Living-donor lung transplantation for patients on extracorporeal membrane oxygenation support: A case series
Abstract
In Japan, the average waiting time for deceased-donor lung transplantation exceeds 900 days, and living-donor lung transplantation (LDLT) has been performed in a certain number of patients who are critically ill as a life-saving procedure when survival during the waiting period is unlikely.1 The current deceased-donor lung-allocation system is primarily based on waiting time after registration, blood type compatibility, and size matching rather than illness severity and therefore does not prioritize candidates receiving extracorporeal membrane oxygenation (ECMO) support. Therefore, LDLT represents the only realistic life-saving option for selected patients on ECMO support in Japan. This study aimed to characterize 6 cases of LDLT performed under preoperative ECMO support, focusing on perioperative management and outcomes.
Methods
Recipients of LDLT on Preoperative ECMO
All candidates met the standard criteria for deceased-donor lung transplantation. LDLT was pursued when suitable living donors were available and the procedure was technically feasible within the limited time frame. ECMO was initiated as a bridge to transplantation in patients with progressive respiratory failure refractory to maximal medical therapy in whom survival without extracorporeal support was unlikely.
Graft size matching was primarily assessed using predicted postoperative forced vital capacity. In the pediatric segmental transplant case (case 1), volumetric computed tomography–based assessment was used instead because conventional forced vital capacity–based size matching was not applicable.
The electronic medical records at Kyoto University Hospital were searched retrospectively to identify patients who underwent LDLT between August 2010 and September 2025. During this period, 137 LDLTs were performed. Six of these procedures were performed after preoperative ECMO support.
Ethics Statement
The study was approved by the Ethics Committee of Kyoto University Graduate School and Faculty of Medicine (no. R2389-7, February 13, 2026). Oral and written informed consent for study participation were obtained from all patients. Patient consent for the publication of study data was waived by the Ethics Committee in accordance with approval no. R2389-7. In accordance with the ethical standards at our institution, when recipients were incapacitated as a consequence of critical illness or sedation, the decision-making process involved multidisciplinary discussions and detailed explanations to family members and legally authorized representatives. Written informed consent was obtained before transplantation. Postoperative confirmation of consent was pursued if necessary when recipient regained decision-making capacity.