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BACKGROUND: Donors with characteristics that may increase the likelihood of disease transmission with transplantation are noted as increased risk via Public Health Service criteria. This study aimed to establish the implications of declining an increased-risk donor (IRD) organ offer in lung transplantation. METHODS: Adult candidates waitlisted for isolated lung transplantation in the United States using the Organ Procurement and Transplantation Network/United Network of Organ Sharing registry from 2007 to 2017 were identified. Individual match run files identified candidate recipients who matched to an IRD offer. Competing-risks analysis ascertained the likelihood of survival to transplantation. A stratified Cox model and restricted mean survival times estimated the survival benefit associated with the acceptance of an IRD organ. RESULTS: A total of 6,963 candidates met inclusion criteria, and 1,473 (21.2%) accepted an IRD offer. Candidates who accepted an IRD offer were older, more likely to be male, and had a higher lung allocation score at the time of listing (all p < 0.05). At 1 year after an IRD offer decline, 70.5% of candidates underwent a lung transplant, 13.8% died or decompensated, and 14.9% were still awaiting transplant. Compared with those who declined, candidates who accepted the IRD offer had significantly improved cumulative mortality at 1 year (14.1% vs 23.9%, p < 0.001) and 5 years (48.4% vs 53.8%, p < 0.001). CONCLUSIONS: IRD organ declination is associated with a decreased rate of lung transplantation and worse survival. Overall post-transplant survival rates for those who survive to transplantation are equivalent.

Purpose Constrictive pericarditis has become an increasingly recognized long-term post-operative complication of lung transplantation. Heightened clinical suspicion, improved diagnostic imaging and effective surgical treatment of the disease have led to progressive awareness of the pathology. We present our institutional experience with constrictive pericarditis in an effort to investigate the etiology and natural history of the disease. Methods From October 2005 to October 2018, 1,234 patients underwent orthotopic lung transplantation at Duke University Hospital. A prospectively maintained institutional database was queried to identify incident patients and determine baseline clinical data. At a median of 13.8 months (IQR 4.6-124 months), 10 patients (0.8%) developed constrictive pericarditis. Simple descriptive statistics were used to describe cohort characteristics and identify variables associated with constrictive pericarditis after lung transplantation. Results The indication for transplantation at index operation was idiopathic pulmonary fibrosis in 9 of 10 patients (1.2% of the 760 restrictive lung disease patients transplanted in the same time period). All ten patients presented with worsening dyspnea and pleural effusions. Right heart catheterization confirmed constrictive physiology in all cases. Nine patients underwent pericardiectomy with improvement in cardiovascular hemodynamics and resolution of symptoms with no 30-day perioperative mortality. Conclusion Diagnosis of constrictive pericarditis should be considered in patients with new onset heart failure symptoms and/or recurrent pleural effusions within 2 years of lung transplantation. Idiopathic pulmonary fibrosis may be associated with increased risk for constrictive pericarditis. Pericardiectomy is a safe and effective treatment for post-transplant constrictive pericarditis.

Purpose Lung transplantation (LTx) offers a survival benefit for patients with end-stage lung disease. When suitable donors are identified, centers must accept or decline the offer for a matched candidate on their waitlist. The degree to which center-level variability in organ acceptance impacts candidate survival is not established. Methods We performed a retrospective cohort study of candidates aged ≥ 12 waitlisted for isolated LTx in the US using UNOS/OPTN data from May 2007 to May 2017. Centers that never had candidates ranked first on a match run >10 times in a year were excluded. Logistic regression was fit to assess the relationship of offer acceptance with donor-, candidate-, and geographic factors. Listing center was evaluated as a fixed effect to determine the adjusted per-center acceptance rate. Competing risks analysis employing the Fine-Gray model was undertaken to ascertain the relationship between the adjusted per-center acceptance rate and waitlist mortality. Results Of 15,847 unique organ offers, 4,735 (29.9%) were accepted for the first-ranked patients. After adjustment for important covariates, transplant centers varied markedly in acceptance rate practices (9% to 67%). Higher cumulative incidence of 1-year waitlist mortality was associated with lower acceptance rate (Figure 1). For every 10% increase in adjusted center acceptance rate, the risk of waitlist mortality decreased by 36.3% (subdistribution hazard ratio 0.637; CI 0.592, 0.685). Importantly, high-acceptance centers that accepted ≥ 40% of their first-ranked offers had improved 1-year post-transplant survival compared to centers with adjusted organ acceptance rates Conclusion Variability in center-level behavior potentially represents the largest modifiable risk factor for prolonged waitlist times and mortality in LTx. Further intervention is needed to standardize center-level organ offer acceptance practices and minimize waitlist mortality at the national level.

Purpose Despite growing evidence that donation after circulatory death (DCD) lung transplants have comparable survival outcomes and primary graft dysfunction rates to donation after brain death (DBD), DCD continues to be underutilized in the US. We examined DCD donor characteristics associated with non-utilization. Methods In this retrospective study, all adult (age ≥ 18) DCD donors who donated at least one organ for transplant between 1993 and 2017 were analyzed from the UNOS registry. DBD donors and DCD donors who did not successfully donate any organ were excluded. Organ disposition per lung and reasons for non-use of donor lungs were identified. The primary outcome of interest was donor characteristics that correlated with lower transplant rates. Results A total of 12,627 DCD donors met inclusion criteria. Of 25,254 lungs available for analysis, 2.8% were transplanted and 68% were discarded primarily due to poor organ function and ischemic time constraints. Notably, consent was not requested in 15.3% of DCD offers with non-heart beating donor being the leading reason for consent not requested (77.7%). DCD lungs were less likely to be transplanted if the donor had a higher BMI (mean 26.6 vs. 25.4, p=0.008), smoking history (23.7% vs. 7.5%, p Conclusion The underutilization of DCD lungs in the US remains consistent with prior studies, in contrast with 30-40% utilization in several other countries. The most common reasons for non-transplantation of DCD lungs include modifiable pre-donor factors, such as lack of consent request, as well as donor factors, including hypoxemia. Interventions to increase consent and optimize DCD donor conditions, such as selective use of ex vivo lung perfusion, may increase utilization of DCD organs and expand the donor pool.