Ann Thorac Surg 2006;81:1131-1132
© 2006 The Society of Thoracic Surgeons
Case report
Two Successful Lung Transplantations From a Dialysis-Dependent Donor
Dekel Shlomi, MD
a
,
David Shitrit, MD
a
,
Daniele Bendayan, MD
a
,
Gidon Sahar, MD
b
,
Milton Saute, MD
b
,
Mordechai R. Kramer, MD
a
,
*
a Pulmonary Institute and Department of Cardiothoracic Surgery, Rabin Medical Center, Beilinson Campus, Petah Tiqva, Israel
b Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
Accepted for publication January 20, 2005.
* Address correspondence to Dr Kramer, Pulmonary Institute, Rabin Medical Center, Beilinson Campus, Petah Tiqva, 49100 Israel (Email: kramerm{at}netvision.net.il).
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Abstract
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The shortage of organs for lung transplantation has led to the growing use of "marginal" donors. Although patients on hemodialysis are still excluded as lung transplant donors because of the possible effects of renal failure on the lungs, recent data suggest that they may be suitable in selected cases. This article describes the successful transplantation of two lungs from a single donor who had been receiving long-term hemodialysis treatment. In the absence of other causes of pulmonary diseases, such as smoking or lung infection, lungs from dialysis-dependent patients may be acceptable for lung transplantation.
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Introduction
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After obliterative bronchiolitis, the donor shortage is the greatest problem for lung transplantation. This has led to a growing number of reports of the use of "marginal" donors. Today subjects older than 55 years, subjects with a history of tobacco use of more than 20 pack-years, patients with mild radiographic abnormalities on chest roentgenogram or minor gas exchange abnormalities, patients receiving mechanical ventilation for more than 5 days, and even subjects with a history of inhaled drug abuse (cocaine and marijuana) may be accepted as potential lung donors [1]. Although end-stage renal disease requiring chronic hemodialysis is still considered a contraindication, several studies of pulmonary function in patients with end-stage renal disease have demonstrated relatively good lung functions [2–5]. We describe the transplantation of two lungs from a donor who had been treated with hemodialysis for several years. The literature on lung function in this patient population is reviewed. We were able to find only one additional report of two lung transplantations from two dialysis-dependent donors with end-stage renal disease, both with a favorable outcome [6].
The donor was a 59-year-old man with diabetic nephropathy who had been treated by peritoneal dialysis for 2 years followed by hemodialysis for 6 years. The patient did not smoke and did not have any pulmonary disease. He died of intracranial bleeding and his lungs were mechanically ventilated for 36 hours. Chest roentgenogram findings were unremarkable. Blood gas analysis showed a partial arterial oxygen tension (PaO
2) of 450 mm Hg over a fraction of inspired oxygen (FIO
2) of –1.
The donor's two lungs were transplanted in 2 patients simultaneously. The first recipient was a 52-year-old woman with idiopathic pulmonary fibrosis (usual interstitial pneumonia) treated with oral steroids and azathioprine. She was oxygen-dependent and markedly limited in activities of daily living. She underwent right lung transplantation with an ischemic time of 3 hours and the tracheal tube removed after 12 hours. Several days later, pneumonia developed in the transplanted lung and was treated successfully with meropenem. The patient was discharged from the hospital 27 days after transplantation. Transbronchial biopsy 1 month after transplantation showed mild fibrosis and interstitial inflammation without evidence of rejection. Today, one year after transplantation, the patient is oxygen-free and able to climb one flight of stairs. Forced expiratory volume in 1 second increased from 33% of predicted value before transplantation to 52%.
The second recipient was a 60-year-old woman with emphysema secondary to heavy smoking. Pulmonary function tests showed forced expiratory volume in 1 second (34%), total lung capacity (124%), residual volume (238%), and carbon dioxide diffusion (54%) of predicted values. The patient had significant limitation in activities of daily living and was being treated with bronchodilators and nocturnal oxygen. She underwent left lung transplantation from the same donor with extubation after 24 hours. Recovery was excellent, and the patient was discharged from the hospital 15 days after transplantation. Several weeks later she complained of increasing shortness of breath. Bronchoscopy revealed left main bronchial stenosis at the anastomosis site that was treated with stent insertion. Today, one year after transplantation, the patient is oxygen-free and able to climb one flight of stairs without dyspnea. Forced expiratory volume in 1 second is 50% of predicted value.
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Comment
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Although end-stage renal disease treated with peritoneal dialysis or hemodialysis can have secondary pulmonary effects, in nonsmokers without primary lung disease, the changes are only minor. In a study of 29 patients on chronic dialysis, Myers and colleagues [7] found nearly normal pulmonary function in 23 patients and a minor restrictive pattern in 6. Volume overload between dialysis sessions had no effect on pulmonary function. There was a trend toward mild overinflation and air trapping in the presence of normal airway resistance, indicating narrowing of the terminal airways. Bush and Gabriel [2] reported a minor, clinically nonsignificant reduction in spirometric variables in a patient on hemodialysis. There was a small increase in residual volume and a mild reduction in carbon dioxide diffusion of 87.5% of predicted value. Herrero and colleagues [3] noted that patients receiving hemodialysis for more than 5 years had a lower carbon dioxide diffusion than patients before hemodialysis treatment and patients receiving hemodialysis for less than 12 months. However, given the fact that the mean carbon dioxide diffusion of the patients on hemodialysis for more than 5 years was near normal (86.2% of predicted value), the clinical relevance of these changes is questionable.
Mild pulmonary hypertension was found in 37.9% of patients on hemodialysis by Yigla and colleagues [8]. Four of 6 patients with normal pulmonary arterial pressure had developed mild to moderate pulmonary hypertension after the onset of hemodialysis. One-minute arteriovenous access compression in 4 patients decreased the mean systolic pulmonary arterial pressure from 52 ± 7 to 41 ± 4 mm Hg. Interestingly, the hypertension normalized in 4 of 5 patients who underwent kidney transplantation. This data indicates that while mild to moderate pulmonary hypertension may develop during hemodialysis treatment, this phenomenon is reversible in most cases and may be related to a high cardiac output state. In our opinion, mild to moderate pulmonary hypertension in hemodialysis patients should not be a contraindication for lung donation. However more studies are required.
Hemodialysis may be associated with mild transient hypoxemia [4, 5]. Possible mechanisms are complement activation leading to leukocyte activation and stasis at the pulmonary vessels, the type of membrane and dialysate buffer, or carbon dioxide loss that leading to hypoventilation. Therefore the hypoxemia does not reflect a real pulmonary disease.
Our review of the English language medical literature yielded only two additional cases of lung transplantation from dialysis-dependent donors [6], both successful. The first involved a 54-year-old man with chronic obstructive pulmonary disease who received a left lung transplant from a 27-year-old man who had been on hemodialysis for focal glomerular sclerosis. The second involved a 19-year-old woman with cystic fibrosis who underwent successful bilateral lung transplantation.
Our patients underwent successful lung transplantation from the same donor, a nonsmoker on hemodialysis for 6 years for diabetic nephropathy. Both patients had good recoveries without complications related to the quality of the lungs from the donor.
We conclude that in the absence of other causes of pulmonary disease, such as smoking or lung infection, dialysis-dependent patients can serve as donors for lung transplantation.
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References
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- Bhorade SM, Vigneswaran W, McCabe MA, Garrity ER. Liberalization of donor criteria may expand the donor pool without adverse consequence in lung transplantation J Heart Lung Transplant 2000;19:1199-1204.[Medline]
- Bush A, Gabriel R. Pulmonary function in chronic renal failureeffects of dialysis and transplantation. Thorax 1991;46:424-429.[Abstract/Free Full Text]
- Herrero JA, Alvarez-Sala JL, Coronel F, et al. Pulmonary diffusing capacity in chronic dialysis patients Respir Med 2002;96:487-492.[Medline]
- Fawcett S, Hoenich NA, Laker MF, Schorr Jr W, Ward MK, Kerr DN. Haemodialysis-induced respiratory changes Nephrol Dial Transplant 1987;2:161-168.[Abstract/Free Full Text]
- Quebbeman EJ, Maierhofer WJ, Piering WF. Mechanisms producing hypoxemia during hemodialysis Crit Care Med 1984;12:359-363.[Medline]
- Conte Jr JV, Ferber LR, Borja M, et al. Lung transplantation from dialysis dependent donors J Heart Lung Transplant 2000;19:894-896.[Medline]
- Myers BD, Rubin AE, Schey G, Bruderman I, Pokroy NR, Zevi J. Functional characteristics of the lung in chronic uremia treated by renal dialysis therapy Chest 1974;68:191-194.
- Yigla M, Nakhoul F, Sabag A, et al. Pulmonary hypertension in patients with end-stage renal disease Chest 2003;123:1577-1592.[Abstract/Free Full Text]
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Abstract
Introduction
