The Public Health Service "Increased Risk" 2020 Policy Change Has not Improved Organ Utilization in the United States: A Nationwide Cohort Study.

Objective: To assess the effects of the 2020 United States Public Health Service (PHS) "Increased Risk" Guidelines update. Background: Donors labeled as "Increased Risk" for transmission of infectious diseases have been found to have decreased organ utilization rates despite no significant impact on recipient survival. Recently, the PHS provided an updated guideline focused on "Increased Risk" organ donors, which included the removal of the "Increased Risk" label and the elimination of the separate informed consent form, although the actual increased risk status of donors is still ultimately transmitted to transplant physicians. We sought to analyze the effect of this update on organ utilization rates. Methods: This was a retrospective analysis of the Organ Procurement and Transplantation Network database which compared donor organ utilization in the 2 years before the June 2020 PHS Guideline update for increased-risk donor organs (June 2018-May 2020) versus the 2 years after the update (August 2020-July 2022). The organ utilization rate for each donor was determined by dividing the number of organs transplanted by the total number of organs available for procurement. Student t test and multivariable logistic regression models were used for analysis. Results: There were 17,272 donors in the preupdate cohort and 17,922 donors in the postupdate cohort; of these, 4,977 (28.8%) and 3,893 (21.7%) donors were considered "Increased Risk", respectively. There was a 2% decrease in overall organ utilization rates after the update, driven by a 3% decrease in liver utilization rates and a 2% decrease in lung utilization rates. After multivariable adjustment, donors in the postupdate cohort had 10% decreased odds of having all organs transplanted. Conclusions: The 2020 PHS "Increased Risk" Donor Guideline update was not associated with an increase in organ utilization rates in the first 2 years after its implementation, despite a decrease in the proportion of donors considered to be at higher risk. Further efforts to educate the community on the safe usage of high-risk organs are needed and may increase organ utilization.

Tracheostomy is associated with decreased vasoactive-inotropic score in postoperative cardiac surgery patients on prolonged mechanical ventilation.

Objective: We sought to quantify the influence that tracheostomy placement has on the hemodynamic stability of postoperative cardiac surgery patients with persistent ventilatory requirements. Methods: A retrospective, single-center, and observational analysis of postoperative cardiac surgery patients with prolonged mechanical ventilation who underwent tracheostomy placement from 2018 to 2022 was conducted. Patients were excluded if receiving mechanical circulatory support or if they had an unrelated significant complication 3 days surrounding tracheostomy placement. Vasoactive and inotropic requirements were quantified using the Vasoactive-Inotrope Score. Results: Sixty-one patients were identified, of whom 58 met inclusion criteria. The median vasoactive-inotrope score over the 3 days before tracheostomy compared with 3 days after decreased from 3.35 days (interquartile range, 0-8.79) to 0 days (interquartile range, 0-7.79 days) (P = .027). Graphic representation of this trend demonstrates a clear inflection point at the time of tracheostomy. Also, after tracheostomy placement, fewer patients were on vasoactive/inotropic infusions (67.2% [n = 39] pre vs 24.1% [n = 14] post; P < .001) and sedative infusions (62.1% [n = 36] pre vs 27.6% [n = 16] post; P < .001). The percent of patients on active mechanical ventilation did not differ. Conclusions: The median vasoactive-inotrope score in cardiac surgery patients with prolonged mechanical ventilation was significantly reduced after tracheostomy placement. There was also a significant reduction in the number of patients on vasoactive/inotropic and sedative infusions 3 days after tracheostomy. These data suggest that tracheostomy has a positive effect on the hemodynamic stability of patients after cardiac surgery and should be considered to facilitate postoperative recovery.

Textbook outcome: A novel metric in heart transplantation outcomes.

OBJECTIVE: Assessing heart transplant program quality using short-term survival is insufficient. We define and validate the composite metric textbook outcome and examine its association with overall survival. METHODS: We identified all primary, isolated adult heart transplants in the United Network for Organ Sharing/Organ Procurement and Transplantation Network Standard Transplant Analysis and Research files from May 1, 2005, to December 31, 2017. Textbook outcome was defined as length of stay 30 days or less; ejection fraction greater than 50% during 1-year follow-up; functional status 80% to 100% at 1 year; freedom from acute rejection, dialysis, and stroke during the index hospitalization; and freedom from graft failure, dialysis, rejection, retransplantation, and mortality during the first year post-transplant. Univariate and multivariate analyses were performed. Factors independently associated with textbook outcome were used to create a predictive nomogram. Conditional survival at 1 year was measured. RESULTS: A total of 24,620 patients were identified with 11,169 (45.4%, 95% confidence interval, 44.7-46.0) experiencing textbook outcome. Patients with textbook outcome were more likely free from preoperative mechanical support (odds ratio, 3.504, 95% confidence interval, 2.766 to 4.439, P < .001), free from preoperative dialysis (odds ratio, 2.295, 95% confidence interval, 1.868-2.819, P < .001), to be not hospitalized (odds ratio, 1.264, 95% confidence interval, 1.183-1.349, P < .001), to be nondiabetic (odds ratio, 1.187, 95% confidence interval, 1.113-1.266, P < .001), and to be nonsmokers (odds ratio, 1.160, 95% confidence interval,1.097-1.228, P < .001). Patients with textbook outcome have improved long-term survival relative to patients without textbook outcome who survive at least 1 year (hazard ratio for death, 0.547, 95% confidence interval, 0.504-0.593, P < .001). CONCLUSIONS: Textbook outcome is an alternative means of examining heart transplant outcomes and is associated with long-term survival. The use of textbook outcome as an adjunctive metric provides a holistic view of patient and center outcomes.

Does Failure to Rescue Drive Race/Ethnicity-based Disparities in Survival After Heart Transplantation?

OBJECTIVE: The objective was to assess whether race/ethnicity is an independent predictor of failure to rescue (FTR) after orthotopic heart transplantation (OHT). SUMMARY BACKGROUND DATA: Outcomes following OHT vary by patient level factors; for example, non-White patients have worse outcomes than White patients after OHT. Failure to rescue is an important factor associated with cardiac surgery outcomes, but its relationship to demographic factors is unknown. METHODS: Using the United Network for Organ Sharing database, we included all adult patients who underwent primary isolated OHT between 1/1/2006 snd 6/30/2021. FTR was defined as the inability to prevent mortality after at least one of the UNOS-designated postoperative complications. Donor, recipient, and transplant characteristics, including complications and FTR, were compared across race/ethnicity. Logistic regression models were created to identify factors associated with complications and FTR. Kaplan Meier and adjusted Cox proportional hazards models evaluated the association between race/ethnicity and posttransplant survival. RESULTS: There were 33,244 adult, isolated heart transplant recipients included: the distribution of race/ethnicity was 66% (n=21,937) White, 21.2% (7,062) Black, 8.3% (2,768) Hispanic, and 3.3% (1,096) Asian. The frequency of complications and FTR differed significantly by race/ethnicity. After adjustment, Hispanic recipients were more likely to experience FTR than White recipients (OR 1.327, 95% CI[1.075-1.639], P =0.02). Black recipients had lower 5-year survival compared with other races/ethnicities (HR 1.276, 95% CI[1.207-1.348], P <0.0001). CONCLUSIONS: In the US, Black recipients have an increased risk of mortality after OHT compared with White recipients, without associated differences in FTR. In contrast, Hispanic recipients have an increased likelihood of FTR, but no significant mortality difference compared with White recipients. These findings highlight the need for tailored approaches to addressing race/ethnicity-based health inequities in the practice of heart transplantation.

Is Transplantation With Coronavirus Disease 2019-Positive Donor Lungs Safe? A US Nationwide Analysis.

BACKGROUND: Since the beginning of the pandemic, coronavirus disease 2019 (COVID-19) has caused debilitating lung failure in many patients. Practitioners have understandably been hesitant to use lungs from donors with COVID-19 for transplantation. This study aimed to analyze the characteristics and short-term outcomes of lung transplantation from donors with recent positive COVID-19 testing results. METHODS: Lung transplantations performed between January 2020 and June 2022 were queried from the United Network for Organ Sharing database. Pediatric, multiorgan, and repeat lung transplantations were excluded. Propensity scoring matched recipients of lungs from donors with recent positive COVID-19 testing results to recipients of lungs from donors with negative COVID-19 testing results, and comparisons of 30-day mortality, 3-month mortality, and perioperative outcomes were performed. RESULTS: A total of 5270 patients underwent lung transplantation during the study dates, including 51 patients who received lungs from donors with recent positive COVID-19 testing results. Forty-five recipients of lungs from donors with recent positive COVID-19 testing results were matched with 135 recipients of lungs from donors with negative COVID-19 testing results. After matching, there was no difference in 30-day (log-rank P = .42) and 3-month (log-rank P = .42) mortality. The incidence of other perioperative complications was similar between the groups. CONCLUSIONS: The 30-day and 3-month survival outcomes were similar between recipients of lungs from donors with recent positive COVID-19 testing results and recipients of lungs from donors with negative COVID-19 testing results. This finding suggests that highly selected COVID-19-positive donors without evidence of active infection may be safely considered for lung transplantation. Further studies should explore long-term outcomes to provide reassurance about the safety of this practice.

Intraoperative Red Blood Cell Transfusion and Primary Graft Dysfunction After Lung Transplantation.

BACKGROUND: In this international, multicenter study of patients undergoing lung transplantation (LT), we explored the association between the amount of intraoperative packed red blood cell (PRBC) transfusion and occurrence of primary graft dysfunction (PGD) and associated outcomes. METHODS: The Extracorporeal Life Support in LT Registry includes data on LT recipients from 9 high-volume (>40 transplants/y) transplant centers (2 from Europe, 7 from the United States). Adult patients who underwent bilateral orthotopic lung transplant from January 2016 to January 2020 were included. The primary outcome of interest was the occurrence of grade 3 PGD in the first 72 h after LT. RESULTS: We included 729 patients who underwent bilateral orthotopic lung transplant between January 2016 and November 2020. LT recipient population tertiles based on the amount of intraoperative PRBC transfusion (0, 1-4, and >4 units) were significantly different in terms of diagnosis, age, gender, body mass index, mean pulmonary artery pressure, lung allocation score, hemoglobin, prior chest surgery, preoperative hospitalization, and extracorporeal membrane oxygenation requirement. Inverse probability treatment weighting logistic regression showed that intraoperative PRBC transfusion of >4 units was significantly ( P < 0.001) associated with grade 3 PGD within 72 h (odds ratio [95% confidence interval], 2.2 [1.6-3.1]). Inverse probability treatment weighting analysis excluding patients with extracorporeal membrane oxygenation support produced similar findings (odds ratio [95% confidence interval], 2.4 [1.7-3.4], P < 0.001). CONCLUSIONS: In this multicenter, international registry study of LT patients, intraoperative transfusion of >4 units of PRBCs was associated with an increased risk of grade 3 PGD within 72 h. Efforts to improve post-LT outcomes should include perioperative blood conservation measures.

Racial Disparities in Coronavirus Disease 2019 Mortality Are Present in Heart Transplant Recipients.

BACKGROUND: Studies have demonstrated the devastating effects of coronavirus disease 2019 (COVID-19) on vulnerable populations. Although they receive close follow-up, heart transplant recipients represent a particularly vulnerable population, given long-term immunosuppression and comorbid conditions. We sought to investigate the association between race/ethnicity and the probability of death due to COVID-19 in adult heart transplant recipients in the United States. METHODS: Adult isolated heart transplant recipients were identified using the Organ Procurement and Transplantation Network database. Recipients who were described as deceased or lost to follow-up before January 2020 were excluded. Recipients were stratified into 4 cohorts by race/ethnicity. The primary outcome of interest was death due to COVID-19. RESULTS: A total of 22 157 adult recipients were identified. During the course of follow-up, 153 recipients had COVID-19 reported as the primary cause of death. COVID-19 mortality was significantly different between race/ethnicity cohorts (Black, n = 34 [0.79%]; Hispanic, n = 23 [1.33%]; White, n = 92 [0.60%]; other, n = 4 [0.44%]; P = .007). COVID-19 was listed as a contributing cause of mortality in 0.12% of Black, 0.23% of Hispanic, 0.04% of White, and 0.33% of other recipients (P = .002). No significant difference in non-COVID mortality or all-cause mortality was observed. After multivariable adjustment, Black (hazard ratio, 2.78 [1.40-5.52]; P = .003) and Hispanic (hazard ratio, 3.92 [1.88-8.16]; P < .001) recipients were at higher risk of death due to COVID-19 compared with White recipients. CONCLUSIONS: Compared with White recipients, Black and Hispanic recipients experienced higher rates of COVID-19 mortality after transplantation. These findings suggest that racial/ethnic disparities of COVID-19 mortality in the general population persist in adult heart transplant recipients.

Rationale and Design of the Randomized Controlled Trial of New Oral Anticoagulants Versus Warfarin for Post Cardiac Surgery Atrial Fibrillation: The NEW-AF Trial.

OBJECTIVE: This manuscript describes the rationale and design of a randomized, controlled trial comparing outcomes with Warfarin vs Novel Oral Anticoagulant (NOAC) therapy in patients with new onset atrial fibrillation after cardiac surgery. BACKGROUND: New onset atrial fibrillation commonly occurs after cardiac surgery and is associated with increased rates of stroke and mortality. in nonsurgical patients with atrial fibrillation, NOACs have been shown to confer equivalent benefits for stroke prevention with less bleeding risk and less tedious monitoring requirements compared with Warfarin. However, NOAC use has yet to be adopted widely in cardiac surgery patients. METHODS: The NEW-AF study has been designed as a pragmatic, prospective, randomized controlled trial that will compare financial, convenience and safety outcomes for patients with new onset atrial fibrillation after cardiac surgery that are treated with NOACs versus Warfarin. RESULTS: Study results may contribute to optimizing the options for stroke prophylaxis in cardiac surgery patients and catalyze more widespread application of NOAC therapy in this patient population. CONCLUSIONS: The study is ongoing and actively enrolling at the time of the publication. The trial is registered with clinicaltrials.gov under registration number NCT03702582.

Factors Related to Survival in Low-Glomerular Filtration Rate Cohorts Undergoing Lung Transplant.

BACKGROUND: Historically, a glomerular filtration rate (GFR) of less than 50 mL/min per 1.73 m2 has been considered a contraindication to lung transplantation. Combined or sequential lung-kidney transplantation is an option for those with a GFR less than 30 mL/min per 1.73 m2. Patients with a GFR of 30 to 50 mL/min per 1.73 m2 are provided with no options for transplantation. This study explores factors associated with improved survival in patients who undergo isolated lung transplantation with a GFR of 30 to 50 mL/min per 1.73 m2. METHODS: The United Network for Organ Sharing database was queried for adult patients undergoing primary isolated lung transplantation between January 2007 and March 2018. Regression models were used to identify factors associated with improved survival in lung recipients with a preoperative GFR of 30 to 50 mL/min per 1.73 m2. The propensity score method was used to match highly performing patients (outpatient recipients aged less than 60 years) with a GFR of 30 to 50 mL/min per 1.73 m2 with patients who had a GFR greater than 50 mL/min per 1.73 m2. Kaplan-Meier, Cox, and logistic regression analyses compared outcomes in matched populations. RESULTS: A total of 21,282 lung transplantations were performed during the study period. Compared with patients with a GFR greater than 50 mL/min per 1.73 m2, survival was significantly worse for patients with a GFR of 30 to 50 mL/min per 1.73 m2. Multivariate analysis of patients with a GFR of 30 to 50 mL/min per 1.73 m2 demonstrated outpatient status and age less than 60 years to be predictive of superior survival. After propensity matching, survival of this highly performing subset with a GFR of 30 to 50 mL/min per 1.73 m2 was no different from that of patients with a normal GFR. CONCLUSIONS: Outpatient recipients aged less than 60 years represent an optimal subset of patients with a GFR of 30 to 50 mL/min per 1.73 m2. Lung transplant listing should not be declined based only on a GFR less than 50 mL/min per 1.73 m2.

Veno-venous Extracorporeal Membrane Oxygenation for Respiratory Failure in COVID-19 Patients: Early Experience From a Major Academic Medical Center in North America.

AND BACKGROUND DATA: VV ECMO can be utilized as an advanced therapy in select patients with COVID-19 respiratory failure refractory to traditional critical care management and optimal mechanical ventilation. Anticipating a need for such therapies during the pandemic, our center created a targeted protocol for ECMO therapy in COVID-19 patients that allows us to provide this life-saving therapy to our sickest patients without overburdening already stretched resources or excessively exposing healthcare staff to infection risk. METHODS: As a major regional referral program, we used the framework of our well-established ECMO service-line to outline specific team structures, modified patient eligibility criteria, cannulation strategies, and management protocols for the COVID-19 ECMO program. RESULTS: During the first month of the COVID-19 outbreak in Massachusetts, 6 patients were placed on VV ECMO for refractory hypoxemic respiratory failure. The median (interquartile range) age was 47 years (43-53) with most patients being male (83%) and obese (67%). All cannulations were performed at the bedside in the intensive care unit in patients who had undergone a trial of rescue therapies for acute respiratory distress syndrome including lung protective ventilation, paralysis, prone positioning, and inhaled nitric oxide. At the time of this report, 83% (5/6) of the patients are still alive with 1 death on ECMO, attributed to hemorrhagic stroke. 67% of patients (4/6) have been successfully decannulated, including 2 that have been successfully extubated and one who was discharged from the hospital. The median duration of VV ECMO therapy for patients who have been decannulated is 12 days (4-18 days). CONCLUSIONS: This is 1 the first case series describing VV ECMO outcomes in COVID-19 patients. Our initial data suggest that VV ECMO can be successfully utilized in appropriately selected COVID-19 patients with advanced respiratory failure.

Failure to rescue in the era of the lung allocation score: The impact of center volume.

BACKGROUND: Failure to Rescue (FTR) is a valuable surgical quality improvement metric. The aim of this study is to assess the relationship between center volume and FTR following lung transplantation. METHODS: Using the database of the United Network for Organ Sharing (UNOS) all adult, primary, isolated lung recipients in the United States between May 2005 and March 2016 were identified. FTR was defined as operative mortality after any of five specific complications. FTR was compared across terciles of transplantation centers stratified based on operative volume. RESULTS: 17,185 lung recipients met study criteria. The composite FTR rate (Death following at least one complication) was 20.7%. Following stratification by volume, FTR rates increased from high to middle tercile centers (19.3% vs. 23.0%). Multivariate logistic regression models suggested an independent relationship between higher center volume and lower FTR rates (p < 0.001). CONCLUSION: Higher volume lung transplantation centers have lower rates of failure to rescue.

Failure to Rescue Contributes to Center-Level Differences in Mortality After Lung Transplantation.

BACKGROUND: The clinical response to postoperative complications after lung transplantation (LTx) may contribute to mortality differences among transplantation centers. The ability to avoid mortality after a complication-failure to rescue (FTR)-may be an effective quality metric in LTx. METHODS: The United Network for Organ Sharing database was queried for adult, first-time, lung-only transplantations from May 2005 to December 2015. Transplantation centers were stratified into equal-sized terciles on the basis of observed operative mortality rates. Several postoperative complications were identified, including stroke, acute rejection, acute kidney injury requiring hemodialysis, airway dehiscence, and extracorporeal membrane oxygenation 72 hours after surgery. Rates of FTR were calculated as the number of operative mortalities in patients who had complications divided by the number of patients who had any postoperative complications. RESULTS: Our study population included 16,411 LTx operations performed at 69 transplantation centers. LTx centers were stratified into terciles with average perioperative mortality of 4.0% for low-mortality centers, 6.9% for intermediate-mortality centers, and 12.4% for high-mortality centers. Low-mortality centers had slightly lower complication rates (low, 15.0% vs intermediate, 17.1% vs high, 19.1%; P < .001). Differences in FTR rate were significantly more pronounced (low, 14.9% vs intermediate, 23.9% vs high, 34.2%; P < .001). Multivariable logistic regression and generalized linear models demonstrated an independent association between high FTR rates and high mortality in LTx (P < .001). CONCLUSIONS: Differences in rates of FTR contribute significantly to per-center variability in mortality after LTx. FTR can serve as a quality metric to identify opportunities for improvement in management of perioperative adverse events.

Lung transplantation delays gastric motility in patients without prior gastrointestinal surgery-A single-center experience of 412 consecutive patients.

PURPOSE: To examine the impact of lung transplantation on gastric motility. METHODS: Adult recipients at a large, single center, who were retrospectively evaluated with solid gastric emptying (SGE) study post-lung transplantation, but had no history of gastrointestinal intervention (ie, pyloroplasty or fundoplication), were selected between June 2005 and August 2013. Multivariable logistic regression was performed to determine risk factors associated with delayed gastric emptying (DGE) after transplantation. RESULTS: Delayed gastric emptying (DGE) was noted in 236 patients (57%) after transplantation. On multivariable logistic regression, an underlining diagnosis of cystic fibrosis (CF)/bronchiectasis (adjusted odds ratio [AOR] 3.26, P < .01) was a significant risk factor in predicting DGE after lung transplantation. There was no survival difference between patients with postoperative DGE vs those without (log-rank test P = .53). CONCLUSIONS: Delayed gastric emptying is very common following lung transplantation, occurring in over half of all lung transplant recipients with increased prevalence in patients with CF. The association with cystic fibrosis could be secondary to extra-pulmonary manifestations of the underlying disease or indicative of increased intraoperative vagal nerve injury. We speculate that DGE may play a substantial role in the increased reflux-induced allograft injury seen after lung transplantation. Further prospective studies are needed to validate this hypothesis.

Successful Treatment of an Aggressive Tracheal Malignancy With Immunotherapy.

Immune checkpoint inhibitors are emerging as therapeutic options for oncology patients in whom conventional treatment regimens have failed. These immunotherapies counteract tumor-induced tolerance and have been shown to be effective in thoracic malignancies, including non-small cell lung cancer (NSCLC). This report highlights the successful use of nivolumab-an immunotherapeutic agent that binds to proteins involved in T-cell proliferation-for the management of recurrent tracheal squamous cell cancer after exhaustion of conventional surgical, chemotherapeutic, and radiation therapy options. Observations provide a strong indication of the potential value of checkpoint inhibitors for managing a wide array of thoracic malignancies.

Medication Nonadherence After Lung Transplantation in Adult Recipients.

BACKGROUND: Our objective was to identify potential avenues for resource allocation and patient advocacy to improve outcomes by evaluating the association between recipient sociodemographic and patient characteristics and medication nonadherence after lung transplantation. METHODS: States US adult, lung-only transplantations per the United Network for Organ Sharing database were analyzed from October 1996 through December 2006, based on the period during which nonadherence information was recorded. Generalized linear models were used to determine the association of demographic, disease, and transplantation center characteristics with early nonadherence (defined as within the first year after transplantation) as well as late nonadherence (years 2 to 4 after transplantation). Outcomes comparing adherent and nonadherent patients were also evaluated. RESULTS: Patients (n = 7,284) were included for analysis. Early and late nonadherence rates were 3.1% and 10.6%, respectively. Factors associated with early nonadherence were Medicaid insurance compared with private insurance (adjusted odds ratio [AOR] 2.45, 95% confidence interval [CI]: 1.16 to 5.15), and black race (AOR 2.38, 95% CI: 1.08 to 5.25). Medicaid insurance and black race were also associated with late nonadherence (AOR 2.38, 95% CI: 1.51 to 3.73 and OR 1.73, 95% CI: 1.04 to 2.89, respectively), as were age 18 to 20 years (AOR 3.41, 95% CI: 1.29 to 8.99) and grade school or lower education (AOR 1.88, 95% CI: 1.05 to 3.35). Early and late nonadherence were both associated with significantly shorter unadjusted survival (p < 0.001). CONCLUSIONS: Identifying patients at risk of nonadherence may enable resource allocation and patient advocacy to improve outcomes.

The effect of prior pneumonectomy or lobectomy on subsequent lung transplantation.

BACKGROUND: Lung transplantation in patients with prior lobectomy or pneumonectomy is not well understood. Using the United Network for Organ Sharing (UNOS) database, we address the impact of prior major lung resection on lung transplantation outcomes. METHODS: Retrospective review of adult lung transplants from October 1999 to December 2011 in the UNOS database identified 15,300 lung transplants; 102 patients had undergone major lung resection, defined as prior pneumonectomy (n = 22) or lobectomy (n = 80). Propensity match with nonparametric 3:1 nearest-neighbor matching algorithm adjusted for treatment-level differences. After matching, the primary outcome (90-day mortality) and secondary outcome (airway dehiscence, need for dialysis, length of stay more than 25 days) were assessed with univariable and multivariable methods. Subanalysis of pneumonectomy and lobectomy individually compared with matched nonresection patients was done in a similar manner. The Kaplan-Meier method estimated long-term survival. RESULTS: After matching, no significant differences were noted between groups for recipient, donor, or operative characteristics. There were 10 double lung and 12 single lung transplants after pneumonectomy and 51 double lung and 29 single lung transplants after lobectomy. Mortality at 90 days was 13.9% (n = 14) for the resection group and 8.6% (n = 1,247) for the nonresection group (p = 0.09). After matching, a significant increase was noted in 90-day mortality (p = 0.017) and perioperative dialysis (p = 0.039) for the resection versus nonresection patients. Dialysis was significantly higher among pneumonectomy patients (p = 0.03). No long-term survival difference was observed (p = 0.514). CONCLUSIONS: After propensity-matching, resection was associated with increased 90-day mortality and dialysis. Careful patient selection is necessary with patients who have undergone prior major lung resection, given their increased risk of perioperative mortality and dialysis.

Differential outcomes with early and late repeat transplantation in the era of the lung allocation score.

BACKGROUND: Rates of repeat lung transplantation have increased since implementation of the lung allocation score (LAS). The purpose of this study is to compare survival between repeat (ReTx) and primary (LTx) lung transplant recipients in the LAS era. METHODS: We extracted data from 9,270 LTx and 456 ReTx recipients since LAS implementation, from the United Network for Organ Sharing registry. Propensity scoring was used to match ReTx and LTx recipients. Kaplan-Meier analysis compared survival between LTx and ReTx groups, with and without stratification based on time between first and second transplant. Multivariable Cox models estimated predictors of survival in lung recipients. RESULTS: Comparing all ReTx to LTx demonstrates a survival advantage for LTx that is diminished with propensity score matching (p = 0.174). Considering LTx against ReTx greater than 90 days after the initial procedure, there are similar survival results (p < 0.067). In contrast, ReTx within 90 days was associated with a survival disadvantage that persisted despite matching (p = 0.011). In ReTx populations, factors conferring worse outcomes include intensive care unit admission, unilateral transplantation, poor functional status, and primary graft dysfunction as the indication for retransplantation (p < 0.05). CONCLUSIONS: Late lung retransplantation appears to be as beneficial as primary transplantation in propensity-matched patients. However, survival is severely diminished in those retransplanted less than 90 days after primary transplantation. The utility of early retransplantation needs to be carefully weighed in light of risks.

Assessment of different threshold preoperative glomerular filtration rates as markers of outcomes in lung transplantation.

BACKGROUND: The evidence behind the widely used pre-lung transplant glomerular filtration rate (GFR) cutoff of 50 mL/min per 1.73 m2 is limited. This study reviews data from a large cohort to assess outcomes associated with this historical cutoff and to estimate other possible cutoffs that might be appropriate in lung transplantation. METHODS: We conducted a retrospective cohort analysis of lung recipients at a single center. Recursive partitioning and receiver operating characteristics analysis were used to estimate other potential GFR cutoffs with 1-year mortality as the outcome. Postoperative outcomes around the various cutoffs, including survival, acute kidney injury, and dialysis, were assessed using χ2, Kaplan-Meier, and Cox regression methods. RESULTS: A total of 794 lung recipients met study inclusion criteria. Compared with 778 patients with GFR 50 mL/min per 1.73 m2 or greater at time of transplant, 16 patients with GFR below this cutoff were older and more likely to have restrictive disease. One-year mortality below the cutoff was 31.3% compared with 15.1% above the cutoff (p=0.021). Recursive partitioning estimated potential GFR cutoff values between 46 and 61 mL/min per 1.73 m2. Patients with GFR below these cutoffs were at significantly higher risk for adverse outcomes (p<0.05). Receiver operating characteristics analysis was less successful at identifying meaningful cutoff values with areas under the curve approximately 0.5. CONCLUSIONS: Study results support the practice of requiring candidate GFR 50 mL/min per 1.73 m2 or greater for lung transplantation. Future work should focus on reproducing the analysis in a larger cohort of patients including more individuals with low GFR.