Pediatric Donor Lungs for Adult Transplant Recipients: Feasibility and Outcomes

Abstract

Background There is a limited experience using pediatric organs for adult lung transplantation (LTx), with size matching the major concern. We reviewed our experience transplanting pediatric donor lungs into adult recipients with endpoints of post-LTx complications and overall patient survival.

Methods From 2/1990 to 12/2007, 609 adults underwent primary LTx at our institution. Thirty-eight (6.2%) patients underwent LTx with organs from pediatric donors (≤16 years). Of these, median donor age was 13 years (range: 7 to 16) and median recipient age 55 (range: 24 to 66). Endpoints analyzed included size matching accuracy, airway and pleural complications, time to extubation, intensive care unit (ICU) and hospital lengths of stay, as well as survival.

Results Gross undersizing of the donor lung was present in 2/38 (5.3%) and of the donor bronchus in 11/38 (29%). Five patients (13%) experienced a major postoperative airway complication. Thoracentesis prior to discharge was necessary in 4/38 (11%) patients and chest tube reinsertion in 10/38 (26%) for pleural effusion. Median time to extubation was 2 days. ICU and hospital lengths of stay were 6 and 16 days, respectively. Kaplan–Meier survival at 30 days, 1 year, 3 years, and 5 years post-transplant was 89%, 74%, 63%, and 55%.

Conclusions Despite sizing concerns, transplantation of pediatric lungs into adult recipients is feasible. Size mismatch may predispose to higher rates of airway and pleural complications. Hospital course and overall survival appear comparable to adult-to-adult LTx, and concerns over size matching should not preclude pediatric organ use for adult candidates.

Keywords

transplantation - lung - pediatric - outcomes (includes mortality morbidity)

• References

• 1 Klein AS, Messersmith EE, Ratner LE, Kochik R, Baliga PK, Ojo AO. Organ donation and utilization in the United States, 1999-2008. Am J Transplant 2010; 10 (4 Pt 2) 973-986
• 2 Reyes KG, Mason DP, Thuita L , et al. Guidelines for donor lung selection: time for revision?. Ann Thorac Surg 2010; 89 (6) 1756-1764, discussion 1764–1765
• 3 Yeung JC, Cypel M, Waddell TK, van Raemdonck D, Keshavjee S. Update on donor assessment, resuscitation, and acceptance criteria, including novel techniques—non-heart-beating donor lung retrieval and ex vivo donor lung perfusion. Thorac Surg Clin 2009; 19 (2) 261-274
• 4 Ingemansson R, Eyjolfsson A, Mared L , et al. Clinical transplantation of initially rejected donor lungs after reconditioning ex vivo. Ann Thorac Surg 2009; 87 (1) 255-260
• 5 Oto T, Rowland M, Griffiths AP , et al. Third-time lung transplant using extended criteria lungs. Ann Thorac Surg 2007; 84 (2) 642-644
• 6 Mason DP, Thuita L, Nowicki ER, Murthy SC, Pettersson GB, Blackstone EH. Should lung transplantation be performed for patients on mechanical respiratory support? The US experience. J Thorac Cardiovasc Surg 2010; 139 (3) 765-773, e1
• 7 Cypel M, Liu M, Rubacha M , et al. Functional repair of human donor lungs by IL-10 gene therapy. Sci Transl Med 2009; 1 (4) 4ra9
• 8 Zhao Y, Al-Kaade S, Keller CA, deMello DE. Atelectasis—an unusual and late complication of lung transplant. Clin Transplant 2002; 16 (3) 233-239
• 9 Kawut SM, Lederer DJ, Keshavjee S , et al. Outcomes after lung retransplantation in the modern era. Am J Respir Crit Care Med 2008; 177 (1) 114-120
• 10 Mason DP, Batizy LH, Wu J , et al. Matching donor to recipient in lung transplantation: How much does size matter?. J Thorac Cardiovasc Surg 2009; 137 (5) 1234-1240, e1
• 11 Bhayana S, Kuo YF, Madan P , et al. Pediatric en bloc kidney transplantation to adult recipients: more than suboptimal?. Transplantation 2010; 90 (3) 248-254
• 12 Wengerter K, Matas AJ, Tellis VA, Quinn T, Soberman R, Veith FJ. Transplantation of pediatric donor kidneys to adult recipients. Is there a critical donor age?. Ann Surg 1986; 204 (2) 172-175
• 13 Csapo Z, Knight RJ, Podder H , et al. Transplantation of single pediatric kidneys into adult recipients. Transplant Proc 2005; 37 (2) 697-698
• 14 Emre S, Soejima Y, Altaca G , et al. Safety and risk of using pediatric donor livers in adult liver transplantation. Liver Transpl 2001; 7 (1) 41-47
• 15 Alvarez A, Algar FJ, Santos F , et al. Pediatric lung transplantation. Transplant Proc 2005; 37 (3) 1519-1522
• 16 Mallory Jr GB, Schecter MG, Elidemir O. Management of the pediatric organ donor to optimize lung donation. Pediatr Pulmonol 2009; 44 (6) 536-546
• 17 Masters IB, Ware RS, Zimmerman PV , et al. Airway sizes and proportions in children quantified by a video-bronchoscopic technique. BMC Pulm Med 2006; 6: 5
• 18 Murthy SC, Blackstone EH, Gildea TR , et al; Members of Cleveland Clinic’s Pulmonary Transplant Team. Impact of anastomotic airway complications after lung transplantation. Ann Thorac Surg 2007; 84 (2) 401-409, 409, e1–e4
• 19 Choong CK, Sweet SC, Zoole JB , et al. Bronchial airway anastomotic complications after pediatric lung transplantation: incidence, cause, management, and outcome. J Thorac Cardiovasc Surg 2006; 131 (1) 198-203
• 20 Anile M, Venuta F, Diso D , et al. Treatment of complex airway lesions after lung transplantation with self-expandable nitinol stents: early experience. Transplant Proc 2010; 42 (4) 1279-1280
• 21 Fernandez-Bussy S, Akindipe O, Kulkarni V, Swafford W, Baz M, Jantz MA. Clinical experience with a new removable tracheobronchial stent in the management of airway complications after lung transplantation. J Heart Lung Transplant 2009; 28 (7) 683-688
• 22 Anderson MB, Kriett JM, Harrell J , et al. Techniques for bronchial anastomosis. J Heart Lung Transplant 1995; 14 (6 Pt 1) 1090-1094
• 23 Boffa DJ, Mason DP, Su JW , et al. Decortication after lung transplantation. Ann Thorac Surg 2008; 85 (3) 1039-1043
• 24 Smith PW, Wang H, Parini V , et al. Lung transplantation in patients 60 years and older: results, complications, and outcomes. Ann Thorac Surg 2006; 82 (5) 1835-1841, discussion 1841
• 25 Novick RJ, Stitt LW, Al-Kattan K , et al. Pulmonary retransplantation: predictors of graft function and survival in 230 patients. Pulmonary Retransplant Registry. Ann Thorac Surg 1998; 65 (1) 227-234
• 26 Mason DP, Thuita L, Alster JM , et al. Should lung transplantation be performed using donation after cardiac death? The United States experience. J Thorac Cardiovasc Surg 2008; 136 (4) 1061-1066