Acute Kidney Injury Increases Mortality After Lung Transplantation

doi:10.1016/j.athoracsur.2011.11.032

The Annals of Thoracic Surgery

Volume 94, Issue 1, July 2012, Pages 185-192

Presented at the Poster Session of the Forty-eighth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–Feb 1, 2012.

https://doi.org/10.1016/j.athoracsur.2011.11.032 Get rights and content

Background

Acute kidney injury requiring renal replacement therapy (RRT) is associated with increased mortality after cardiac surgery. Studies examining the impact of RRT after lung transplantation (LTx) are limited. We evaluated risk factors and outcomes associated with RRT after LTx.

Methods

We retrospectively reviewed all LTx recipients in the United Network for Organ Sharing database. Preoperative renal function was stratified by glomerular filtration rate (GFR) as determined by the Modification of Diet in Renal Disease formula (strata: ≥90, 60 to 90, and <60 mL · min⁻¹· 1.73m⁻²). Primary outcomes were 30-day, 1-year, and 5-year survival and need for post-LTx RRT. Risk adjusted multivariable Cox proportional hazards regression examined mortality. A multivariable logistic regression model evaluated risk factors for RRT.

Results

From 2001 to 2011, 12,108 patients underwent LTx. After LTx, 655 patients (5.51%) required RRT. Patients requiring post-LTx RRT had decreased survival at 30 days (96.7% versus 76.0%, p < 0.001), 1 year (85.5% versus 35.8%, p < 0.001), and 5 years (56.4% versus 20.0%, p < 0.001). These differences persisted on multivariable analysis at 30 days (hazard ratio [HR] 7.98 [6.16 to 10.33], p < 0.001), 1 year (HR 7.93 [6.84 to 9.19], p < 0.001), and 5 years (HR 5.39 [4.75 to 6.11], p < 0.001). Preoperative kidney function was an important predictor of post-LTx RRT for a GFR of 60 to 90 (odds ratio 1.42 [1.16 to 1.75], p = 0.001) and a GFR less than 60 (odds ratio 2.68 [2.07 to 3.46], p < 0.001]. High center volume was protective.

Conclusions

In the largest study to evaluate acute kidney injury after LTx, the incidence of RRT is 5.51%. The need for post-LTx RRT dramatically increases both short- and long-term mortality. Several variables, including preoperative renal function, are predictors of post-LTx RRT and could be used to identify transplant candidates at risk for acute kidney injury.

Section snippets

Data Source

For this study, we utilized the UNOS database from the UNOS registry, an open cohort of all patients undergoing LTx in the United States. The Johns Hopkins Medicine Institutional Review Board approved this study.

Study Design

This study is a retrospective cohort design of all adults (aged 18 years or older) who underwent LTx from 2000 to 2010. Patients undergoing retransplantation, combined heart-lung transplants, multiorgan transplants, patients on preoperative RRT, and patients missing preoperative

Cohort Statistics

From 2001 to 2010, 13,499 patients receiving a LTx were included in the UNOS database. After excluding pediatric patients (n = 533), redo LTx (n = 497), multiorgan transplants (n = 34), patients requiring preoperative RRT (n = 9), and patients missing preoperative creatinine (n = 318), the final cohort comprised 12,108 patients.

The mean age of the entire cohort was 52 ± 13 years, and 6,657 (55.0%) were male. By strata, 5,273 recipients (43.6%) had a GFR 90 or more, 5,476 recipients (45.2%) had

Comment

This analysis represents the largest study to date to examine the incidence, impact, and risk factors for requiring RRT in the perioperative period after LTx. In our study of 12,108 LTx, we found a 5.51% incidence of RRT. The need for RRT after LTx was associated with decreased survival at 30 days, 1 year, and 5 years on both univariate and multivariable analysis. Although much of the difference in mortality occurs early, the need for RRT is still associated with increased 5-year mortality

References (26)

N. Al-Naamani et al.
The modification of diet in renal disease (MDRD) and the prediction of kidney outcomes after lung transplantation
J Heart Lung Transplant
(2008)
K. Barraclough et al.
Predictors of decline in renal function after lung transplantation
J Heart Lung Transplant
(2006)
P.N. Rocha et al.
Acute renal failure after lung transplantation: incidence, predictors and impact on perioperative morbidity and mortality
Am J Transplant
(2005)
G.J. Arnaoutakis et al.
Severe acute kidney injury according to the RIFLE (risk, injury, failure, loss, end stage) criteria affects mortality in lung transplantation
J Heart Lung Transplant
(2011)
D.P. Mason et al.
Dialysis after lung transplantation: prevalence, risk factors and outcome
J Heart Lung Transplant
(2007)
G.M. Chertow et al.
Independent association between acute renal failure and mortality following cardiac surgery
Am J Med
(1998)
A. Kuitunen et al.
Acute renal failure after cardiac surgery: evaluation of the RIFLE classification
Ann Thorac Surg
(2006)
G.J. Arnaoutakis et al.
RIFLE criteria for acute kidney injury in aortic arch surgery
J Thorac Cardiovasc Surg
(2007)
J.D. Christie et al.
Clinical risk factors for primary graft failure following lung transplantation
Chest
(2003)
J. Currey et al.
Implementation of a management guideline aimed at minimizing the severity of primary graft dysfunction after lung transplant
J Thorac Cardiovasc Surg
(2010)

H. Cardinal et al.

The evolution of kidney function after lung transplantation: a retrospective cohort study

Transplant Proc

(2009)

E.S. Weiss et al.

The impact of center volume on survival in lung transplantation: an analysis of more than 10,000 cases

Ann Thorac Surg

(2009)

F. Jacques et al.

Acute renal failure following lung transplantation: risk factors, mortality, and long-term consequences

Eur J Cardiothorac Surg

(2011 Jun 10)

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Long-Term Survival Following Primary Graft Dysfunction Development in Lung Transplantation
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Primary graft dysfunction (PGD) is a known risk factor for early mortality following lung transplant (LT). However, the outcomes of patients who achieve long-term survival following index hospitalization are unknown. We aimed to determine the long-term association of PGD grade 3 (PGD3) in patients without in-hospital mortality.
LT recipients were identified from the United Network for Organ Sharing Database. Patients were stratified based on the grade of PGD at 72 h (No PGD, Grade 1/2 or Grade 3). Groups were assessed with comparative statistics. Long-term survival was evaluated using Kaplan–Meier methods and a multivariable shared frailty model including recipient, donor, and transplant characteristics.
The PGD3 group had significantly increased length of stay, dialysis, and treated rejection post-transplant (P < 0.001). Unadjusted survival analysis revealed a significant difference in long-term survival (P < 0.001) between groups; however, following adjustment, PGD3 was not independently associated with long-term survival (hazard ratio: 0.972; 95% confidence interval: 0.862-1.096). Increased mortality was significantly associated with increased recipient age and treated rejection. Decreased mortality was significantly associated with no donor diabetes, bilateral LT as compared to single LT, transplant in 2015-2016 and 2017-2018, and no post-transplant dialysis.
While PGD3 remains a challenge post LT, PGD3 at 72 h is not independently associated with decreased long-term survival, while complications such as dialysis and rejection are, in patients who survive index hospitalization. Transplant providers should be aggressive in preventing further complications in recipients with severe PGD to minimize the negative association on long-term survival.
Donor respiratory multidrug-resistant bacteria and lung transplantation outcomes
2024, Journal of Infection
Respiratory culture screening is mandatory for all potential lung transplant donors. There is limited evidence on the significance of donor multidrug-resistant (MDR) bacteria on transplant outcomes. Establishing the safety of allografts colonized with MDR bacteria has implications for widening an already limited donor pool.
We aimed to describe the prevalence of respiratory MDR bacteria among our donor population and to test for associations with posttransplant outcomes.
This retrospective observational study included all adult patients who underwent lung-only transplantation for the first time at King Faisal Specialist Hospital & Research Centre in Riyadh from January 2015 through May 2022. The study evaluated donor bronchoalveolar lavage and bronchial swab cultures.
Sixty-seven of 181 donors (37%) had respiratory MDR bacteria, most commonly MDR Acinetobacter baumannii (n = 24), methicillin-resistant Staphylococcus aureus (n = 18), MDR Klebsiella pneumoniae (n = 8), MDR Pseudomonas aeruginosa (n = 7), and Stenotrophomonas maltophilia (n = 6).
Donor respiratory MDR bacteria were not significantly associated with allograft survival or chronic lung allograft dysfunction (CLAD) in adjusted hazard models. Sensitivity analyses revealed an increased risk for 90-day mortality among recipients of allografts with MDR Klebsiella pneumoniae (n = 6 with strains resistant to a carbapenem and n = 2 resistant to a third-generation cephalosporin only) compared to those receiving culture-negative allografts (25.0% versus 11.1%, p = 0.04). MDR Klebsiella pneumoniae (aHR 3.31, 95%CI 0.95-11.56) and Stenotrophomonas maltophilia (aHR 5.35, 95%CI 1.26-22.77) were associated with an increased risk for CLAD compared to negative cultures.
Our data suggest the potential safety of using lung allografts with MDR bacteria in the setting of appropriate prophylaxis; however, caution should be exercised in the case of MDR Klebsiella pneumoniae.
Simultaneous Lung-Kidney Transplantation in the United States
2023, Annals of Thoracic Surgery
Simultaneous lung-kidney transplantation is rarely performed. Contemporary national practice trends and outcomes are unclear.
From the United Network for Organ Sharing database, we identified 108 lung-kidney transplant recipients (2005-2022). They were compared with isolated lung recipients with pretransplantation dialysis or estimated glomerular filtration rate (eGFR) ≤30 mL/min per 1.73 m² (n = 372) and isolated non–dialysis-dependent lung recipients with 30 < eGFR < 50 mL/min per 1.73 m² (n = 1416), respectively. Lung-kidney recipients were also compared with recipients of the contralateral kidney from the same donors (n = 90).
Lung-kidney transplantation was performed by 36 centers, with increasing annual volume (1 in 2005, 16 in 2022; P < .01). Forty percent (44/108) of lung-kidney recipients received pretransplantation dialysis, and of those without pretransplantation dialysis, median eGFR was 30.7 mL/min per 1.73 m². Lung-kidney recipients had improved survival compared with isolated lung recipients with eGFR ≤30 mL/min per 1.73 m² or pretransplantation dialysis (adjusted hazard ratio, 0.59; 95% CI, 0.38-0.92). However, no survival benefit was observed when lung-kidney recipients were compared with isolated lung recipients with 30 < eGFR < 50 mL/min per 1.73 m² and no pretransplantation dialysis (adjusted hazard ratio, 0.88; 95% CI, 0.55-1.41). Compared with isolated kidney recipients using the contralateral kidney from the same donors, lung-kidney recipients had a higher risk of kidney allograft loss (adjusted hazard ratio, 3.27; 95% CI, 1.22-8.78), a difference largely accounted for by patient death with a functioning kidney allograft.
Recipients of lung-kidney transplants had improved survival compared with isolated lung recipients with eGFR ≤30 mL/min per 1.73 m² or pretransplantation dialysis. However, lung-kidney recipients had a higher rate of kidney allograft loss than recipients of the contralateral kidney allograft from the same donors.
Postoperative Acute Kidney Injury and Long-Term Outcomes After Lung Transplantation
2023, Annals of Thoracic Surgery
This study sought to characterize perioperative risk factors of acute kidney injury (AKI) and report outcomes associated with its development in the immediate postoperative setting after lung transplantation.
Study investigator performed a retrospective analysis of all adult patients undergoing primary lung transplantation at a single institution from January 1, 2011 to December 31, 2021 AKI was defined using Kidney Disease: Improving Global Outcomes (KDIGO) criteria after lung transplantation and was stratified on the basis of whether patients required renal replacement therapy (RRT; AKI–no RRT vs AKI-RRT).
Of the 754 patients included, 369 (48.9%) any AKI developed in the postoperative period (252 AKI–no RRT vs 117 AKI-RRT). Risk factors for postoperative AKI included higher preoperative creatinine levels (odds ratio [OR], 5.15; P < .001), lower preoperative estimated glomerular filtration rate (OR, 0.99; P < 0.018), delayed chest closure (OR, 2.72; P < .001), and higher volumes of postoperative blood products (OR, 1.09; P < .001) in the multivariable analysis. On univariate analysis, both AKI groups were also associated with higher rates of pneumonia (P < .001), reintubation (P < .001), mortality on index admission (P < 0.001), longer ventilator duration (P < .001), longer intensive care unit length of stay (P < .001), and longer hospital length of stay (P < .001), with the highest rates in the AKI-RRT group. In a multivariable survival analysis, postoperative AKI–no RRT (hazard ratio [HR], 1.50; P = .006) and AKI-RRT (HR, 2.70; P < .001) were associated with significantly worse survival independent of severe grade 3 primary graft dysfunction at 72 hours (HR, 1.45; P = .038).
The development of postoperative AKI was associated with numerous preoperative and intraoperative factors. Postoperative AKI remained significantly associated with poorer posttransplantation survival. Severe cases of AKI necessitating RRT portended the worst survival after lung transplantation.
Benefit of Kidney Transplantation for Post Lung Transplantation Renal Failure
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Nephrotoxicity is a significant side effect of thoracic transplantation. Many lung transplant patients will require subsequent renal transplantation (KAL). Recently, simultaneous lung/kidney transplants (SLuK) have become an attractive option for patients with end-stage renal disease at the time of lung transplantation. This article explores SLuK outcomes compared to conventional KAL, as well as outcomes among KAL patients against those were KAL listed but never transplanted.
The United Network for Organ Sharing/the Organ Procurement and Transportation Network database was used to identify SLuK patients (n = 74), KAL transplants (n = 456), and patients who were listed for KAL but were never transplanted (n = 626). Significance was determined by chi², Wilcoxon rank sum test, or independent t-tests. Death-censored graft survival for subgroups was estimated using Kaplan–Meier with log-rank for significance. Analyses were completed using SPSS Statistics 28.
The SLuK cohort was older (P = 0.04), more likely diabetic (P < 0.001), and had shorter life expectancies (P < 0.001) than KAL patients. Of those SLuK transplants within 5 y, 84% of patients were alive 1 y post transplant and 82% were alive 3 y post-transplant (compared to 74.6% and 60.3% of overall SLuK). Patients who did undergo KAL were younger and had a lower body mass index (both P < 0.001) compared to those who did not. Those who received a kidney had increased survival times compared to WL patients (P < 0.001).
Conventional KAL transplants are still favorable for average lung recipients. However, recent improvements have made SLuK an option for patients with renal dysfunction. Those patients who were able to receive KAL transplants were better surgical candidates than those who remained on the waitlist.
Conventional and Novel Approaches to Immunosuppression in Lung Transplantation
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Original articleGeneral thoracicAcute Kidney Injury Increases Mortality After Lung Transplantation

Background

Methods

Results

Conclusions

Section snippets

Data Source

Study Design

Cohort Statistics

Comment

J Heart Lung Transplant

J Heart Lung Transplant

Am J Transplant

J Heart Lung Transplant

J Heart Lung Transplant

Am J Med

Ann Thorac Surg

J Thorac Cardiovasc Surg

Chest

J Thorac Cardiovasc Surg

Transplant Proc

Ann Thorac Surg

Acute renal failure following lung transplantation: risk factors, mortality, and long-term consequences

Eur J Cardiothorac Surg

Original article
General thoracic
Acute Kidney Injury Increases Mortality After Lung Transplantation