Postoperative Outcomes and Risk Profiles in Dual Liver-Lung Transplantation: A Single-Center Retrospective Analysis

Dual liver-lung transplantation (DLLT) is an uncommon but definitive therapy for carefully selected patients with concurrent end-stage hepatic and pulmonary disease. The combined operative complexity and dual-organ immunosuppressive burden may predispose recipients to early morbidity and graft-threatening complications [1-4].

To characterize early and late postoperative events (including acute cellular rejection (ACR), infectious complications, malignancy, and hospital readmissions) after DLLT and to describe associated clinical patterns.

We performed a retrospective cohort study of adult DLLT recipients at a single tertiary center (2013-2024). Variables included demographics, transplant indications, ischemia times, readmissions (0-3 months; 3-12 months), infections (timing/etiology/site), biopsy-proven rejection, malignancy, and survival. ACR was biopsy-confirmed in cases of unexplained transaminitis beyond 30 days posttransplant. Analyses were descriptive, consistent with STROBE recommendations for small cohorts.

Ten patients (mean age 53.7 years; 50% female) underwent DLLT. Liver etiologies included alcohol-related cirrhosis (n = 2), HCV (n = 1), cryptogenic (n = 1), autoimmune (n = 1), cystic fibrosis (n = 1), and unspecified (n = 4). Lung indications were IPF (n = 5), pulmonary hypertension (n = 2), ILD (n = 2), and CF (n = 1). All patients were readmitted within 90 days, most commonly for infection (40%), diarrhea (20%), critical illness myopathy (20%), rejection (10%), and biliary stricture (10%). Biopsy-proven ACR occurred in 4/10 patients (40%) after the first month, uniformly presenting with hepatocellular transaminemia; 3/4 received pulse-dose IV corticosteroids and 2/3 subsequently developed invasive fungal disease (Aspergillus and Candida). Overall, 9/10 experienced infection within 6 months, predominantly pulmonary (fungal/bacterial pneumonias). Three patients developed malignancy (basal cell carcinoma, prostate carcinoma, and angiosarcoma [fatal]). Survival was 90% at 1 year, 70% at 3 years, and 60% at 5 years; no 10 year survivors were observed.

DLLT is associated with early readmission and a high infectious burden, particularly invasive fungal disease after steroid-treated ACR. Despite significant early morbidity, short-term survival is favorable. Multicenter studies are needed to refine candidate selection, balance rejection prophylaxis with antifungal strategies, and standardize long-term oncologic and dermatologic surveillance in DLLT.