Mean Lung Allocation Score Research Articles

Outcomes of single-lung retransplantation after double-lung transplantation

ObjectiveTo compare outcomes of single-lung retransplantation (SLRTx) and double-lung retransplantation (DLRTx) after an initial double-lung transplantation. MethodsThe Organ Procurement and Transplantation Network/United Network for Organ Sharing database between May 2005 and December 2022 was retrospectively analyzed. Multiorgan transplantations, repeated retransplantations, and lung retransplantations when the status of the initial transplantation was unknown were excluded. ResultsA total of 891 patients were included in the analysis, included 698 (78.3%) with DLRTx and 193 (21.7%) with SLRTx. The mean lung allocation score was higher in the DLRTx group (59.6 ± 20.7 vs 55.1 ± 19.3; P = .007). The use of extracorporeal membrane oxygenation (ECMO) bridge to lung transplantation was similar in the 2 groups (P = .125), as was waitlist time (P = .610). The need for mechanical ventilation (54.6% vs 35.8%; P = .005) and ECMO (17.9% vs 9.0%; P = .069) at 72 hours post-transplantation was greater in the DLRTx group. However, median post-transplantation hospital stay (21.5 [interquartile range (IQR), 12-35] days versus 20 [IQR, 12-35] days; P = .119) and in-hospital mortality (10.9% [n = 76/698] vs 12.4% [n = 24/193]; P = .547) were comparable in the 2 groups. Long-term survival was significantly better in the DLRTx group (P < .001, log-rank test). In the propensity score–weighted multivariable model, the DLRTx group had 28% lower risk of mortality at any point during follow-up compared to the SLRTx group (hazard ratio, 0.72; 95% confidence interval, 0.57-0.91; P = .006). ConclusionsThe less invasiveness of single-lung transplantation in the retransplantation setting has minimal short-term benefit and is associated with significantly worse long-term survival. Double-lung retransplantation should remain the standard for lung retransplantation after initial double-lung transplantation.

Lung Transplantation for COVID-19-related Lung Disease: Clinical Experience and Call for a Global Registry.

Lung Transplantation for COVID-19-related Lung Disease: Clinical Experience and Call for a Global Registry.

Worsening in the Lung Transplant-Valued Life Activities Scale is Associated with Mortality in Lung Transplant Recipients

<h3>Purpose</h3> The Lung Transplant-Valued Life Activities (LT-VLA) scale is a patient-reported outcome measure of physical functioning and disability, validated in lung recipients. We hypothesized that worsening LT-VLA disability would predict reduced survival after lung transplant (LT). <h3>Methods</h3> We analyzed data from participants in Breathe Again, a single-center prospective cohort of adults undergoing lung transplantation from 2010 to 2017. Participants completed the LT-VLA assessment before and at 6-month intervals up to 3 years after transplant. The 15-item LT-VLA can be completed in ≤3 minutes and measures patient-reported ability to complete a spectrum of physical activities that the respondent deems important. Participants rate the level of difficulty in performing each activity on a 4-point scale (0 = no difficulty, 1 = some, 2 = a great deal, 3 = unable to perform). In the LT-VLA score (0-3) higher value represents greater disability, with a 0.3-point change being a clinically important difference. We tested the association between LT-VLA scores over time and mortality by Cox proportional hazard models, modeling LT-VLA as a time-varying predictor adjusted for pre-operative age, gender, race, and diagnosis, as well as allograft function modeled as a time-varying covariate. <h3>Results</h3> Among 238 participants, 45% were female and 72% white, with mean age of 56 (± 12) years, 72% transplanted for pulmonary fibrosis. Mean Lung Allocation Score was 58 ± 22, and 93% of subjects received bilateral LT. A 0.3-point worsening in LT-VLA during any 6-month period up to 3 years after LT was associated with a 10% increased risk of mortality (HR 1.1, 95% confidence interval 1.04 to 1.2, p = 0.001). <h3>Conclusion</h3> Worsening patient-reported disability after transplant was associated with death, independent of lung allograft function. Longitudinal assessment of patient-reported disability, feasible by the brief LT-VLA scale applied remotely, may allow identification of lung recipients who may benefit from interventions to prevent poor outcomes.

The Effect of Post Operative Tracheostomy on Outcomes in Lung Transplant Patients

<h3>Purpose</h3> Tracheostomy (trach) placement after lung transplantation (LTx) may be required in patients with prolonged ventilator dependence. However, little research exists on predictors and outcomes for recipients with post-LTx trachs. We examined baseline data and compared short and intermediate term patient outcomes with and without post-LTx trachs. <h3>Methods</h3> Baseline data, short/long term outcomes from patients s/p LTx performed between 1/1/12 and 6/31/19 who required trach during the index hospitalization were evaluated and compared with the trach-free cohort. <h3>Results</h3> Compared to trach-free patients, the trach cohort patients were younger (51.6±13.6 vs. 56.9±10.8, p=0.034) and had a higher mean lung allocation score (LAS) (66.6±22.8 vs. 55.2±20.7, p=0.014). They were more likely to be inpatient at time of LTx (54.2% vs 32.1%, p=0.035), had a bilateral LTx (60.8% vs 35.9%, p=0.001) and require extracorporeal life support (ECLS) pre- (16.7% vs. 1.9%, p=0.0005) and post-LTx (16.7% vs. 0.6%, p=0.001). Trach cohort patients had longer mechanical ventilation (p=0.0001) and hospital length of stay (HLOS) (p=0.0001). More patients in the trach cohort required acute rehab on discharge (p=0.0016). Although index in-hospital mortality of the trach cohort was higher (16.7% vs 2.5%, p=0.013), there was no difference in 1 year mortality (16.7% vs 8.3%, p=0.229) c/w trach-free cohort. There was significantly reduced long-term survival in trach patients (Fig.1) with limited follow up. <h3>Conclusion</h3> LTx recipients requiring post-op trach appear to be sicker, as evidenced by higher LAS and greater ECLS use pre-LTx. Trach cohort had longer duration of mechanical ventilation, post-op HLOS and discharge to acute rehabilitation. In our study, the need for post-LTx trach was associated with increased short term mortality. Although 1 year post-LTx mortality was similar between the groups, long term survival was worse in trach cohort with larger and longer studies needed.

ASSOCIATION OF DONOR ALLOCATION SEQUENCE WITH OUTCOMES AFTER LUNG TRANSPLANTATION

SESSION TITLE: Transplantation Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: There is limited data regarding the association of donor allocation sequence number with early complications such as primary graft dysfunction (PGD) and survival after lung transplantation (LT). METHODS: We included 152 consecutive patients who underwent LT over a two-year period (11/2014-12/2016; mean age 56.8±13.2 years; M:F 93:59). The data regarding the allocation characteristics as well as graft survival were obtained directly from the United Network for Organ Sharing (UNOS) database. This data was merged with the institutional recipient database. Recipient data included baseline characteristics, peri-operative and post-operative course, complications and hospital outcomes. Primary graft dysfunction was analyzed as the primary outcome variable whereas the hospital length of stay and survival at one, and three-year post transplant were secondary outcome variables. RESULTS: The most common diagnostic group was restrictive lung diseases (n=81, 52.2%) with a mean lung allocation score (LAS) of 44.8±15 and majority underwent bilateral LT (n=98). The median allocation sequence was 4.5 for the study group (IQR 2-13). The study group was divided into patients who were transplanted at sequence #1 (n=29) vs those transplanted with organs accepted at lower allocation sequence. Patients with higher mean LAS (56.4±19.5 vs 42.1±12.4, p<0.001), restrictive disorders as the transplant indication (72% vs 48.7%, p=0.03), hospitalized at the time of LT (28% vs 9%, p=0.06) and bridged to LT using ECMO (21% vs 3%, p=0.001) were significantly more likely to be transplanted at sequence #1. Despite being sicker, recipients of allocation sequence #1 had significantly lower incidence of PGD 2 or 3 at 0 hours (24%, vs 61%, p<0.001; mean PF ratio: 357±81 vs 273±107, p<0.001) and 72 hours (14% vs 28%, p=0.15 mean PF ratio: 303±147 vs 198±167, p=0.002). Although, the recipients of allocation at sequence #1 experienced equivalent hospital survival, their survival trended lower at one-year and three-year follow up (p=NS). CONCLUSIONS: While patients transplanted at allocation sequence #1 tend to be sicker, they have better oxygenation during the first 72 hours after LT and lower risk of PGD. Nonetheless, a higher donor allocation sequence is not associated with superior one-year or three-year survival. CLINICAL IMPLICATIONS: By virtue of being prioritized for LT, sicker recipients may be transplanted with better quality donor lungs. While this allocation strategy may be successful in reducing early complications, it fails to improve post-LT survival. DISCLOSURES: My spouse/partner as a Employee relationship with Abbott Labs Please note: $20001 - $100000 Added 06/05/2020 by Amit Banga, source=Web Response, value=Salary No relevant relationships by SRINIVAS Bollineni, source=Web Response No relevant relationships by John Joerns, source=Web Response No relevant relationships by Vaidehi Kaza, source=Web Response No relevant relationships by Adrian Lawrence, source=Admin input No relevant relationships by Manish Mohanka, source=Web Response No relevant relationships by John Murala, source=Web Response No relevant relationships by Matthias Peltz, source=Web Response No relevant relationships by Lauren Shaffer, source=Web Response No relevant relationships by Fernando Torres, source=Web Response No relevant relationships by Michael Wait, source=Web Response

Low Lung Allocation Score Predicts Poor Waitlist Outcomes for Patients on Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplantation

Extracorporeal membrane oxygenation (ECMO) is increasingly used as a bridge to lung transplantation in the United States. However, ECMO is not separately distinguished from assisted ventilation in the lung allocation score (LAS), and there is a wide range in LAS for candidates on ECMO. In this study, we examined the relationship between LAS and waitlist outcomes in patients on ECMO. This is a retrospective cohort study of lung transplant candidates on ECMO from 5/4/05 until 12/31/18 using data from the United Network for Organ Sharing. We modeled LAS as a continuous variable and as high LAS (top 50% of scores) versus low LAS (bottom 50% of scores). The LAS used was the first one calculated within two days of ECMO initiation. The primary outcomes were transplantation and a composite of death or removal from the waitlist for clinical deterioration. The secondary outcome was post-transplant survival. We used an adjusted competing risk regression model to compare waitlist outcomes and an adjusted Cox regression model to examine post-transplant survival. In total, 954 patients were bridged on ECMO with 594 (62.2%) receiving transplants and 329 (34.4%) dying or being removed from the waitlist. The mean LAS in the low and high LAS cohorts were 78.2 (SD ± 15.6) and 90.7 (SD ± 1.36), respectively. The low LAS cohort had decreased chance of transplant (SHR 0.80, 95% CI 0.67-0.96, p=0.02) and increased risk of death or waitlist removal (SHR 1.34, 95% CI 1.05-1.70, p=0.02) (Figure 1). For every 10 point increase in LAS, the risk of transplant increased by 14% (p<0.01) and the risk of death decreased by 11% (p=0.02). There was no difference in post-transplant survival time between the low and high LAS cohorts (HR 0.82, 95% CI 0.60-1.12, p=0.21). Among patients on ECMO as bridge to transplant, a lower LAS was associated with decreased risk of transplant and increased risk of death or clinical worsening without any difference in post-transplant survival.

Lung Volume Reduction Surgery Prior to Lung Transplantation: A Propensity-Matched Analysis

Lung volume reduction surgery (LVRS) is a therapeutic option in the treatment of chronic obstructive pulmonary disease (COPD), the most common indication for lung transplantation (LTx). LVRS prior to LTx is controversial. Single institution studies report contradicting results, and the impact of undergoing LVRS prior to LTx on outcomes after LTx is unclear. We performed a propensity-matched analysis of outcomes after LTx in patients who underwent LVRS using a national database of LTx. We reviewed the Scientific Registry of Transplant Recipients for all adults (age>18) who underwent first-time LTx for COPD in the Lung Allocation Score (LAS) era. We used patient demographics and LAS to match patients who did and did not undergo LVRS. The primary exposure was prior LVRS. We used multivariate logistic regression modeling to evaluate the primary outcome, one-year mortality, and secondary outcomes, chronic rejection by one year requiring treatment and prolonged ventilation (>5 days). Long-term survival was compared using Kaplan Meier testing. A total of 5,061 patients underwent LTx between January 2005 and March 2017. The average patient age at transplant was 60.7±6.0 years, and 2,591 (51.2%) patients were male. The mean LAS at transplant was 34.9±6.1. A total of 111 (2.2%) patients underwent LVRS prior to LTx. Propensity matching generated 111 matches. Multivariate logistic regression modeling in this group revealed a 16% increased risk of mortality at one year among patients who underwent LVRS prior to LTx (OR: 1.16, 95% CI: 1.01-1.32, p=0.03). There was no statistically significant difference in risk of chronic rejection by one year requiring treatment (p=0.5) or prolonged ventilator support (p=0.5) among the two groups. The Kaplan Meier survival analysis demonstrated a significant survival deficit between patients who received LVRS and those who did not at five years post-transplant (52.3% vs. 66.3% p=0.01). In this national, propensity matched analysis of LVRS prior to LTx, we show that LVRS is associated with a significantly increased risk of mortality. Patients who undergo LVRS and remain in need of LTx should be carefully assessed and followed post-operatively. Further studies are necessary to identify why these patients may be at increased risk of adverse outcomes after LTx.

A Novel Diagnostic Algorithm for Heparin-Induced Thrombocytopenia in a Retrospective Cohort of Lung Transplant Recipients.

Heparin-induced thrombocytopenia (HIT) is characterized by thrombocytopenia and potential for thromboembolism. Lung transplant recipients are at risk of developing HIT due to heparin exposure peritransplant. We describe the incidence and impact of HIT in lung transplant recipient index hospital length of stay and survival. A retrospective cohort was obtained from electronic medical records which were queried for all recipients treated with bivalirudin (institutional treatment of choice for HIT) between January 1, 2005, and February 16, 2017 (N = 1171). Patients who developed HIT >30 days after transplant or after their index transplant admission were excluded. A diagnostic algorithm was used retrospectively to determine clinical HIT with an intermediate or high pretest clinical suspicion ("4T" score ≥4) and either (1) positive anti-heparin-platelet-factor 4 (HPF4) assay and a positive functional platelet assay or (2) a positive HPF4 assay only, in patients who did not undergo cardiopulmonary bypass. Among all lung transplant recipients, 2.1% were found to develop HIT in the peritransplant period (N = 25, mean = 88%) with a mean lung allocation score of 50.8 and an incidence of venous thromboembolism of 72%, most upper extremity in location. When matched with historical controls, patients with HIT had a longer overall index hospital length of stay of 43 days (P = .008). There was no difference in short- or long-term survival posttransplant. Vigilance for the development of HIT in lung transplant recipients is necessary to prevent further morbidity from thromboembolic events. In our cohort, HIT increased hospital length of stay but did not appear to affect recipient survival.

Extracorporeal Membrane Oxygenation for Primary Graft Dysfunction after Lung Transplantation

Purpose Primary graft dysfunction (PGD) is the leading course of early death after lung transplantation. Extracorporeal membrane oxygenation (ECMO) was used as the last resort for PGD. The aim of this study is to explore the outcome and predictor for in-house mortality in post-lung transplant patients who required ECMO for PGD. Methods Between January 2006 and December 2015, 1049 cases of lung transplantation were performed at our center. Ninety-six patients (9.15 %) required ECMO support after lung transplantation. And 52 patients (4.96 %) required ECMO support for PGD. We retrospectively collected patient demographics and survival outcome of these patients. Results The mean age was 61.9 years ± 14.9 years. The mean lung allocation score was 49.5 ± 18.3. Seven patients (13.5 %) required veno-arterial ECMO due to concomitant hemodynamical instability. The patients were on ECMO for 5.00 ± 10.6 days. Forty-four patients (84.6 %) were successfully decannulated. There were 23 in-house mortalities. The 90-day, 1-year and 5-year survival of patients who required ECMO after lung transplantation were 67.3 %, 50.0 %, and 31.5 %, respectively. There is no significant difference on survival outcome when compared to the patient group required ECMO post-transplant due to the other causes. Univariate and multivariate analysis indicated that when the patient was placed on ECMO within 48 hours after transplantation, the patient was more likely to prevent in-house mortality regardless of patients’ preoperative conditions or duration of ECMO support. Conclusion Earlier recognition of PGD and initiation of ECMO may be beneficial in this population.

Utilization and Cost Analysis of Lung Transplantation and Survival After 10 Years of Adapting the Lung Allocation Score.

Lungs are allocated in the United States using the lung allocation score (LAS). We investigated the effect of LAS trends on lung transplant-related costs, healthcare utilization, and mortality. Utilization data from Mayo Clinic (Florida and Minnesota) from 2005 to 2015 were obtained from the electronic health records (N = 465). Costs were categorized as 1-year posttransplant or transplant episode and standardized using 2015 Medicare reimbursement and cost-to-charge ratios. Regression analysis was used to assess the relationship of LAS to length of stay (LOS), mortality, and cost of transplant. The mean LAS at transplant increased from 45.7 to 58.3 during the study period, whereas the 1-year survival improved from 88.1% to 92.5% (P < 0.0001). The proportion of patients transplanted with LAS of 60 or greater increased from 16.9% to 33.3%. Posttransplant, overall, and intensive care unit LOS increased with increasing LAS. Patients with higher LAS had substantially higher transplant episode costs. An increase of LAS at transplant by 10 points increased inflation-adjusted costs by 12.0% (95% confidence interval, 9.3%-14.5%). The mean LAS at transplant has significantly increased over time associated with increases in LOS, resource utilization and cost. Lung allocation score has not jeopardized overall survival, but a high LAS (>60) at transplant is associated with increased mortality.

Epidemiology of Clostridium difficile Infection in the Lung Transplant Population at a High Volume Transplant Center

Introduction:Clostridium difficile infection (CDI) is a leading cause of health care-associated infections in the United States. Significant risk factors for CDI include antibiotic and hospital exposure. Immunosuppression increases susceptibility to CDI. In the lung transplant (LTx) population, incidence of CDI ranges from 6-22.5%. We aim to provide an update on epidemiology of post-operative CDI in the LTx population in a high-volume lung transplant center. Methods: Adult patients who received a LTx at our institution from January 2014-January 2018 were identified and charts were reviewed for a positive PCR assay for CDI (CDI+) after LTx. We also collected relevant demographic and treatment data to make comparisons between the CDI+ and non-CDI (CDI-) populations. Statistics, including t-tests, chi-square and logistic regression were performed with SPSS v25.0. Results: A total of 376 patients underwent LTx during the study period. The overall incidence of CDI post-LTx was 6.4% (24/376 patients). Post-LTx CDI- and CDI+ patients were similar in terms of gender (67% vs 54% male, p=0.20), mean age at time of transplant (64 vs 61 years, p=0.18), race (76% vs 79% Caucasian, p=0.40) and mean Lung Allocation Score (LAS) (50 vs 52, p=0.77). Indication for transplant was significantly different between groups (p=<0.001), namely because there were no CDI+ patients with primary pulmonary hypertension. Of the 24 CDI+ patients, 11 had incident CDI on the same admission as LTx (average time post-LTx: 31 days) and 13 had infection at a subsequent admission (average time post-LTx: 303 days). Seventeen patients had 1 episode of CDI, four patients had 1 recurrence, and 3 patients had multiple recurrences. Most patients (96%) received peri-operative antibiotics for longer than 3 days after transplant. In terms of disease severity, 71% had mild-moderate CDI, 16.5% had severe CDI, and 12.5% had severe/complicated CDI. There were no deaths from CDI. In a logistic regression model, no available risk factor predicted the development of CDI. Conclusion: In our large LTx cohort, the incidence of CDI post-LTx was low compared to other studies. There were no obvious predictors for development of CDI in this population. Interestingly, age at time of LTx and LAS were similar in both groups. Further studies are warranted to further examine the effect of CDI on the morbidity and mortality of LTx patients.

Tailored Approach to Surgical Exposure Reduces Surgical Site Complications after Bilateral Lung Transplantation.

We evaluated the effects of tailoring the operative approach on major surgical site complications and outcomes in lung transplant recipients. Beginning in July 2013, bilateral lung transplants at a single institution were performed either through sternotomy or clamshell depending on proximity of hilar structures by computed tomography (CT), anticipated complexity, past surgical history, and surgeon experience. Patient demographics and outcomes were collected in the institution's Transplant Information Services (TIS). A major surgical site complication was defined as a sterile or infected incision requiring operative intervention. One hundred six bilateral lung transplants (68 via clamshell and 38 via median sternotomy) were performed between July 2013 and June 2016. Median sternotomy patients were older (mean age 55 vs. 50 y, p = 0.04), and less likely to have cystic fibrosis (5 [13%] vs. 19 [28%], p = 0.21) or diabetes (5 [13%] vs. 26 [38%], p = 0.01). There was no statistically significant difference in mean lung allocation score (LAS) (45 vs. 48, p = 0.39) and body mass index (BMI; kg/m2; 25.3 vs. 24.4, p = 0.29) between the sternotomy and clamshell group. Fifteen (14.2%) patients experienced a total of 25 surgical site complications (19 major and 6 minor). No sternotomy patient had a major surgical site complication and 11 (16.2%) clamshell patients had a major surgical site complication (p = 0.01). Of these 11 patients, 5 (45%) required multiple operative revisions related to the surgical site. Freedom from major surgical site complications at three years was 100% for sternotomy patients and 80% for clamshell patients (p = 0.017). Tailoring the operative approach can reduce surgical site complications in lung transplant patients by avoiding a clamshell whenever feasible.

Frailty and maximal exercise capacity in adult lung transplant candidates.

Frail lung transplant candidates are more likely to be delisted or die without receiving a transplant. Further knowledge of what frailty represents in this population will assist in developing interventions to prevent frailty from developing. We set out to determine whether frail lung transplant candidates have reduced exercise capacity independent of disease severity and diagnosis. Sixty-eight adult lung transplant candidates underwent cardiopulmonary exercise testing (CPET) and a frailty assessment (Fried's Frailty Phenotype (FFP)). Primary outcomes were peak workload and peak aerobic capacity (V˙O2). We used linear regression to adjust for age, gender, diagnosis, and lung allocation score (LAS). The mean±SD age was 57±11 years, 51% were women, 57% had interstitial lung disease, 32% had chronic obstructive pulmonary disease, 11% had cystic fibrosis, and the mean LAS was 40.2 (range 19.2-94.5). In adjusted models, peak workload decreased by 10W (95% CI 4.7 to 14.6) and peak V˙O2 decreased by 1.8mL/kg/min (95% CI 0.6 to 2.9) per 1 unit increment in FFP score. After adjustment, exercise tolerance was 38W lower (95% CI 18.4 to 58.1) and peak V˙O2 was 8.5mL/kg/min lower (95% CI 3.3 to 13.7) among frail participants compared to non-frail participants. Frailty accounted for 16% of the variance (R2) of watts and 19% of the variance of V˙O2 in adjusted models. Frailty contributes to reduced exercise capacity among lung transplant candidates independent of disease severity.

Lung Transplant Mortality Is Improving in Recipients With a Lung Allocation Score in the Upper Quartile

Since the introduction of the Lung Allocation Score (LAS), the mean LAS has risen. Still, it remains uncertain whether mortality has improved in the most severely ill lung transplant recipients over this time period. Using the United Network for Organ Sharing database, we identified 3,548 adult lung transplant recipients from May 4, 2005, to March 31, 2014, with a match-time LAS in the upper quartile (>75th%ile). We divided this population across three eras: 1= May 4, 2005, to December 31, 2008 (n= 1,280); 2= January 1, 2009, to December 31, 2011 (n= 1,266); and 3= January 1, 2012, to March 31, 2014 (n= 1,002). Cox proportional hazards models were constructed for the primary outcomes of 30-day and 1-year mortality to assess the independent impact of the era of transplantation. The mean LAS at time of transplant for patients in the upper quartile in eras 1, 2, and 3 was 63, 73, and 79, respectively (p < 0.001). Later eras of transplantation benefited from a significant improvement in survival at 1 year (log-rank p= 0.001) but not at 30 days (log-rank p= 0.152). After risk adjustment, lung transplantation in more recent eras was associated with improved mortality at both 30 days (era 3 hazard ratio [HR]= 0.50, 95% confidence interval [CI] 0.32% to 0.78%, p= 0.002) and 1 year (era 2 HR= 0.77, 95% CI 0.64% to 0.94%, p= 0.008; era 3 HR= 0.54, 95% CI 0.43% to 0.68%, p < 0.001). Despite a progressively rising LAS, survival is improving among recipients with the highest LAS at the time of lung transplantation. This calls into question the notion of a maximum LAS beyond which lung transplantation becomes futile, a so-called LAS ceiling.

Distribution of donor lungs in the United States: a case for broader geographic sharing.

To evaluate the association between allocation of donor lungs by geographic sharing type (GST) and lung allocation score (LAS). UNOS data included lung transplant recipients between 5/4/05 and 09/30/15 (n = 17 416) grouped by GST of donor lungs: local, regional, or national. Recipients were stratified by LAS <50, 50-75, and >75. Kaplan-Meier analysis was used to assess five-yr survival. The majority of lungs were shared locally (n = 9200; 52.8%) followed by nationally (n = 5356; 30.8%) and regionally (n = 2860; 16.4%). There was a significant difference in the mean LAS at transplant (local: 43.7 ± 15; regional: 49.5 ± 18.8; national 51 ± 19.4; p < 0.001). There was a significant association between GST and LAS (p < 0.001). The majority (n = 7431; 58.2%) of recipients with LAS <50 received local lungs. Recipients with LAS >75 received a majority of their organs from national (n = 881; 45.4%) and regional (n = 414; 21.6%) donors. Although statistically significant (p = 0.024), absolute decline in five-yr survival by GST in the national GST was only 1.1% compared to the local GST. Nearly half of all lungs in the United States are allocated locally to recipients with an LAS <50. Additional studies should determine if organ sharing over broader geographies would improve waitlist outcomes.

Combined Lung-Kidney Transplantation: An Analysis of the UNOS/OPTN Database

Poor outcomes after thoracic transplantation with concurrent renal dysfunction are well described: without transplantation or with thoracic-only transplantation, patients face unacceptably high mortality. Outcomes after combined lung-kidney transplantation (LKT) remain largely uninvestigated. The United Network for Organ Sharing/Organ Procurement and Transplantation Network database was queried to identify all LKTs, lung transplantations (LTs), and kidney transplantations (KTs) performed in the United States from 1995 to 2013. Survival was calculated using the Kaplan-Meier method and compared using log-rank tests or Cox regression models. Thirty-one LKTs were performed. Mean recipient age was 45.4 ± 13.5 years; 48.3 per cent were male. Retransplantation for graft failure was the leading indication for LT (n = 13) and the most common renal indication was calcineurin inhibitor nephrotoxicity (n = 11). Mean lung allocation score was 46.6 ± 14.4, mean creatinine was 3.7 ± 2.8 g/dL, and glomerular filtration rate was 23.1 (interquartile range 11.9, 38.3) mL/min/1.7 m(2), and 11 (35.5%) were dialysis dependent. Patient survival after LKT was 92.9 per cent, 71.0 per cent, and 71.0 per cent at one month, six months, and one year, with a median survival of 95.2 months. One- and five-year survival after LKT, 71.0 per cent and 59.9 per cent, were similar to LT (n = 23,913), 81.7 per cent and 51.4 per cent (P = 0.061 and 0.55), and inferior to KT (n = 175,269), 94.9 per cent and 82.8 per cent (P < 0.0001), respectively. Patient survival after LKT was similar to isolated LT, and these results suggest that LKT is a feasible therapeutic option for LT candidates with significant renal dysfunction.

(670) - Assessment of Human Lungs Recovered From Uncontrolled Donation After Circulatory Determination of Death (uDCDD) Donors By Ex-Vivo Lung Perfusion (EVLP) and CT Scan

s S247 Methods: The UNOS/OPTN database was queried to identify all LKT, LT, and KT performed in the U.S. from 1995-2013. Survival was calculated using the Kaplan-Meier method & compared using log-rank tests or Cox regression models. Results: Thirty-one LKT, including 3 heart-lung-kidney transplants, were performed. Median follow-up was 14.46 months (19 days 8.51 years). The mean age of LKT recipients was 44.8 ± 13.1 years & 48% were male. Redo lung transplant for graft failure was the leading indication for LT (n= 13), followed by cystic fibrosis (n= 4). The most common renal indication was calcineurin inhibitor nephrotoxicity (n= 11). Mean lung allocation score (LAS) was 46.6 ± 14.4. No patient required extracorporeal membrane oxygenation. Mean creatinine was 3.7 ± 2.8 mg/dL, MDRD estimated GFR was 26.1 ± 17.6 mL/min/1.73m2, & 11 patients were dialysis-dependent. Ischemic time for lung & kidney grafts was 4.6 ± 1.7 & 12.6 ± 8.1 hours. Patient survival after LKT was 93%, 71%, & 71% at 1 month, 6 months, & 1 year with median survival 95.2 months. Relative to single-organ transplant, 1 & 5 year survival after LKT, 71% & 60%, were similar to LT (n= 23,913), 82% & 51% (p = 0.061 & 0.55), & inferior to KT (n= 175,269), 95% & 83% (p < 0.0001). Outcomes improved in the LAS era: 1 & 5 year survival for LKT (n= 23) were 78% & 72% & remained similar to LT (n= 12,755), 84% & 53% (p = 0.30 & 0.88). Redo status did not increase mortality after LKT at 1 (HR 1.05, 95% CI [0.28, 3.93] & 4 years (HR 1.18 [0.36, 3.88]), in contrast to significantly increased mortality after LT: HR 1.89 [1.68, 2.14] & HR 1.75 [1.60,1.92]. Conclusion: This is the first study to describe outcomes after lung-kidney transplantation. Patient survival following lung-kidney transplant is similar to lung-only transplant & is an acceptable option for lung-transplant candidates with significant renal dysfunction.

(667) - Frailty Is Associated With Increased Mortality and Hospitalization in COPD

s S247 Methods: The UNOS/OPTN database was queried to identify all LKT, LT, and KT performed in the U.S. from 1995-2013. Survival was calculated using the Kaplan-Meier method & compared using log-rank tests or Cox regression models. Results: Thirty-one LKT, including 3 heart-lung-kidney transplants, were performed. Median follow-up was 14.46 months (19 days 8.51 years). The mean age of LKT recipients was 44.8 ± 13.1 years & 48% were male. Redo lung transplant for graft failure was the leading indication for LT (n= 13), followed by cystic fibrosis (n= 4). The most common renal indication was calcineurin inhibitor nephrotoxicity (n= 11). Mean lung allocation score (LAS) was 46.6 ± 14.4. No patient required extracorporeal membrane oxygenation. Mean creatinine was 3.7 ± 2.8 mg/dL, MDRD estimated GFR was 26.1 ± 17.6 mL/min/1.73m2, & 11 patients were dialysis-dependent. Ischemic time for lung & kidney grafts was 4.6 ± 1.7 & 12.6 ± 8.1 hours. Patient survival after LKT was 93%, 71%, & 71% at 1 month, 6 months, & 1 year with median survival 95.2 months. Relative to single-organ transplant, 1 & 5 year survival after LKT, 71% & 60%, were similar to LT (n= 23,913), 82% & 51% (p = 0.061 & 0.55), & inferior to KT (n= 175,269), 95% & 83% (p < 0.0001). Outcomes improved in the LAS era: 1 & 5 year survival for LKT (n= 23) were 78% & 72% & remained similar to LT (n= 12,755), 84% & 53% (p = 0.30 & 0.88). Redo status did not increase mortality after LKT at 1 (HR 1.05, 95% CI [0.28, 3.93] & 4 years (HR 1.18 [0.36, 3.88]), in contrast to significantly increased mortality after LT: HR 1.89 [1.68, 2.14] & HR 1.75 [1.60,1.92]. Conclusion: This is the first study to describe outcomes after lung-kidney transplantation. Patient survival following lung-kidney transplant is similar to lung-only transplant & is an acceptable option for lung-transplant candidates with significant renal dysfunction.

(668) - 100 Lung Transplants Delivered in Ireland

s S247 Methods: The UNOS/OPTN database was queried to identify all LKT, LT, and KT performed in the U.S. from 1995-2013. Survival was calculated using the Kaplan-Meier method & compared using log-rank tests or Cox regression models. Results: Thirty-one LKT, including 3 heart-lung-kidney transplants, were performed. Median follow-up was 14.46 months (19 days 8.51 years). The mean age of LKT recipients was 44.8 ± 13.1 years & 48% were male. Redo lung transplant for graft failure was the leading indication for LT (n= 13), followed by cystic fibrosis (n= 4). The most common renal indication was calcineurin inhibitor nephrotoxicity (n= 11). Mean lung allocation score (LAS) was 46.6 ± 14.4. No patient required extracorporeal membrane oxygenation. Mean creatinine was 3.7 ± 2.8 mg/dL, MDRD estimated GFR was 26.1 ± 17.6 mL/min/1.73m2, & 11 patients were dialysis-dependent. Ischemic time for lung & kidney grafts was 4.6 ± 1.7 & 12.6 ± 8.1 hours. Patient survival after LKT was 93%, 71%, & 71% at 1 month, 6 months, & 1 year with median survival 95.2 months. Relative to single-organ transplant, 1 & 5 year survival after LKT, 71% & 60%, were similar to LT (n= 23,913), 82% & 51% (p = 0.061 & 0.55), & inferior to KT (n= 175,269), 95% & 83% (p < 0.0001). Outcomes improved in the LAS era: 1 & 5 year survival for LKT (n= 23) were 78% & 72% & remained similar to LT (n= 12,755), 84% & 53% (p = 0.30 & 0.88). Redo status did not increase mortality after LKT at 1 (HR 1.05, 95% CI [0.28, 3.93] & 4 years (HR 1.18 [0.36, 3.88]), in contrast to significantly increased mortality after LT: HR 1.89 [1.68, 2.14] & HR 1.75 [1.60,1.92]. Conclusion: This is the first study to describe outcomes after lung-kidney transplantation. Patient survival following lung-kidney transplant is similar to lung-only transplant & is an acceptable option for lung-transplant candidates with significant renal dysfunction.

Impact of pulmonary hypertension on survival in patients with cystic fibrosis undergoing lung transplantation: An analysis of the UNOS registry

BackgroundPulmonary hypertension (PH) is a comorbidity reported in patients with cystic fibrosis (CF) with research limited to single-center studies. MethodsTo assess the impact of PH in patients with CF who received a lung transplant (LTx), the United Network for Organ Sharing was queried from 1987 to 2012, restricting analysis to transplant patients 6–55years old between 1/1/2005 and 7/6/2011. ResultsOf 23,951 lung transplants, 1177 met inclusion criteria with 831 having mean pulmonary artery pressure (mPAP) data available. For the entire cohort, mean age was 30.3 (SD=9.2, range 12–55), and mean mPAP was 26.5 (SD=7.8, range 5–66) mmHg. A total of 470 (57%) had PH defined as mPAP≥25mmHg. Comparing PH to non-PH groups, mean forced expiratory volume in one second (FEV1) was 24.4 (SD=13.8) vs. 26 (SD=13.9) % of predicted, mean supplemental oxygen requirement at rest was 4.5 (SD=4.1) vs. 3.7 (SD=3.0) liters per minute, and mean lung allocation score was 49 (SD=16) vs. 43 (SD=12), respectively. For the PH group, median survival was 84.4months compared to 67.1months for the non-PH group (log-rank p-value=0.326). The adjusted hazard ratio for PH vs. non-PH was 0.862 (95% CI: 0.653–1.138; p=0.293), thus indicating no statistically significant effect of PH on survival. ConclusionsA high prevalence of PH was found in CF patients prior to LTx. Based on our models despite PH being prevalent, there is no strong evidence suggesting that it significantly alters the risk of death in CF patients after LTx.