Lung transplantation in patients 70 years old or older: Have outcomes changed after implementation of the lung allocation score?

Lung transplant outcomes in recipients of advanced age: Are two always better than one?

BACKGROUND

Lung transplantation has become more common in patients aged 65 years and older. We aimed to examine outcomes across age groups and identify risk factors for decreased survival.

METHODS

United Network for Organ Sharing data for all primary lung transplants from January 1, 2006, to March 8, 2023, were retrospectively reviewed. The impact of recipient age on survival was analyzed.

RESULTS

Of the 33,644 lung transplant recipients who were identified, 23,125 (69%), 7270 (21%), 2895 (9%), and 354 (1%) were aged 12 to 64, 65 to 69, 70 to 74, and 75 to 79 years, respectively. Older patients underwent single lung transplantation more often (12-64 years: 19%, 65-69 years: 41%, 70-74 years: 57%, 75-79 years: 75%, P < .001). Median survival was greater in bilateral compared with single lung transplant in all groups except those aged 75 to 79 years (12-64 years: 7.6 vs 5.6, P < .001; 65-69 years: 5.8 vs 4.8, P < .001; 70-74 years: 5.0 vs 3.9, P < .001; 75-79 years: 4.0 vs 3.9 years, P = .919). Previous cardiac surgery was associated with increased risk of death (hazard ratio, 1.27; 95% confidence interval, 1.14-1.41, P < .001) and greater likelihood of receiving a single lung transplant with older age (12-64 years: 45.3%, 65-79 years: 71.0%, P < .001).

CONCLUSIONS

Bilateral lung transplantation offers a survival advantage over single lung transplantation in recipients up to 74 years of age. Recipients aged 75 to 79 have poor long-term survival. Previous cardiac surgery is associated with worse long-term survival, necessitating careful patient selection, especially in older patients being offered a single lung transplant.

The role of coronary artery disease in lung transplantation: a propensity-matched analysis

BACKGROUND AND AIMS

Candidate selection for lung transplantation (LuTx) is pivotal to ensure individual patient benefit as well as optimal donor organ allocation. The impact of coronary artery disease (CAD) on post-transplant outcomes remains controversial. We provide comprehensive data on the relevance of CAD for short- and long-term outcomes following LuTx and identify risk factors for mortality.

METHODS

We retrospectively analyzed all adult patients (≥ 18 years) undergoing primary and isolated LuTx between January 2000 and August 2021 at the LMU University Hospital transplant center. Using 1:1 propensity score matching, 98 corresponding pairs of LuTx patients with and without relevant CAD were identified.

RESULTS

Among 1,003 patients having undergone LuTx, 104 (10.4%) had relevant CAD at baseline. There were no significant differences in in-hospital mortality (8.2% vs. 8.2%, p > 0.999) as well as overall survival (HR 0.90, 95%CI [0.61, 1.32], p = 0.800) between matched CAD and non-CAD patients. Similarly, cardiovascular events such as myocardial infarction (7.1% CAD vs. 2.0% non-CAD, p = 0.170), revascularization by percutaneous coronary intervention (5.1% vs. 1.0%, p = 0.212), and stroke (2.0% vs. 6.1%, p = 0.279), did not differ statistically between both matched groups. 7.1% in the CAD group and 2.0% in the non-CAD group (p = 0.078) died from cardiovascular causes. Cox regression analysis identified age at transplantation (HR 1.02, 95%CI [1.01, 1.04], p < 0.001), elevated bilirubin (HR 1.33, 95%CI [1.15, 1.54], p < 0.001), obstructive lung disease (HR 1.43, 95%CI [1.01, 2.02], p = 0.041), decreased forced vital capacity (HR 0.99, 95%CI [0.99, 1.00], p = 0.042), necessity of reoperation (HR 3.51, 95%CI [2.97, 4.14], p < 0.001) and early transplantation time (HR 0.97, 95%CI [0.95, 0.99], p = 0.001) as risk factors for all-cause mortality, but not relevant CAD (HR 0.96, 95%CI [0.71, 1.29], p = 0.788). Double lung transplant was associated with lower all-cause mortality (HR 0.65, 95%CI [0.52, 0.80], p < 0.001), but higher in-hospital mortality (OR 2.04, 95%CI [1.04, 4.01], p = 0.039).

CONCLUSION

In this cohort, relevant CAD was not associated with worse outcomes and should therefore not be considered a contraindication for LuTx. Nonetheless, cardiovascular events in CAD patients highlight the necessity of control of cardiovascular risk factors and a structured cardiac follow-up.

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.

Outcomes of Lung Transplant Candidates Aged ≥70 Years During the Lung Allocation Score Era

BACKGROUND

With the increasing age of lung transplant candidates, we studied waitlist and posttransplantation outcomes of candidates ≥70 years during the Lung Allocation Score era.

METHODS

Adult lung transplant candidates from 2005 to 2020 in the United Network for Organ Sharing database were included and stratified on the basis of age at listing into 18 to 59 years old, 60 to 69 years old, and ≥70 years old. Baseline characteristics, waitlist outcomes, and posttransplantation outcomes were assessed.

RESULTS

A total of 37,623 candidates were included (52.3% aged 18-59 years, 40.6% aged 60-69 years, 7.1% aged ≥70 years). Candidates ≥70 years were more likely than younger candidates to receive a transplant (81.9% vs 72.7% [aged 60-69 years] vs 61.6% [aged 18-59 years]) and less likely to die or to deteriorate on the waitlist within 1 year (9.1% vs 10.1% [aged 60-69 years] vs 12.2% [aged 18-59 years]; P < .001). Donors for older recipients were more likely to be extended criteria (75.7% vs 70.1% [aged 60-69 years] vs 65.7% [aged 18-59 years]; P < .001). Recipients ≥70 years were found to have lower rates of acute rejection (6.7% vs 7.4% [aged 60-69 years] vs 9.2% [aged 18-59 years]; P < .001) and prolonged intubation (21.7% vs 27.4% [aged 60-69 years] vs 34.5% [aged 18-59 years]; P < .001). Recipients aged ≥70 years had increased 1-year (adjusted hazard ratio [aHR], 1.19 [95% CI, 1.06-1.33]; P < .001), 3-year (aHR, 1.28 [95% CI, 1.18-1.39]; P < .001), and 5-year mortality (aHR, 1.29 [95% CI, 1.21-1.38]; P < .001) compared with recipients aged 60 to 69 years.

CONCLUSIONS

Candidates ≥70 years had favorable waitlist and perioperative outcomes despite increased use of extended criteria donors. Careful selection of candidates and postoperative surveillance may improve posttransplantation survival in this population.

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.

Reoperative CABG in a patient with prior concomitant lung transplantation and two-vessel CABG

BACKGROUND

Lung transplants (LTx) are being offered to increasingly older patients, and as a result, more concomitant coronary artery disease is being encountered in LTx candidates. While concurrent coronary artery bypass grafting (CABG) and LTx have become more common, the long-term considerations of reoperative CABG in patients following CABG with concomitant LTx are not fully understood.

CASE PRESENTATION

A 75-year-old man with a history of bilateral LTx and concomitant CABG X 2 15 years prior presented to the emergency room with tachycardia and chest discomfort radiating to the left upper extremity. Emergent coronary angiography revealed severe three-vessel coronary artery disease with two occluded saphenous vein grafts, severe distal obtuse marginal (OM) and left circumflex disease, a collateralized chronic total occlusion of the mid LAD, and tortuosity of the proximal right innominate artery. The patient underwent a complex redo sternotomy and CABG X 2 due to dense adhesions in the mediastinum and pleura bilaterally. The postoperative course was complicated by left leg SVG harvest site cellulitis treated with IV antibiotics and hypervolemia treated with diuresis. The patient was discharged postoperatively on day 13.

DISCUSSION

To our knowledge, this is the first reported successful reoperative CABG in a patient with a history of concomitant LTx and CABG. This case demonstrates feasibility, though additional caution is required due to the technical complexity and risk of immunosuppression in such complex patients.

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.

Safety of Crossing Donor-specific Antibodies in Lung Transplantation

BACKGROUND

Donor-specific antibodies (DSAs) have been associated with antibody-mediated rejection, chronic lung allograft dysfunction (CLAD), and increased mortality in lung transplant recipients. Our center performs transplants in the presence of DSA, and we sought to evaluate the safety of this practice with respect to graft loss, CLAD onset, and primary graft dysfunction (PGD).

METHODS

We reviewed recipients transplanted from 2010 to 2017, classifying them as DSA positive (DSA+) or negative. We used Kaplan-Meier estimation to test the association between DSA status and time to death or retransplant and time to CLAD onset. We further tested associations with severe PGD and rejection in the first year using logistic regression and Fisher exact testing.

RESULTS

Three hundred thirteen patients met inclusion criteria, 30 (10%) of whom were DSA+. DSA+ patients were more likely to be female, bridged to transplant, and receive induction therapy. There was no association between DSA status and time to death or retransplant (log rank P = 0.581) nor death-censored time to CLAD onset (log rank P = 0.278), but DSA+ patients were at increased risk of severe PGD (odds ratio 2.88; 95% confidence interval, 1.10-7.29; P = 0.031) and more frequent antibody-mediated rejection in the first posttransplant year.

CONCLUSIONS

Crossing DSA at time of lung transplant was not associated with an increased risk of death or CLAD in our cohort, but patients developed severe PGD and antibody-mediated rejection more frequently. However, these risks are likely manageable when balanced against the benefits of expanded access for sensitized candidates.

The Intersection of Aging and Lung Transplantation: its Impact on Transplant Evaluation, Outcomes, and Clinical Care

Purpose

Older adults (age ≥ 65 years) are the fastest growing age group undergoing lung transplantation. Further, international consensus document for the selection of lung transplant candidates no longer suggest a fixed upper age limit. Although carefully selected older adults can derive great benefit, understanding which older adults will do well after transplant with improved survival and health-related qualiy of life is key to informed decision-making. Herein, we review the epidemiology of aging in lung transplantation and its impact on outcomes, highlight selected physiological measures that may be informative when evaluating and managing older lung transplant patients, and identify directions for future research.

Recent Findings

In general, listing and transplanting older, sicker patients has contributed to worse clinical outcomes and greater healthcare use. Emerging evidence suggest that measures of physiological age, such as frailty, body composition, and neurocognitive and psychosocial function, may better identify risk for poor transplant outcomes than chronlogical age.

Summary

The evidence base to inform transplant decision-making and improvements in care for older adults is small but growing. Multipronged efforts at the intersection of aging and lung transplantation are needed to improve the clinical and patient centered outcomes for this large and growing cohort of patients. Future research should focus on identifying novel and ideally modifiable risk factors for poor outcomes specific to older adults, better approaches to measuring physiological aging (e.g., frailty, body composition, neurocognitive and psychosocial function), and the underlying mechanisms of physiological aging. Finally, interventions that can improve clinical and patient centered outcomes for older adults are needed.

Critical Care of the Lung Transplant Patient

Lung transplantation is a therapeutic option for end-stage lung disease that improves survival and quality of life. Prelung transplant admission to the intensive care unit (ICU) for bridge to transplant with mechanical ventilation and extracorporeal membrane oxygenation (ECMO) is common. Primary graft dysfunction is an important immediate complication of lung transplantation with short- and long-term morbidity and mortality. Later transplant-related causes of respiratory failure necessitating ICU admission include acute cellular rejection, atypical infections, and chronic lung allograft dysfunction. Lung transplantation for COVID-19-related ARDS is increasingly common..

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.

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.

New models for donor-recipient matching in lung transplantations

Objective

One of the main problems of lung transplantation is the shortage of organs as well as reduced survival rates. In the absence of an international standardized model for lung donor-recipient allocation, we set out to develop such a model based on the characteristics of past experiences with lung donors and recipients with the aim of improving the outcomes of the entire transplantation process.

Methods

This was a retrospective analysis of 404 lung transplants carried out at the Reina Sofía University Hospital (Córdoba, Spain) over 23 years. We analyzed various clinical variables obtained via our experience of clinical practice in the donation and transplantation process. These were used to create various classification models, including classical statistical methods and also incorporating newer machine-learning approaches.

Results

The proposed model represents a powerful tool for donor-recipient matching, which in this current work, exceeded the capacity of classical statistical methods. The variables that predicted an increase in the probability of survival were: higher pre-transplant and post-transplant functional vital capacity (FVC), lower pre-transplant carbon dioxide (PCO2) pressure, lower donor mechanical ventilation, and shorter ischemia time. The variables that negatively influenced transplant survival were low forced expiratory volume in the first second (FEV1) pre-transplant, lower arterial oxygen pressure (PaO2)/fraction of inspired oxygen (FiO2) ratio, bilobar transplant, elderly recipient and donor, donor-recipient graft disproportion requiring a surgical reduction (Tailor), type of combined transplant, need for cardiopulmonary bypass during the surgery, death of the donor due to head trauma, hospitalization status before surgery, and female and male recipient donor sex.

Conclusions

These results show the difficulty of the problem which required the introduction of other variables into the analysis. The combination of classical statistical methods and machine learning can support decision-making about the compatibility between donors and recipients. This helps to facilitate reliable prediction and to optimize the grafts for transplantation, thereby improving the transplanted patient survival rate.

The Lung Allocation Score and Its Relevance

Lung transplantation in the United States, under oversight by the Organ Procurement Transplantation Network (OPTN) in the 1990s, operated under a system of allocation based on location within geographic donor service areas, wait time of potential recipients, and ABO compatibility. On May 4, 2005, the lung allocation score (LAS) was implemented by the OPTN Thoracic Organ Transplantation Committee to prioritize patients on the wait list based on a balance of wait list mortality and posttransplant survival, thus eliminating time on the wait list as a factor of prioritization. Patients were categorized into four main disease categories labeled group A (obstructive lung disease), B (pulmonary hypertension), C (cystic fibrosis), and D (restrictive lung disease/interstitial lung disease) with variables within each group impacting the calculation of the LAS. Implementation of the LAS led to a decrease in the number of wait list deaths without an increase in 1-year posttransplant survival. LAS adjustments through the addition, modification or elimination of covariates to improve the estimates of patient severity of illness, have since been made in addition to establishing criteria for LAS value exceptions for pulmonary hypertension patients. Despite the success of the LAS, concerns about the prioritization, and transplantation of older, sicker individuals have made some aspects of the LAS controversial. Future changes in US lung allocation are anticipated with the current development of a continuous distribution model that incorporates the LAS, geographic distribution, and unaccounted aspects of organ allocation into an integrated score.

The therapy of idiopathic pulmonary fibrosis: what is next?

Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive, fibrosing interstitial lung disease, characterised by progressive scarring of the lung and associated with a high burden of disease and early death. The pathophysiological understanding, clinical diagnostics and therapy of IPF have significantly evolved in recent years. While the recent introduction of the two antifibrotic drugs pirfenidone and nintedanib led to a significant reduction in lung function decline, there is still no cure for IPF; thus, new therapeutic approaches are needed. Currently, several clinical phase I-III trials are focusing on novel therapeutic targets. Furthermore, new approaches in nonpharmacological treatments in palliative care, pulmonary rehabilitation, lung transplantation, management of comorbidities and acute exacerbations aim to improve symptom control and quality of life. Here we summarise new therapeutic attempts and potential future approaches to treat this devastating disease.

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.

Single Versus Bilateral Lung Transplantation for Idiopathic Pulmonary Fibrosis in the Lung Allocation Score Era

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is a progressive and fatal disease. Lung transplantation is the only therapy associated with prolonged survival. The ideal transplant procedure for IPF is unclear. Outcomes after single transplantation (SLTx) versus bilateral lung transplantation (BLTx) in IPF patients after introduction of the Lung Allocation Score were examined.

METHODS

Records of patients undergoing lung transplantation for IPF at our institution between May 2005 and March 2017 were reviewed to examine the effect of transplant laterality. Primary outcomes were overall, rejection-free, and bronchiolitis obliterans (BOS)-free survival at 1 and 5 years post-transplant.

RESULTS

Lung transplantation was performed in 151 IPF patients post-Lung Allocation Score. Most recipients were male with average age 59 ± 8 years. SLTx was performed in 94 patients (62%). In the overall cohort, comparative survival between SLTx and BLTx was similar at 1 and 5 years before and after adjusting for age and pulmonary hypertension (PH). SLTx was associated with shorter ventilator time and intensive care unit stay and trended toward improved survival over BLTx in patients without PH.

CONCLUSIONS

The use of SLTx versus BLTx in IPF did not correspond to significantly different survival adjusting for age and PH. BLTx was associated with prolonged postoperative ventilation and length of stay compared with SLTx. Patients without PH, all older patients, and patients with PH and advanced disease should be considered for SLTx for IPF.

The Management of Patients With Idiopathic Pulmonary Fibrosis

Idiopathic pulmonary fibrosis (IPF), the most common form of fibrosing idiopathic interstitial pneumonia, is an inexorably progressive disease with a 5-year survival of ~20%. In the last decade, our understanding of disease pathobiology has increased significantly and this has inevitably impacted on the approach to treatment. Indeed, the paradigm shift from a chronic inflammatory disorder to a primarily fibrotic one coupled with a more precise disease definition and redefined diagnostic criteria have resulted in a massive increase in the number of clinical trials evaluating novel candidate drugs. Most of these trials, however, have been negative, probably because of the multitude and redundancy of cell types, growth factors and profibrotic pathways involved in disease pathogenesis. As a consequence, until recently IPF has lacked effective therapies. Finally, in 2014, two large phase 3 clinical trials have provided robust evidence that pirfenidone, a compound with anti-fibrotic, anti-oxidant and anti-inflammatory properties, and nintedanib, a tyrosine kinase inhibitor with selectivity for vascular endothelial growth factor, platelet-derived growth factor and fibroblast growth factor receptors are able to slow down functional decline and disease progression with an acceptable safety profile. While this is a major achievement, neither pirfenidone nor nintedanib cures IPF and most patients continue to experience disease progression and/or exacerbation despite treatment. Therefore, in recent years increasingly more attention has been paid to preservation of quality of life and, in the advanced phase of the disease, palliation of symptoms. Lung transplantation, the only curative treatment, remains a viable option for only a minority of highly selected patients. The unmet medical need in IPF remains high, and more efficacious and better tolerated drugs are urgently needed. However, a truly effective therapeutic approach should also address quality of life and highly prevalent concomitant conditions and complications of IPF.

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.

Noteworthy Literature Published in 2016 for Thoracic Organ Transplantation Anesthesiologists

This article is first in the series to review the published literature on perioperative issues in patients undergoing thoracic solid organ transplantations. We present recent literature from 2016 on preoperative considerations, organ preservation, intraoperative anesthesia management, surgical techniques, postoperative complications, and the impact of perioperative management on short- and long-term outcomes that are pertinent to thoracic transplantation anesthesiologists.

The utility of 6-minute walk distance in predicting waitlist mortality for lung transplant candidates

BACKGROUND

The lung allocation score (LAS) has led to improved organ allocation for transplant candidates. At present, the 6-minute walk distance (6MWD) is treated as a binary categorical variable of whether or not a candidate can walk more than 150 feet in 6 minutes. In this study, we tested the hypothesis that 6MWD is presently under-utilized with respect to discriminatory power, and that, as a continuous variable, could better prognosticate risk of waitlist mortality.

METHODS

A retrospective cohort analysis was performed using the Organ Procurement and Transplantation Network/United Network for Organ Sharing (OPTN/UNOS) transplant database. Candidates listed for isolated lung transplant between May 2005 and December 2011 were included. The population was stratified by 6MWD quartiles and unadjusted survival rates were estimated. Multivariable Cox proportional hazards modeling was used to assess the effect of 6MWD on risk of death. The Scientific Registry of Transplant Recipients (SRTR) Waitlist Risk Model was used to adjust for confounders. The optimal 6MWD for discriminative accuracy in predicting waitlist mortality was assessed by receiver-operating characteristic (ROC) curves.

RESULTS

Analysis was performed on 12,298 recipients. Recipients were segregated into quartiles by distance walked. Waitlist mortality decreased as 6MWD increased. In the multivariable model, significant variables included 6MWD, male gender, non-white ethnicity and restrictive lung diseases. ROC curves discriminated 6-month mortality was best at 655 feet.

CONCLUSIONS

The 6MWD is a significant predictor of waitlist mortality. A cut-off of 150 feet sub-optimally identifies candidates with increased risk of mortality. A cut-off between 550 and 655 feet is more optimal if 6MWD is to be treated as a dichotomous variable. Utilization of the LAS as a continuous variable could further enhance predictive capabilities.

"Age" in lung transplantation: factors related to outcomes and other considerations

The age of lung transplant recipients is steadily increasing. Older donors are more frequently considered. The risk factors associated with advanced age in lung transplantation warrant discussion to ensure optimal outcomes in this complex endeavor. This report provides a summary of the pertinent topics and available evidence.

A global perspective of lung transplantation: Part 1 - Recipient selection and choice of procedure

Lung transplantation has grown considerably in recent years and its availability has spread to an expanding number of countries worldwide. Importantly, survival has also steadily improved, making this an increasingly viable procedure for patients with end-stage lung disease and limited life expectancy. In this first of a series of articles, recipient selection and type of transplant operation are reviewed. Pulmonary fibrotic disorders are now the most indication in the U.S., followed by chronic obstructive pulmonary disease and cystic fibrosis. Transplant centers have liberalized criteria to include older and more critically ill candidates. A careful, systematic, multi-disciplinary selection process is critical in identifying potential barriers that may increase risk and optimize long-term outcomes.

[Indications of lung transplantation: Patients selection, timing of listing, and choice of procedure]

Lung transplantation (LT) is now considered as an excellent treatment option for selected patients with end-stage pulmonary diseases, such as COPD, cystic fibrosis, idiopathic pulmonary fibrosis, and pulmonary arterial hypertension. The 2 goals of LT are to provide a survival benefit and to improve quality of life. The 3-step decision process leading to LT is discussed in this review. The first step is the selection of candidates, which requires a careful examination in order to check absolute and relative contraindications. The second step is the timing of listing for LT; it requires the knowledge of disease-specific prognostic factors available in international guidelines, and discussed in this paper. The third step is the choice of procedure: indications of heart-lung, single-lung, and bilateral-lung transplantation are described. In conclusion, this document provides guidelines to help pulmonologists in the referral and selection processes of candidates for transplantation in order to optimize the outcome of LT.

The clinical effectiveness and cost-effectiveness of treatments for idiopathic pulmonary fibrosis: a systematic review and economic evaluation

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is a life-limiting lung disease that generally affects people over 60 years old. The main symptoms are shortness of breath and cough, and as the disease progresses there is a considerable impact on day-to-day life. Few treatments are currently available.

OBJECTIVES

To conduct a systematic review of clinical effectiveness and an analysis of cost-effectiveness of treatments for IPF based on an economic model informed by systematic reviews of cost-effectiveness and quality of life.

DATA SOURCES

Eleven electronic bibliographic databases, including MEDLINE, EMBASE, Web of Science, and The Cochrane Library and the Centre for Reviews and Dissemination databases, were searched from database inception to July 2013. Reference lists of relevant publications were also checked and experts consulted.

METHODS

Two reviewers independently screened references for the systematic reviews, extracted and checked data from the included studies and appraised their risk of bias. An advisory group was consulted about the choice of interventions until consensus was reached about eligibility. A narrative review with meta-analysis was undertaken, and a network meta-analysis (NMA) was performed. A decision-analytic Markov model was developed to estimate cost-effectiveness of pharmacological treatments for IPF. Parameter values were obtained from NMA and systematic reviews. Univariate and probabilistic sensitivity analyses were undertaken. The model perspective is NHS and Personal Social Services, and discount rate is 3.5% for costs and health benefits.

RESULTS

Fourteen studies were included in the review of clinical effectiveness, of which one evaluated azathioprine, three N-acetylcysteine (NAC) (alone or in combination), four pirfenidone, one BIBF 1120, one sildenafil, one thalidomide, two pulmonary rehabilitation, and one a disease management programme. Study quality was generally good, with a low risk of bias. The current evidence suggests that some treatments appear to be clinically effective. The model base-case results show increased survival for five pharmacological treatments, compared with best supportive care, at increased cost. General recommendations cannot be made of their cost-effectiveness owing to limitations in the evidence base.

LIMITATIONS

Few direct comparisons of treatments were identified. An indirect comparison through a NMA was performed; however, caution is recommended in the interpretation of these results. In relation to the economic model, there is an assumption that pharmacological treatments have a constant effect on the relative rate of per cent predicted forced vital capacity decline.

CONCLUSIONS

Few interventions have any statistically significant effect on IPF and a lack of studies on palliative care approaches was identified. Research is required into the effects of symptom control interventions, in particular pulmonary rehabilitation and thalidomide. Other research priorities include a well-conducted randomised controlled trial on inhaled NAC therapy and an updated evidence synthesis once the results of ongoing studies are reported.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012002116.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Lung transplantation in IIP: A review

The idiopathic interstitial pneumonias (IIP) encompass a large and diverse subtype of interstitial lung disease (ILD) with idiopathic pulmonary fibrosis (IPF) and non-specific interstitial pneumonia (NSIP) being the most common types. Although pharmacologic treatments are available for most types of IIP, many patients progress to advanced lung disease and require lung transplantation. Close monitoring with serial functional and radiographic tests for disease progression coupled with early referral for lung transplantation are of great importance in the management of patients with IIP. Both single and bilateral lung transplantation are acceptable procedures for IIP. Procedure selection is a complex decision influenced by multiple factors related to patient, donor and transplant centre. While single lung transplant may reduce waitlist time and mortality, the long-term outcomes after bilateral lung transplantation may be slightly superior. There are numerous complications following lung transplantation including primary graft dysfunction, chronic lung allograft dysfunction (CLAD), infections, gastroesophageal reflux disease (GERD) and airway disease that limit post-transplant longevity. The median survival after lung transplantation is 4.7 years in patients with ILD, which is less than in patients with other underlying lung diseases. Although long-term survival is limited, this intervention still conveys a survival benefit and improved quality of life in suitable IIP patients with advanced lung disease and chronic hypoxemic respiratory failure.

Management of Idiopathic Pulmonary Fibrosis in the Elderly Patient: Addressing Key Questions

Idiopathic pulmonary fibrosis (IPF) is strongly associated with advanced age. Making an accurate diagnosis of IPF is critical, as it remains only one of many potential diagnoses for an elderly patient with newly recognized interstitial lung disease. Optimal management of IPF, especially in older-aged patients, hinges on such factors as balancing the application of standard-of-care measures with the patient's overall health status (robustness vs frailty) and considering the patient's wishes, desires, and expectations. IPF is known to be associated with certain comorbidities that tend to be more prevalent in the elderly population. Until recently, options for the pharmacologic management of IPF were limited and included therapies such as immunosuppressive agents, which may pose substantial risk to the elderly patient. However, the antifibrotic agents pirfenidone and nintedanib have now become commercially available in the United States for the treatment of IPF. The monitoring and treatment of patients with IPF, especially elderly patients with comorbid medical conditions, require consideration of adverse side effects, the avoidance of potential drug-drug interactions, treatment of comorbidities, and the timely implementation of supportive and palliative measures. Individualized counseling to guide decision-making and enhance quality of life is also integral to optimal management of the elderly patient with IPF.

Impact of induction immunosuppression on survival in heart transplant recipients: a contemporary analysis of agents

INTRODUCTION

The impact of induction immunosuppression on long-term survival in heart transplant recipients is unclear. Over the past three decades, practices have varied as induction agents have changed and experiences grew. We sought to evaluate the effect of contemporary induction immunosuppression agents in heart transplant recipients with the primary endpoint of survival, utilizing national registry data.

METHODS

We queried the United Network for Organ Sharing (UNOS) data registry for all heart transplants from 1987 to 2012. We restricted our analysis to adult (≥18 yr) recipients performed from 2001-2011 (to allow for the potential for a minimum of 12 months post-transplant follow-up) who received either: no antibody based induction (NONE) or the contemporary agents (INDUCED) of either: basiliximab/daclizumab (IL-2Rab), alemtuzumab, or ATG/ALG/thymoglobulin. Kaplan-Meier estimates of the survival function as well as Cox proportional hazards models were utilized.

RESULTS

Of the 17 857 heart transplants that met the inclusion criteria, there were 4635 (26%) reported deaths during the follow-up period. There were 8216 (46%) patients who were INDUCED. Of the INDUCED agents, 55% were IL-2Rab, 4% alemtuzumab, and 40% ALG/ATG/thymoglobulin. Donor and recipient characteristics were evaluated. Overall, being INDUCED did not significantly affect survival in univariable (p = 0.522) and multivariable (p = 0.130) Cox models as well as a propensity score adjusted model (p = 0.733). Among those induced, ATG/ALG/thymoglobulin appeared to have superior survival as compared with IL-2Rab (log-rank p = 0.007, univariable hazard ratio [HR] = 0.886; 95% CI: 0.811-0.968; p = 0.522). However, in a multivariable Cox model that adjusted for recipient age, VAD, BMI, steroid use, CMV match, and ischemic time, the hazard ratio for ALG/ATG/thymoglobulin vs. IL-2Rab was no longer statistically significant (HR = 0.948; 95% CI: 0.850-1.058; p = 0.341).

CONCLUSION

In a contemporary analysis of heart transplant recipients, an overall analysis of induction agents does not appear to impact survival, as compared to no induction immunosuppression. While ALG/ATG/thymoglobulin appeared to have a beneficial effect on survival compared to IL-2Rab in the univariable model, this difference was no longer statistically significant once we adjusted for clinically relevant covariates.

Contemporary analysis of early outcomes after lung transplantation in the elderly using a national registry

BACKGROUND

With an increasing number of potential recipients and a comparatively static number of donors, lung transplantation (LT) in the elderly has come under significant scrutiny. Previous studies have been limited by single-center experiences with small population sizes and often mixed results. Using a national registry, we sought to evaluate the following: (1) differences in survival outcomes in septuagenarians compared with sexagenarians; and (2) the effect of temporal trends on the development of other comorbidities in this population.

METHODS

We analyzed the Scientific Registry of Transplant Recipients (SRTR) data files from the United Network for Organ Sharing (UNOS) database to identify recipients who underwent LT between the years 2000 and 2013. The study period was divided into two equal eras. Using Kaplan-Meier analysis, we compared the 30-day, 3-month, 1-year, 3-year and 5-year patient survival between septuagenarians and sexagenarians in both eras. Separate multivariate analyses were performed to estimate the risk of renal failure, risk of rejection and length of hospital stay (LOS) post-LT in each of these time periods.

RESULTS

A total of 6,596 patients were identified comprising 1,726 (26.2%) during 2000 to 2005 and 4,870 (73.8%) during 2006 to 2012. In the "early era," 32 (1.9%) septuagenarians and 1,694 (98.1%) sexagenarians underwent LT, whereas 543 (11.1%) septuagenarians and 4,327 (88.9%) sexagenarians underwent transplantation in the "latter era." A comparison of patient survival between the two groups in the early era revealed no difference at 30 days (95.7% vs 93.8%, p = 0.65). However, 3-month (91.2% vs 75%, p = 0.04) and 1-year patient survival (79.5% vs 62.5%, p = 0.048) were both lower in the septuagenarian group. In the later era, however, there were no differences in 30-day (96.2% vs 96.8, p = 0.5), 3-month (92.7% vs 91.9%, p = 0.56) or 1-year (81.7% vs 78.6%, p = 0.12) patient survival between the two age groups. Survival rates at 3 years (63.7% vs 49.3%, p < 0.001) and 5 years (47.5% vs 28.2%, p < 0.001) were each significantly lower in the septuagenarian group.

CONCLUSION

Overall, LT outcomes for the elderly have improved significantly over time and early outcomes in the modern era rival those found in younger recipients.

WITHDRAWN: The future of lung transplantation

This article has been withdrawn for editorial reasons because the journal will be published only in English. In order to avoid duplicated records, this article can be found at http://dx.doi.org/10.1016/j.rppnen.2014.09.006. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

Antibody desensitization therapy in highly sensitized lung transplant candidates

As HLAs antibody detection technology has evolved, there is now detailed HLA antibody information available on prospective transplant recipients. Determining single antigen antibody specificity allows for a calculated panel reactive antibodies (cPRA) value, providing an estimate of the effective donor pool. For broadly sensitized lung transplant candidates (cPRA ≥ 80%), our center adopted a pretransplant multi-modal desensitization protocol in an effort to decrease the cPRA and expand the donor pool. This desensitization protocol included plasmapheresis, solumedrol, bortezomib and rituximab given in combination over 19 days followed by intravenous immunoglobulin. Eight of 18 candidates completed therapy with the primary reasons for early discontinuation being transplant (by avoiding unacceptable antigens) or thrombocytopenia. In a mixed-model analysis, there were no significant changes in PRA or cPRA changes over time with the protocol. A sub-analysis of the median fluorescence intensity (MFI) change indicated a small decline that was significant in antibodies with MFI 5000-10,000. Nine of 18 candidates subsequently had a transplant. Posttransplant survival in these nine recipients was comparable to other pretransplant-sensitized recipients who did not receive therapy. In summary, an aggressive multi-modal desensitization protocol does not significantly reduce pretransplant HLA antibodies in a broadly sensitized lung transplant candidate cohort.

Aortic valve replacement 10 years after lung transplantation

Age-related native pathologic conditions are an inevitable sequela in long-term survivors of solid organ transplantation. A sexagenarian presented with severe aortic valve stenosis 10 years after lung transplantation (LTx). Despite overwhelming concerns of infection because of long-term immunosuppression and the risk of postoperative deterioration of function in transplanted lungs, an open heart surgical procedure with appropriate perioperative management was undertaken, and a successful aortic valve replacement (AVR) was performed.