Live related donor lobar lung transplantation recipients surviving well over a decade: still an option in times of advanced donor management

Living donor lobar lung transplantation (LDLLT) is performed as a life-saving procedure for critically ill patients who are unlikely to survive the long wait for cadaveric lungs. It has been proved life saving for various lung diseases and appears to provide similar or better survival than cadaveric lung transplantation. We are reporting two LDLLT recipients surviving for more than a decade with good lung functions.

Lung transplantation is now established as a treatment option for end-stage pulmonary disease [1]. The demand for organs is ever increasing and far exceeds the supply. The number of suitable organ donors could be increased by proper donor management, non-heart beating donor, ex-vivo lung perfusion and LDLLT [2, 3]. Usually, LDLLT is a last option chosen to save critically ill patient with end-stage pulmonary disease who cannot wait for organs from cadaveric donor [4]. In the present cases, the patients had cystic fibrosis and had rapid deterioration of their lung function which left us without any choice but to offer them option of LDLLT with relatives as donors.

The ethical dilemma in LDLLT is whether family members should be risked in order to save a relative [5]. Two lungs obtained from live donors can adequately support an adult cystic fibrosis patient [6]. In our first case, donors were 7–10% taller compared to recipient, while in the second case they were equal or shorter than the recipient. However, donor lower lobes filled up recipient hemithorices adequately. LDLLT is severely limited by availability of suitable wishful donor in the family. Most important criteria to be met is suitably matching blood group. If more than one wishful donor in family meets this criteria, then height, weight and age matching comes in picture. Size mismatching can be overcome to a certain extent using various surgical techniques, however they were not required in the present cases [4]. Although LDLLT may be associated with the limitation of size mismatch, it holds promise for providing well-functioning pulmonary lobar grafts to critically ill patients with poor life expectancy [7]. The donor procedure is safe with minimum morbidity, well tolerated physiologically, and the great majority of donors are extremely satisfied with their decision to donate [6, 8]. In two recent large LDLLT series, there was no mortality in live lobar donors and 15–20% donors suffered some kind of morbidity which is acceptable and similar to the standard lung resection; moreover donor pulmonary function was found well preserved [9, 10]. In present cases, the donors made excellent recovery without any complication and are experiencing healthy lifestyle more than a decade after surgery. LDLLT provides acceptable long-term survival when compared to recipients of cadaveric grafts [8]. This could possibly be because of avoidance of organ transport on ice, thus preserving the grafts structurally and functionally as well as less chance of rejection, probably because of sharing genetic pool with the donors. In our first case, the donors were recipient’s first relatives and she never had biopsy proven rejection in any of the donated lobes. After 12 years of transplantation, she is following up with good lung function tests and having near-normal lifestyle. In our second case, although one of the donors was not related to the recipient biologically, she never had biopsy proven rejection and shown consistently good lung function since 14 years of transplantation.

In case of lung transplantation, the breathing capacity and exercise tolerance increases initially after surgery, then plateau and after 5–7 years and then starts decreasing as transplanted lungs inevitably develop bronchiolitis obliterans. Interestingly, in both our LDLLT recipients lung function has improved over time and recipients feel that the breathing and exercise capacity has increased over the years and it was always better than before. These two cases do not represent our institute’s experience of LDLLT, but embodies good outcome and long term survival in patients undergoing LDLLT.

LDLLT is a source of organs which could be life saving in end-stage lung disease patients who are likely to die on list waiting for cadaveric organs. As the procedure involves risk to healthy donors, proper assessment of family members as a donor, appropriate recipient-donor size matching and superlative timing of recipient-donor surgeries is a key to success. Although cadaveric donors remain the main source of organs, LDLLT should continue to be used under properly selected circumstances, to maintain the viability of this potentially life-saving procedure.

Written informed consent was obtained from the patients for publication of this Case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.