Lung transplantation for interstitial lung disease: evolution over three decades

Abstract

Background: Interstitial lung disease (ILD) has emerged as the most common indication for lung transplantation globally. However, post-transplant survival varies depending on the underlying disease phenotype and comorbidities. This study aimed to describe the demographics, disease classification, outcomes and factors associated with post-transplant survival in a large single-centre cohort.

Methods: Data were retrospectively assessed for 284 recipients who underwent lung transplantation for ILD in our centre between 1987 and 2020. Patient characteristics and outcomes were stratified by three eras: 1987-2000, 2001-2010 and 2011-2020.

Results: Median patients' age at time of transplantation was significantly higher in the most recent decade (56 (51-61) years, p<0.0001). Recipients aged over 50 years had worse overall survival compared with younger patients (adjusted HR, aHR 2.36, 95% CI 1.55 to 3.72, p=0.0001). Better survival was seen with bilateral versus single lung transplantation in patients younger than 50 years (log-rank p=0.0195). However, this survival benefit was no longer present in patients aged over 50 years. Reduced survival was observed in fibrotic non-specific interstitial pneumonia compared with idiopathic pulmonary fibrosis, which remained the most common indication throughout (aHR 2.61, 95% CI 1.40 to 4.60, p=0.0015).

Conclusion: In patients transplanted for end-stage ILD, older age and fibrotic non-specific interstitial pneumonia were associated with poorer post-transplant survival. The benefit of bilateral over single lung transplantation diminished with increasing age, suggesting that single lung transplantation might still be a feasible option in older candidates.

Keywords: interstitial fibrosis; lung transplantation.

Figure 1

Kaplan-Meier curves demonstrating overall survival (top left, median survival 5 years), across the three decades (top right, median survival 1987–2000: 2.8 years, 2001–2010: 5.9 years and 2010–2020: 4.9 years) and according to age (middle left: overall, middle right: 1987–2000, bottom left: 2001–2010, bottom right: 2011–2020).

Figure 2

Kaplan-Meier curves comparing post-transplant survival by organ transplanted in all patients (top left), patients aged ≥50 years (middle left), <50 years (bottom left) and across eras: 1987–2000 (top right), 2001–2010 (middle right) and 2011–2020 (bottom right). Median survival in patients aged ≥50 years with bilateral lung transplantation was 4.7 years (30-day, 1-year, 3-year and 5-year overall survival 88%, 73%, 59% and 42%, respectively) compared with 4.3 years in single lung transplantation (30-day, 1-year, 3-year and 5-year overall survival 85%, 70%, 56% and 43%, respectively). Median survival in patients aged <50 years with bilateral lung transplantation was 9.1 years (30-day, 1-year, 3-year and 5-year overall survival 92%, 86%, 80% and 73%, respectively) compared with 5.6 years in single lung transplantation (30-day, 1-year, 3-year and 5-year overall survival 80%, 77%, 59% and 52%).

Figure 3

Kaplan-Meier survival curves by ILD classification (top) and fibrotic NSIP compared with IPF (middle) and sarcoidosis (bottom). Other comparisons were not significantly different. cHP, chronic hypersensitivity pneumonitis; CTD-ILD, connective tissue disease-related interstitial lung disease; IPF, idiopathic pulmonary fibrosis; NSIP, non-specific interstitial pneumonia.