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Postoperative renal failure has been shown to be an important predictor of adverse outcomes after many surgical procedures. The purpose of this study was to examine the incidence of renal failure after lung transplantation and determine predictors and outcomes of renal failure in lung transplant recipients. We performed a retrospective cohort study of all adult patients undergoing lung transplantation from 2005 to 2022 using the United Network for Organ Sharing database. Multivariable logistic regression was used to determine factors associated with postoperative renal failure requiring dialysis. Postoperative complications and mortality were compared between patients experiencing postoperative renal failure and those without renal failure. Kaplan-Meier survival analysis was used to evaluate differences in survival between groups. Overall, 33,614 patients underwent lung transplantation during the study period, with 2,406 (7%) experiencing postoperative renal failure. Following adjustment, recipient factors associated with increased odds of renal failure included female sex (odds ratio, OR 1.10, 95% CI 1.00-1.21), black race (OR 1.59 (white reference), 95% CI 1.39-1.1.82), diabetes (OR 1.19, 95% CI 1.07-1.36), pre-operative dialysis (OR 9.45, 95% CI 6.18-14.44), higher lung allocation score (OR 1.01, 95% CI 1.01-1.01), ventilator use (OR 1.65, 95% CI 1.38-1.97) and ECMO use (OR 1.71, 95% CI 1.41-2.08). Patients with postoperative renal failure were more likely to experience acute rejection (14% vs 8%, P<0.001), had higher 30-day mortality and lower survival at 1- and 5-years following transplantation compared to those without renal failure (Figure). Renal failure after lung transplantation portends a grave prognosis, with limited modifiable risk factors. Further studies are needed to determine if renal sparing strategies in the peri-operative period may help alleviate this complication, and to identify patients who may benefit from lung-kidney transplantation. [ABSTRACT FROM AUTHOR]

Ex-vivo lung perfusion(EVLP) may allow for evaluation and rehabilitation of marginal donor lungs, including those from donation after circulatory death(DCD) donors, with outcomes understudied. We evaluated the short-term and mid-term outcomes of DCD lungs managed with or without EVLP. We conducted retrospective review of the United Network for Organ Sharing(UNOS) registry of all primary adult DCD lung transplants performed from February 18, 2018 onwards, dichotomizing them as those managed with or without EVLP. Baseline characteristics and short-term outcomes were compared. Two-year survival was examined with Kaplan Meier curves and multivariable Cox proportional hazards regression. Of 757 DCD lung transplants, 189(25%) were managed with EVLP with no significant differences in donor characteristics. Recipients of EVLP-managed lungs had longer wait-list duration(40 vs 32 days, p=0.01), longer organ preservation times(12.6±3.8 vs 6.6±2.2 hours, p<0.01), and longer distance traveled[268 (98-490 vs 132(49-305) nautical miles, p<0.01]. Recipients of EVLP-managed DCD lungs were more likely to remain intubated (51% vs 43%, p=0.04), be on ECMO (22% vs 14%, p<0.01), and have grade 3 primary graft dysfunction (31% vs 23%, p=0.04) at 72 hours. One(86% vs 77%) and two-year(74% vs 65%, log-rank p=0.02) survival were significantly worse with EVLP-managed lungs. On multivariable Cox proportional hazards regression, EVLP was significantly associated with worse two-year survival(adjusted HR 1.45, 95% CI 1.01-2.08) when preservation time was not used as an adjuster(EVLP aHR 1.28, 95% CI 0.74-2.21). A quarter of DCD lung transplants are managed with EVLP in the United States, with inferior short-term and mid-term outcomes compared to those not managed with EVLP, possibly related to the obligate increase in preservation times. Further studies are needed to define the role of EVLP in the preservation of DCD lungs prior to transplantation. [ABSTRACT FROM AUTHOR]

While the outcomes of ECMO as a bridge to lung transplantation have been extensively studied, little is known regarding the use of post-operative ECMO in a contemporary cohort. The purpose of the study was the determine predictors and outcomes of post-operative ECMO in a national cohort. This was a retrospective cohort study of all adult lung transplantation recipients using the 2015 to 2022 United Network for Organ Sharing database. We used multivariable logistic regression to determine covariates associated with ECMO use at 72 hours following operation. Additionally, several outcomes including post-operative stroke, acute rejection and early (30-day and in-hospital) mortality as well as 1- and 5-year survival were compared between those requiring post-operative ECMO and all other lung recipients. Of 18,014 lung transplant recipients included in analysis, 1,430 (8%) required ECMO support following transplantation. Several recipient factors were associated with increased odds of post-operative ECMO use, including female gender (adjusted odds ratio, AOR 1.28, 95% CI 1.13-1.45), high BMI (AOR 1.05/kg/m2, 95% CI 1.04-1.06), preoperative ventilation (AOR 1.61, 95% CI 1.30-2.01) or dialysis (AOR 3.89, 95% CI 2.20-6.88), elevated serum bilirubin (AOR 1.08/mg/dL, 95% CI 1.04-1.12) and donor organ ischemic time > 4 hours (AOR 1.69, 95% CI 1.39-2.06). Those requiring post-operative ECMO experienced significantly higher rates of stroke (6% vs 2%, P<0.001), acute rejection (13% vs 7%, P<0.001) and early mortality along with decreased 1- and 5-year survival (Figure), compared to others. Patients requiring ECMO at 72 hours following lung transplantation experience markedly worse early outcomes and 5-year survival compared to all other lung recipients. Identification and management of pre-, intra-, and post-operative risk factors for severe PGD requiring post-operative ECMO may improve lung transplantation outcomes. [ABSTRACT FROM AUTHOR]

The development of modern antiviral therapy for HCV has allowed for the transplantation of HCV NAT+ donor lungs with good short-term outcomes. We sought to evaluate trends and mid-term outcomes of lung transplant recipients of HCV NAT+ donor allografts. All adults undergoing single-organ lung transplantation in the United Network for Organ Sharing database from January 2016 to June 2022 were included in the study. Lung transplant recipients were stratified based on donor HCV NAT status (HCV NAT + vs NAT-). Baseline characteristics and outcomes, including postoperative complications, early (30-day and in-hospital) mortality and both 1- and 3-year survival were compared between groups. A total of 15,414 patients underwent lung transplantation during the study period, with 422 (3%) receiving HCV NAT+ donor lungs. Regions 1 (17%), and 6/8 (both 0%) had the highest and lowest proportions, respectively, of HCV NAT+ donor transplants. Utilization of HCV NAT+ donors steadily increased throughout the study period from 2 (0.1%) in 2016 to a peak of 117 (5%) in 2019. Donors who were HCV NAT+ were older (34 vs 36 years, P<0.001), more often male (55% vs 45%, P<0.01) and categorized as CDC high risk (83% vs 17%, P<0.001). Recipients of HCV NAT+ donor lungs were similar in age (61 vs 62 years, P=0.99) and male gender (57% vs 61%, P=0.15) but had lower lung allocation scores (38 vs 41, P<0.001) compared to others. Rates of postoperative ECMO (7% vs 8%, P=0.34), dialysis (7% vs 8%, P=0.40), reintubation (16% vs 19%, P=0.17) and acute rejection (14% vs 15%, P=0.49) were similar between groups. Additionally, early mortality (both 30-day and in-hospital) as well as 1- and 3-year survival (Figure) were not significantly different between groups. Lung transplant recipients of HCV NAT+ donor allografts experience similar rates of acute rejection, early mortality and 3-year survival compared to all other lung recipients. Increased use of HCV NAT+ donor allografts may help to expand the donor pool and alleviate donor shortages. [ABSTRACT FROM AUTHOR]

Normothermic regional perfusion is increasingly used in donation after circulatory death heart procurement, but its impact when the lung is also procured is unknown. The goal of this study was to examine utilization and outcomes of lung transplants in the setting of DCD heart procurement with or without NRP. We examined the United Network for Organ Sharing of all DCD heart donors from December 1, 2019 to June 23, 2022 with recorded brain death and cross clamp times, with a difference of greater than 30 minutes considered NRP procurements. Baseline characteristics, in-hospital outcomes, and one-year survival of lung transplant recipients were compared between those whose donors were managed with NRP versus no NRP. Of 447 DCD heart procurements with adequate data, 157(35%) were conducted with NRP. There were 62 DCD lung transplant recipients where the heart was also procured, of which 22(35%) came from NRP-managed donors and 40 (65%) from non-NRP managed donors. Lung utilization rates were not significantly different between NRP and non-NRP managed DCD heart donors (14% vs 14%, p=0.95). Donors in the NRP group were more frequently male (100% vs 70%, p<0.01) while recipients had significantly lower lung allocation scores [37 (34-41) vs 40 (36-57), p=0.02]. There were no other differences in other baseline characteristics, including EVLP use(18% vs 14%, p=0.73). Rates of ECMO (14% vs 15%, p=0.92), grade 3 PGD (18% vs 23%, p=0.70), intubation (36% vs 48%, p=0.40), and inhaled nitric use (14% vs 15%, p=0.88) 72 hours post-transplant were not significantly different. One-year survival was comparable between the two groups (86% vs 86%, p=0.94). A small number of DCD lung transplants are performed when the heart was also procured, with approximately one-third of these donors managed with NRP. While sample size was limited, NRP did not have a detrimental impact on short-term outcomes or one-year survival in lung transplant recipients. [ABSTRACT FROM AUTHOR]

Ex-vivo lung perfusion (EVLP) can be used to assess and rehabilitate donor lungs to expand the donor pool. However, the frequency of EVLP utilization and its outcomes are not well-studied. The goal of this study was to describe the characteristics and outcomes of lungs transplants performed with EVLP in the US. We conducted retrospective review of the UNOS registry of all primary adult lung transplant recipients from Feb 28, 2018 to June 30, 2021, excluding recipients with prior transplants, multiorgan transplants, and those waitlisted for other organs. Lung transplants were dichotomized as those that were performed with EVLP versus no EVLP. Baseline characteristics and short-term outcomes were compared. One-year survival was assessed by the Kaplan Meier method and multivariable Cox proportional hazards regression. Of 8,204 lung transplants performed during our study period, 426(5.2%) were performed with EVLP. Perfusion was performed by the OPO in 29(7%), transplant center in 291(68%), and external perfusion center in 106(25%) of cases. EVLP donors were older (39±13 vs 36±14 yrs, p<0.01), more likely DCD (31% vs 5%, p<0.01), and had lower P:F ratio(415±124 vs 442±130, p<0.01). Recipients had lower LAS scores[39(35-53) vs 41 (35-57), p<0.01)]. EVLP lungs traveled further[232(122-489) vs 169 (71-270) nautical miles, p<0.01], had longer ischemic times(11.5±4.1 vs 5.5±1.6 hrs, p<0.01), and were more likely double lung transplants(85% vs 76%, p<0.01). At 72 hours, recipients of EVLP lungs were more likely to remain intubated(47% vs 30%, p<0.01), be on ECMO(16% vs 8%, p<0.01), and experience PGD grade III (24% vs 17%, p<0.01). They also had higher total length of stay[21(13-39) vs 18(13-30) days, p<0.01). EVLP was associated with worse one-year survival on univariable(84% vs 88%, HR 1.41, 95% CI 1.07-1.85, p=0.02) but not multivariable analysis(aHR 1.18, 95% CI 0.88-1.59, p=0.26), particularly after adjusting for DCD donation(aHR 1.46, 95% CI 1.11-1.91) EVLP technology is used in a minority of donor lungs in the United States. A majority of the EVLP procedures are performed by the transplant centers with a higher proportion of DCD donors. The short-term outcomes and one-year survival of recipients of EVLP lungs appear worse than those not managed with EVLP. The role of this technology in the broad filed of lung transplantation remains to be defined. [ABSTRACT FROM AUTHOR]

Veno-venous Extra-corporeal Membrane Oxygenation (VV ECMO) has been used as a bridge to lung transplantation with acceptable outcomes. Patients with primary or secondary pulmonary arterial hypertension and/or right ventricular dysfunction have a higher risk profile and will need Veno-arterial ECMO (VA ECMO) as a bridge to lung transplantation. There is limited information on outcome of lung transplantation after VA ECMO. We hypothesized that VA ECMO, as part of a multidisciplinary ECMO program yields similar outcomes as VV ECMO as a bridge in lung transplantation. Records of all patients who had undergone ECMO with the intention to bridge to lung transplantation from January 1, 2012 to January 1, 2020 were reviewed. VV ECMO was performed via a single site dual lumen cannula or via dual peripheral cannulation sites. VA ECMO was performed via peripheral vessels or central cannulation without sternotomy. During this interval, 58 patients were placed on ECMO with the intention to bridge to lung transplantation: 27 on VV ECMO, and 31 on VA ECMO. 84% of patients on ECMO as a bridge were breathing spontaneously and ambulatory. Median duration of VV and VA ECMO were 7 days and 21 days, respectively. Incidence of ECMO-related complications were similar in the two groups. 81% of VV ECMO and 81% of VA ECMO patients underwent lung transplantation. Incidence of Primary Graft Dysfunction III at 72 hours in the VV ECMO and the VA ECMO cohorts were 0% and 4%, respectively. Median Intensive Care Unit and hospital stay of the two groups were similar. 30 days and in-hospital survival of the VV ECMO and VA ECMO groups were 100% and 96%, (p=NS). 1-year and 3-year survival of the two groups were also similar, AND did not differ when compared to the contemporary cohort of lung transplant recipients that were not bridged with ECMO. VA ECMO, as part of a multi-disciplinary ECMO team, can be used as a bridge to lung transplantation, with similar outcomes as VV ECMO. Moreover, in this selected cohort, the short and medium term survival of bridged patients is similar to non-bridged patients. [ABSTRACT FROM AUTHOR]

Primary graft dysfunction (PGD) remains a feared complication and contributes to significant morbidity and mortality following lung transplantation. The goal of this study was to evaluate factors associated with grade 3 PGD at a large volume lung transplant center. We conducted retrospective review of all adult lung transplant recipients performed at University of California Los Angeles from January 1999 to August 2021, including data on donor and recipient baseline characteristics, laboratory values, and operative variables. The primary outcome was grade 3 PGD at 48 or 72 hours after lung transplantation. Donor and recipient factors associated with grade 3 PGD were examined with multivariable logistic regression. Of 1230 lung transplants performed during the study period with adequate PGD data, grade 3 PGD at 48 or 72 hours occurred in 86(7.0%) recipients. Recipients who developed grade 3 PGD were less likely male(49% vs 60%, p<0.04), white(56% vs 69%, p=0.04), and diagnosis groups A(15% vs 21%, p<0.01) and C (1% vs 5%, p<0.01). They were more likely to be diabetic(31% vs 22%, p=0.04), receive double lungs(65% vs 53%, p=0.04), and be completed on cardiopulmonary bypass(76% vs 64%, p=0.04). Recipients who developed grade 3 PGD also had higher BMI(27±4 vs 25±4 kg/m2, p<0.01), PA pressures (50±21 vs 41±16 mmHg systolic and 21±10 vs 18±8 mmHg diastolic, p<0.01) and longer ischemic times (5.4±1.7 vs 4.7±1.3 hours, p<0.01). The grade 3 PGD group also had a lower proportion of male donors(52% vs 66%, p<0.01). On multivariable logistic regression, factors associated with increased odds of grade 3 PGD were recipient BMI (aOR 1.11, 95% CI 1.04-1.17), increasing PA systolic pressure (aOR 1.02 per mmHg, 95% CI 1.01-1.03), and increasing ischemic time (aOR 1.40 per hr, 95% CI 1.19-1.64). Male donors (aOR 0.49, 95% CI 0.30-0.79) were associated with lower odds of grade 3 PGD. The c-statistic for the multivariable model was 0.73. Increasing recipient BMI, PA systolic pressures, and ischemic time were associated with developing grade 3 PGD 48 or 72 hours after lung transplantation, whereas male donors were protective in our single center study. These variables may help inform donor and recipient selection to reduce the risk of PGD following lung transplantation. [ABSTRACT FROM AUTHOR]

Atrial fibrillation is common following lung transplantation and may contribute to increased risk of stroke. The goal of this study was to characterize the incidence of atrial fibrillation in lung transplant recipients with and without a concomitant modified Maze procedure. We conducted retrospective review of adult lung transplant recipients at University of California Los Angeles from June 2008 to August 2021 and identified those who received a concomitant modified Maze procedure, which were performed for intraoperative or history of atrial fibrillation or flutter when technically feasible. Baseline characteristics and incidence of post-operative atrial fibrillation were compared between Maze and non-Maze recipients. Multivariable logistic regression was used to evaluate predictors of postoperative atrial fibrillation. Of 757 lung transplant recipients identified in our cohort, 61(8%) had concomitant modified Maze. Recipients in the Maze group were older [63(57-67) vs 61(52-66), p=0.02), more likely diagnosis groups A (23% vs 15%) and B (11% vs 4%, p<0.01), had higher CVP [8(4-11) vs 5(3-8) mmHg, p<0.01], pulmonary capillary wedge pressure (13±6 vs 11±6 mmHg, p=0.03), and were more likely to have a left atrial appendage ligation (87% vs 2%, p<0.01). Post-operative atrial fibrillation was significantly higher in the Maze group (44% vs 25%, p<0.01), but no patients in the Maze group developed a stroke at the index lung transplant hospitalization. On multivariable analysis, predictors of post-operative atrial fibrillation included Maze (aOR 2.51, 95% CI 1.40-4.50), male recipient (aOR 1.71, 95% CI 1.18-2.46), hypertension (aOR 1.54, 95% CI 1.09-2.18), BMI (aOR 1.07 per kg/m2, 95% CI 1.07), and white (aOR 5.30, 95% CI 1.53-18.36) and Hispanic race (aOR 3.75, 95% CI 1.05-13.44). Lung transplant recipients with atrial fibrillation and receiving concomitant Maze still have a significantly higher rate of postoperative atrial fibrillation compared to those who do not require Maze. These patients should have their left atrial appendage ligated when technically feasible to reduce the future risk of stroke. [ABSTRACT FROM AUTHOR]

With the advent of a cure for HCV, HCV NAT+ donor lungs are being increasingly utilized for transplantation, but their outcomes are understudied. Our goal was to examine one-year survival of lung transplant recipients from HCV NAT+ donors. We conducted retrospective review of all primary adult lung transplant recipients in the UNOS registry between January 1, 2015 and June 12, 2020. Donors were identified as being HCV NAT+ or HCV NAT-. One-year survival was examined with the Kaplan Meier method and a multivariable Cox-proportional hazards model. Of 11809 lung transplants performed during the study period, 222 (2%) came from HCV NAT+ donors. HCV NAT+ donors tended to be younger (33±8 vs 35±14 yrs, p=0.01) and were more likely to be white (82% vs 61%, p<0.01), blood group O (61% vs 50%, p<0.01), CDC high risk (84% vs 24%, p<0.01), and have drug intoxication as cause of death (61% vs 12%, p<0.01). Recipients of HCV NAT+ donor lungs were less likely to have diabetes (10% vs 20%, p<0.01), cystic fibrosis (5% vs 9%, p<0.01), IPF (28% vs 36%, p<0.01), have chronic steroid use (32% vs 44%) or be treated with IV antibiotics 2 weeks prior transplant (5% vs 12%, p=0.02). They had lower LAS scores (42±15 vs 48 ± 18, p<0.01), oxygen requirements at rest (4.5 vs 5.5 L, p<0.01), and were more likely to receive double lungs (83% vs 74%, p<0.01). One-year survival was not significantly different among recipients of HCV NAT+ and NAT- donor lungs on univariate (HR 1.00, 95% CI 0.62-1.62, p=0.98) or multivariate analysis (aHR 0.94, 95% CI 0.53-1.67, p=0.84). Incidence of treatment for acute rejection at one year was also not significantly different (23% vs 23%, p=0.86). Despite coming from high-risk donors, HCV NAT+ lungs have similar one-year survival and acute rejection as those coming from HCV NAT- donors. While longer-term studies are necessary, this report supports the use of NAT+ donor lungs among lung transplant candidates. [ABSTRACT FROM AUTHOR]

Donor lungs are insufflated with high oxygen levels during the transport, allowing continued aerobic metabolism. Complex operations are associated with more adverse outcomes, if performed at night. We hypothesized that for donors with cross clamp after 1:30 AM, the recipient operation can be delayed until morning with acceptable short-term outcomes. This study was approved by IRB. From 3/18/18 to 10/16/20, the recipients of all donor lungs whose cross clamp was scheduled after 1:30 AM were prospectively enrolled in this study. Skin incision of the recipient operation was delayed until 6:30 AM. A contemporary cohort of lung transplant recipients who were matched in age, diagnosis group, Lung Allocation Score and the procedure type served as control and in-hospital outcomes were examined. During this interval, 27 lung transplant recipients were enrolled in this study. Outcomes were compared to a matched cohort. Data are presented in Table 1. 22 of the recipients were among the Diagnosis Group D, 2 each were in Diagnosis Groups B and C, and I in the Diagnosis group A. 19 of the 27 recipients underwent double lung transplantation. Mean ischemic allograft time was significantly higher in the study cohort (335 vs 245 min), although there was no difference in adverse outcomes when compared to a conventionally managed cohort. For lung transplant recipients whose donor cross clamp is scheduled after 1:30 AM, the recipient operation can be safely delayed until 6:30 AM, with acceptable short-term outcomes. In experienced lung transplant centers, adoption of such policy may lead to alternative workflow and improved coverage schedule. [ABSTRACT FROM AUTHOR]

Purpose Extracorporeal membrane oxygenation (ECMO) is underutilized as bridge to lung transplantation (LTx) when compared to conventional mechanical ventilation (MV) in patients with end-stage lung failure. We sought to evaluate short-term outcomes in lung transplant recipients requiring preoperative advanced life support. Methods We retrospectively reviewed UNOS database to identify primary adult LTx recipients (1/2008 to 6/2017) who had no support (NO), MV, ECMO or both MV and ECMO (MVE) prior to LTx. Baseline characteristics were compared via chi-square and ANOVA. One-year survival was compared among the four groups using the Kaplan-Meier method and multivariate Cox proportional hazards regression for one-year survival was conducted to adjust for potential confounders. Results Of 16,392 recipients, there were 204 (1.2%) ECMO, 719 (4.4%) MV, and 350 (2.1%) MVE prior to transplant, with survival depicted in Fig 1. The NO cohort was older (57y) compared to MV (52y), ECMO (48y), and MVE (45y), p<.01. A majority of recipients were male, 54-60%, in each cohort. COPD was most common in the NO cohort (25%) compared to ECMO (5%), MV (17%), and MVE (1%), p<.01. IPF was the single most common diagnosis in each group, NO (37%), ECMO (39%), MV (34%), and MVE (39%). Ischemic time was longer in patients supported with MV (5.5h), ECMO (5.8h), and MVE (6.1h) compared to NO cohort (5.1h), p<.01. Single lung transplant was most common in the NO group (32%) compared to the others (6-16%), p<.01. On multivariate analysis, MV (HR 1.62, p<0.01) and MVE (HR=2.25, p<0.01) were significantly associated with worse survival while ECMO (HR 1.28, p<0.22) was not. Conclusion Short-term survival utilizing ECMO as a bridge to LTx is favorable. Further evaluation into patient selection and direct comparison to conventional MV is warranted. [ABSTRACT FROM AUTHOR]