Donor Selection for Single and Double Lung Transplantation: Chest Size Matching and Other Factors Influencing Posttransplantation Vital Capacity

doi:10.1378/chest.98.2.308

Chest

Volume 98, Issue 2, August 1990, Pages 308-313

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In six single lung transplant (SLT) and six double lung transplant (DLT) recipients, the relationships of the recipient’s posttransplantation vital capacity (posttx VC_R) to the recipient’s predicted normal vital capacity (pred VC_R) and the donor’s predicted normal vital capacity (pred VC_D) were investigated. After left SLT the left posttx VC_R was correlated with the left predicted VC_D (r = 0.83; p<0.05); however, no correlation was found between these after DLT. In contrast, there was a tendency toward correlation between the posttx VC_R and the predicted VC_R after DLT (r = 0.75; p<0.1), but no such trend was apparent after SLT. These results suggest that posttx VC_R depends primarily on predicted VC_D after SLT and on pred VC_R after DLT. Therefore, in donor-recipient size matching for lung transplantation, a donor with a pred VC_D greater than the pred VC_R should be chosen for a left SLT recipient, whereas a donor with a pred VC_D near the pred VC_R would be suitable for a DLT recipient.

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Patients

Between November 1983 and December 1987, 15 SLTs and seven DLTs were performed at the Toronto (Canada) General Hospital. Thirteen of the 15 SLT recipients had idiopathic pulmonary fibrosis, one had familial pulmonary fibrosis, and one had eosinophilic granuloma. Three of the seven DLT recipients had α₁-antitrypsin deficiency emphysema, one had idiopathic emphysema, one had bronchiolitis obliterans, one had eosinophilic granuloma, and one had primary pulmonary hypertension.

Among the 15 SLT

RESULTS

The characteristics of recipients and donors are shown in Table 1. In the SLT group, the age was significantly younger in the donors (30 ± 10 years) than the recipients (48 ± 12 years). Thirteen recipients were male and two were female, whereas eight donors were male and seven were female. Weight, height, and body surface area (BSA) were all significantly smaller in the donors than in the recipients.

In the DLT group, the age of the donors (26 ± 9 years) was also younger than the recipients (37

DISCUSSION

Since 1983, successful SLTs and DLTs have been performed for both severe obstructive and restrictive lung diseases.1, 2, 3, 4, 5, 6 Although both operations lead to substantial improvement in pulmonary function, limited attention has been given to donor-recipient factors that influence the posttransplantation pulmonary function of the recipient.

To our knowledge, the best approach to donor-recipient size matching for lung transplantation has not been determined. A suitable lung donor has

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(1988)

There are more references available in the full text version of this article.

Cited by (34)

Lung protective ventilation based on donor size is associated with a lower risk of severe primary graft dysfunction after lung transplantation
2021, Journal of Heart and Lung Transplantation
Citation Excerpt :
Size matching has long been an area of investigation in lung transplantation. In the past, size matching has been evaluated on the basis of height, weight,28 thoracic perimeter,29,30 matching chest radiographs,31,32 and predicted lung size.33 Historically, height has been the most commonly used parameter to size match donors to recipients.
Mechanical ventilation immediately after lung transplantation may impact the development of primary graft dysfunction (PGD), particularly in cases of donor-recipient size mismatch as ventilation is typically based on recipient rather than donor size.
We conducted a retrospective cohort study of adult bilateral lung transplant recipients at our center between January 2010 and January 2017. We defined donor-based lung protective ventilation (dLPV) as 6 to 8 ml/kg of donor ideal body weight and plateau pressure <30 cm H₂O. We calculated the donor-recipient predicted total lung capacity (pTLC) ratio and used logistic regression to examine relationships between pTLC ratio, dLPV and PGD grade 3 at 48 to 72 hours. We used Cox proportional hazards modelling to examine the relationship between pTLC ratio, dLPV and 1-year survival.
The cohort included 373 recipients; 24 (6.4%) developed PGD grade 3 at 48 to 72 hours, and 213 (57.3%) received dLPV. Mean pTLC ratio was 1.04 ± 0.18. dLPV was associated with significantly lower risks of PGD grade 3 (OR = 0.44; 95% CI: 0.29-0.68, p < 0.001) and 1-year mortality (HR = 0.49; 95% CI: 0.29-0.8, p = 0.018). There was a significant association between pTLC ratio and the risk of PGD grade 3, but this was attenuated by the use of dLPV.
dLPV is associated with decreased risk of PGD grade 3 at 48 to 72 hours and decreased 1-year mortality. Additionally, dLPV attenuates the association between pTLC and both PGD grade 3 and 1-year mortality. Donor-based ventilation strategies may help to mitigate the risk of PGD and other adverse outcomes associated with size mismatch after lung transplantation.
Predictive equations for lung volumes from computed tomography for size matching in pulmonary transplantation
2016, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
These authors also showed an 8% absolute decrease in forced expiratory volume in 1 second/forced vital capacity ratio in the same cohorts. Although other size-matching strategies have sporadically been described, including chest roentgenogram dimensions, inframammary circumference, and vital capacity,15-17 the only other widely used methods are donor pTLC versus recipient pTLC and donor pTLC versus recipient actual TLC. For pTLC, the PFT predictive equations were created based on PFT measurements in a normal population.18-22
Size matching for lung transplantation is widely accomplished using height comparisons between donors and recipients. This gross approximation allows for wide variation in lung size and, potentially, size mismatch. Three-dimensional computed tomography (3D-CT) volumetry comparisons could offer more accurate size matching. Although recipient CT scans are universally available, donor CT scans are rarely performed. Therefore, predicted donor lung volumes could be used for comparison to measured recipient lung volumes, but no such predictive equations exist. We aimed to use 3D-CT volumetry measurements from a normal patient population to generate equations for predicted total lung volume (pTLV), predicted right lung volume (pRLV), and predicted left lung volume (pLLV), for size-matching purposes.
Chest CT scans of 400 normal patients were retrospectively evaluated. 3D-CT volumetry was performed to measure total lung volume, right lung volume, and left lung volume of each patient, and predictive equations were generated. The fitted model was tested in a separate group of 100 patients. The model was externally validated by comparison of total lung volume with total lung capacity from pulmonary function tests in a subset of those patients.
Age, gender, height, and race were independent predictors of lung volume. In the test group, there were strong linear correlations between predicted and actual lung volumes measured by 3D-CT volumetry for pTLV (r = 0.72), pRLV (r = 0.72), and pLLV (r = 0.69). A strong linear correlation was also observed when comparing pTLV and total lung capacity (r = 0.82).
We successfully created a predictive model for pTLV, pRLV, and pLLV. These may serve as reference standards and predict donor lung volume for size matching in lung transplantation.
Size matching in lung transplantation: An evidence-based review
2013, Journal of Heart and Lung Transplantation
Citation Excerpt :
This observation is true of all of the studies described in this report. Several studies have reported that recipient post-operative measured TLC or VC has been closely related to the recipient TLC or VC predicted in both BLT4,12,15 and SLT.2,15 Thus, some groups have reported that their matching strategy is to pair donors and recipients based on the closest match between donor pTLC and recipient pTLC.22
The evidence base for size matching between donors and recipients in lung transplantation has not recently been reviewed in a comprehensive manner. Our aim in this study was to assimilate published studies that have addressed size matching of donors to recipients and to establish a pragmatic understanding of the range of lung sizes that may be used for lung transplantation. A comprehensive literature search was performed using Medline and PubMed up to and including September 2012, to identify scientific articles that relate to size matching between donors and lung transplant recipients. Seventy-two articles were identified, of which 21 had addressed the question of the impact of size mismatching on outcomes in lung transplantation. No study has specifically tested the consequences of intentionally mismatching above or below the hypothetical limits for double lung transplantation of a predicted total lung capacity for the donor of between 75% and 125% of the recipient predicted total lung capacity as set out in the ISHLT consensus report on lung donor acceptability criteria. Research is lacking that has robustly defined limits for size mismatch for single lung transplantation and for recipients with restrictive lung pathologies such as pulmonary fibrosis. Published research on the impact of size mismatching between lung transplant donors and recipients is limited by study design and size. It is centered on addressing the issue of mismatch in double lung transplantation in cohorts with a diagnostically heterogeneous make-up and in single lung transplant patients with chronic obstructive pulmonary disease.
Lung size mismatch in bilateral lung transplantation is associated with allograft function and bronchiolitis obliterans syndrome
2012, Chest
Citation Excerpt :
Expressing allograft function in relation to donor predicted lung function likely captured the actual restriction of an oversized allograft in a smaller recipient's thorax. Prior studies concluded that wide discrepancies in lung sizing do not to influence allograft function.3,4,18–20 In the present study, we also found no difference in allograft function in terms of FVC, FVC (% predicted-recipient), and FEV1.
Size mismatch between donor lungs and a recipient thorax could affect the major determinants of maximal expiratory airflow: airway resistance, propensity of airways to collapse, and lung elastic recoil.
A retrospective review of 159 adults who received bilateral lung transplants was performed. The predicted total lung capacity (pTLC) for donors and recipients was calculated based on sex and height. Size matching was represented using the following formula: pTLC ratio = donor pTLC / recipient pTLC. Patients were grouped according to those with a pTLC ratio > 1.0 (oversized) or those with a pTLC ratio ≤ 1.0 (undersized). Allograft function was analyzed in relation to the pTLC ratio and to recipient and donor predicted function.
The 96 patients in the oversized cohort had a mean pTLC ratio of 1.16 ± 0.13 vs 0.89 ± 0.09 in the 63 patients of the undersized group. At 1 to 6 months posttransplant, the patients in the oversized cohort had higher FEV₁/FVC ratios (0.895 ± 0.13 vs 0.821 ± 0.13, P < .01) and lower time constant estimates of lung emptying (0.38 ± 0.2 vs 0.64 ± 0.4, P < .01) than patients in the undersized cohort. Although the FVCs expressed as % predicted for the recipient were not different between cohorts, the FVCs expressed as % predicted for the donor organ were lower in the oversized cohort compared with the undersized cohort (at 1-6 months, 52.4% ± 17.1% vs 65.3% ± 18.3%, P < .001). Kaplan-Meier estimates for the occurrence of bronchiolitis obliterans syndrome (BOS) showed that patients in the oversized cohort had a lower probability of BOS (P < .001).
A pTLC ratio > 1.0, suggestive of an oversized allograft, is associated with higher expiratory airflow capacity and a less frequent occurrence of BOS.
Comparison of pulmonary function test and computed tomography volumetry in living lung donors
2011, Journal of Heart and Lung Transplantation
We previously proposed calculating forced vital capacity (FVC) by the number of segments for size matching in living-donor lobar lung transplantation (LDLLT). The primary purpose of this study was to compare spirometry-obtained calculations of lower lobe volumes with three-dimensional (3D) computed tomography (CT) volumetric images. Our second goal was to compare the data of pulmonary function tests with CT volumetry in living lung donors.
Pulmonary function test, including FVC and total lung capacity (TLC), and 3D CT volumetry were performed pre-operatively in 21 healthy donor candidates for LDLLT. The relationship of 3D CT volumetric data and calculated volume of lower lobes by the number of segments was investigated. Also studied were 3D CT volumetric data in relation to FVC and TLC. Various pre-operative variables were analyzed retrospectively.
According to 3D CT volumetry, the right and left lower lobe volume was 26.3% ± 2.9% and 22.6% ± 3.1% of the total lung volume, respectively. We found a significant, strong correlation between each lower lobe volume and the total lung volume. Because the calculated volumes of right and left lower lobes by the number of segments were 26.3% and 21.1%, respectively, our results implied that the volume of both lower lobes was accurately described by the number of segments. FVC was significantly associated with TLC and the total lung volume.
We confirmed that it would be justified to estimate graft FVC by the number of segments according to the CT volumetric data in LDLLT.
How to predict forced vital capacity after living-donor lobar-lung transplantation
2004, Journal of Heart and Lung Transplantation
Living-donor lobar-lung transplantation (LDLLT) has evolved from a rarely performed experimental procedure to an accepted therapy for selected patients who are unlikely to survive the long wait for cadaveric lungs. However, a convincing study has not been performed that shows the effects of small grafts and of pre-operative variables in predicting functional outcome of recipients after LDLLT.
From October 1998 to March 2002, 2 male and 11 female patients underwent LDLLT. Mean age was 27.3 years (range, 8–53 years). Diagnoses included primary pulmonary hypertension (n = 5), idiopathic interstitial pneumonia (n = 2), bronchiolitis obliterans (n = 2), bronchiectasis (n = 2), lymphangioleiomyomatosis (n = 1), and cystic fibrosis (n = 1). Donors included 12 men and 14 women with a mean age of 40 years. Given that the right lower lobe consists of 5 segments, the left lower lobe of 4, and the whole lung of 19, we estimated the graft forced vital capacity (FVC) based on the donor's measured FVC and compared this with the recipient's FVC measured after LDLLT.
Currently, all patients are alive, with a mean follow-up of 22.2 months (range, 10–51 months). The recipients' FVC measured at 6 months (1,813 ± 86 ml) correlated well with the graft FVC (1,803 ± 70 ml), estimated based on the donors' measured FVC (r = 0.802, p = 0.00098).
Recipient FVC after LDLLT can be predicted by measuring donor FVC before surgery regardless of the diagnosis of the recipient.

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Chest

Donor Selection for Single and Double Lung Transplantation: Chest Size Matching and Other Factors Influencing Posttransplantation Vital Capacity

Section snippets

Patients

RESULTS

DISCUSSION

J Thorac Surg

Chest

Chest

Unilateral lung transplantation for pulmonary fibrosis

N Engl J Med

Experience with single-lung transplantation for pulmonary fibrosis

JAMA