The Association Between Frailty and Chronic Lung Allograft Dysfunction After Lung Transplantation

Improvements in Patient-Reported Functioning after Lung Transplant is Associated with Improved Quality of Life and Survival

Lung transplantation aims to improve health-related quality of life (HRQL) and survival. While lung function improvements are associated with these outcomes, the association between physical functioning and these outcomes is less clear. We investigated the association between changes in patient-reported physical functioning and HRQL, chronic lung allograft dysfunction (CLAD), and survival after lung transplantation. This single-center prospective cohort study analyzed 220 lung transplant recipients who completed the 15-item Lung Transplant Valued Life Activities (LT-VLA) before and repeatedly after transplant. HRQL was assessed using generic, respiratory disease-specific, and utility measures. Associations between 0.3-point changes (the minimally important difference) in LT-VLA as a time-varying predictor on HRQL, CLAD, and mortality were tested using linear regression and Cox proportional hazard models. Models were adjusted for demographics, disease diagnosis, and post-operative lung function as a time-varying covariate. Participants were 45% female and 75% White, with a mean age of 56 (±12) years. Each 0.3-point improvement in LT-VLA was associated with substantially improved HRQL across all measures (adjusted p-values <0.01). Each 0.3-point improvement in LT-VLA was associated with a 13% reduced hazard of CLAD (adjusted HR: 0.87, 95% CI: 0.76-0.99, p=0.03) and a 19% reduced hazard of mortality (adjusted HR: 0.81, 95% CI: 0.67-0.95, p=0.01). Improvements in patient-reported physical functioning after lung transplantation are associated with improved HRQL and reduced risk of CLAD and death, independent of allograft function. The simplicity of the LT-VLA suggests it could be a valuable monitoring or outcome measure in both clinical and research settings.

Advances in lung transplantation: 60 years on

Lung transplantation is a well-established treatment for advanced lung disease, improving survival and quality of life. Over the last 60 years all aspects of lung transplantation have evolved significantly and exponential growth in transplant volume. This has been particularly evident over the last decade with a substantial increase in lung transplant numbers as a result of innovations in donor utilization procurement, including the use donation after circulatory death and ex-vivo lung perfusion organs. Donor lungs have proved to be surprisingly robust, and therefore the donor pool is actually larger than previously thought. Parallel to this, lung transplant outcomes have continued to improve with improved acute management as well as microbiological and immunological insights and innovations. The management of lung transplant recipients continues to be complex and heavily dependent on a tertiary care multidisciplinary paradigm. Whilst long term outcomes continue to be limited by chronic lung allograft dysfunction improvements in diagnostics, mechanistic understanding and evolutions in treatment paradigms have all contributed to a median survival that in some centres approaches 10 years. As ongoing studies build on developing novel approaches to diagnosis and treatment of transplant complications and improvements in donor utilization more individuals will have the opportunity to benefit from lung transplantation. As has always been the case, early referral for transplant consideration is important to achieve best results.

Immune aging: biological mechanisms, clinical symptoms, and management in lung transplant recipients

While chronologic age can be precisely defined, clinical manifestations of advanced age occur in different ways and at different rates across individuals. The observed phenotype of advanced age likely reflects a superposition of several biological aging mechanisms which have gained increasing attention as the world contends with an aging population. Even within the immune system, there are multiple age-associated biological mechanisms at play, including telomere dysfunction, epigenetic dysregulation, immune senescence programs, and mitochondrial dysfunction. These biological mechanisms have associated clinical syndromes, such as telomere dysfunction leading to short telomere syndrome (STS), and optimal patient management may require recognition of biologically based aging syndromes. Within the clinical context of lung transplantation, select immune aging mechanisms are particularly pronounced. Indeed, STS is increasingly recognized as an indication for lung transplantation. At the same time, common aging phenotypes may be evoked by the stress of transplantation because lung allografts face a potent immune response, necessitating higher levels of immune suppression and associated toxicities, relative to other solid organs. Age-associated conditions exacerbated by lung transplant include bone marrow suppression, herpes viral infections, liver cirrhosis, hypogammaglobulinemia, frailty, and cancer risk. This review aims to dissect the molecular mechanisms of immune aging and describe their clinical manifestations in the context of lung transplantation. While these mechanisms are more likely to manifest in the context of lung transplantation, this mechanism-based approach to clinical syndromes of immune aging has broad relevance to geriatric medicine.

Association of frailty with postoperative outcomes following thoracic transplantation: A national analysis

Objective

Frailty has been repeatedly associated with inferior outcomes after surgical hospitalizations. However, a thorough evaluation of the impact of frailty on the clinical and financial outcomes of patients undergoing solid-organ thoracic transplantation is sparse in the literature. We evaluated the association of frailty, as determined by an administrative tool, with postoperative outcomes and healthcare resource use after heart or lung transplantation.

Methods

The Nationwide Readmissions Database was used to identify all adult hospitalizations for heart or lung transplant from 2014 to 2020. Patients were grouped as frail or nonfrail using International Classification of Diseases codes associated with conditions in the Johns Hopkins Adjusted Clinical Groups cluster. Multivariable regression models were developed to evaluate the association of frailty status on in-hospital mortality, complications, length of stay, costs, and unplanned readmissions.

Results

Of an estimated 35,862 heart or lung transplant recipients, 7316 (20.4%) were considered frail. After multivariable adjustment, frailty in heart transplantation was associated with greater odds of in-hospital mortality (adjusted odds ratio, 1.54; 95% CI, 1.19-1.99) and infectious complications (adjusted odds ratio, 1.77; 95% CI, 1.45-2.15; P < .001). Frailty in lung transplantation was also associated with higher odds of in-hospital mortality (adjusted odds ratio, 1.38; 95% CI, 1.11-1.69) and infectious complications (adjusted odds ratio, 1.93; 95% CI, 1.60-2.31). In addition, frailty in both heart transplantation and lung transplantation was associated with increased postoperative length of stay and greater costs.

Conclusions

Among transplant recipients, those classified as frail were associated with increased in-hospital mortality, perioperative complications, and resource use.