Bronchiolitis obliterans syndrome occurs earlier in the post-lung allocation score era.

In 2005, the time-based waiting list for lung transplantation was replaced by an illness/benefit lung allocation score (LAS). Although short-term outcomes after transplantation have been reported to be similar before and after the new system, little is known about long-term results. The objective of this study was to evaluate the impact of LAS on the development of bronchiolitis obliterans syndrome as well as on overall 3-year and bronchiolitis obliterans syndrome-related survival. Data obtained from the United Network for Organ Sharing were used to review 8091 patients who underwent lung transplantation from 2002 to 2008. Patients were stratified according to time of transplantation into those treated before initiation of the LAS (pre-LAS group, January 2002-April 2005, n = 3729) and those treated after implementation of the score (post-LAS group, May 2005-May 2008, n = 4362). Overall, 3-year survivals for patient groups were compared using a univariate analysis, Cox proportional hazards model to generate a relative risk, and Kaplan-Meier curve analyses. During the 3-year follow-up period, bronchiolitis obliterans syndrome developed in 22% of lung transplant recipients (n = 1801). Although the incidence of postoperative bronchiolitis obliterans syndrome development was similar between groups, post-LAS patients incurred fewer bronchiolitis obliterans syndrome-free days (609 ± 7.5 vs 682 ± 9; P <.0001; log-rank test P = .0108) than did pre-LAS patients. Overall 3-year survival was lower in post-LAS patients and approached statistical significance (P = .05). Similarly, bronchiolitis obliterans syndrome-related survival was worse for patients in the post-LAS group (log-rank test P = .01). In the current LAS era, lung transplant recipients have significantly fewer bronchiolitis obliterans syndrome-free days after 3-year follow-up. Compared with the pre-LAS population, overall and bronchiolitis obliterans syndrome-related survival appears worse in the post-LAS era. Limitation of known risk factors for development of bronchiolitis obliterans syndrome-may prove even more important in this patient population.

Emaminia A ，Hennessy SA ，Hranjec T ，LaPar DJ ，Kozower BD ，Jones DR ，Kron IL ，Lau CL ... -  《-》

Impact of lung allocation score on survival in cystic fibrosis lung transplant recipients.

The lung allocation score (LAS) has changed organ allocation for lung transplantation in the United States. Previous investigations of transplant recipients reported an association between high LAS and an increased risk of death after lung transplantation. We hypothesize that a high LAS predicts survival in lung transplant recipients with cystic fibrosis (CF) in the United Network for Organ Sharing Scientific Registry of Transplant Recipients database. A cohort study was conducted of 1,437 U.S. adult lung transplant recipients with CF from May 1, 2005, through December 31, 2012. The cohort was divided into a high-risk group and a low-risk group based on LAS. Survival data were examined using Kaplan-Meier estimates and Cox proportional hazard models to compare survival. The primary outcome was adjusted survival at 1 year after lung transplantation. The high-risk group of 318 patients with a median LAS of 69.6 (interquartile range 56.3-87.2) was compared with a low-risk group of 1,119 patients with a median LAS of 38.8 (interquartile range 36.3-42.3). Patients in the high-risk group had a 41% increased relative risk of cumulative mortality at 1 year after transplantation compared with the low-risk group (16.1% vs 12.0%). After adjustment for known predictors of mortality, the risk of death at 1 year after transplantation remained elevated (hazard ratio = 1.41; 95% confidence interval = 1.00-2.01). The high-risk group had worse survival at 90 days and 2 years after lung transplantation. High LAS are associated with worse survival in lung transplant recipients with CF.

Braun AT ，Dasenbrook EC ，Shah AS ，Orens JB ，Merlo CA ... -  《-》

Donor factors are associated with bronchiolitis obliterans syndrome after lung transplantation.

Bronchiolitis obliterans syndrome (BOS) is the major hurdle preventing long-term success in lung transplantation, and is the primary reason for the 50% 5-year survival. Recipient and perioperative risk factors have been investigated in BOS, but less is known about donor factors. Therefore, we investigated what donor factors are important in the development of BOS. We performed a retrospective review of the United Network for Organ Sharing lung transplant database from 1987 to 2008. Lung transplant recipients had yearly follow-up. Donor factors were evaluated for their influence on BOS development. Kaplan-Meier plots of BOS-free survival were compared for each donor factor and a multivariate Cox proportional hazard model for BOS was created with donor factors. A total of 17,222 lung transplant recipients were identified; 6,991 recipients had sufficient follow-up BOS data. Of these recipients 57% (n = 3,984) developed BOS within 5 years. Recipients who received lungs from donors who were younger, without an active pulmonary infection, or those without current tobacco use had longer BOS-free survival. Recipients who received lungs with higher partial pressures of oxygen in arterial blood (Pao(2)) developed more BOS (p < 0.0001). Donor high Pao(2), older age, and current tobacco use were independent predictors of BOS in lung transplant recipients. Donor factors and donor management strategies are important contributors to development of recipient BOS. Identification of these factors may help limit BOS and may identify recipients at high risk. Surprisingly, high Pao(2) in the donor is an independent predictor of BOS development.

Hennessy SA ，Hranjec T ，Swenson BR ，Kozower BD ，Jones DR ，Ailawadi G ，Kron IL ，Lau CL ... -  《-》

Differential outcomes with early and late repeat transplantation in the era of the lung allocation score.

Rates of repeat lung transplantation have increased since implementation of the lung allocation score (LAS). The purpose of this study is to compare survival between repeat (ReTx) and primary (LTx) lung transplant recipients in the LAS era. We extracted data from 9,270 LTx and 456 ReTx recipients since LAS implementation, from the United Network for Organ Sharing registry. Propensity scoring was used to match ReTx and LTx recipients. Kaplan-Meier analysis compared survival between LTx and ReTx groups, with and without stratification based on time between first and second transplant. Multivariable Cox models estimated predictors of survival in lung recipients. Comparing all ReTx to LTx demonstrates a survival advantage for LTx that is diminished with propensity score matching (p = 0.174). Considering LTx against ReTx greater than 90 days after the initial procedure, there are similar survival results (p < 0.067). In contrast, ReTx within 90 days was associated with a survival disadvantage that persisted despite matching (p = 0.011). In ReTx populations, factors conferring worse outcomes include intensive care unit admission, unilateral transplantation, poor functional status, and primary graft dysfunction as the indication for retransplantation (p < 0.05). Late lung retransplantation appears to be as beneficial as primary transplantation in propensity-matched patients. However, survival is severely diminished in those retransplanted less than 90 days after primary transplantation. The utility of early retransplantation needs to be carefully weighed in light of risks.

Osho AA ，Castleberry AW ，Snyder LD ，Palmer SM ，Ganapathi AM ，Hirji SA ，Lin SS ，Davis RD ，Hartwig MG ... -  《-》

Bronchiolitis obliterans syndrome-free survival after lung transplantation: An International Society for Heart and Lung Transplantation Thoracic Transplant Registry analysis.

Lung transplant (LTx) recipients have low long-term survival and a high incidence of bronchiolitis obliterans syndrome (BOS). However, few long-term, multicenter, and precise estimates of BOS-free survival (a composite outcome of death or BOS) incidence exist. This retrospective cohort study of primary LTx recipients (1994-2011) reported to the International Society of Heart and Lung Transplantation Thoracic Transplant Registry assessed outcomes through 2012. For the composite primary outcome of BOS-free survival, we used Kaplan-Meier survival and Cox proportional hazards regression, censoring for loss to follow-up, end of study, and re-LTx. Although standard Thoracic Transplant Registry analyses censor at the last consecutive annual complete BOS status report, our analyses allowed for partially missing BOS data. Due to BOS reporting standards, 99.1% of the cohort received LTx in North America. During 79,896 person-years of follow-up, single LTx (6,599 of 15,268 [43%]) and bilateral LTx (8,699 of 15,268 [57%]) recipients had a median BOS-free survival of 3.16 years (95% confidence interval [CI], 2.99-3.30 years) and 3.58 years (95% CI, 3.53-3.72 years), respectively. Almost 90% of the single and bilateral LTx recipients developed the composite outcome within 10 years of transplantation. Standard Registry analyses "overestimated" median BOS-free survival by 0.42 years and "underestimated" the median survival after BOS by about a half-year for both single and bilateral LTx (p < 0.05). Most LTx recipients die or develop BOS within 4 years, and very few remain alive and free from BOS at 10 years post-LTx. Less inclusive Thoracic Transplant Registry analytic methods tend to overestimate BOS-free survival. The Registry would benefit from improved international reporting of BOS and other chronic lung allograft dysfunction (CLAD) events.

Kulkarni HS ，Cherikh WS ，Chambers DC ，Garcia VC ，Hachem RR ，Kreisel D ，Puri V ，Kozower BD ，Byers DE ，Witt CA ，Alexander-Brett J ，Aguilar PR ，Tague LK ，Furuya Y ，Patterson GA ，Trulock EP 3rd ，Yusen RD ... -  《-》