, it is generally felt that the sicker nature of the lobar recipients is responsible for the higher 3-month mortality in the living lobar as compared with bilateral cadaveric recipients.

Analysis of pulmonary function after both living donor lobar and bilateral cadaveric lung transplantation showed that both groups of recipients demonstrated improvement during the first year after transplantation and that pulmonary function was equivalent between the groups by 6 months after transplantation. Lobar recipients demonstrated an improvement in both FVC and FEV1 by 6 months after transplantation, whereas cadaveric recipients had an improvement in FVC by 12 months after transplantation and maintained a stable FEV1. As discussed above, these results are similar to other reports of bilateral lung transplantation for a variety of indications including cystic fibrosis, obstructive airway disease, and pulmonary vascular disease [21–23], as well as to our initial reports with living donor lobar transplantation [3–5, 7, 8]. In addition, these data also demonstrate that pulmonary function in lobar recipients does not decline significantly with time after reaching a steady state, at least through 36 months postoperatively. After this time, the number of patients becomes small, and further follow-up is needed, as some decline would be expected because of the development of such processes as bronchiolitis obliterans and other complications [17, 24].

The comparison of pulmonary function between the living donor lobar and cadaveric recipients with time demonstrated that FVC and FEV1 were significantly lower at 1 and 3 months after transplantation in the living donor lobar group as compared with the cadaveric group. However, by 6 months after transplantation this difference had resolved, and the values remained equivalent throughout the study period. These results are somewhat intriguing, although not entirely unexpected. It is generally accepted that the initial improvement seen in pulmonary function during the first year after transplantation is in large part caused by improved chest wall mechanics and alveolar recruitment, which occur with operative recovery [25, 26]. However, the process is undoubtedly multifactorial and influenced by other factors such as pulmonary compliance, episodes of infection and rejection, and other postoperative complications.

Although one might have expected the lobes in the lobar recipients to have persistently decreased flows as compared with bilateral cadaveric grafts from a strict physiologic standpoint, it seems likely that the lobes are able to provide similar flows through both careful donor and recipient selection (whereby a relatively large lobe is placed in a relatively small recipient) and through continued alveolar dilatation and recruitment in the graft as opposed to growth [27]. The explanation of the lower FVC and FEV1 seen at 1 and 3 months in lobar recipients as compared with bilateral cadaveric recipients is likewise multifactorial, but is likely related to topographic and resulting mechanical issues because of the fact that the lobe is not perfectly opposed to the chest wall, as occurs with bilateral cadaveric grafts. It is possible that with time and scarring, the mechanics between the chest wall and lobe improve, resulting in an improvement in pulmonary flows as demonstrated in this study.

An additional possibility is that the improvement seen in FVC and FEV1 in the lobar recipients after 3 months was the result of the death of those recipients with lower pulmonary flows, as opposed to a general improvement in the group. We therefore conducted a subgroup analysis comparing the pulmonary function of those recipients who survived less than or at least 2 years after transplantation. Those lobar recipients surviving less than 2 years after transplantation did demonstrate a drop in FEV1 and FVC at 12 months after transplantation. No differences were seen in the cadaveric analysis; thus the improvement seen with time in the cadaveric group is unlikely to be caused by the early death of recipients with poorer pulmonary functions. In addition, because the bilateral cadaveric and living donor lobar FEV1 and FVC were comparable by 12 months after transplantation, and the decrease seen in FEV1 and FVC in the subgroup analysis of lobar recipients was not seen until 12 months after transplantation, it seems that the overall improvement in the lobar group occurs despite the decrease seen at 12 months in the lobar recipients who survived less than 2 years, implying that the FEV1 and FVC of the lobar group also improve during the first 12 months postoperatively. This drop in FEV and FVC seen in the less than 2-year lobar survivors at 12 months could also potentially serve as a marker of lobar recipients with higher rates of mortality; however, further analysis with a larger cohort would be needed for validation. Interestingly there were no significant changes in mid-expiratory flows, which have been shown to precede changes in FEV1 in patients who develop bronchiolitis obliterans syndrome [28].

Exercise capacities were also comparable in the lobar and cadaveric lung transplant recipients when assessed by exercise stress testing. Although the peak oxygen consumptions achieved by both groups of transplant recipients are below 80% of the normal predicted value, they are certainly adequate to permit a comfortable lifestyle and at least moderate levels of work and exercise [16]. These peak exercise capacities are similar to those previously reported for recipients of double lung and heart-lung transplants [20, 29].

Limitations of the present study include the relatively small sample number of patients in each group, especially at the more distant time points, and the different demographics of the patients undergoing living donor lobar versus bilateral cadaveric lung transplantation in terms of age, underlying lung disease, and preoperative severity of illness. To assess the long-term pulmonary function, we analyzed patients who survived at least 3 months after transplantation. This type of death-censored analysis has the obvious potential of introducing a selection bias in the population of the long-term patients who were characterized and compared in the study.

Living donor lobar lung transplantation has been lifesaving in severely ill patients who would either die or become unsuitable recipients before a cadaveric organ becomes available. The results of this study are important in addressing the concern of whether the relatively undersized bilateral lobar grafts can provide comparable pulmonary function to full-sized bilateral cadaveric grafts in the adult recipient. Although initial pulmonary flows are lower after transplantation, by 6 months after transplantation, the values are similar in both living donor lobar and bilateral cadaveric lung transplant recipients. Additionally, the living donor lobar recipients are able to reach similar levels of exercise tolerance. Although cadaveric transplantation is preferable because of the inherent risk to the donors, living donor lobar lung transplantation should continue to be used under properly selected circumstances [30].


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
References
 
We gratefully acknowledge the assistance of Susan M. Farr, RPFT, and Cynthia Schmitz, MA, RCEP, in performing and collecting pulmonary function and exercise testing studies in the lung transplant recipients at the University of Southern California. This work was supported by a grant to Doctor Barr from the Cystic Fibrosis Foundation (CFF G965). Additional support was provided by grants from the Heart and Lung Surgery Foundation of Los Angeles, the University of Southern California University Hospital, and the Hastings Foundation. Doctor Bowdish was the recipient of the 2002 American Society of Transplant Surgeons Thoracic Surgery Fellowship.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Pierson III RN, Barr ML, McCullough KP, et al. Thoracic organ transplantation Am J Transplant 2004;4(Suppl 9):93-105.
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  11. Baker CJ, Barr ML, Schenkel FA, Starnes VA. Living donor lung transplantationIn: Baumgartner WA, Reitz B, Kasper E, Theodore J, editors. Heart and lung transplantation. Philadelphia: WB Saunders; 2002503–10.
  12. Schenkel FA, Barr ML, Starnes VA. Living-donor lobar lung transplantation: donor evaluation and selectionIn: Norman DJ, Turka LA, editors. Primer on transplantation. Moorestown, NJ: American Society of Transplantation; 2001645–7.
  13. Conte JV, Reitz BA. Operative technique of single-lung, bilateral lung, and heart-lung transplantationIn: Baumgartner WA, Reitz B, Kasper E, Theodore J, editors. Heart and lung transplantation. Philadelphia: WB Saunders; 2002200–16.
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  17. Estenne M, Maurer JR, Boehler A, et al. Bronchiolitis obliterans syndrome 2001: an update of the diagnostic criteria J Heart Lung Transplant 2002;21:297-310.[Medline]
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