The United States Experience With Combined Lung+Liver Transplantation

Background: Combined lung+liver transplant (CLLT) is a rare procedure for patients with end-stage lung and liver failure, but has recently gained traction, with many academic centers performing CLLT for the first time. This study describes the state of CLLT in the United States and assesses outcomes. Methods: The United Network for Organ Sharing Database was queried for all CLLT between October 1994 and March 2024. Transplant sequence was determined by utilizing individual organ ischemic times. Cumulative risk was assessed to determine primary causes of graft failure or death after CLLT, and risk stratification was defined based on patient survival status, lung-graft status, or liver-graft status. Posttransplant survival was further assessed utilizing Kaplan-Meier survival analysis. Results: A total of 193 CLLTs were analyzed across 39 centers. The number of CLLTs has increased over the last decade. Most of the transplants were lung(s) followed by liver (157 of 179, 87.7%). Most were male (121 of 179, 67.6%), and the median age at transplant was 47 years (interquartile range, 25-59 years). Kaplan-Meier survival at 1 month, 6 months, 1 year, 3 years, 5 years, and 10 years was: 96.3% (95% CI, 92.6%-99.0%), 85.1% (95% CI, 80.1%-90.5%), 81.5% (95% CI, 76.0%-87.4%), 70.4% (95% CI, 63.7%-77.9%), 63.2% (95% CI, 55.7%-71.6%), and 53.3% (95% CI, 44.1%-64.3%). No difference was evident in survival between lung-first or liver-first sequences. Most deaths were due to non-graft-related causes. Conclusions: CLLT is growing in popularity and serves as a viable option for patients with combined end-stage lung disease and end-stage liver disease. CLLT shows excellent longitudinal survival. No difference exists in survival between a lung-first approach and a liver-first approach. Most deaths after CLLT are unrelated to liver-graft or lung-graft failure.