Incidence, Outcomes and Predictors of Early Postoperative Vasoplegia in Lung Transplantation: Experience from a 6-Year Period

Abstract

<h3>Purpose</h3> Postoperative complications contribute to graft dysfunction, non-pulmonary morbidity, increased mortality and a ripple effect on long-term outcomes. We hypothesized vasoplegia plays a central role in postoperative adverse events and development of multiple organ dysfunction. <h3>Methods</h3> Perioperative data of 279 lung transplant (LTx) recipients operated between 2015-2020 was retrospectively curated by our institutional Informatics Team using a Clinical Data Warehouse. Vasoplegia was defined according to Tsiouris et al., and acute kidney injury (AKI) to KDIGO criteria. <h3>Results</h3> Vasoplegia affected 116 (41.6%) patients with 36 (31.0%) having mild, 64 (55.2%) moderate, and 16 (13.8%) severe vasoplegia. Vasoplegia was associated with higher incidence of any AKI (78.5% vs 65%, <i>p</i> 0.015) and vasoplegic patients were more likely to develop AKI stage III (52.6%) when compared to AKI stage I (16.4%, <i>p</i> 0.036) or no AKI (21.5%, <i>p</i> < 0.001). The need for renal replacement therapy doubled (47.4% vs 24.5%, <i>p</i> < 0.001) in the vasoplegic group. Vasoplegic patients had higher incidence of delayed chest closure (18.4% vs 9.2%, <i>p</i> 0.025), needed longer ventilation duration (70 [32-368] vs 34 [19-105] hours, <i>p</i> < 0.001) and increased ICU length of stay (12.9 [5-30] vs 6.8 [3-20] days, <i>p</i> < 0.001). Their 30-day mortality was 11.2% compared to 5.5% in patients with no vasoplegia (<i>p</i> 0.082). One-year mortality was also increased (20.7% vs 11.7%, <i>p</i> 0.039) and severe vasoplegia represented a hazard (HR 2.60, 95% CI 1.14-5.94, <i>p</i> 0.023) for long-term survival (<i>p</i> 0.037). Vasoplegic patients showed increased inflammatory markers at 72 hours, including white blood cells (<i>p</i> 0.037), neutrophils (<i>p</i> 0.042) and C-reactive protein (CRP, <i>p</i> 0.010). Multivariate regression analysis identified preoperative bilirubin as a predictor of vasoplegia (<i>p</i> 0.008). Underlying infectious lung disease (<i>p</i> 0.041), preoperative pulmonary artery systolic pressure (<i>p</i> 0.036), pre-LTx glomerular filtration rate (<i>p</i> 0.035) and CRP (<i>p</i> 0.040) were identified as predictors of vasoplegia severity. <h3>Conclusion</h3> Vasoplegia is a common and critical condition after LTx in its entire spectrum. It has a tremendous impact on perioperative and longer-term clinical outcomes. Preoperative status as well as procedural factors and inflammatory response are major determinants of vasoplegia.