Five Year Follow-Up of Staged Bilateral Lung Transplantation for High-Risk Patients with Interstitial Lung Disease: A Matched Case-Control Study

Abstract

The choice of single (SOLT) or bilateral orthotopic lung transplant (BOLT) for interstitial lung disease (ILD) remains controversial. Our center adopted a staged BOLT approach for higher surgical risk ILD patients, in which they undergo a single lung transplant followed by a planned contralateral transplant at a later date. Long-term outcomes were compared to matched SOLT and BOLT recipients. Patients undergoing lung transplant for ILD at our institution 1/2009-8/2013 were eligible. Pediatric recipients, recipients of redo or multi-organ transplantation, and those with a diagnosis other than ILD were excluded. Staged BOLT recipients were matched to conventional SOLT and BOLT recipients in a 1:2:2 fashion based on criteria including age within 3 years and lung allocation score within 10 points. Patient and graft survival were estimated using the Kaplan Meier method. In staged BOLT recipients, the incidence of chronic lung allograft dysfunction (CLAD) was determined as persistent decline (≥20%) in FEV1 from baseline based on an average of two peak FEV1 values after second lung transplant, and compared to the incidence in control groups. A total of 192 patients with ILD met inclusion criteria. Of those, 12 (6.3%) received a staged BOLT, 106 (55.2%) received a conventional SOLT, and 74 (38.5%) received a conventional BOLT. Following matching, there were 24 control SOLTs and 24 control BOLTs. On unadjusted analysis, control SOLT, control BOLT, and staged BOLT recipients had comparable 5 year overall survival (p=0.29, Figure), graft survival (p=0.4), and incidences of CLAD (43.5%, 45.8%, 30.8%). At our institution, staged BOLT recipients exhibited long-term outcomes comparable to conventional SOLT and BOLT recipients with similar baseline characteristics. This novel approach may provide an additional long-term survival benefit for a small subset of patients who would have otherwise undergone an isolated SOLT.