Results of Lung Transplantation in Idiopathic Pulmonary Fibrosis Patients

doi:10.1016/j.transproceed.2010.05.046

Transplantation Proceedings

Volume 42, Issue 8, October 2010, Pages 3211-3213

https://doi.org/10.1016/j.transproceed.2010.05.046 Get rights and content

Abstract

Lung transplantation (OLT) remains the only available therapy for patients with end-stage idiopathic pulmonary fibrosis (IPF). The objective of this study was to review our experience of OLT for end-stage IPF (IPFLT) patients, seeking to identify variables associated with survival for comparison with outcomes of other indications for LT (OILT). From October 1993 to December 2009, we performed 310 consecutive OLT in 301 patients for treatment of various end-stage pulmonary conditions. The indications for OLT were: IPF (n = 89, 30.5%) chronic obstructive pulmonary disease (n = 82), cystic fibrosis (n = 80), bronchiectasis (n = 12), alfa-1-antitrypsin deficit (n = 6), primary pulmonary hypertension (n = 4), bronchiolitis obliterans (n = 4), other conditions (n = 15). We observed significant differences in the actuarial survival between the IPFLT and the OILT groups particularly at the expense of worse perioperative 30-day and early 1-year mortality in the IPFLT group. Upon univariate and multivariate analyses, the need for cardiopulmonary bypass, previous recipient ventilator dependence, and donor age >50 years were all associated with poorer survival rates among IPF patients. In our experience, survival did not differ between patients who underwent a single versus a bilateral sequential lung transplant (BSLT); however, BSLT cases were associated with short-term damage but long-term survival. The functional results in the IPFLT group were excellent. We observed significant improvements in the values of arterial oxygen pressure (PaO₂), arterial carbon dioxide pressure (PaCO₂), forced vital capacity (FVC%) and forced expiratory volume in 1 second (FEV1%) at 6, 12, and 36 months compared to their pretransplant baseline results.

Section snippets

Patients and Methods

From October 1993 to December 2009, we performed 310 consecutive OLTs in 301 patients for treatment of various end-stage pulmonary conditions. The indications for OLT were: IPF (n = 89, 30.5%) chronic obstructive pulmonary disease (n = 82), cystic fibrosis (n = 80), bronchiectasis (n = 12), alfa-1-antitrypsin deficit (n = 6), primary pulmonary hypertension (n = 4), bronchiolitis obliterans syndrome (BOS n = 4), and other conditions (n = 15). Nine patients with cystic fibrosis and BOS required

Results

Eighty-nine OLTs were performed in IPF patients, most of whom were ambulatory. Four (4.5%) subjects received transplants under an urgency code, which gave them priority over elective patients due to the onset of an irreversible respiratory crisis that required mechanical ventilation. In most cases (82%), we performed an SLT. CB was needed more frequently in BSLT cases (25% vs 5.5%, P = .013). The ischemia times of the first and the second lung were 324 ± 64 (175–520) and 489 ± 62 (345–570)

Discussion

OLT remains the only available therapy for patients with end-stage IPF lung disease. Transplant outcomes are believed to be worse for IPF patients than those transplanted for other indications, although there is no explanation for this difference.2, 3 However, the largest observational studies demonstrating a high early mortality after OLT for IPF were not well controlled for donor, recipient, and transplant variables.⁵ In our series, we observed significant differences in the actuarial

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Cited by (21)

The Effect of Blood Transfusion in Lung Donors on Recipient Survival
2021, Annals of Thoracic Surgery
Citation Excerpt :
Study data show that the effect of donor transfusion is limited to the acute postoperative period, with a significant increase in 90-day mortality for recipients of lungs with massive transfusion compared with no transfusion. This effect is more substantial when considering that massive transfusion lungs were from donors with favorable qualities (young age without smoking history, drug abuse, or comorbidities), and were more likely to be transplanted to patients with low-risk pulmonary disease such as chronic obstructive pulmonary disease and cystic fibrosis than high-risk disease such as idiopathic pulmonary fibrosis.18 The risk stratification, based on 90-day predictive mortality, showed that donor lungs with massive transfusion continued to impose higher odds of mortality when compared with no transfusion even in the lowest-risk transplants.
Blood transfusion can have detrimental effects on the pulmonary system, leading to lung injury and respiratory decompensation with subsequent increased morbidity and mortality in surgical and critically ill patients. How much of this effect is carried from a lung donor to transplant recipient is not fully understood, raising questions regarding transplant suitability of lungs from transfused donors.
United Network for Organ Sharing data were reviewed. Lung transplants from adult donors and known donor transfusion status were included; multiorgan transplants and retransplants were excluded. Recipient mortality was evaluated based on donor and recipient characteristics using a Kaplan-Meier survival estimate, Cox proportional hazards, and logistic regression models. We further assessed whether recipient mortality risk modified the donor transfusion effect.
From March 1996 to June 2017, 20,294 transplants were identified. Outcome analysis based on transfusion status showed nonsignificant difference in 1-year mortality (P = .214). Ninety-day recipient mortality was significantly higher with transfusion of >10 units (U) vs 1-10 U or no transfusion (8.5%, 6.1%, and 6.0%, respectively, P = .005). Multivariable analysis showed increased 90-day mortality with transfusion of >10 U compared to no transfusion (odds ratio 1.62, P < .001), whereas 1-10 U showed no difference (odds ratio 1.07, P = .390). When stratified by recipient transplant risk, transfusion of >10 U was associated with increased mortality even with the lowest-risk recipients, while transfusion of 1-10 U showed no mortality increase even in the highest-risk recipients.
Donor transfusion of >10 U of blood was associated with increased 90-day recipient mortality even in low-risk transplants. This risk should be considered when evaluating donor lungs.
Lung Transplantation in Interstitial Lung Disease
2018, Interstitial Lung Disease
Effect of pulmonary hypertension on survival in patients with idiopathic pulmonary fibrosis after lung transplantation: An analysis of the United Network of Organ Sharing registry
2015, Journal of Heart and Lung Transplantation
Pulmonary hypertension (PH) is a comorbidity associated with idiopathic pulmonary fibrosis (IPF). There is limited research regarding the effect on survival after lung transplantation (LTx).
To assess the effect of PH on survival in patients with IPF who received LTx, the United Network for Organ Sharing was queried for eligible patients with recorded mean (PA_mean) and systolic (PA_systolic) pulmonary artery pressure. The analysis was restricted to the post-lung allocation scoring system starting May 1, 2005, to provide a cohort receiving present-day therapies and management. The last update of the data set was July 6, 2012, so a cutoff date of July 6, 2011, was chosen to allow for the possibility of at least 1 year of follow-up. Thresholds of ≥25 and ≥35 mm Hg were chosen for PA_mean and PA_systolic, respectively, as indicators of PH.
Of 23,951 LTxs in the UNOS data set, 2,542 met inclusion criteria, 1,234 (49%) with PA_mean ≥ 25 mm Hg and 1,680 (66%) with PA_systolic ≥ 35 mm Hg. PA_mean and PA_systolic were highly correlated, with an estimated correlation coefficient ρ = 0.93 (p < 0.001). Patients with PH (PA_mean ≥ 25 mm Hg or PA_systolic ≥ 35 mm Hg) tended to have higher ischemic times, lung allocation score values, forced vital capacity percentage predicted at LTx, and supplemental oxygen requirement at rest values. In addition, a larger proportion of patients with PH was African American, male, had diabetes, and received bilateral LTx compared with single LTx. Comparing PA_mean < 25 vs ≥ 25 mm Hg and PA_systolic < 35 vs ≥ 35 mm Hg, median survival in months was 60.4 (95% confidence interval [CI], 55.2–80.4) vs 61.4 (95% CI, 56.9–66.9; log-rank p = 0.876) and 57.6 (95% CI, 50.9–68.0) vs 64.3 (95% CI, 57.5–71.3; log-rank p = 0. 247), respectively. Hazard ratios for both definitions of PH from univariable and multivariable Cox proportional hazard models were close to 1 and none were statistically significant.
On the basis of our models and despite PH being prevalent, there is no strong evidence suggesting that PH significantly alters the risk of death in IPF patients after LTx.
Safety, feasibility, and effect of remote ischemic conditioning in patients undergoing lung transplantation
2014, Journal of Heart and Lung Transplantation
Citation Excerpt :
These patients had higher pulmonary artery pressures than those with chronic obstructive pulmonary disease (mean, 27.1 mm Hg vs 23.6 mm Hg), but this alone did not account for the greater benefit seen in this group. The primary diagnosis for most of these patients was idiopathic pulmonary fibrosis (IPF), a condition that has been associated with a greater incidence of PGD and less favorable outcomes after transplantation than other end-stage lung diseases.40,41 Much of the excess mortality in IPF recipients occurs early after transplantation; conversely, survival beyond 5 years was higher in this patient group than in others.42
Primary graft dysfunction (PGD) remains a significant problem after lung transplantation. Data from animal and clinical studies suggest that remote ischemic conditioning (RIC) may reduce ischemia-reperfusion injury in solid organ transplantation.
A pilot randomized controlled trial of 60 patients undergoing bilateral sequential lung transplantation assessed the utility of RIC in attenuating PGD. Treated recipients underwent 3 cycles of lower limb ischemic conditioning before allograft reperfusion. The primary outcome measure was a comparison of the partial pressure of arterial oxygen/fraction of inspired oxygen ratio (P/F ratio) between treatment groups.
No adverse effects of tourniquet application were observed. The mean lowest P/F ratio during the first 24 hours after transplantation was 271.3 mm Hg in the treatment arm vs 256.1 mm Hg in the control arm (p = 0.46). PGD grade and severity and the rate of acute rejection also showed a tendency to favor the treatment arm. Sub-group analysis demonstrated a significant benefit of treatment in patients with a primary diagnosis of restrictive lung disease, a group at high risk for the development of PGD. RIC was not accompanied by systemic release of high-molecular-weight group box 1. Levels of cytokines, high-molecular-weight group box 1, and endogenous secretory receptor for advanced glycation end products peaked within 2 hours after reperfusion and likely reflected donor organ quality rather than an effect of RIC.
RIC did not significantly improve P/F ratios or PGD in this randomized controlled trial. However, encouraging results in this small study warrant a large multicenter trial of RIC in lung transplantation.
Comorbidities impacting on prognosis after lung transplant
2014, Archivos de Bronconeumologia
Esta revisión pretende exponer de forma sucinta aquellas circunstancias clínicas previas al trasplante pulmonar que pueden repercutir negativamente en el pronóstico del trasplante a corto y largo plazo. Se plantean los métodos de rastreo y diagnóstico de comorbilidades comunes de impacto pronóstico negativo sobre el trasplante, tanto de patologías pulmonares como extrapulmonares, y se proponen medidas dirigidas a su corrección. La coordinación y el intercambio de información entre los centros que remiten a los candidatos y los centros trasplantadores permitirán detectar y corregir estas comorbilidades con el fin de minimizar los riesgos y de mejorar las expectativas de supervivencia de los pacientes trasplantados.
The aim of this review is to give an overview of the clinical circumstances presenting before lung transplant that may have negative repercussions on the long and short-term prognosis of the transplant. Methods for screening and diagnosis of common comorbidities with negative impact on the prognosis of the transplant are proposed, both for pulmonary and extrapulmonary diseases, and measures aimed at correcting these factors are discussed. Coordination and information exchange between referral centers and transplant centers would allow these comorbidities to be detected and corrected, with the aim of minimizing the risks and improving the life expectancy of transplant receivers.
Lung Transplantation for Interstitial Lung Disease
2012, Clinics in Chest Medicine
Citation Excerpt :
With this limitation, several recent analyses suggest that there may be a benefit to bilateral lung transplant in selected patients with IPF. It seems there is an increased risk of complications early with bilateral lung transplant but a longer-term potential survival benefit may ultimately prevail.17–21 Regardless of the rationale for the choice of procedure, recent data indicate that bilateral lung transplantation is increasing in frequency.

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Thoracic transplantationLung: OutcomeResults of Lung Transplantation in Idiopathic Pulmonary Fibrosis Patients

Abstract

Section snippets

Patients and Methods

Results

Discussion

Am J Transplant

Ann Thorac Surg

Trasplant Proc

J Heart Lung Transplant

Thoracic transplantation
Lung: Outcome
Results of Lung Transplantation in Idiopathic Pulmonary Fibrosis Patients