Thirty years of lung transplantation: development of postoperative outcome and survival over three decades

Abstract

Background: Lung transplantation (LuTX) can be the last resort for patients with end-stage lung diseases. In the last decades, improvements were implemented in transplant medicine, from immunosuppression throughout preservation of the donor organ to enhance lung allograft survival. This retrospective study aims to illustrate the development of the LuTX-program at the University Hospital of Munich, LMU, Munich, Germany, since its launch in 1990 by depicting and comparing postoperative outcome.

Methods: We analyzed all LuTX performed from 1990 to 2019. Data was collected on indication for transplantation (TX), date, type (double/single) and postoperative survival. Survival analysis and Kaplan-Meier estimator were used to identify factors that are detrimental to post-LuTX-outcome.

Results: A total of 1,054 LuTX were performed over 30 years, comprising overall 1,024 patients (30 retransplantations). The best results regarding five-year survival rates (5-YSR) were observed in patients with lymphangioleiomyomatosis (LAM) and hypersensitivity pneumonitis (HP) (5-YSR: LAM: 78.6%, HP: 73.6%). We could show that besides that the type of LuTX played a crucial role in post-TX survival, depicting double superior to single LuTX (5-YSR: single: 47.2%, double: 64.5%). Additionally, cytomegalovirus (CMV) risk constellation (high/intermediate risk; P=0.02) and infection (P<0.001) were identified as risk factors for deteriorated survival.

Conclusions: Data analysis demonstrates that the field of LuTX has undergone enormous progress over the years. Therapeutic advances and improvements in interdisciplinary cooperation, pre- and postoperative management, changes in immunosuppressive medication, diagnosis and treatment of allograft rejections have clearly improved lung allograft and patient survival.

Keywords: Lung transplantation (LuTX); chronic obstructive pulmonary disease (COPD); interstitial lung disease (ILD); postoperative survival.

Figure 1

Annually performed LuTX by underlying diagnosis. CF, cystic fibrosis; COPD, chronic obstructive pulmonary disease; GF, graft failure; HP, hypersensitivity pneumonitis; ILD, interstitial lung disease; LAM, lymphangioleiomyomatosis; LuTX, lung transplantation; PH, pulmonary hypertension.

Figure 2

Type of transplantation (single vs. double LuTX). LuTX, lung transplantation.

Figure 3

CLAD and type of transplantation. CLAD, chronic lung allograft dysfunction; LuTX, lung transplantation.

Figure 4

CLAD and DSA. CLAD, chronic lung allograft dysfunction; DSA, donor-specific antibodies.

Figure 5

Overall survival (1990 to 2019). LuTX, lung transplantation.

Figure 6

Survival by decade of LuTX. LuTX, lung transplantation.

Figure 7

Survival by underlying disease. CF, cystic fibrosis; COPD, chronic obstructive pulmonary disease; GF, graft failure; HP, hypersensitivity pneumonitis; ILD, interstitial lung disease; LAM, lymphangioleiomyomatosis; LuTX, lung transplantation; PH, pulmonary hypertension.

Figure 8

Survival by type of transplantation (single vs. double LuTX). LuTX, lung transplantation.

Figure 9

Survival by type of cardiocirculatory support. CPB, cardiopulmonary bypass; ECMO, extracorporeal membrane oxygenation; LuTX, lung transplantation.

Figure 10

Survival before and after the introduction of the LAS. LAS, lung allocation score; LuTX, lung transplantation.

Figure 11

Survival by CMV risk constellation. LuTX, lung transplantation; CMV, cytomegalovirus; LuTX, lung transplantation.