Liver-First Strategy for Combined Lung and Liver Transplantation: 15-Year Single-Center Experience.

Combined lung and liver transplantation is an uncommon procedure and poses several management challenges. At our institution, since 2005, we have been performing liver transplantation before lung transplantation (liver first strategy), because this strategy might improve the liver coagulopathy thus reducing the risk of bleeding, and spare the successively transplanted lung allograft from the liver reperfusion fluid. Aim of this study was to present our 15-year experience with the liver first strategy for combined lung-liver transplantation. Records of lung-transplanted patients between 01/2005 and 10/2021 at our institution were retrospectively reviewed. Outcomes were compared between patients undergoing combined lung-liver vs. patients undergoing lung-only transplantation. Median (IQR) follow-up was 53 (22-93) months. During the study period, among the 1822 lung-transplanted patients, 17 (0.9%) patients required combined lung-liver transplantation (male sex, n=15; median age, 30 years; lung transplant indication: cystic fibrosis, n=15; lung fibrosis, n=1; porto-pulmonary hypertension, n=1), the remaining 1805 (99.1%) patients undergoing lung-only transplantation. While median lung cold ischemic time (min.) was longer (first lung, 610 vs. 401, p<0.01; second lung, 692 vs. 510, p<0.01) and the intraoperative need for packed red blood cells greater (10 vs. 2 units, p<0.01) in the combined group, only one patient in this group showed primary graft dysfunction (PGD) grade 3 at 72 hours after transplantation (5.9% vs. 5.4%, p=0.61). Prevalence of rethoracotomy for bleeding (18% vs. 10%, p=0.41), temporary dialysis (24% vs. 11%, p=0.12), anti-HLA donor-specific antibodies (DSA, 12% vs. 19%, p=0.35), and in-hospital mortality (12% vs. 7%, p=0.32) did not differ in the lung-liver vs. lung-only transplantation group. Median and hospital stay time (33 vs. 23 days, p<0.01) was longer in the lung-liver group. At-5 years, lung graft survival (62% vs. 66%) and freedom from chronic lung allograft dysfunction (62% vs. 63%) did not differ between the lung-liver vs. lung-only groups (p=0.74 and p=0.71, respectively). Notwithstanding the longer ischemic times and the complexity of the procedure, the liverfirst strategy for combined lung-liver transplantation did not impair lung graft survival and function. [ABSTRACT FROM AUTHOR]