Approaches to the Management of Sensitized Lung Transplant Candidates: Findings from an International Survey

Abstract

Highly sensitized lung transplant candidates undergo transplant at a significantly lower rate than unsensitized candidates. We conducted a survey to understand the approach to waitlist and peri-operative management of these candidates across programs worldwide. Lung transplant programs were invited to complete the survey either online or by telephone. Survey questions pertained to programs' method of human leukocyte antigen (HLA) antibody detection, characterization of HLA antibody risk, incorporation of virtual (VCM) and actual crossmatch (ACM) results in organ allocation decisions, and use of pre or peri-operative desensitization therapy between January 2018 and October 2019. 57 adult (39/57), pediatric (4/57), and combined (14/57) lung transplant programs were surveyed. Respondents were transplant physicians (46/57), surgeons (3/57), or several multi-disciplinary team members (8/57) from programs in North America (39/57), Europe (11/57), Asia (3/57), Australia (3/57), and Africa (1/57). Regarding organ allocation, 32/57 programs decline offers for candidates who are highly sensitized/critically ill on the basis of an unacceptable VCM. A high degree of sensitization is a contraindication to transplant at 12/57 programs, and a contraindication to using mechanical support as bridge-to-transplant at 19/57. At 19/57 programs, offers are accepted regardless of positive VCM results if the prospective flow crossmatch (4/19) or complement-dependent cytotoxicity crossmatch (15/19) is negative, either for all candidates (9/19) or only for those who are highly sensitized/critically ill (10/19). A minority of programs (8/57) accept offers regardless of positive VCM or ACM results, either for all candidates (1/8) or only for those who are highly sensitized/critically ill (7/8). All of these programs use plasmapheresis, intravenous immune globulin, thymoglobulin, and/or rituximab peri-operatively. Currently, 13/57 programs treat highly sensitized candidates on the waitlist with various desensitization therapies to improve their likelihood of receiving an acceptable offer. There is significant variation in the management of sensitized lung transplant candidates across programs. Further research and international consensus are needed to improve access to transplant for these patients.