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Survival shorter in extended-criteria lung recipients

Key clinical point: Lung transplant recipients who received extended-criteria donor (ECD) lungs have lower rates of 1-year survival than recipients of standard donor lungs.

Major finding: Recipients of ECD lungs had a 41% higher risk of death than recipients of standard lungs, and those who had more severe lung disease had lower rates of 1-year survival after receiving ECD lungs, compared with standard donor lungs.

Data source: Retrospective analysis of 10,995 lung recipients, from the Organ Procurement and Transplantation Network/United Network for Organ Sharing database, 3,792 of whom who received extended-criteria donor organs over 7.5 years.

Disclosures: Dr. Mulligan and his coauthors had no financial relationships to disclose.

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Impact worst in severe disease

This study provides “greater clarity to the definition and significance of using lungs from an extended-criteria donor,” Benjamin Wei, MD, of the University of Alabama at Birmingham said in his invited commentary (J Thorac Cardiovasc Surg. 2016;152:899-900). “Now, we have more data about what constitutes an ECD for lung transplantation.”

The study also brought clarity on components of donor factors that do not affect survival – namely radiologic, bronchoscope, or laboratory criteria – Dr. Wei said. At the same time, the study raises questions about how transplant surgeons should use the findings. “Do we shy away from using donors with these high risk factors in low-risk recipients, high-risk recipients, neither, or both?” Dr. Wei asks. The study did not compare ECD lungs vs. no transplant, and becoming more selective in donors could cause more patients to die on the waiting list, he said.

A host of other questions also remain unanswered, Dr. Wei said, such as how a single standard-donor lung transplant compares with bilateral ECD transplants, or a single ECD lung vs. bilateral ECD lungs, and if use of ECD lungs by the criteria Dr. Mulligan and his coauthors outlined influences allograft patient survival.

“Of note, this study also did not include recipients receiving donor after cardiac death lungs or extracorporeal membrane oxygenation, both increasingly common situations,” he said. Nonetheless, the findings provide more information that transplant surgeons can base their decision-making on.

Dr. Wei had no financial relationships to disclose.


 

FROM THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY

The availability of lungs for transplant has been severely limited by usable donors, but organs from so-called extended criteria donors – those aged 65 years or older, had a 20 pack-years or more smoking history or history of diabetes mellitus, or were black – were found to be associated with shorter survival than lungs from standard donor lungs, and recipients with more severe lung disease had the lowest survival rates from extended-criteria organs, an analysis of the national donor database found.

“Matching donor quality to recipient severity is critical to achieve optimal outcomes in lung transplantation,” Matthew J. Mulligan, MD, and his colleagues from the University of Maryland, Baltimore, said in the September issue of the Journal of Thoracic and Cardiovascular Surgery (2016;152:891-8). Dr. Mulligan previously presented the study results in April 2015 at the annual meeting of the American Association for Thoracic Surgery in Seattle.

The researchers analyzed 10,995 patients who received donor lungs between May 2005 and December 2012, 3,792 of whom received extended-criteria donor (ECD) organs. The study population was taken from the Organ Procurement and Transplantation Network/United Network for Organ Sharing database. Dr. Mulligan and his coauthors said this is the largest study examining ECD in lung transplants to date.

The goal of the study was to identify donor factors associated with reduced 1-year survival after transplantation, Dr. Mulligan and his colleagues said. “In the current literature, there is a paucity of data to guide the decision of matching donor quality to recipient severity,” the study authors said.

Recipients of extended-criteria lungs had a 41% increased risk of death, compared with recipients standard donor lungs, but individuals with more severe lung disease were at even greater risk with extended-criterial lungs, Dr. Mulligan and his colleagues said. Those who had a lung allocation score (LAS) less than 70 had a 1-year survival of 87% with standard donor lungs vs. 82% with extended-criteria lungs, while those who had a LAS of 70 or greater had survival rates of 80% and 72%, respectively.

Other donor factors that were inconsequential in recipient survival, Dr. Mulligan and his coauthors reported, included an abnormal chest x-ray, purulent secretions on bronchoscopy, blood type, mechanism of death (stroke, blunt trauma, gunshot, asphyxiation, and so on), or diagnosis of coronary artery disease and hypertension.

The researchers also did a Cox regression analysis, and found that recipients of extended-criteria lungs with a LAS greater than 70 had an 81% greater risk of death, compared with 37% for those with a LAS of 70 or greater who received standard-donor lungs, and 42% with a LAS of 70 or less and an extended-criteria donor lung.

These findings support the idea of not using ECD lungs in high-risk individuals with LAS greater than 70. “More important, ECD lungs were associated with the worst survival when transplanted into high-risk recipients,” Dr. Mulligan and his colleagues said.

The authors did acknowledge the inherent limitations of a retrospective analysis, but the large patient population is a redeeming factor of the study, Dr. Mulligan and his colleagues said. “Notwithstanding these limitations, the current study provides a rigorous analysis of a large number of lung transplants in the modern era, and the results reported will be useful to the lung transplant community,” the study authors said.

Dr. Mulligan and his coauthors had no relationships to disclose.

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