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Infection remains a common cause of death throughout the lifespan of a lung transplant recipient. The increased susceptibility of lung transplant recipients is multifactorial including exposure of the graft to the external environment, impaired mucociliary clearance, and high levels of immunosuppression. Long-term outcomes in lung transplant recipients remain poor compared with other solid organ transplants largely due to deaths from infections and chronic allograft dysfunction. Antibacterial, antifungal, and antiviral prophylaxis may be used after lung transplantation to target a number of different opportunistic infections for varying durations of time. The first-month posttransplant is most commonly characterized by nosocomial infections and donor-derived infections. Following the first month to the first 6 months after transplant-a period of intense immunosuppression-is associated with opportunistic infections. While immunosuppression is reduced after the first year posttransplant, infection remains a risk with community-acquired and rarer infectious agents. Clinicians should be vigilant for infection at all time points after transplant. The use of patient-tailored prophylaxis and treatments help ensure graft and patient survival.

On November 24, 2017, US lung transplant policy replaced donor service area with 250-nautical-mile radius as the first unit of allocation. Understanding this policy's economic impact is important, because the United States is poised to adopt the broadest feasible geographic organ distribution. All lung transplant recipients from January 1, 2015, to December 31, 2018, in the Scientific Registry of Transplant Recipients, were included. Recipients before and after November 24, 2017 were in the donor service area-first and 250-nautical-mile donor service area-free periods, respectively. Travel time was estimated using a Google application; mode was assigned as flying when driving time was longer than 60 min. Travel costs were estimated by mode and distance. Travel distance and time for organ procurement increased under the policy change. The estimated proportion of organs traveling by air increased from 61% to 76%. Estimated average costs increased by $14 051 if travel mode changed to flying, resulting in an average increase of $1264 for all transplants. Travel costs were highest for candidates

Patients with connective tissue disease (CTD) and advanced lung disease are often considered suboptimal candidates for lung transplantation (LTx) due to their underlying medical complexity and potential surgical risk. There is substantial variability across LTx centers regarding the evaluation and listing of these patients. The International Society for Heart and Lung Transplantation-supported consensus document on lung transplantation in patients with CTD standardization aims to clarify definitions of each disease state included under the term CTD, to describe the extrapulmonary manifestations of each disease requiring consideration before transplantation, and to outline the absolute contraindications to transplantation allowing risk stratification during the evaluation and selection of candidates for LTx.

Kaposi sarcoma (KS) can develop following organ transplantation through reactivation of recipient human herpesvirus 8 (HHV‐8) infection or through donor‐derived HHV‐8 transmission. We describe 6 cases of donor‐derived HHV‐8 infection and KS investigated from July 2018 to January 2020. Organs from 6 donors, retrospectively identified as HHV‐8‐positive, with a history of drug use disorder, were transplanted into 22 recipients. Four of 6 donors had risk factors for HHV‐8 infection reported in donor history questionnaires. Fourteen of 22 organ recipients (64%) had evidence of posttransplant HHV‐8 infection. Lung recipients were particularly susceptible to KS. Four of the 6 recipients who developed KS died from KS or associated complications. The US opioid crisis has resulted in an increasing number and proportion of organ donors with substance use disorder, and particularly injection drug use history, which may increase the risk of HHV‐8 transmission to recipients. Better awareness of the risk of posttransplant KS for recipients of organs from donors with HHV‐8 infection risk could be useful for recipient management. Testing donors and recipients for HHV‐8 is currently challenging with no validated commercial serology kits available. Limited HHV‐8 antibody testing is available through some US reference laboratories and the Centers for Disease Control and Prevention., The authors report a series of human herpesvirus 8 infections transmitted from deceased donors with drug use and/or sexual risk factors that led to Kaposi sarcoma in organ transplant recipients.

Background The patient ranking process for donor lung allocation in the United States is carried out by a classification-based, computerized algorithm, known as the match system. Experts have suggested that a continuous, points-based allocation framework would better serve waiting list candidates by removing hard boundaries and increasing transparency into the relative importance of factors used to prioritize candidates. We applied discrete choice modeling to match run data to determine the feasibility of approximating current lung allocation policy by one or more composite scores. Our study aimed to demystify the points-based approach to organ allocation policy; quantify the relative importance of factors used in current policy; and provide a viable policy option that adapts the current, classification-based system to the continuous allocation framework. Methods Rank ordered logistic regression models were estimated using 6466 match runs for 5913 adult donors and 534 match runs for 488 pediatric donors from 2018. Four primary attributes are used to rank candidates and were included in the models: (1) medical priority, (2) candidate age, (3) candidate’s transplant center proximity to the donor hospital, and (4) blood type compatibility with the donor. Results Two composite scores were developed, one for adult and one for pediatric donor allocation. Candidate rankings based on the composite scores were highly correlated with current policy rankings (Kendall’s Tau ~ 0.80, Spearman correlation > 90%), indicating both scores strongly reflect current policy. In both models, candidates are ranked higher if they have higher medical priority, are registered at a transplant center closer to the donor hospital, or have an identical blood type to the donor. Proximity was the most important attribute. Under a points-based scoring system, candidates in further away zones are sometimes ranked higher than more proximal candidates compared to current policy. Conclusions Revealed preference analysis of lung allocation match runs produced composite scores that capture the essence of current policy while removing rigid boundaries of the current classification-based system. A carefully crafted, continuous version of lung allocation policy has the potential to make better use of the limited supply of donor lungs in a manner consistent with the priorities of the transplant community.

Efforts are underway to transition the current lung allocation system to a continuous distribution framework whereby multiple factors are simultaneously combined into a Composite Allocation Score (CAS) to prioritize candidates for lung transplant. The purpose of this study was to compare discrete CAS scenarios with the current concentric circle-based allocation system to assess their potential effects on the US lung transplantation system using the Scientific Registry of Transplant Recipients' thoracic simulated allocation model. Six alternative CAS scenarios were compared over 10 simulation runs using data from individuals on the lung transplant waiting list from January 1, 2018, through December 31, 2019. Outcome measures were transplant rate, count, waitlist deaths, posttransplant deaths within 2 years, donor-to-recipient distance, and percentage of organs predicted to have flown. Across scenarios, waitlist deaths decreased by 36% to 47%, with larger decreases in deaths at lower placement efficiency weight and higher weighting of the waitlist outcomes. When waitlist outcomes were equally weighted to posttransplant outcomes, more transplants occurred in individuals with the highest expected posttransplant survival. All CAS scenarios led to improved overall measures of equity compared with the current Lung Allocation Score system, including reduced waitlist deaths, and resulted in similar posttransplant survival.

Bronchoalveolar lavage (BAL) is a key clinical and research tool in lung transplantation (LTx). However, BAL collection and processing are not standardized across LTx centers. This International Society for Heart and Lung Transplantation-supported consensus document on BAL standardization aims to clarify definitions and propose common approaches to improve clinical and research practice standards. The following 9 areas are covered: (1) bronchoscopy procedure and BAL collection, (2) sample handling, (3) sample processing for microbiology, (4) cytology, (5) research, (6) microbiome, (7) sample inventory/tracking, (8) donor bronchoscopy, and (9) pediatric considerations. This consensus document aims to harmonize clinical and research practices for BAL collection and processing in LTx. The overarching goal is to enhance standardization and multicenter collaboration within the international LTx community and enable improvement and development of new BAL-based diagnostics. ispartof: JOURNAL OF HEART AND LUNG TRANSPLANTATION vol:39 issue:11 pages:1171-1190 ispartof: location:United States status: published

Improved predictive models are needed in lung transplantation in the setting of a proposed allocation system that incorporates longer-term post-transplant survival in the United States. Allocation systems require accurate mortality predictions to justly allocate organs.Utilizing the United Network for Organ Sharing database (2005-2017), we fit models to predict 1-year mortality based on the Lung Allocation Score (LAS), the Chan, et al, 2019 model, a novel "clinician" model (a priori clinician selection of pre-transplant covariates), and two machine learning models (Least Absolute Shrinkage and Selection Operator; LASSO and Random Forests) for predicting 1-year and 3-year post-transplant mortality. We compared predictive accuracy among models. We evaluated the calibration of models by comparing average predicted probability vs observed outcome per decile. We repeated analyses fit for 3-year mortality, disease category, including donor covariates, and LAS era.The area under the cure for all models was low, ranging from 0.55 to 0.62. All exhibited reasonable negative predictive values (0.87-0.90), but the positive predictive value for was poor (all0.25). Evaluating LAS calibration found 1-year post-transplant estimates consistently overestimated risk of mortality, with greater differences in higher deciles. LASSO, Random Forests, and clinician models showed no improvement when evaluated by disease category or with the addition of donor covariates and performed worse for 3-year outcomes.The LAS overestimated patients' risk of post-transplant death, thus underestimating transplant benefit in the sickest candidates. Novel models based on pre-transplant recipient covariates failed to improve prediction. There should be wariness in post-transplant survival predictions from available models.

Lung transplant recipients (LTR) with Covid-19 may have higher mortality than non-lung solid organ transplant recipients (SOTR), but direct comparisons are limited. Risk factors for mortality specifically in LTR have not been explored. We performed a multicenter cohort study of adult SOTR with Covid-19 to compare mortality by 28-days between hospitalized LTR and non-lung SOTR. Multivariable logistic regression models were used to assess comorbidity-adjusted mortality among LTR vs. non-lung SOTR and to determine risk factors for death in LTR. Of 1,616 SOTR with Covid-19, 1,051 (65%) were hospitalized including 117/159 (74%) LTR and 934/1457 (64%) non-lung SOTR (p=0.02). Mortality was higher among LTR compared to non-lung SOTR (24% vs. 16%, respectively, p=0.035) and lung transplant was independently associated with death after adjusting for age and comorbidities (aOR 1.7, 95% CI 1.0-2.6, p=0.05). Among LTR, independent risk factors for mortality included single lung transplant (aOR 2.8, 95% CI 1.0-7.7, p=0.04) and chronic lung allograft dysfunction (aOR 3.6, 95% CI 1.0-12.4, p=0.05), but not age >65 years, heart failure, or obesity. Among SOTR hospitalized for Covid-19, LTR had higher mortality than non-lung SOTR. In LTR, single lung transplant and chronic allograft dysfunction were independently associated with mortality.

AIMS Dental clearance is typically part of the evaluation process prior to placement on the lung transplant waiting list. Individuals with cystic fibrosis (CF) are thought to be at low risk for dental disease. We hypothesized that individuals with CF in need of lung transplantation would have lower dental disease prevalence and shorter waitlist evaluation time than individuals with non-CF lung diseases. METHODS AND RESULTS We conducted a retrospective study of individuals who received a lung transplant between 2011 and 2017 at the University of Washington (Seattle, WA, USA) (N = 280). Untreated dental disease was assessed by the individual's dentist. Waitlist evaluation time was defined as the time, in days, from the initial evaluation by a transplant pulmonologist to placement on the lung transplant waiting list. We used logistic and linear regression models for hypothesis testing. The prevalence of untreated dental disease did not differ by CF status (p = 0.99). There was no difference in waitlist evaluation time for transplant recipients by CF status (p = 0.78) or by dental disease status (p = 0.93). CONCLUSIONS Our findings provide further evidence that individuals with CF are not at low risk for dental disease. Ensuring optimal oral health is important for all individuals with lung diseases.

Lung transplantation can be lifesaving in end-stage cystic fibrosis (CF), but long-term survival is limited by chronic lung allograft dysfunction (CLAD). Persistent upper airway Pseudomonas aeruginosa (PsA) colonization can seed the allograft. While de novo PsA infection is associated with CLAD in non-CF recipients, this association is less clear for CF recipients experiencing PsA recolonization. Here, we evaluate host and pathogen contributions to this phenomenon. In the context of PsA infection, brushings from the airways of CF recipients demonstrate type 1 interferon gene suppression. Airway epithelial cell (AEC) cultures demonstrate similar findings in the absence of pathogens or immune cells, contrasting with the pre-transplant CF AEC phenotype. Type 1 interferon promoters are relatively hypermethylated in CF AECs. CF subjects in this cohort have more mucoid PsA, while non-CF PsA subjects have decreased microbiome α diversity. Peri-transplant protocols may benefit from consideration of this host and microbiome equilibrium.

Lung transplantation has become an increasingly frequent treatment for patients with a variety of end-stage lung diseases. Survival after lung transplantation has improved over time but is still limited as compared to other solid organ transplant recipients. There are a myriad of pulmonary issues that may arise after a lung transplant as well as a large number of non-pulmonary complications frequently related to immunosuppressant effects and/or toxicities. Non-pulmonary complications include, but are not limited to, renal dysfunction, hematologic abnormalities, gastrointestinal complications, neurologic sequelae, oncologic manifestations, and metabolic derangements. For these reasons, following a lung transplant, recipients require intensive, life-long monitoring for the assessment, evaluation, and management of both allograft and non-allograft transplant-related complications.

Background: We examined the association of adult lung transplant candidates’ self-reported affect with transplant-related outcomes, evaluating whether a positive (vs negative) frame of mind might be protective. Method: Consenting waitlisted candidates from 6 centers completed the questionnaires including the Positive and Negative Affect Schedule annually and posttransplant. Univariate logistic regression analysis was performed to determine the association of baseline affect with outcomes of death or delisting. Models were subsequently adjusted for age, marital status, and education. Results: Questionnaires were completed by 169 candidates (77.9% participation). Mean positive affect, negative affect, and positive-to-negative affect ratio (positivity ratio) were similar to expected norms. The scores of the questionnaire did not change significantly over time. Fifteen (8.9%) waitlisted participants died. Candidates who died while waiting had lower positivity ratios compared to those who survived (1.82 vs 2.45; P = .02). A more negative affect was associated with increased death on the waiting list (adjusted odds ratio [OR] 1.10; P = .021). Conversely, a higher positivity ratio was associated with decreased death while waiting (adjusted OR: 0.45; P = .027). Conclusion: Negative affect may represent a novel risk factor for death on the waitlist. Enhancing positive affect may represent a useful target for psychological optimization in lung transplant candidates.

While lung transplantation is a potentially life-saving therapeutic option for many patients with end-stage pulmonary disease, overall outcomes remain inferior to recipients of other solid organ transplants. The immediate post-operative period presents a particularly high risk time for this extremely vulnerable population with a wide array of possible early complications including infection, rejection, pulmonary edema, primary graft dysfunction, bleeding, wound and airway complications, and venous thromboembolism. This chapter reviews important diagnostic considerations for lung transplant recipients with pulmonary infiltrates in the immediate post-operative period, specifically pertaining to infection, rejection, and pulmonary edema.

Purpose The Organ Procurement and Transplantation Network (OPTN) US lung allocation policy was altered in 2017 by changing the first geographic unit of lung allocation from the donation service area (DSA) to a 250 nautical mile (NM) radius around the donor hospital. Methods OPTN data on lung candidates and recipients age gt; 11 was analyzed pre (11/26/2015- 11/24/2017) and post allocation policy change (11/25/2017- 11/24/2019). Cohorts were compared to study the differences. Results An increase was seen in the match lung allocation score (LAS) at transplant from pre to post era (mean pre=47.25 vs. post=49.79, p Conclusion Under the current system, lungs are being placed to sicker candidates with similar short-term post-transplant outcomes compared to the older allocation system. The next step for the lung allocation system in the US is a move to the Continuous Distribution framework to avoid hard boundaries in geography and other clinical classifications. The OPTN Lung Transplantation Committee is using these results and additional analyses to make evidence-based decisions for allocating lungs under the new framework.

Background Lung transplantation is an intervention that improves survival for adult patients with cystic fibrosis (CF). Some patients with CF are never referred for lung transplant evaluation despite meeting physiologic criteria for referral. Methods We performed a retrospective analysis of adult patients (≥18years of age) in the Cystic Fibrosis Foundation Patient Registry (CFFPR), eligible for their first evaluation for lung transplantation during the years 2001–2008 based on FEV1 Results Within the CFFPR, 1240 patients met eligibility criteria. Eight hundred and nine (65.2%) were referred for lung transplant evaluation, and 431 (34.8%) were not referred. In a multivariable model, Medicaid insurance (OR 1.79, 95% CI 1.29–2.47), older age (per 5year increase; OR 1.25, 95% CI 1.13–1.39), lack of high school graduate education (OR 2.27, 95% CI 1.42–3.64), and Burkholderia cepacia complex sputum culture positivity (OR 2.48, 95% CI 1.50–4.12) were associated with non-referral, while number of pulmonary exacerbations (OR 0.93, 95% CI 0.87–0.99) and supplemental oxygen use (OR 0.59, 95% CI 0.43–0.81) were associated with increased referral. Conclusions Despite meeting lung function criteria for lung transplant evaluation, 35% of patients with CF had not yet been referred to a lung transplant center. Predictors of non-referral included markers of low socioeconomic status, older age and B. cepacia complex sputum culture. Further work is needed to understand the outcomes for non-referred patients in order to refine referral recommendations in this population.

Background Pulmonary infection secondary to nontuberculous mycobacteria (NTM) is associated with significant morbidity and mortality, especially in individuals with underlying structural lung disease. Such infections are challenging to treat due to high virulence, antibiotic resistance, and the lack of effective and tolerable therapies. At many transplant centers, the isolation of NTM may be considered a contraindication for lung transplantation. Methods Institutional and referral medical records, microbiology, radiology and pathology databases were reviewed for patients who underwent lung transplantation at the University of Washington between 2006-2020. 8 patients with NTM disease were identified according to the American Thoracic Society (ATS) guidelines. 9 patients with sputum cultures positive for NTM, but not diagnosed with NTM disease were also evaluated. Results Patients with NTM disease continued antimycobacterial therapy pre- and post-operatively. NTM organisms isolated included M avium complex, M fortuitum, M abscessus, M kansasii, and M fortiutum. In the cohort with NTM-disease, one patient died within a year of transplantation (14%), three died within 1-5 years (43%), and four (51%) are still alive 1-9 years post-transplantation. Only one patient clearly died as a direct cause of the NTM infection, and this occurred early post-transplantation due to disseminated M abscessus infection. Of the other deceased patients with pre-existing NTM disease, one died due to graft rejection at 3 years, one died due to graft rejection with concomitant non-NTM pneumonia at 2 years, and one died due to cardiac arrest at 4 years. In the cohort without NTM disease, none died within 1 year of transplantation, 22% died within 1-5 years, 11% died more than 5 years post-transplant, and 66% are still alive 1-14 years post-transplant. The probability of survival more than 1 year and more than 5 years post-transplant and 38% in patients with NTM-disease, and 100% and 56% in patients without NTM disease. Conclusion NTM infection in the lung transplant candidate is uncommon and challenging, however successful treatment can occur, perhaps in the setting of certain subspecies and with prolonged combination antimicrobial therapy. Disclosures All Authors: No reported disclosures

Purpose The OPTN added fields to the deceased donor registration (DDR) form on 3/31/2015 and to the transplant recipient registration (TRR) form on 2/28/2018 to capture the utilization of ex vivo lung perfusion (EVLP) on donor lungs prior to transplantation (Tx) in the US. The aim is to examine the data fields currently being collected, summarize the use of EVLP over time, and to compare early transplant outcomes between EVLP lungs and lungs where EVLP was not considered. Methods All adult deceased donors with at least one lung recovered for Tx from 4/1/15- 6/30/19 were analyzed. The prevalence of EVLP was examined over time and by recovering OPO. Post-transplant 1-year recipient survival (Tx between 4/1/15-6/30/18) was compared between donors of lungs with EVLP vs. no EVLP. Results For adult deceased donors (N=10,167), 19,295 lungs were recovered for the purpose of Tx. EVLP was intended in of 785 lungs and 485 (61.8%) of EVLP donor lungs were Tx. Since data collection began the use of perfusion has increased from 1.7% (N=16) of lungs to 7.4% (N=97) in the most recent quarter (Figure 1). Approximately 65% of the lungs perfused were from non-DCD donors and 35% from DCD donors. 51 of the 58 OPOs have recovered at least one lung that has been perfused. Over time the discard rate for perfused lungs has decreased from approximately 50% in the earliest quarter to approximately 25% in the most recent quarter. 1-yr patient survival between groups (EVLP, n=136; non-EVLP, n=7,169) was not significantly different (p= 0.06). Conclusion The number of donor lungs perfused prior to Tx in the US has grown over the past 4 years to approximately 7% of all recovered donor lungs. Geographically, the use of EVLP varied greatly across OPOs. Early recipient outcomes did not differ statistically between EVLP intended donor lungs compared to conventional donation.

Atrial fibrillation and flutter (AF/AFL) are common following lung transplant surgery although risk factors for AF/AFL development are controversial. We reevaluated risk factors and the effects of prophylactic beta blocker use on incident AF/AFL. We performed a single-center retrospective study of

Airway complications remain a major cause of morbidity and mortality after cardiothoracic transplantation. The reported incidence of airway ischemic complications varies widely, contributed to by the lack of a universally accepted grading system and standardized definitions. Furthermore, the majority of the existing classification systems fail to integrate the wide range of possible bronchial complications that may develop after lung transplant. Hence, a Working Group was created by the International Society for Heart and Lung Transplantation with the aim of elaborating a universal definition of adult and pediatric airway complications and grading system. One such area of focus is to understand the problem in the context of a more standardized consensus of classifying airway ischemia. This consensus definition will have major clinical, therapeutics, and research implications.

Following transplantation, medical management of the lung transplant recipient is vital for maintaining the health of the allograft and to promote an overall successful outcome after a lung transplant surgery. This includes vigilant and meticulous monitoring for all lung transplant-related issues, including administering appropriate immunosuppression with antirejection medications while monitoring for associated toxicities and drug interactions as well as prompt detection of infection and lung allograft rejection. In addition, there must be full awareness of the many non-pulmonary complications that may arise following lung transplantation, a large number of which are related to immunosuppressant effects or toxicities. Non-pulmonary complications include but are not limited to renal dysfunction, hematologic abnormalities, gastrointestinal complications, neurologic sequelae, oncologic manifestations, and metabolic derangements. While monitoring lung allograft function following transplantation is critical to overall survival, monitoring of the subsequent non-pulmonary complications is also important to avoid increased morbidity and mortality in lung transplant recipients. The lung transplant pulmonologist must assume the role of a very thorough internist for the lung transplant recipient in order to monitor and address the many complications occurring after lung transplantation. This chapter focuses on the medical management of non-pulmonary issues in the lung transplant recipient.

Acute cellular and antibody-mediated (humoral) rejections are two forms of acute rejection seen following lung transplantation. The management of acute cellular and antibody-mediated rejection is complex and may be individualized based on the unique situation of each patient. The prevention of acute cellular rejection starts with induction immunosuppression and frequent clinical monitoring as well as through the management of potential risk factors such as gastroesophageal reflux disease and various infections. Antibody-mediated rejection is less understood and requires further study. The mainstay of treatment for acute cellular rejection as well as antibody-mediated rejection is through the augmentation of immunosuppression through a variety of medical strategies. The management of acute cellular rejection and antibody-mediated rejection is important due to the associations with the development of chronic lung allograft dysfunction, the primary cause of mortality following lung transplantation. With optimal management and further study, the goal is for improved survival and quality of life for all lung transplant recipients.

Background Ganciclovir-resistant (ganR) cytomegalovirus (CMV) is an emerging and important problem in solid organ transplant (SOT) recipients. Only through direct comparison of ganR- and ganciclovir-sensitive (ganS) CMV infection can risk factors and outcomes attributable specifically to ganciclovir resistance appropriately be determined. Methods We performed a retrospective, case-control (1:3) study of SOT recipients with genotypically confirmed ganR-CMV (n = 37) and ganS-CMV infection (n = 109), matched by donor/recipient CMV serostatus, year and organ transplanted, and clinical manifestation. We used χ2 (categorical) and Mann-Whitney (continuous) tests to determine predisposing factors and morbidity attributable to resistance, and Kaplan-Meier plots to analyze survival differences. Results The rate of ganR-CMV was 1% (37/3467) overall and 4.1% (32/777) among CMV donor-positive, recipient-negative patients, and was stable over the study period. GanR-CMV was associated with increased prior exposure to ganciclovir (median, 153 vs 91 days, P < .001). Eighteen percent (3/17) of lung transplant recipients with ganR-CMV had received

Purpose The OPTN/UNOS added fields to the deceased donor registration form on 3/31/2015 and the transplants recipient registration (TRR) form on 2/28/2018 to collect data on the utilization of ex vivo lung perfusion (EVLP) on donor lung. The steadily increasing use of EVLP, early outcomes, and new data collected on the TRR are summarized. Methods To determine trends in the use of EVLP, all deceased donor lungs recovered from 4/1/2015- 6/30/2018 were analyzed and divided into an EVLP and non-EVLP cohort. TRR data was available for recipients receiving a transplant between 2/28/2018- 6/30/2018. One year lung recipient survival was compared for the cohort spanning 4/1/2015- 6/30/2017. Results EVLP was utilized on 447 of 14,269 recovered lungs procured from 7,524 deceased donors. Of the 447 with EVLP utilized, 165 (34.6%) were DCD donors and 270 (56.6%) were transplanted. A total of 49 out of 58 (84%) OPOs perfused at least 1 lung. By examining the use of EVLP by annual quarters, the earliest quarter had 16 lungs perfused (1.7%) while the most recent quarter had 70 lungs perfused (5.8%). The discard rate for EVLP lungs was statistically higher than lungs that were not perfused (43.4% vs. 4.4%, p Conclusion Since April 2015, the use of EVLP has increased to the current reported level of almost 6% of deceased donor lungs recovered for transplant in the US. The majority of EVLP lungs are perfused at the recovery site by transplant programs and there is no evidence of a negative impact on one year recipient survival. Continued data collection on donor lung perfusion on both the DDR and TRR will allow the OPTN to better understand the utilization of this evolving technology.

Purpose of review Lung transplantation is an important therapeutic treatment for many patients with life-threatening pulmonary diseases; however, long-term survival is still relatively limited compared with other solid organ transplants. Over the last year, several articles have been published helping to increase our knowledge of infections in lung transplant recipients. In particular, important new information has been published recently regarding cytomegalovirus (CMV) and fungal infections following lung transplantation. Recent findings Recent studies indicate prolonged (≥12 months) antiviral prophylaxis for CMV after lung transplant may be beneficial in high-risk transplant recipients. Epidemiologic studies show invasive fungal infections are increasingly being recognized following solid organ transplantation, particularly with Aspergillus and Candida species. Pulmonary infections with CMV and Aspergillus are likely contributors to the development of bronchiolitis obliterans syndrome (BOS). Summary Lung transplantation has many potential posttransplant complications with infection being a major contributor. More information has become available regarding CMV prophylaxis, CMV treatment, pulmonary fungal infection epidemiology, and the role of both CMV and Aspergillus on the development of BOS, which helps toward the goal of increasing long-term survival in lung transplant recipients.

Infections complications following lung transplantation are associated with significant morbidity and mortality. Management of infections is most challenging in patients with cystic fibrosis (CF), but all lung transplant recipients are at heightened risk for opportunistic infections. Particularly in CF, pretransplant infections with PSEUDOMONAS AERUGINOSA, other highly resistant bacteria (e.g., STENOTROPHOMONAS, BURKHOLDERIA), and mycobacteria play a major role in recipient selection and post-lung transplant outcomes. Understanding the clinical impact and management strategies for each of these different pathogens is critical to maximizing the benefit of lung transplantation. In the review, we discuss each of these infections both as pretransplant risk factors as well as posttransplant pathogens and the individual issues that arise with each infection.

Background Prior studies reveal that a significant proportion of patients with cystic fibrosis (CF) and advanced lung disease are not referred for lung transplant (LTx) evaluation. We sought to assess expert CF physician perspectives on the timing of LTx referral and investigate their LTx knowledge. Methods We developed an online anonymous survey that was distributed by the Cystic Fibrosis Foundation (CFF) to the medical directors of all CFF-accredited care centers in the United States in 2015. The survey addressed only adult patients (≥18 years old) and was sent to 119 adult CF physicians, 86 CFF-affiliated CF physicians (who see adults and children, but have smaller program sizes than adult or pediatric centers), and 127 pediatric CF physicians (who see some adults, but mostly children). The focus of the questions was on CFF-care center characteristics, physician experience and indications/contraindications to referral for LTx evaluation. Results There were 114/332 (34%) total responses to the survey. The response rates were: 57/119 (48%) adult physicians, 12/86 (14%) affiliate physicians and 43/127 (34%) pediatric physicians; 2 physicians did not include their CFF center type. Despite the poor ability of FEV1