Is There an Age Limit to Lung Transplantation?

Risk factors for mid- and long-term mortality in lung transplant recipients aged 70 years and older

OBJECTIVES

With increased lung transplantation in those aged 70 and older, limited literature addresses risk factors affecting their survival. Our study aims to identify independent factors impacting mid- and long-term mortality in this elderly population.

METHODS

This study analyzed lung transplant patients over 70 from May 2005 to December 2022 using United Network for Organ Sharing data. The 3- or 5-year cohort excluded multi-organ, secondary transplantation and loss to follow-up. Univariable Cox analysis was conducted to assess recipient, donor and transplant factors. Factors with a significance level of P < 0.2 were subsequently included in a multivariable Cox model to identify correlations with 3- and 5-year mortality in patients aged over 70.

RESULTS

Multivariable analysis has identified key factors affecting 3- and 5-year mortality in elderly lung transplant patients over 70. Common notable factors include recipient total bilirubin, intensive care unit status at the time of transplantation, donor diabetes, Cytomegalovirus (CMV) mismatch and single lung transplantation. Additionally, Hispanic/Latino patients and ischaemia time of the transplant significantly impact the 3-year mortality, while recipient age, diabetes, nitric oxide use before transplantation and creatinine were identified as unique independent risk factors affecting the 5-year morality.

CONCLUSIONS

The study identified several independent risk factors that impact the mid- and long-term survival of lung transplantation for individuals over 70 years. These findings can contribute to the optimization of lung transplant treatment strategies and perioperative management in elderly patients, thereby enhancing the survival rate of this age group.

A single-centre analysis of lung transplantation outcomes in recipients aged 70 or older

OBJECTIVES

As life expectancies continue to increase, a greater proportion of older patients will require lung transplants (LTs). However, there are no well-defined age cutoffs for which LT can be performed safely. At our high-volume LT centre, we explored outcomes for LT recipients ≥70 vs <70 years old.

METHODS

This is a retrospective single-centre study of survival after LT among older recipients. Data were stratified by recipient age (≥70 vs <70 years old) and procedure type (single versus double LT). Demographics and clinical variables were compared using Chi-square test and 2 sample t-test. Survival was assessed by Kaplan-Meier curves and compared by log-rank test with propensity score matching.

RESULTS

A total of 988 LTs were performed at our centre over 10 years, including 289 LTs in patients ≥70 years old and 699 LTs in patients <70 years old. The recipient groups differed significantly by race (P < 0.0001), sex (P = 0.003) and disease aetiology (P < 0.0001). Older patients were less likely to receive a double LT compared to younger patients (P < 0.0001) and had lower rates of intraoperative cardiopulmonary bypass (P = 0.019) and shorter length of stay (P = 0.001). Both groups had overall high 1-year survival (85.8% vs 89.1%, respectively). Survival did not differ between groups after propensity matching (P = 0.15).

CONCLUSIONS

Our data showed high survival for older and younger LT recipients. There were no statistically significant differences observed in survival between the groups after propensity matching, however, a trend in favour of younger patients was observed.

Donor and Recipient Age in Interstitial Lung Disease: Types of Lung Transplant Survival Outcomes

INTRODUCTION

Lung transplantation is the last option for patients with end-stage interstitial lung disease (ILD), yet organ allocation remains a challenge. This single-center study investigated the correlation of procedure type and donor and recipient age with survival outcomes in patients with ILD.

METHODS

We performed a retrospective study of lung recipients diagnosed with ILD who were transplanted in our center. Survival was assessed using Kaplan-Meier curves and log-rank tests according to the following variables: double lung transplant (DLT) or single lung transplant (SLT), recipient age <65 and ≥65, recipient sex, donor sex, and donor age. Cox proportional hazards regression was performed using the same variables. P values < 0.05 were considered significant.

RESULTS

Of 969 lung recipients transplanted at our center, 648 (66.8%) were diagnosed with ILD. There was no significant difference in survival for patients <65 or ≥65 when compared by DLT versus SLT. There were no significant differences in survival based on donor age. Survival at 5 y was significantly higher for recipient age <65 versus ≥65 (P = 0.0014). For DLT patients <65 or ≥65, there was no significant survival difference. However, for SLT patients, survival at 5 y was significantly higher for patients <65 (P = 0.0109).

CONCLUSIONS

Our findings suggest that donor age did not have a significant association with survival of patients with ILD posttransplant. In older patients with ILD, there was no significant difference for DLT versus SLT. However, within the SLT group, younger patients with ILD showed better survival compared to older patients.

Two Staged Single Lung Transplants in the Current Era: A United Network for Organ Sharing Study

BACKGROUND

We hypothesized that outcomes after 2 staged, contralateral single lung transplantation procedures (SSLTs) may be equivalent to those of double lung transplantation (DLT) by capitalizing on the known long-term survival advantages of DLT.

METHODS

Using the United Network for Organ Sharing data set (1987-2018), the largest national data set available, the outcomes of 278 SSLTs were retrospectively analyzed and compared with the outcomes of 21,121 standard DLTs.

RESULTS

During SSLT, the median interval between the 2 transplants was 960 days, and the indication for the second transplant was most often chronic lung allograft dysfunction (n = 148; 53.2%) or the same disease that necessitated the first transplant (n = 81; 29.1%). The patients who underwent SSLT were significantly older and had a higher baseline creatinine level than the patients who underwent DLT. Most posttransplantation short-term outcomes were equivalent between the second stage of SSLT and DLT, but renal insufficiency requiring hemodialysis was notably higher after SSLT. There were no differences in long-term survival. In multivariate analysis, baseline creatinine, O2 support at rest, ventilator support at the time of the second transplantation, and posttransplantation renal insufficiency requiring dialysis were independent predictors of 1-year mortality after SSLT.

CONCLUSIONS

Over a study period of 30 years, long-term survival after SSLT was comparable with survival after DLT. With further analysis of individual risk profiles, including the contributions of preoperative renal function and functional status, SSLT can be a valuable option for patients who would have undergone single lung transplantation to reap the long-term benefits of a second transplant.

Lung Transplantation Outcomes in Recipients Aged 70 Years or Older and the Impact of Center Volume

OBJECTIVE

To evaluate trends and outcomes of lung transplants (LTx) in recipients ≥ 70 years.

METHODS

We performed a retrospective analysis of the UNOS database identifying all patients undergoing LTx (May 2005-December 2022). Baseline characteristics and postoperative outcomes were compared by age (<70 years, ≥70 years) and center volume. Kaplan-Meier analyses were performed with pairwise comparisons between subgroups.

RESULTS

34,957 patients underwent LTx, of which 3236 (9.3%) were ≥70 years. The rate of LTx in recipients ≥ 70 has increased over time, particularly in low-volume centers (LVCs); consequently, high-volume centers (HVCs) and LVCs perform similar rates of LTx for recipients ≥ 70. Recipients ≥ 70 had higher rates of receiving from donor after circulatory death lungs and of extended donor criteria. Recipients ≥ 70 were more likely to die of cardiovascular diseases or malignancy, while recipients < 70 of chronic primary graft failure. Survival time was shorter for recipients ≥ 70 compared to recipients < 70 old (hazard ratio (HR): 1.36, 95% confidence interval (CI): 1.28-1.44, p < 0.001). HVCs were associated with a survival advantage in recipients < 70 (HR: 0.91, 95% CI: 0.88-0.94, p < 0.001); however, in recipients ≥ 70, survival was similar between HVCs and LVCs (HR: 1.11, 95% CI: 0.99-1.25, p < 0.08). HVCs were more likely to perform a bilateral LTx (BLT) for obstructive lung diseases compared to LVCs, but there was no difference in BLT and single LTx likelihood for restrictive lung diseases.

CONCLUSIONS

Careful consideration is needed for recipient ≥ 70 selection, donor assessment, and post-transplant care to improve outcomes. Further research should explore strategies that advance perioperative care in centers with low long-term survival for recipients ≥ 70.

Listing Dilemmas: Age, Frailty, Weight, Preexisting Cancers, and Systemic Diseases

Selection of lung transplant candidates is an evolving field that pushes the boundaries of what is considered the norm. Given the continually changing demographics of the typical lung transplant recipient as well as the growing list of risk factors that predispose patients to poor posttransplant outcomes, we explore the dilemmas in lung transplant candidate selections pertaining to older age, frailty, low and high body mass index, preexisting cancers, and systemic autoimmune rheumatic diseases.

Lung transplantation in the septuagenarian can be successfully performed though long-term results impacted by diseases of aging

BACKGROUND

Advanced age is considered a risk factor for lung transplantation (LTX). We sought to evaluate the long-term outcomes of LTX in the septuagenarian.

METHODS

LTX recipients in the UNOS transplant registry (May 1, 2005 to June 12, 2020) were stratified into 18-59, 60-69, and > = 70 years of age. Recipient and transplant characteristics were evaluated for survival, cause of death (COD), length of stay (LOS), and complications. A Kaplan-Meier analysis examined long-term survival for all patients stratified by age, specifically looking at cause of death.

RESULTS

A total of 27632 recipients were identified. As recipients aged, we found a decrease in proportion of cystic fibrosis and an increase in restrictive disease while obstructive disease peaked in the 60-69yo cohort (p<0.001). Septuagenarians had higher rates of single LTX, male gender and white race (p<0.001). Older recipients had significantly longer donor recovery distances traveled with paradoxical shorter ischemic times, shorter hospital LOS and were transplanted at higher volume centers. There was no difference with in-hospital mortality among groups (p = 0.5). Acute rejection during initial hospitalization, rejection within 1 year, and post-transplant dialysis incidence decreased with age. Graft failure was a common COD in younger patients while malignancy and cardio/cerebrovascular diseases were common COD in > = 70yo.

CONCLUSION

Select septuagenarian LTX candidates may be safely transplanted with relatively few complications. Immunosenescence and conditions of the aged are likely contributing factors to the decreased rejection and graft failure observations. Septuagenarians should not be excluded from LTX consideration based solely on age. Transplantation in septuagenarians should only be done in very selected patients (screened for malignancies and atherosclerotic disease) and these recipients should be carefully followed after transplantation because of these risk factors. This article is protected by copyright. All rights reserved.

Current trends in candidate selection, contraindications, and indications for lung transplantation

Lung transplantation is an established treatment option that can improve quality of life and prolong survival for select patients diagnosed with end-stage lung disease. Given the gaps in organ donation and failures to make effective use of available organs, careful selection of candidates for lung transplant remains one of the most important considerations of the transplant community. Toward this end, we briefly reviewed recent trends in pretransplant evaluation, candidate selection, organ allocation, and organ preservation techniques. Since the latest consensus statement regarding appropriate selection of lung transplant candidates, many advances in the science and practice of lung transplantation have emerged and influenced our perspective of ‘contraindications’ to transplant. These advances have made it increasingly possible to pursue lung transplant in patients with risk factors for decreased survival—namely, older recipient age, increased body mass index, previous chest surgery, poorer nutritional status, and presence of chronic infection, cardiovascular disease, or extrapulmonary comorbid conditions. Therefore, we reviewed the updated evidence demonstrating the prognostic impact of these risk factors in lung transplant recipients. Lastly, we reviewed the salient evidence for current trends in disease-specific indications for lung transplantation, such as chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis, cystic fibrosis, emphysema due to alpha-1 antitrypsin deficiency, and pulmonary arterial hypertension, among other less common end-stage diseases. Overall, lung transplant remains an exciting field with considerable hope for patients as they experience remarkable improvements in quality of life and survival in the modern era.

Outcomes after lung transplantation in recipients aged 70 years or older

BACKGROUND

The proportion of lung transplant (LTx) recipients older than 70 years is increasing, thus we assessed long-term survival after LTx in this cohort relative to younger counterparts.

PATIENTS AND METHODS

We retrospectively reviewed charts of patients who underwent LTx between 2012 and 2016 at our center and divided patients by age: group A (<65 years), B (65-69 years), and C (≥70 years). Survival statistics were evaluated using the Kaplan-Meier method and Cox regression.

RESULTS

The study included 375 LTx recipients: 221 (58.9%) in group A, 109 (29.1%) in group B, and 45 (12.0%) in group C. Group C was mostly men (37/45 [82.2%]; P = 0.003) and had the highest mean serum creatinine at listing (P = 0.02). Survival at 1, 3, and 5 years after transplant in group A (93.2%, 70.1%, 58.8%) was significantly higher than group B (83.5%, 59.6%, 44.0%; P = 0.005, 0.028, 0.006, log-rank test) and was similar to group C (86.7%, 64.4%, 57.8%), although trended higher at 1 year (P = 0.139, 0.274, 0.489, log-rank test). Groups B and C had comparable survival at all time points.

CONCLUSIONS

Although survival decreased after age 65, long-term survival was comparable between LTx recipients aged 65-69 years and recipients ≥70 years.

Antithymocyte globulin is associated with a lower incidence of de novo donor-specific antibody detection in lung transplant recipients: A single-center experience

Purpose

Induction immunosuppression has improved the long‐term outcomes after lung transplant. This is the first report exploring the association of induction immunosuppression with the development of de novo donor‐specific human leukocyte antigen (HLA) antibodies (DSA) in lung transplant recipients (LTR).

Methods

Sixty‐seven consecutive primary LTR were followed for 3 years posttransplant. A total of 41/67 (61%) LTR‐received induction immunosuppression using a single dose of rabbit Antithymocyte Globulin (rATG; 1.5 mg/kg) within 24 h of transplant. All recipients had a negative flow cytometry crossmatch on the day of transplant. Serum samples at 1, 3, 6, and 12 months posttransplant were assessed for the presence of de novo HLA DSA.

Results

De novo HLA DSA were detected in 22/67 (32.8%) LTR within 1‐year posttransplant. Of these, 9/41 (21.9%) occurred in the induction therapy group and 13/26 (50%) in the noninduction group. Class II DSA were detected in 3/41 (7.3%) LTR who received induction compared to 9/26 (34.6%) LTR without induction immunosuppression (p = .005). Differences in overall survival or freedom from chronic lung allograft dysfunction rates between the two groups were not statistically significant.

Conclusion

Induction immunosuppression utilizing a modified regimen of single‐dose rATG is associated with a significant reduction in de novo DSA production in LTR.

Inpatient Lung Transplant Evaluation Is Associated With Increased Risk of Morbidity, Mortality, and Cost of Care After Transplant

Lung transplantation is an important option for patients with end-stage lung disease. Many of these patients deteriorate rapidly and require inpatient care at the time of the transplant evaluation.

RESEARCH QUESTION

How does the setting of lung transplant evaluation relate to perioperative outcomes, short-term postoperative outcomes, and healthcare costs accrued after transplant?

DESIGN

We reviewed the records of patients who underwent primary, bilateral lung transplantation at our center between January 1, 2014 and May 31, 2016. Patient evaluation setting was categorized as inpatient, outpatient, or combined. Demographics, clinical characteristics, and cost of care were assessed.

RESULTS

The study included 207 patients: 40 (19.3%) evaluated as inpatients, 146 (70.5%) as outpatients, and 21 (10.1%) as combined. Inpatients had the highest mean lung allocation scores (71.2 vs 49.7 [combined] and 40.8 [outpatient]; P < 0.001), lowest functional status at listing (P < 0.001), highest number of blood products used during surgery (P < 0.001), highest incidence of re-exploration for bleeding (P = 0.006), and longest posttransplant hospital stays (median, 35 vs 15 days [combined] and 12 days [outpatient]; P < 0.001). One-year survival trended lower for inpatients (log-rank, P = 0.056). Inpatient evaluations had the highest total, variable, and fixed costs of posttransplant care (P < 0.001).

CONCLUSION

Inpatient lung transplant evaluation was associated with longer hospital stays, higher perioperative morbidity, and lower 1-year survival. Partial or complete inpatient evaluation was associated with a higher cost of care posttransplant.

Comparing outcomes in patients with end-stage chronic obstructive pulmonary disease: single versus bilateral lung transplants

OBJECTIVES

Debate continues on whether a bilateral (BLT) or a single lung transplantation (SLT) is preferred for patients with end-stage chronic obstructive pulmonary disease (COPD). The purpose of this study is to examine the interplay between patient age and transplant type on survival outcomes.

METHODS

We performed a retrospective study of lung transplants for COPD at our centre from February 2012 to March 2020 (n = 186). Demographics and clinical parameters were compared between patients based on their age (≤65 vs >65 years old) and type of transplant (single vs bilateral). Cox proportional hazards regression was also performed. P-values <0.05 were considered significant.

RESULTS

Of the 186 patients with COPD who received lung transplants, 71 (38.2%) received BLTs and 115 (61.8%) received SLTs. There was no significant difference in survival outcomes when looking at patients with single versus BLTs (P = 0.870). There was also no difference in survival between the 2 age groups ≤65 versus > 65 years (P = 0.723). The Cox model itself also did not show a statistically significant improvement in survival outcomes (P = 0.126).

CONCLUSIONS

Lung transplant outcomes in patients with end-stage COPD demonstrated non-inferior results in patients with an SLT compared to patients with a BLT. When we compared the age groups, neither transplant type showed superior survival benefits, suggesting there may be some utility in an SLT in younger recipients.

Selection Criteria for Lung Transplantation: Controversies and New Developments

Lung transplantation is an accepted therapeutic option for end-stage lung diseases. The imbalance between limited availability and vast need of donor organs necessitates careful selection of recipient candidates, ensuring the best possible utilization of the scarce resource of organs. Nonetheless, possible lung transplant candidates who could experience a meaningful improvement in survival and quality of life should not be excluded solely based on the complexity of their case. In this review, controversial issues or difficult limitations for lung transplantation, and new developments in recipient selection criteria, are discussed, which may help broaden recipient eligibility for lung transplantation without compromising long-term outcomes.

Frailty in Lung Transplantation - Candidate Assessment and Optimization

The concept of frailty has gained considerable interest in clinical solid organ transplantation over the past decade. Frailty as a phenotypic construct to describe a patient's risk from biologic stresses, has an impact on posttransplant survival. There is keen interest in characterizing frailty in lung transplantation, both to determine which patients are suitable candidates for listing and also to prepare for their care in the aftermath of lung transplantation. Here we review the current status of research on frailty in lung transplant candidates and recipients. This review will highlight areas of uncertainty for frailty in clinical lung transplantation which are likely to impact the state-of-the-art in the field for the next decade.

Lung transplantation for the treatment of irreversible acute respiratory distress syndrome

BACKGROUND

Despite advances in critical care for acute respiratory distress syndrome (ARDS), some survivors in the acute phase are unable to wean from extracorporeal membrane oxygenation (ECMO) or mechanical ventilation. To date, little is known regarding whether lung transplantation confers a survival benefit for irreversible ARDS.

METHODS

This retrospective study was conducted using the United Network for Organ Sharing database (May 2005-December 2018). Patients with restrictive lung disease were divided into two groups: patients with and without ARDS. Propensity score matching identified recipients without ARDS for the control group.

RESULTS

A total of 63 patients with ARDS were waitlisted for lung transplantation, while 39 received a lung transplant after a median waitlist duration of 8 days. Seventy-eight patients were matched as controls. In the ARDS group, the median age was 30 years, and the median lung allocation score was 88.4. Among the 39 recipients, 30 (76.9%) received ECMO support prior to transplantation. Lung transplantation for ARDS and restrictive lung disease showed similar 90-day (87.2% vs. 88.5%, p = .80), 1-year (82.1% vs. 85.9%, p = .52), and 3-year (69.2% vs. 65.4%, p = .94) survival rates.

CONCLUSIONS

Lung transplantation provides acceptable outcomes in selected patients with irreversible ARDS.

[Early outcomes following lung transplantation in patients aged 65 years and older]

INTRODUCTION

The number of lung transplantations performed is increasing worldwide. With an improved experience and outcomes, the age of the recipient on its own has ceased to be an absolute contra-indication. We report our first experience with lung transplantation in patients aged 65 years or older.

METHODS

From January 2014 to March 2019, the files of patients aged 65 years or older undergoing lung transplantation were retrospectively reviewed.

RESULTS

During the study period, 241 patients underwent lung transplantation in Bichat hospital (Paris, France), including 25 recipients aged 65 years or older. Underlying diagnoses were interstitial (72%) and obstructive (28%) disease. The rate of single lung transplantation was 80%. Sixteen patients required ECMO assistance during the procedure. Early complications were mostly grade III primary graft dysfunction (12%) and cellular rejection (20%). Overall one-year survival rate was 76%.

CONCLUSION

After a careful selection of the recipients, the early results of our retrospective single center series are encouraging. We continue to consider lung transplantation in rigorously selected recipients of aged 65 years and more.

Advances in Human Lung Transplantation

Lung transplantation improves survival and quality of life in patients with advanced pulmonary disease. Over the past several decades, the volume of lung transplants has grown substantially, with increasing transplantation of older and acutely ill individuals facilitated by improved utilization and preservation of available donor organs. Other advances include improvements in the diagnosis and mechanistic understanding of frequent post-transplant complications, such as primary graft dysfunction, acute rejection, and chronic lung allograft dysfunction (CLAD). CLAD occurs as a result of the host immune response to the allograft and is the principal factor limiting long-term survival after lung transplantation. Two distinct clinical phenotypes of CLAD have emerged, bronchiolitis obliterans syndrome and restrictive allograft syndrome, and this distinction has enabled further understanding of underlying immune mechanisms. Building on these advances, ongoing studies are exploring novel approaches to diagnose, prevent, and treat CLAD. Such studies are necessary to improve long-term outcomes for lung transplant recipients.

Extremes of Age Decrease Survival in Adults After Lung Transplant

BACKGROUND

Age has been implicated as a factor in the plateau of long-term survival after lung transplant.

METHODS

We used data from the Scientific Registry of Transplant Recipients to identify all recipients of lung transplant aged ≥18 years of age between January 1, 2006, and February 19, 2015. A total of 14,253 patients were included in the analysis. Survival was estimated using a nonproportional hazard model and random-survival forest methodology was used to examine risk factors for death. Final selection of model variables was performed using bootstrap aggregation. Age was analyzed as both a continuous and categorical variable (age <30, 30-55, and >55 years). Risk factors for death were obtained for the entire cohort and additional age-specific risk factors were identified for each age category.

RESULTS

The median age at transplant was 59 years. There were 1,098 (7.7%) recipients <30 years, 4,201 (29.5%) 30 to 55 years, and 8,954 (62.8%) >55 years of age. Age was the most significant risk factor for death at all time-points following transplant and its impact becomes more prominent as time from transplant increases. Risk factors for death for all patients included extremes of age, higher creatinine, single lung transplant, hospitalization before transplant, and increased bilirubin. Risk factors for death differed by age with social determinants of health disproportionately affecting survival for those in the youngest age category.

CONCLUSIONS

The youngest and oldest adult recipients experienced the lowest posttransplant survival through divergent pathways that may present opportunities for intervention to improve survival after lung transplant.

Lung transplantation for idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is a progressive lung disease with a poor prognosis. Lung transplantation is the only intervention shown to increase life expectancy for patients with IPF, but it is associated with disease-specific challenges. In this Review, we discuss the importance of a proactive approach to the management of IPF comorbidities, including gastro-oesophageal reflux, pulmonary hypertension, coronary artery disease, and malignancy. With a donor pool too small to meet demand and unacceptably high mortality on transplant waiting lists, we discuss different systems used internationally to facilitate organ allocation. We explore the rapidly evolving landscape of transplantation for patients with IPF with regards to antifibrotic therapy, technological advances in extracorporeal life support, advances in understanding of the genetics of the disease, and the importance of a holistic multidisciplinary approach to care. Finally, we consider potential advances over the next decade that are envisaged to improve transplantation outcomes in patients with advanced IPF.

Solid organ transplantation in older adults. Infectious and other age-related considerations

In the U.S., older adults aged 65 or above comprise nearly one quarter of the solid organ transplant (SOT) waitlists, and the number of transplants performed in this age group continues to increase. There are no specific guidelines for the assessment and follow up of the older SOT candidate or recipient. Older adults are at increased risk of infectious complications after SOT. Despite these complications and even with the use of suboptimal donors, overall outcomes are favorable. We provide an overview to specific consideration as they relate to the older SOT candidate and recipient.

Characterizing idiopathic pulmonary fibrosis patients using US Medicare-advantage health plan claims data

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is a rare life-threating interstitial lung disease (ILD). This study characterizes demographics, health care utilization, and comorbidities among elderly IPF patients and estimates prevalence and incidence rates for selected outcomes.

METHODS

Cohort study using a large US health insurance database (Optum's Medicare Advantage plan).

INCLUSION CRITERIA

≥ 1 diagnosis code for IPF (2008 - 2014), age ≥65 years, no diagnosis of IPF or other ILD in prior 12 months. Demographics, health care utilization, comorbidities and incidence rates for various outcomes were estimated. Follow-up continued until the earliest of: health plan disenrollment, death, a claim for another known cause of ILD, or end of the study period.

RESULTS

4,716 patients were eligible; 53.4% had IPF diagnostic testing. Median age was 77.5 years, 50.3% were male, median follow-up time was 0.8 years. Incidence rates ranged from 1.0/1,000 person-years (lung transplantation) to 374.3/1,000 person-years (arterial hypertension). Baseline characteristics and incidence rates were similar for cohorts of patients with and without IPF diagnostic testing.

CONCLUSIONS

Elderly IPF patients experience a variety of comorbidities before and after IPF diagnosis. Therapies for IPF and for the associated comorbidities may reduce morbidity and associated health care utilization of these patients.

Non-cystic fibrosis bronchiectasis in the elderly: current perspectives

Bronchiectasis is a chronic lung disease with permanently damaged airways predisposing to recurrent respiratory tract infections. There is an increasing prevalence of bronchiectasis in the elderly, affecting approximately 10 patients per 1,000 population. Studies have shown that older, frailer patients tend to have a more severe and symptomatic disease, with those aged 80 and above with worse quality of life, increased hospitalization and increased mortality. These patients will be encountered by clinicians working in all aspects of elderly care. This review covers the various investigations and aspects of treatment for bronchiectasis and how they may be utilized in a more older and generally frailer population.

Outcomes of lung transplant recipients with preoperative atrial fibrillation

Background

Preoperative atrial fibrillation is associated with poor outcomes after cardiac surgery, but its effect on lung transplantation outcomes remains unknown.

Methods

We retrospectively reviewed the charts of 235 patients who underwent lung transplantation in our institution from 2013 to 2015, analyzing demographics, length of stay, survival, readmissions, and cardiac events. Mean recipient age was 59 ± 11 years, and 142 (60.4%) were men. Patients were grouped according to pre-transplantation atrial fibrillation status (atrial fibrillation/no atrial fibrillation).

Results

The atrial fibrillation group ( n = 38; 16.2%) was significantly older with a longer ischemic time, more postoperative atrial arrhythmias (73.7% vs. 20.8%, p = 0.01), and a longer median postoperative length of stay (16 vs. 13 days, p = 0.02). The median total hospital stay in the first postoperative year was also higher in the atrial fibrillation group (27 vs. 21 days, p = 0.25). Short-term survival and survival during follow-up did not differ significantly between groups.

Conclusions

Lung transplant recipients with preoperative atrial fibrillation are at increased risk of adverse cardiovascular outcomes and longer hospital stay. Preoperative atrial fibrillation may portend adverse events after lung transplantation.

Lung transplantation in elderly patients

Consensus statements on the selection of lung transplant candidates have consistently identified older age as a relative contraindication to transplantation. A combination of population-level demographic changes, revision of the lung allocation score (LAS), and clearer data on outcomes in elderly transplant recipients has, however, driven a steady increase in the threshold at which age is taken into consideration. This article reviews the current state of lung transplantation in elderly patients with an emphasis on the factors that have increased lung transplantation in older age groups, their expected outcomes including survival and health-related quality of life, and the factors that go in to appropriate candidate and procedure selection in this population.

Age-Dependent Gender Disparities in Post Lung Transplant Survival Among Patients With Idiopathic Pulmonary Fibrosis

BACKGROUND

The influence of age and gender on survival after lung transplant in patients with idiopathic pulmonary fibrosis (IPF) is not well defined.

METHODS

The United Network for Organ Sharing database was queried to identify IPF patients receiving lung transplant between 2005 and 2015.

RESULTS

There were 6,677 patients receiving lung transplant between May 2015 and June 2015 who met the inclusion criteria, predominantly males (n = 4,769, 71%). Within 1 year posttransplant, the survival curves of male and female recipients diverged, with male recipients having significantly worse survival (log-rank test p = 0.008). Univariate Cox proportional hazards regressions demonstrated no gender difference in survival below age 65 years (HR = 1.051; 95% CI = 0.945, 1.168; p = 0.362) but a significant increase in mortality hazard associated with male gender among patients age 65 years and older (HR = 1.161; 95% CI = 1.000, 1.347; p = 0.049). Multivariable Cox regression accounting for age modulation of the gender effect further demonstrated the emergence of a male disadvantage in post-transplant survival above age 65 years at transplantation.

CONCLUSIONS

In patients with IPF receiving lung transplant at greater than 65 years of age, male gender is associated with significantly increased risk for death, so referral for lung transplant in IPF should be considered early in the disease course.

Comprehensive Care of the Lung Transplant Patient

Lung transplantation has evolved into a life-saving treatment with improved quality of life for patients with end-stage respiratory failure unresponsive to other medical or surgical interventions. With improving survival rates, the number of lung transplant recipients with preexisting and posttransplant comorbidities that require attention continues to increase. A partnership between transplant and nontransplant care providers is necessary to deliver comprehensive and optimal care for transplant candidates and recipients. The goals of this partnership include timely referral and assistance with transplant evaluation, optimization of comorbidities and preparation for transplantation, management of common posttransplant medical comorbidities, immunization, screening for malignancy, and counseling for a healthy lifestyle to maximize the likelihood of a good outcome. We aim to provide an outline of the main aspects of the care of candidates for and recipients of lung transplants for nontransplant physicians and other care providers.