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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]

The advent of direct acting antivirals has allowed for utilization of HCV NAT+ donors with good short-term outcomes. The goal of this study was to compare clinical outcomes among heart transplant recipients who received hearts from HCV NAT+ donors to those from NAT- donors. We examined the UNOS registry of all primary orthotopic adult heart transplants from March 15, 2015 to August 31, 2021 and identified their donors as HCV NAT+ or NAT-. Those with multiorgan transplants or waitlisted for other organs were excluded. Baseline characteristics, three-year survival, and treatment for rejection at one year were compared between the two groups. Of 16,491 heart transplants meeting study criteria, 729(4%) hearts came from HCV NAT+ donors. HCV NAT+ donors were older (34±8 vs 32±11 years, p<0.01), more likely males(75% vs 70%, p<0.01), white race(83% vs 63%, p<0.01), and blood group O(60% vs 50%, p<0.01). They were more likely to have drug use as cause of death(59% vs 18%, p<0.01) and classified as CDC high risk (87% vs 29%, p<0.01). Recipients were more likely blood group O(48% vs 39%, p<0.01) and have positive hepatitis C serologies(5% vs 2%, p<0.01). They were less likely Status 1A (58% vs 67%, p<0.01) or Status 1 (4% vs 9%, p<0.01) or 2 (36% vs 48%, p<0.01). Distance traveled (241 vs 139 nautical miles, p<0.01) and ischemia times (3.48 vs 3.23 hours, p<0.01) were greater in the HCV NAT+ group, while wait list duration was similar (69 vs 69 days, p=0.20). Three-year survival (87% vs 85%,Figure; log-rank p=0.26) and treatment for rejection in first year post transplant (19% vs 18%, p=0.72) were not significantly different between the two groups. HCV NAT+ donors are being increasingly used for heart transplantation, particularly for lower status recipients with otherwise longer wait times. Three-year survival and treatment for rejection at one year are comparable to those from HCV NAT- donors. Therefore, HCV NAT+ donor hearts should continue to be utilized with monitoring of long-term outcomes. [ABSTRACT FROM AUTHOR]

Despite the increasing number of heart-kidney transplants being performed in recent years, renal failure after heart transplantation remains a pervasive recipient complication. The purpose of this study was to determine the predictors and outcomes of renal failure after heart transplantation in a contemporary cohort. This was a retrospective cohort study of all adults undergoing isolated heart transplantation in the 2018-2022 United Network for Organ Sharing database. Heart recipients were stratified into those experiencing postoperative renal failure requiring dialysis prior to discharge and those without renal failure. We used multivariable logistic regression to determine factors associated with postoperative renal failure and compared postoperative outcomes between groups. Of 10,545 patients undergoing heart transplantation, 1,485 (14%) experienced postoperative renal failure. Factors associated with increased odds of renal failure included: increasing creatinine (odds ratio, OR 2.09/mg/dL 95% CI 1.85-2.35), pretransplant dialysis (OR 4.83, 95% CI 3.46-6.74), ventilation (OR 1.86, 95% CI 1.28-2.69) or extracorporeal membrane oxygenation (OR 1.78, 95% CI 1.38-2.29) prior to transplant, and prior cardiac surgery (OR 1.41, 95% CI 1.25-1.59). Patients with renal failure following heart transplantation experienced markedly higher rates of primary graft dysfunction (5% vs 1%, P<0.001) and 30-day mortality as well as lower 1- and 3-year survival compared to those without renal failure (Figure). Renal failure occurred frequently in a contemporary cohort of isolated heart transplant patients, with limited modifiable risk factors for its development. Renal-sparing strategies need to be considered in the care of heart transplant recipients with these known risk factors. Despite the increasing number of heart-kidney transplants being performed, these data suggest that additional patients may benefit from dual organ 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]

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 direct acting antivirals, hepatitis C viremic donors are being increasingly used for heart transplantation. Single institutions have reported increased incidence of acute rejection when utilizing these hearts. The goal of this study was to evaluate one-year acute rejection following heart transplant from HCV viremic donors. We conducted retrospective review of UNOS of all primary adult heart transplants conducted between March 31, 2015 and June 30, 2020, excluding recipients with prior transplants, multiorgan transplants, or those waitlisted for other organs. Donors were dichotomized as being HCV NAT+ or HCV NAT-. One-year acute rejection requiring treatment was compared and evaluated by univariable and multivariable logistic regression. Of 11,058 heart transplant recipients in our cohort during the study period, 432 (3.9%) came from HCV NAT+ donors. HCV NAT+ donors were significantly older (34±8 vs 32±11 years, p<0.01), more likely to be white (82% vs 64%, p<0.01), blood group O (61% vs 49%, p<0.01), CDC high risk (88% vs 30%, p<0.01), and have drug use as cause of death (61% vs 17%, p<0.01). Recipients in the HCV NAT+ group were older [58(49-64) vs 56 (46-63) years, p<0.01), had higher ischemic times (3.5±1.0 vs 3.1±1.1 hours, p<0.01) and were more likely to be blood group O (49% vs 39%, p<0.01) and HCV antibody positive (5% vs 2%, p<0.01). They were less likely to be on inotropes (31% vs 37%, p<0.01) or any life support (81% vs 86%, p<0.01) at the time of transplant. Incidence of acute rejection requiring treatment within one year was not significantly different between the two groups (21% HCV NAT+ vs 19% HCV NAT-, p = 0.31). Donor HCV NAT+ was not associated with one-year acute rejection on either univariable (OR 1.13, 95% CI 0.89-1.43) or multivariable (aOR 1.08, 95% CI 0.84-1.41) logistic regression. Despite single center studies reporting potential increases in acute rejection when utilizing HCV-viremic donor hearts for transplantation, our UNOS registry analysis did not demonstrate increased treatment for acute rejection after one year. We should continue to utilize these donor hearts with careful surveillance and monitoring of long-term outcomes. [ABSTRACT FROM AUTHOR]

Heart transplantation from Hepatitis C (HCV) viremic donors is an increasingly utilized strategy, though long-term outcomes with respect to cardiac allograft vasculopathy (CAV) are unknown. HCV is implicated as a potent trigger of the inflammatory cascade and may be associated with CAV. We report the incidence of CAV and subclinical disease in recipients of HCV-viremic donors (nucleic amplification test positive: NAT+) vs non-viremic donors (nucleic amplification test negative: NAT-) We retrospectively reviewed coronary angiograms with intravascular ultrasound (IVUS) of patients who received NAT+ and NAT- hearts between January 2014 and July 2020 at two large academic institutions. Donor-derived acute HCV infection was treated with a direct-acting antiviral agent per site protocol. CAV was graded according to ISHLT guidelines. Maximal intimal thickness (MIT) of the left main and left anterior descending artery was measured by IVUS. MIT ≥ 0.5mm was considered significant subclinical disease. Two-sample t tests were performed for continuous variables. Chi-square or Fisher's exact test were used for categorical variables. Among 178 patients, 65 received NAT+ donor hearts. Average recipient age was 58 and 55 years in the NAT+ and NAT- groups respectively and 15% vs 27% were female. NAT- donors were older (42 vs 36 years), but with no significant difference in cardiac risk factors including tobacco use, hypertension, and diabetes. CAV ≥ grade 1 was present in 9.1% of the NAT+ vs 18.8% of the NAT- group at 1 year (p=0.16), and 19.4% vs 21.0% at 2 years (p=1). Rates of significant IVUS disease were 53.7% in NAT+ vs 70.5% in NAT- at 1 year (p=0.068), and 72.2% vs 78.3% at 2 years (p=0.3). Among heart transplant recipients from HCV viremic donors our data show no difference in rates of angiographic CAV or subclinical disease by IVUS at 1 or 2 years. While these results are encouraging, longer follow up is needed to assess CAV risk in this population. [ABSTRACT FROM AUTHOR]