Score Era Research Articles

(357) - The Second Time Around: Re-Evaluating Lung Retransplant Outcomes in the Lung Allocation Score Era

(357) - The Second Time Around: Re-Evaluating Lung Retransplant Outcomes in the Lung Allocation Score Era

Outcomes of Lung Transplant Candidates Aged ≥70 Years During the Lung Allocation Score Era

BackgroundWith the increasing age of lung transplant candidates, we studied waitlist and posttransplantation outcomes of candidates ≥70 years during the Lung Allocation Score era. MethodsAdult lung transplant candidates from 2005 to 2020 in the United Network for Organ Sharing database were included and stratified on the basis of age at listing into 18 to 59 years old, 60 to 69 years old, and ≥70 years old. Baseline characteristics, waitlist outcomes, and posttransplantation outcomes were assessed. ResultsA total of 37,623 candidates were included (52.3% aged 18-59 years, 40.6% aged 60-69 years, 7.1% aged ≥70 years). Candidates ≥70 years were more likely than younger candidates to receive a transplant (81.9% vs 72.7% [aged 60-69 years] vs 61.6% [aged 18-59 years]) and less likely to die or to deteriorate on the waitlist within 1 year (9.1% vs 10.1% [aged 60-69 years] vs 12.2% [aged 18-59 years]; P < .001). Donors for older recipients were more likely to be extended criteria (75.7% vs 70.1% [aged 60-69 years] vs 65.7% [aged 18-59 years]; P < .001). Recipients ≥70 years were found to have lower rates of acute rejection (6.7% vs 7.4% [aged 60-69 years] vs 9.2% [aged 18-59 years]; P < .001) and prolonged intubation (21.7% vs 27.4% [aged 60-69 years] vs 34.5% [aged 18-59 years]; P < .001). Recipients aged ≥70 years had increased 1-year (adjusted hazard ratio [aHR], 1.19 [95% CI, 1.06-1.33]; P < .001), 3-year (aHR, 1.28 [95% CI, 1.18-1.39]; P < .001), and 5-year mortality (aHR, 1.29 [95% CI, 1.21-1.38]; P < .001) compared with recipients aged 60 to 69 years. ConclusionsCandidates ≥70 years had favorable waitlist and perioperative outcomes despite increased use of extended criteria donors. Careful selection of candidates and postoperative surveillance may improve posttransplantation survival in this population.

35. Microsurgical Practice with use of Smart Phone Camera as The Microscopic Field: A Training Protocol for Medical Students

Background: Accessibility to microsurgical equipment is a major barrier to proper training of surgeons prior to live patient free flap surgery. A novel technique is presented that uses a smartphone camera as the microscopic field, eliminating the need for an expensive operative microscope for surgical practice. Practice and repetition are the key components of surgical education. A convenient and cost effective simulation protocol could reduce the time frame of the microsurgery learning curve. Furthermore, the adoption of a microsurgical protocol that does not require access to a surgical microscope increases accessibility to aspiring surgeons and promotes repetition of microsurgical techniques. Methods: The Pocket Suture™ smartphone stand is a commercially available device that allows the smart phone camera to be used as magnification. The proposed education protocol included suture practice, vessel dissection, free tissue transfer in nonliving animal models, with vessel anastomosis and patency confirmation performed with a smartphone camera for field magnification. Video of the suturing technique allowed feedback from the mentor. Results: A progressive suturing protocol leading to the ability to perform microsurgical anastomosis on non living animal models was developed. The basic costs for the stand, instrument set and suture were less than $500. Conclusion: This protocol allows medical students interested in plastic surgery early exposure to advanced technical challenges that may solidify their specialty choice. The low cost eliminates many barriers to early microsurgery training. The protocol may also provide program directors another data point for resident recruitment in the post USMLE step one score era.

Comparative Analyses of Donor-Recipient Age Differences in Adult Cardiothoracic Transplantation: An Analysis of the UNOS/OPTN Database

<h3>Purpose</h3> Broad trends towards increased thoracic organ transplantation in older recipients are well-described. Additionally, usage of older donor organs is well-accepted by many programs. However, little is known about comparative recipient and donor age demographics, and how these may vary with time. <h3>Methods</h3> Using UNOS/OPTN STAR database for both isolated heart (iHTx) and lung transplantation (iLTx) in adults (1988-2017), annual composition of donor organ pool, recipient waitlist pool, and transplanted patient pool, were characterized with respect to age. The 30-day and 1-year recipient survival outcomes are reported. <h3>Results</h3> For iHTx, temporal trends of increased transplantation of older recipients were observed; increased percentages of recipients aged 60-69 and >70 were identified, with decreases in recipients aged 50-59 and 40-49. These trends were identified in iLTx as well, and were more substantial. In both iHTx and iLTx, by 2017, recipients aged 60-69 accounted for the single largest age range undergoing transplantation. However, analysis of survival outcomes from 2010-17 for iHTx (durable continuous flow mechanical circulatory support era), and from 2006-17 for iLTx (lung allocation score era) revealed reduced 30-day and 1-year survival as a function of recipient age, with exception of iLTx in the age 18-29 group. In contrast, no clear temporal trends were observed with respect to donor heart and lung age demographics. Heart and lung donors aged 18-29 accounted for the single largest age range, followed by ages 30-39. <h3>Conclusion</h3> Cardiothoracic transplantation involves a transference of organs from younger to older individuals, and the extent of this has increased more recently. However, older recipients have decreased short-term survival, which likely translates to diminished long-term survival, given a decreased prospective life expectancy even for healthy older individuals. These findings may have implications for organ allocation policies.

Lung transplantation for chronic obstructive pulmonary disease: A call to modify the lung allocation score to decrease waitlist mortality

ObjectiveApproximately 40% of lung transplants for chronic obstructive pulmonary disease (COPD) in the lung allocation score era are single lung transplantations (SLTs). We hypothesized that double lung transplantation (DLT) results in superior survival, but that mortality on the waitlist may compel clinicians to perform SLT. We investigated both waitlist mortality in COPD patients with restricted versus unrestricted listing preferences and posttransplant survival in SLT versus DLT to identify key predictors of mortality. MethodsA retrospective analysis of waitlist mortality and posttransplant survival in patients with COPD was conducted using post-lung allocation score data from the United Network for Organ Sharing database between 2005 and 2018. ResultsOf 6740 patients with COPD on the waitlist, 328 (4.87%) died and 320 (4.75%) were removed due to clinical deterioration. Median survival on the waitlist was significantly worse in patients listed as restricted for DLT (4.39 vs 6.09 years; P = .002) compared with patients listed as unrestricted (hazard ratio, 1.34; 95% CI, 1.13-1.57). Factors that increase waitlist mortality include female sex, increased pulmonary artery pressure, and increased wait time. Median posttransplant survival was 5.3 years in SLT versus 6.5 years in DLT (P < .001). DLT recipients are younger, male patients with a higher lung allocation score. The survival advantage of DLT persisted in adjusted analysis (hazard ratio, 0.819; 95% CI, 0.741-0.905). ConclusionsRestricted listing preference is associated with increased waitlist mortality, but DLT recipients have superior posttransplant survival. Because the lung allocation score does not prioritize COPD, concern for increased waitlist mortality with restricted listing preference may drive continued use of SLT despite better posttransplant survival in DLT.

Non-pulmonarycomplicationsafter lung transplantation: part II.

Lung transplantation (LT) is a viable therapeutic option in the treatment of advanced lung disease. With improvements in post-transplant survival, complications involving different organ systems after LT are increasingly seen. While non-infectious, extrapulmonary complications after LT are not frequently responsible for early post-transplant mortality, they significantly impact the quality of life and long-term survival. These complications are, therefore, becoming increasingly relevant as patients with LT are living longer. These complications encompass almost all organ systems and are driven by a combination of the pre-existing comorbidities, events, and complications around the operative procedure and recovery, and perhaps most importantly, medication side effects of the post-LT regimen. In the first of the two-part review, we covered the general approach to management of extrapulmonary complications and covered specific complications pertaining to cardiovascular, renal, neuropsychiatric, and ophthalmologic organ systems. In the current article, we discuss most relevant complications pertaining to the hematologic, endocrine, and gastrointestinal organ systems. In addition, we discuss two of the most common and consequential complications under the miscellaneous category, namely malignancy and venous thrombo-embolism after LT. These two complications have gained increasing significance in the lung allocation score era where progressively sicker and older patients are being transplanted.

Renal Outcomes After Liver Transplantation in the MELD-Na Score Era in Patients with Pre-Transplant Renal Impairment

Renal Outcomes After Liver Transplantation in the MELD-Na Score Era in Patients with Pre-Transplant Renal Impairment

Lung Transplant Recipients With Prior Coronary Artery Bypass Grafting Are at Increased Risk of Death and Early Perioperative Hemorrhage

Prior coronary artery bypass grafting (CABG) has been considered a relative contraindication to lung transplantation due to the atherosclerotic disease burden and technical challenges. We hypothesized that lung transplant recipients with prior CABG have increased mortality compared to recipients without prior CABG. Further, the causes of death are different for lung transplant recipients with prior CABG vs without CABG. The Scientific Registry of Transplant Recipients database was queried to define the survival and causes of death of lung transplant recipients with or without CABG during the Lung Allocation Score era from May 5, 2005 to December 31, 2015. The primary end-points were all-cause mortality at 1 year and 5 years, as well as mortality due to major causes of death. This retrospective study cohort included a total of 13,064 lung transplant recipients, of whom 319 patients had previously undergone CABG, representing 2.4% of all transplants. Patients without prior CABG were more likely to have undergone bilateral lung transplantation compared to those with prior CABG (61.2 % vs 15.7%, P < 0.001). Among patients with prior CABG, single right lung transplant was most common. Overall patient survival at 1 year was 76.8% for lung transplant recipients with prior CABG and 85.4% for patients without prior CABG. Freedom from death due to graft failure at 1 and 5 years in patients with a prior CABG was 93.1% and 76.2% respectively, cardiac and/or cerebrovascular disease 96.2% and 88.5% respectively, and hemorrhage 97.9% and 97.5% respectively. In a multivariate Cox regression model utilizing time-dependent coefficients for recipient age, prior CABG, among several other risk factors, was associated with increased mortality within 1 year. Prior CABG is associated with short- and long-term mortality in lung transplant recipients with history of CABG despite the majority of these patients undergoing single lung transplantation vs bilateral lung transplantation. Graft failure and/or pulmonary causes are the most common cause of death regardless of whether or not the lung transplant recipient had prior CABG, but patients with prior CABG are at increased risk of death due to graft failure, cardiac or cerebrovascular disease, and hemorrhage.

Preoperative risk score accuracy confirmed in a modern ruptured abdominal aortic aneurysm experience

ObjectiveVarious risk score calculators used to predict 30-day mortality after treatment of ruptured abdominal aortic aneurysms (rAAAs) have produced mixed results regarding their usefulness and reproducibility. We prospectively validated the accuracy of our preoperative scoring system in a modern cohort of patients with rAAAs. MethodsA retrospective review of all patients wiith rAAAs who had presented to a single academic center from January 2002 to December 2018 was performed. The patients were divided into three cohorts according to when the institutional practice changes had occurred: the pre-endovascular aneurysm repair (EVAR) era (January 2002 to July 2007), the pre-Harbor View risk score era (August 2007 to October 2013), and the modern era (November 2013 to December 2018). The primary outcome measure was 30-day mortality. Our preoperative risk score assigns 1 point for each of the following: age >76 years, pH <7.2, creatinine >2 mg/dL, and any episode of hypotension (systolic blood pressure <70 mm Hg). The previously reported mortality from a retrospective analysis of the first two cohorts was 22% for 1 point, 69% for 2 points, 78% for 3 points, and 100% for 4 points. The goal of the present study was to prospectively validate the Harborview scoring system in the modern era. ResultsDuring the 17-year study period, 417 patients with rAAAs were treated at our institution. Of the 118 patients treated in the modern era, 45 (38.1%) had undergone open aneurysm repair (OAR), 61 (51.7%) had undergone EVAR, and 12 (10.2%) had received comfort measures only. Excluding the 12 patients without aneurysm repair, we found a statistically significant linear trend between the preoperative risk score and subsequent 30-day mortality for all patients combined (P < .0001), for OAR patients alone (P = .0003), and for EVAR patients alone (P < .0001). After adjustment for the Harborview risk score, the 30-day mortality was 41.3% vs 31.6% after OAR vs EVAR, respectively (P = .2). For all repairs, the 30-day mortality was 14.6% for a score of 0, 35.7% for a score of 1, 68.4% for a score of 2, and 100% for a score of 3 or 4. ConclusionsOur results, representing one of the largest modern series of rAAAs treated at a single institution, have confirmed the accuracy of a simple 4-point preoperative risk score in predicting 30-day mortality in the modern rAAA patient. Such tools should be used when discussing the treatment options with referring physicians, patients, and their family members to help guide transfer and treatment decision-making.

Lung Volume Reduction Surgery Before Lung Transplantation: A Propensity-Matched Analysis

BackgroundLung volume reduction surgery (LVRS) is treatment option for chronic obstructive pulmonary disease, the second most common indication for lung transplantation (LTx) in the United States. Lung volume reduction surgery before LTx is controversial. Single-institution studies report contradicting results, and the impact of undergoing LVRS before LTx on outcomes after LTx is unclear. MethodsWe reviewed the United Network for Organ Sharing database for all adults (aged more than 18 years) who underwent first-time LTx for chronic obstructive pulmonary disease in the lung allocation score era. We used patient demographic and clinical characteristics and lung allocation score to propensity match patients who did and patients who did not undergo LVRS before LTx. The primary exposure was prior LVRS. The primary outcome was graft failure after LTx. Unadjusted Kaplan-Meier and adjusted Cox proportional hazards models were used to assess outcomes. ResultsA total of 4905 patients with chronic obstructive pulmonary disease underwent LTx between May 2005 and March 2017. Of them, 107 patients (2.2%) underwent LVRS before LTx. Propensity matching generated 212 matches (106 LVRS+LTx, and 106 LTx only). Median survival was significantly longer in the LTx only cohort (6.5 vs 3.4 years, P = .034). Lung volume reduction surgery before lung transplantation was associated with significantly increased risk of graft failure after lung transplant (hazard ratio 1.72; 95% confidence interval, 1.13 to 2.60; P = .01). ConclusionsIn this national, propensity-matched analysis of LVRS before LTx, we show that LVRS is associated with a significantly increased risk of graft failure. Patients who undergo LVRS and remain in need of LTx should be carefully assessed and followed postoperatively.

What Awaits on the Other Side: Post-Lung Transplant Morbidity and Mortality After Pre-Transplant Hospitalization.

BackgroundMorbidity and mortality rates after lung transplantation remain high compared to other solid organ transplants. In the lung allocation score era, patients given the highest priority on the waitlist are those with the greatest severity of illness, who often require preoperative hospitalization.Material/MethodsTo determine the association of pre-transplant hospitalization with post-transplant outcomes, we retrospectively evaluated 448 lung transplant recipients at our center between January 2010 and July 2017 (114 hospitalized; 334 outpatient).ResultsSurvival was similar between the groups (hazard ratio 0.93 [95% CI 0.61 to 1.42], p=0.738). However, hospitalized patients had longer hospital and intensive care unit length of stay compared to outpatients – 25 vs. 18 days, (p<0.001) and 9.5 vs. 6 days, (p<0.001), respectively. Hospitalized patients had higher rates of Grade 3 primary graft dysfunction – 29.8% vs. 9.6%, p<0.001 – and remained mechanically ventilated longer – 6 vs. 3 days, p<0.001. A greater percentage of hospitalized patients needed a tracheostomy and a re-operation within 30 days – 39.5% vs. 15.3% (p<0.001) and 22.8% vs. 12.0% (p=0.005) – respectively. After discharge, 28% of hospitalized patients required acute rehabilitation compared with 12% of outpatients (p=0.001).ConclusionsWhile pre-transplant hospitalization is not associated with mortality, it is associated with significant morbidity after transplant.

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.

Impact of donor lung quality on post-transplant recipient outcome in the Lung Allocation Score era in Eurotransplant - a historical prospective study.

SummaryThe aim of this study was to investigate whether there is an impact of donation rates on the quality of lungs used for transplantation and whether donor lung quality affects post‐transplant outcome in the current Lung Allocation Score era. All consecutive adult LTx performed in Eurotransplant (ET) between January 2012 and December 2016 were included (N = 3053). Donors used for LTx in countries with high donation rate were younger (42% vs. 33% ≤45 years, P < 0.0001), were less often smokers (35% vs. 46%, P < 0.0001), had more often clear chest X‐rays (82% vs. 72%, P < 0.0001), had better donor oxygenation ratios (20% vs. 26% with PaO2/FiO2 ≤ 300 mmHg, P < 0.0001), and had better lung donor score values (LDS; 28% vs. 17% with LDS = 6, P < 0.0001) compared with donors used for LTx in countries with low donation rate. Survival rates for the groups LDS = 6 and ≥7 at 5 years were 69.7% and 60.9% (P = 0.007). Lung donor quality significantly impacts on long‐term patient survival. Countries with a low donation rate are more oriented to using donor lungs with a lesser quality compared to countries with a high donation rate. Instead of further stretching donor eligibility criteria, the full potential of the donor pool should be realized.

Characteristics and Outcomes of Lung Transplant Candidates With Preexisting Renal Dysfunction

BackgroundThe proportion of lung transplant candidates with comorbid renal dysfunction (RD) may rise as sicker patients are being considered for lung transplant (LT). There is lack of data regarding the characteristics and outcome of patients with RD and the role of simultaneous lung-kidney transplant (SLuKi) among these patients. MethodsThe United Network of Organ Sharing database was queried for adult patients (18 years or older) undergoing LT between 1995 and 2014. Pretransplant RD was defined as estimated glomerular filtration rate (eGFR), using the Chronic Kidney Disease Epidemiology Collaboration equation of <60 mL/min/1.73 m2 at the time of transplant listing. The recipient, donor, and procedure-related variables and survival were compared among patients with RD undergoing LT alone (split on the basis of eGFR impairment: 30-60 mL/min/1.73 m2 and ≤ 30 mL/min/1.73 m2) vs those with SLuKi. ResultsThe frequency of pretransplant RD was 5.42% (n = 1337). Patients with RD have significantly higher 1-year mortality (23.2% vs 15%; P < .001) and 3-year mortality (38.3% vs 28%; P < .001) than patients with eGFR > 60mL/min/1.73 m2. The proportion of patients with RD undergoing SLuKi was 2.84% (38 of 1337). Both the number and proportion of patients undergoing SLuKi progressively increased during the study period, especially in the lung allocation score era (30 of 38 SLuKi patients in the post lung allocation score era (linear R2 = 0.641, P < .001). The patients who underwent SLuKi were significantly younger, had lower body mass index, serum albumin, and listing eGFR (P < .001 for all comparisons). Patients with SLuKi were more likely to have cystic fibrosis or vascular diseases as the underlying diagnosis (29.7% vs 13.8%, P = .004). Despite higher need of early dialysis support after transplant, there was no difference in the 30-day, 1-year, or 3-year survival between the 2 groups. ConclusionsA significant proportion of LT candidates have a pre-existing RD, and this comorbidity is associated with significantly worse 1- and 3-year survival. Despite being the sicker group at baseline, patients with RD who undergo SLuKi have 1-year outcomes similar to patients with LT alone.

Need for tracheostomy after lung transplant predicts decreased mid- and long-term survival.

Tracheostomy is an important adjunct for lung transplant patients requiring prolonged ventilation. We explored the effects of post-transplant tracheostomy on survival and bronchiolitis obliterans syndrome after lung transplant. A retrospective, single center analysis was performed on all lung transplant recipients during the Lung Allocation Score (LAS) era. Risk factors for post-transplant tracheostomy or death within 30days were assessed. Kaplan-Meier estimates and Cox proportional hazards models were used to examine the association between tracheostomy within 30days after transplant and survival at 1 and 3years. A total of 403 patients underwent single or bilateral lung transplant between May 2005 and February 2016 with complete data for 352 cases, and 35 patients (9.9%) underwent tracheostomy or died (N=10, 2.8%) within 30days. In adjusted analyses, primary graft dysfunction grade 3 (PGD3) was associated with a composite end point of tracheostomy or death within 30days (HR 3.11 (1.69, 5.71), P-value<.001). Tracheostomy within 30days was associated with decreased survival at 1(HR 4.25 [1.75, 10.35] P-value=.001) and 3years (HR 2.74 [1.30, 5.76], P-value=.008), as well as decreased bronchiolitis obliterans (BOS)-free survival at 1 (HR 1.87 [1.02, 3.41] P-value=.042) and 3years (HR 2.15 [1.33, 3.5], P-value=.002). Post-transplant tracheostomy is a marker for advanced lung allograft dysfunction with significant reduction in long-term overall and BOS-free survival.

INCIDENTAL PULMONARY ADENOCARCINOMA DETECTED ONLY IN ONE EXPLANTED LYMPH NODE OF A LUNG TRANSPLANT RECIPIENT WITH OLIGO-METASTATIC RECURRENCE ONE YEAR AFTER TRANSPLANT

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: The most common indications for lung transplant (LT) in the post-lung allocation score (LAS) era are idiopathic pulmonary fibrosis (IPF) and chronic obstructive pulmonary disease (COPD). Unexpected neoplasms are detected in between 1-4% of LT recipients upon pathological review of explants. CASE PRESENTATION: We present a rare case of incidental adenocarcinoma of the lung detected only on an explanted lymph node after LT. A 73-year-old man underwent bilateral sequential LT for IPF. Explant pathology revealed a 0.2 cm focus of pulmonary adenocarcinoma in one out of 21 lymph nodes (strongly positive for TTF-1) without a parenchymal primary focus. The explanted lungs were re-reviewed to confirm the absence of a primary focus (pathological stage pT0, pN1). The patient was subsequently followed with serial imaging including computed tomography (CT) and positron emission tomography (PET) scans. One year after LT he suffered a compression fracture at L1 and was hospitalized for hyponatremia. Workup revealed lesions in the T10 vertebra, right second rib and in the left acetabulum that showed mild uptake on PET scans. He underwent a CT-guided biopsy of the acetabular lesion, which was consistent with adenocarcinoma of pulmonary origin (strongly positive for keratin AE1/AE3 and CK7, while focally positive for TTF-1) – all consistent with a diagnosis of oligometastatic disease. His immunosuppression was lowered but given his leucopenia, he was thought to be a poor candidate for systemic therapy. After multidisciplinary discussions with the patient it was decided the best course of action for this patient would be stereotactic body radiation therapy (SBRT). He was treated with one dose of 20Gy radiation to each of the three sites of metastasis. The patient tolerated the treatment well and had no complications. Four months after initial therapy, repeat PET scan revealed a new FDG avid in the left pubic body concerning for metastasis and showed stable uptake in the three previously treated lesions. After additional discussions the patient and medical team again opted for SBRT to the lesion. He underwent single dose 20Gy radiation without complications. The patient tolerated all procedures well and continues to do well post treatment. DISCUSSION: Diagnosis and management of incidental neoplasms post-LT is challenging. This case highlights the importance of in depth pathological evaluation of lung explants and lymph nodes to look for foci of malignancy not detected on prior clinical evaluation. CONCLUSIONS: High clinical suspicion, lowering immunosuppression and multidisciplinary management are key in managing patients with incidental malignancies detected on lung explants. The incidence of such tumors will likely increase given the higher number of LT for IPF in the post-LAS era. Reference #1: Panchabhai TS, Arrossi AV, Patil PD, Bandyopadhyay D, Budev MM, McCurry KR, Farver C. Unexpected Neoplasms in Lungs Explanted From Lung Transplant Recipients: A Single-Center Experience and Review of Literature. Transplant Proc. 2018;50(1):234-240. DISCLOSURES: No relevant relationships by Hesham Abdelrazek, source=Web Response No relevant relationships by Sreeja Biswas Roy, source=Web Response No relevant relationships by Thomas Luzny, source=Web Response No relevant relationships by Tanmay Panchabhai, source=Web Response no disclosure on file for Nitika Thawani; Speaker/Speaker's Bureau relationship with Genentech Please note: $5001 - $20000 Added 03/18/2019 by Rajat Walia, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Boehringer Ingelheim Please note: $5001 - $20000 Added 03/18/2019 by Rajat Walia, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Grifols Please note: $5001 - $20000 Added 03/18/2019 by Rajat Walia, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Shire Please note: $1001 - $5000 Added 03/18/2019 by Rajat Walia, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Astellas Please note: $5001 - $20000 Added 03/18/2019 by Rajat Walia, source=Web Response, value=Honoraria

Mortality for sarcoidosis patients on the transplant wait list in the Lung Allocation Score era: Experience from a high volume center

Sarcoidosis progresses to end stage fibrotic lung disease in 10% of patients and may necessitate lung transplantation. Organ allocation is currently determined by the Lung Allocation Score (LAS), but its performance in a sarcoidosis population has not been evaluated. To determine sarcoidosis-specific wait list mortality and identify predictive factors of death on the transplantation wait list. This was a single-center retrospective study of all sarcoidosis patients listed for lung transplant from March 2012 to February 2019. We compared patients who were transplanted to those who died awaiting organs. We collected baseline listing characteristics, physiologic testing, and outcomes data. Statistical analysis was performed by 2-tailed Student's t-test, Mann-Whitney U test, and Chi-Square analysis (where appropriate). Receiver-operating characteristic curves were constructed for variables reaching statistical significance. Twenty eight sarcoidosis patients were included in analysis. Mortality among wait listed patients was 18%, which exceeded the mortality of COPD and IPF. LAS scores did not differ at initial listing (41 vs. 46, p = 0.35) or at transplant/death (41 vs. 41, p = 0.91); wait list times also did not statistically differ (307 days vs. 177 days, p = 0.19). We identified bilirubin (AUC = 0.92), DLCO (AUC = 0.84), FEV1/FVC at transplant/death (AUC = 0.85), and composite physiologic index (AUC = 0.86) as predictors of death on the transplant list. Pulmonary hypertension was not associated with death. Unexpected sudden death was common in our cohort and was associated with markers of advanced fibrotic disease, not pulmonary hypertension.

Lung Transplantation for Patients with Cystic Fibrosis and Achromobacter xylosoxidans in the Lung Allocation Score Era

Purpose Lung transplantation is an accepted therapy for patients with end stage lung disease due to Cystic Fibrosis (CF). Up to ten percent of patients with CF are colonized with Achromobacter xylosoxidans, a gram negative organism that due to its intrinsic resistance to many antibiotics may affect negatively impact post-transplant outcomes. Methods We conducted a retrospective cohort analysis of all patients receiving lung transplantation for CF from 6/2005-2015 at the University of Pittsburgh Medical Center. Patients with Burkholderia species were excluded. General and transplant related demographics, pre and post-transplant respiratory cultures, and cause of death were examined. Graft survival was measured through February 2018 or last follow-up. Descriptive statistics were used to compare baseline demographics using parametric and non-parametric tests. Survival was estimated and compared by Kaplan Meier analysis. Results Twenty-nine percent (26/89) of patients had a history of Achromobacter infection prior to transplantation. Pre-transplantation, patients with Achromobacter had a slightly higher FEV1 (25.8 +/- 2.1 vs 22.3 +/- 0.07, p=0.031) but trended towards requiring more mechanical ventilation (42 vs 24%, p=0.081). Compared to patients without Achromobacter, there was not a statistically significant difference in 1 year (0.84 vs 0.94%) and 3 year survival (0.68 vs 0.84%) (Figure 1, p=0.291). Of the Achromobacter patients, forty-two percent (11/26) had positive explant bronchial cultures and forty-six percent (12/26) had Achromobacter isolated after transplantation. Of the 12 patients with recurrent Achromobacter, only 4 had positive explant cultures. Only 1 of 11 deaths was attributable to Achromobacter. Conclusion Lung transplantation is a viable treatment option for patients with end stage CF and a history of infection with Achromobacter and these patients should be considered candidates for transplantation.

Single Versus Bilateral Lung Transplantation for Idiopathic Pulmonary Fibrosis in the Lung Allocation Score Era

BackgroundIdiopathic pulmonary fibrosis (IPF) is a progressive and fatal disease. Lung transplantation is the only therapy associated with prolonged survival. The ideal transplant procedure for IPF is unclear. Outcomes after single transplantation (SLTx) versus bilateral lung transplantation (BLTx) in IPF patients after introduction of the Lung Allocation Score were examined. MethodsRecords of patients undergoing lung transplantation for IPF at our institution between May 2005 and March 2017 were reviewed to examine the effect of transplant laterality. Primary outcomes were overall, rejection-free, and bronchiolitis obliterans (BOS)-free survival at 1 and 5 years post-transplant. ResultsLung transplantation was performed in 151 IPF patients post-Lung Allocation Score. Most recipients were male with average age 59 ± 8 years. SLTx was performed in 94 patients (62%). In the overall cohort, comparative survival between SLTx and BLTx was similar at 1 and 5 years before and after adjusting for age and pulmonary hypertension (PH). SLTx was associated with shorter ventilator time and intensive care unit stay and trended toward improved survival over BLTx in patients without PH. ConclusionsThe use of SLTx versus BLTx in IPF did not correspond to significantly different survival adjusting for age and PH. BLTx was associated with prolonged postoperative ventilation and length of stay compared with SLTx. Patients without PH, all older patients, and patients with PH and advanced disease should be considered for SLTx for IPF.

Traumatically Brain-Injured Donors and the Impact on Lung Transplantation Survival

Concern has been raised over inferior lung transplantation survival associated with traumatic brain injury (TBI) organ donors. Our purpose was to explore the relationship between TBI donors and lung transplantation survival in the lung allocation score (LAS) era. We queried the United Network for Organ Sharing Scientific Registry of Transplant Recipients and identified all adult (≥18 years) lung transplantations performed from May 4, 2005, to December 31, 2015. Recipients were dichotomized based on donor cause of death, TBI versus non-TBI, propensity score across eight variables (final LAS, intensive care unit admission before transplantation, extracorporeal membrane oxygenation before transplantation, donor age 50 years or older, cytomegalovirus antibody recipient-/donor+, ischemia time, annual center transplantation volume, single versus double lung transplantation), and matched 1:1 without replacement. Our primary outcomes were survival at 1, 3, and 5 years by Kaplan-Meier method. A total of 17,610 patients underwent isolated lung transplantation over the study period at 75 different transplantation centers. TBI was the leading cause of death in the donor population: 47% of all donors. Propensity score matching generated 6,782 well-matched donor TBI versus non-TBI pairs (all covariate p > 0.2). Risk-adjusted survival was similar between recipients of TBI donors versus non-TBI donors at 1 year (86% versus 86%, log-rank p= 0.27), 3 years (68% versus 68%, log-rank p= 0.47), and 5 years (55% versus 54%, log-rank p= 0.40). In the largest analysis of TBI donors and the impact on lung transplantation survival to date, we found similar survival out to 5 years in lung transplant recipients of TBI versus non-TBI donors, alleviating concerns over continued transplantation with this unique donor population.