A single-center experience of 1500 lung transplant patients

Abstract

Objective: Over the past 30 years, lung transplantation has emerged as the definitive treatment for end-stage lung disease. In 2005, the lung allocation score (LAS) was introduced to allocate organs according to disease severity. The number of transplants performed annually in the United States continues to increase as centers have become more comfortable expanding donor and recipient criteria and have become more facile with the perioperative and long-term management of these patients. We report a single-center experience with lung transplants, looking at patients before and after the introduction of LAS.

Methods: We retrospectively reviewed 1500 adult lung transplants at a single center performed between 1988 and 2016. Patients were separated into 2 groups, before and after the introduction of LAS: group 1 (April 1988 to April 2005; 792 patients) and group 2 (May 2005 to September 2016; 708 patients).

Results: Differences in demographic data were noted over these periods, reflecting changes in allocation of organs. Group 1 patient average age was 48 ± 13 years, and 404 subjects (51%) were male. Disease processes included emphysema (52%; 412), cystic fibrosis (18.2%; 144), pulmonary fibrosis (16.1%; 128) and pulmonary vascular disease (7.2%; 57). Double lung transplant (77.7%; 615) was performed more frequently than single lung transplant (22.3%; 177). Group 2 average age was 50 ± 14 years, and 430 subjects (59%) were male. Disease processes included pulmonary fibrosis (46%; 335), emphysema (25.8%; 188), cystic fibrosis (17.7%; 127) and pulmonary vascular disease (1.6%; 11). Double lung transplant (96.2%; 681) was performed more frequently than single lung transplant (3.8%; 27). Overall incidence of grade 3 primary graft dysfunction (PGD) in group 1 was significantly lower at 22.1% (175) than in group 2 at 31.6% (230) (P < .001). Nonetheless, overall hospital mortality was not statistically different between the 2 groups (4.4% vs 3.5%; P < .4). Most notably, survival at 1 year was statistically different at 646 (81.6%) for group 1 and 665 (91.4%) for group 2 (P < .02).

Conclusions: Patient demographics over the study period have changed with an increased number of fibrotic patients transplanted. In addition, more aggressive strategies with donor/recipient selection appear to have resulted in a higher incidence of primary graft dysfunction. This does not, however, appear to affect patient survival on index hospitalization or at 1 year. In fact, we have observed a significant improvement in survival at 1 year in the more recent era. This observation suggests that continued expansion of possible donors and recipients, coupled with a more sophisticated understanding of primary graft dysfunction and long-term chronic rejection, can lead to increased transplant volume and prolonged survival.

Keywords: bronchiolitis obliterans; chronic rejection; cystic fibrosis; emphysema; lung allocation score; lung transplantation; primary graft dysfunction; pulmonary fibrosis.

FIGURE 1.

Overall survival of all 1500 transplanted patients as a function of time. Ninety-five percent confidence limits are represented by the thin lines.

FIGURE 2.

Overall survival stratified by diagnosis groups, including cystic fibrosis (CF), chronic obstructive pulmonary disease (COPD), pulmonary fibrosis (IPF), and other (including pulmonary hypertension, α−1 anti-trypsin deficiency, and lymphangioleiomyomastosis). There is a statistically significant difference in survival among the groups (P<.007). Ninety-five percent confidence limits are represented by the thin lines. See Table E1 for survival and 95% confidence intervals separated by disease process.

FIGURE 3.

Overall survival stratified by time groups. Early transplant (group 1) had decreased short- and long-term survival when compared with late transplant (group 2; P<.0001). Ninety-five percent confidence limits are represented by the thin lines.

FIGURE 4.

A, Overall survival stratified by diagnosis groups in early transplant patients. Ninety-five percent confidence limits are represented by the thin lines. See Table E2 for survival and 95% confidence intervals separated by disease process. B, Overall survival stratified by diagnosis groups in late transplant patients. Ninety-five percent 95% confidence limits are represented by the thin lines. See Table E3 for survival and 95% confidence intervals separated by disease process. CF, Cystic fibrosis; COPD, chronic obstructive pulmonary disease; IPF, interstitial pulmonary fibrosis.

FIGURE 5.

A, Overall time to development of bronchiolitis obliterans syndrome (BOS). Ninety-five percent confidence limits are represented by the thin lines. B, Overall time to development of BOS, stratified by time groups. Early transplant (group 1) had a statistically significant reduced freedom from BOS at all time points compared to late transplant (group 2; P<.0001). Ninety-five percent confidence limits are represented by the thin lines.