Single Lung Transplant Recipients Research Articles

Frequency of Unplanned Readmissions Following Lung Transplantation During the SAR-COV-2 Pandemic When Hospital Resources Were Strained

Despite the concerted efforts by lung transplant recipients (LTR) and their medical teams, hospital readmissions are common in the first year following transplantation. Reasons for unplanned readmissions include allograft rejection, infections, and respiratory failure before the SARS-COV-2 pandemic. Clinical predictors of readmissions have changed over time with the higher risk factors of acceptable criteria for recipients and donors. We aimed to assess more recent readmission rates based on group classifications to better understand specific groups that are at risk for various readmissions during the SARS-COV-2 pandemic when hospital resources were strained. A retrospective analysis for LTR at UCSD was performed from 1/1/2018 to 6/30/2022. We recorded the baseline demographics; LAS at the time of lung transplant; mechanical ventilation prior to lung transplant; the need for VV-or VA-ECMO prior to or after lung transplantation; categories for UNOS listing (groups A, B, C, D); PGD grade 3 based on the ISHLT definition; and acquisition of serious donor-derived infections. We recorded the primary reason for all the readmissions and the duration of admission. Descriptive statistics were used for the analysis of this 4.5-year patient cohort. 149 LT were performed. 29 were single LTR while 120 were bilateral LTR. Median age of 57 years, 63 patients (42%) were female. Indications for transplantation included 28 (19%) group A, 19 (13%) group B, 12 (8%) group C, and 90 (60%) group D. The median length of follow-up following lung transplant was 1.7 years. Collectively, there were 73 patients (49%) that required readmissions. On average, there are 2.5 readmissions per patient for our cohort. Most common reasons for unplanned readmission included infections, transplant-related (transplant rejection, other complications of transplant, etc.), and GI Related. This was primarily seen in the group D cohort. The median hospital LOS at readmission was 3.8 days (4 hours to 34.6 days). Despite infection being the leading cause of readmission, only 11 cases were related to COVID-19 infection. No death occurred with a readmission. Groups B and D appear to be at a higher risk for readmission, irrespective of the pre-LT LAS and need for mech vent or VV-ECMO.

Mechanical Thrombectomy in a Single Lung Transplant Recipient: A Salvage Case.

Mechanical Thrombectomy in a Single Lung Transplant Recipient: A Salvage Case.

Quality of life and its association with predictors in lung transplant recipients: a latent profile analysis.

Improving quality of life (QOL) is one of the main aims of lung transplantation (LTx). There is a need to identify those who have poor quality of life early. However, research addressing inter individual quality of life variability among them is lacking. This study aims to identify group patterns in quality of life among lung transplant recipients and examine the predictors associated with quality of life subgroups. In total, 173 lung transplant recipients were recruited from one hospital in Guangdong Province between September 2022 and August 2023. They were assessed using the Lung Transplant Quality of Life scale (LT-QOL), Mindful Attention Awareness Scale (MAAS), Life Orientation Test-Revised scale (LOT-R), and Positive and Negative Affect Scale (PANAS). Latent profile analysis was used to identify QOL subtypes, and logistic regression analysis was used to examine the associations between latent profiles and sociodemographic and psychosocial characteristics. Two distinct QOL profiles were identified: "low HRQOL" profile [N = 53 (30.94%)] and "high HRQOL" profile [N = 120 (69.06%)]. Single lung transplant recipients, and patients who reported post-transplant infection, high levels of negative emotion or low levels of mindfulness and optimism were significantly correlated with the low QOL subgroup. Using the domains of the LT-QOL scale, two profiles were identified among the lung transplant recipients. Our findings highlighted that targeted intervention should be developed based on the characteristics of each latent class, and timely attention must be paid to patients who have undergone single lung transplantation, have had a hospital readmission due to infection, exhibit low levels of optimism, low levels of mindfulness or high negative emotions.

Single lung transplantation using a lung graft from a donor whose contralateral lung is not suitable for lung transplantation.

This study aims to compare the post-transplant survival of untwinned single lung transplantation (SLT) to twinned SLT. In untwinned SLT, the contralateral lung is judged unsuitable for transplantation and might affect the lung graft within the donor body and recipient survival after SLT. A retrospective analysis was conducted on 84 SLT recipients at our center, divided into untwinned SLT and twinned SLT groups. The demographics of donors and recipients, surgical characteristics, complications, mortality, and survival rates were compared. There were no significant differences in recipient and donor demographics between the two groups. Surgical characteristics showed no significant differences. Microbiological findings of the transplanted lungs indicated a low incidence of positive cultures in both groups. 3-month to 1-year mortality and overall survival rates were comparable between the two groups. At our institution, both untwinned and twinned SLT procedures exhibited excellent survival rates without significant differences between the two procedures. The favorable outcomes observed may be associated with the strategic advantages of Japan's MC system and the diligent management of marginal donor lungs although this requires further investigation to elucidate the specific contributory factors.

Fatal Infections Differentially Involve Allograft and Native Lungs in Single Lung Transplant Recipients.

Respiratory infections complicate lung transplantation and increase the risk of allograft dysfunction. Allograft lungs may have different susceptibilities to infection than native lungs, potentially leading to different disease severity in lungs of single lung transplant recipients (SLTRs). To study whether infections affect allograft and native lungs differently in SLTRs but similarly in double LTRs (DLTRs). Using an institutional database of LTRs, medical records were searched, chest computed tomography studies were systematically reviewed, and histopathologic features were recorded per lung lobe and graded semiquantitatively. A multilobar-histopathology score (MLHS) including histopathologic data from each lung and a bilateral ratio (MLHSratio) comparing histopathologies between both lungs were calculated in SLTRs and compared to DLTRs. Six SLTRs died of infection involving the lungs. All allografts showed multifocal histopathologic evidence of infection, but at least 1 lobe of the native lung was uninvolved. In all 5 DLTRs except 1, histopathologic evidence of infection was seen in all lung lobes. On computed tomography, multifocal ground-glass and/or nodular opacities were found in a bilateral distribution in all DLTRs but in only 2 of 6 SLTRs. In SLTRs, the MLHSAllograft was higher than MLHSNative (P = .02). The MLHSratio values of SLTR and DLTR were significantly different (P < .001). Allograft and native lungs appear to harbor different susceptibilities to infections. The results are important for the management of LTRs.

Change in diaphragmatic morphology in single-lung transplant recipients: a computed tomographic study.

Introduction: The influence of lung disease on the diaphragm has been poorly studied. The study aimed to evaluate the diaphragm morphology (height and thickness) in single-lung transplantation (SLTx), using computed tomography (CT), by assessing the evolution of the hemidiaphragm of the transplanted and the native side. Methods: Patients who underwent single lung transplantation in our center (Marseille, France) between January 2009 and January 2022 were retrospectively included. Thoracic or abdominal CT scans performed before and the closest to and at least 3months after the surgery were used to measure the diaphragm crus thickness and the diaphragm dome height. Results: 31 patients mainly transplanted for emphysema or pulmonary fibrosis were included. We demonstrated a significant increase in diaphragm crus thickness on the side of the transplanted lung, with an estimated difference of + 1.25mm, p = <0.001, at the level of the celiac artery, and + 0.90mm, p < 0.001, at the level of the L1 vertebra while no significant difference was observed on the side of the native lung. We showed a significant reduction in the diaphragm height after SLTx on the transplanted side (-1.20cm, p = 0.05), while no change on the native side (+0.02cm, p = 0.88). Conclusion: After a SLTx, diaphragmatic morphology significantly changed on the transplanted lung, while remaining altered on the native lung. These results highlights that an impaired lung may have a negative impact on its diaphragm. Replacement with a healthy lung can promote the recovery of the diaphragm to its anatomical morphology, reinforcing the close relationship between these two organs.

Progress in Combined Liver-lung Transplantation at a Single Center.

A single-center, retrospective review of the medical records of 19 adult lung-liver transplant recipients was conducted, comparing early recipients (2009-2014) with a recent cohort (2015-2021). Patients were also compared with the center's single lung or liver transplant recipients. Recent lung-liver recipients were older (P = 0.004), had a higher body mass index (P = 0.03), and were less likely to have ascites (P = 0.02), reflecting changes in the etiologies of lung and liver disease. Liver cold ischemia time was longer in the modern cohort (P = 0.004), and patients had a longer posttransplant length of hospitalization (P = 0.048). Overall survival was not statistically different between the 2 eras studied (P = 0.61), although 1-y survival was higher in the more recent group (90.9% versus 62.5%). Overall survival after lung-liver transplant was equivalent to lung-alone recipients and was significantly lower than liver-alone recipients (5-y survival: 52%, 51%, and 75%, respectively). Lung-liver recipient mortality was primarily driven by deaths within 6 mo of transplant due to infection and sepsis. Graft failure was not significantly different (liver: P = 0.06; lung: P = 0.74). The severity of illness in lung-liver recipients combined with the infrequency of the procedure supports its continued use. However, particular attention should be paid to patient selection, immunosuppression, and prophylaxis against infection to ensure proper utilization of scarce donor organs.

(929) Long-Term Survival Among Single Lung Transplant Recipients is Shorter Than That of Matched Bilateral Lung Transplant Recipients

(929) Long-Term Survival Among Single Lung Transplant Recipients is Shorter Than That of Matched Bilateral Lung Transplant Recipients

Mechanical ventilation post-bilateral lung transplantation: A scoping review.

Evidence from lung protective ventilation (LPV) in the acute respiratory distress syndrome has commonly been applied to guide periprocedural ventilation in lung transplantation. However, this approach may not adequately consider the distinctive features of respiratory failure and allograft physiology in the lung transplant recipient. This scoping review was conducted to systematically map the research describing ventilation and relevant physiological parameters post-bilateral lung transplantation with the aim to identify any associations with patient outcomes and gaps in the current knowledge base. To identify relevant publications, comprehensive literature searches of electronic bibliographic databases were conducted with the guidance of an experienced librarian in MEDLINE, EMBASE, SCOPUS and the Cochrane Library. The search strategies were peer-reviewed using the PRESS (Peer Review of Electronic Search Strategies) checklist. The reference lists of all relevant review articles were surveyed. Publications were included in the review if they described relevant ventilation parameters in the immediate post-operative period, published between 2000 and 2022 and involved human subjects undergoing bilateral lung transplantation. Publications were excluded if they included animal models, only single-lung transplant recipients or only patients managed with extracorporeal membrane oxygenation. A total of 1212 articles were screened, 27 were subject to full-text review and 11 were included in the analysis. The quality of the included studies was assessed to be poor with no prospective multi-centre randomised controlled trials. The frequency of reported retrospective LPV parameters was as follows: tidal volume (82%), tidal volume indexed to both donor and recipient body weight (27%) and plateau pressure (18%). Data suggest that undersized grafts are at risk of unrecognised higher tidal volume ventilation indexed to donor body weight. The most reported patient-centred outcome was graft dysfunction severity in the first 72 h. This review has identified a significant knowledge gap that indicates uncertainty regarding the safest ventilation practice in lung transplant recipients. The risk may be greatest in patients with established high-grade primary graft dysfunction and undersized allografts, and these factors may define a sub-group that warrants further investigation.

Lung Cancer in Lung Transplant Recipients: Clinical, Radiologic, and Pathologic Characteristics and Treatment Outcome.

This study aimed to investigate clinical and radiologic characteristics of lung cancer in lung transplant recipients and evaluate the treatment course and prognosis. The study included 448 patients who underwent lung transplant between 2005 and 2021. All patients had pretransplant chest computed tomography (CT), 429 patients had posttransplant CT, whereas 19 had no posttransplant CT (median number of posttransplant CT, 6; range, 0-24). Medical records of these patients were reviewed to identify patients who developed lung cancer after lung transplant. Computed tomography and positron emission tomography/CT at the time of lung cancer diagnoses were reviewed to obtain imaging features. Demographics, tumor histology, stages, and survival were compared using Fisher exact test and Wilcoxon rank sum test. Among 448 lung transplant recipients with a median follow-up of 71.3 months after lung transplant, 15 patients (3.3%) developed posttransplant lung cancer (13 unilateral, 2 bilateral; 10 men, 5 women; median age, 63.1 years; median time from transplantation to cancer diagnosis, 3.1 years). Twelve cancers were in native lung, and 3 were in transplanted lung. The incidence of lung cancer was higher in single lung transplant recipients than in bilateral lung transplant recipients (10.3% vs 0.6%, respectively; P < 0.0001). Imaging manifestations varied according to tumor stages. Among 12 patients treated for lung cancer, 2 patients developed posttreatment acute respiratory distress syndrome. The median survival from cancer diagnosis of cancer was 6.2 months. Posttransplant lung cancer was noted in 3% of lung transplant recipients and was more common in unilateral transplant recipients. The prognosis upon diagnosis was poor with rapid clinical deterioration and serious posttreatment complications.

Comparison of donor-derived cell-free DNA between single versus double lung transplant recipients

Plasma donor-derived cell-free DNA (dd-cfDNA) is a sensitive biomarker for the diagnosis of acute rejection in lung transplant recipients; however, differences in dd-cfDNA levels between single and double lung transplant remains unknown. We performed an observational analysis that included 221 patients from two prospective cohort studies who had serial measurements of plasma dd-cfDNA at the time of bronchoscopy and pulmonary function testing, and compared dd-cfDNA between single and double lung transplant recipients across a range of disease states. Levels of dd-cfDNA were lower for single vs. double lung transplant in stable controls (median [IQR]: 0.15% [0.07, 0.44] vs. 0.46% [0.23, 0.74], p<.01) and acute rejection (1.06% [0.75, 2.32] vs. 1.78% [1.18, 5.73], p=.05). Doubling dd-cfDNA for single lung transplant to account for differences in lung mass eliminated this difference. The area under the receiver operating curve (AUC) for the detection of acute rejection was 0.89 and 0.86 for single and double lung transplant, respectively. The optimal dd-cfDNA threshold for the detection of acute rejection was 0.54% in single lung and 1.1% in double lung transplant. In conclusion, accounting for differences in dd-cfDNA in single versus double lung transplant is key for the interpretation of dd-cfDNA testing in research and clinical settings.

Double Trouble: Ischemic Time is Associated with Worse Outcomes After Double Lung but Not Single Lung Transplantation

Purpose Currently accepted clinical guidelines recommend ischemic times of no longer than four to six hours. To maximize organ supply, ischemic times beyond this are sometimes necessitated. We sought to determine whether graft ischemic time is independently associated with all-cause survival in a large, contemporary cohort of single and double lung transplant recipients. Methods Data from adults undergoing initial isolated lung transplantation in the UNOS (United Nation for Organ Sharing) registry from January 2010 to December 2017 were included and compared for all-cause mortality at 1 year. Within single lung transplants, patients were further stratified into 3 ischemic time groups: <3 hours (17%), 3-4.5 hours (45%), 4.5-6 hours (28%), and >6 hours (10%). Meanwhile, in the double lung transplant cohort, ischemic time subgroups were as follows: <4.5 hours (26%), 4.5-6 hours (39%), and >6 hours (35%). Results Ischemic time had no impact on survival following single lung transplantation whether defined categorically (P=0.546) or continuously (HR, 0.986; 95% CI, 0.960-1.011; P=0.272). However, ischemic time was associated with significantly reduced survival following DLT in both definitions (P<0.001). After adjustment for potential confounders, the difference remained significant (HR, 1.041; 95% CI, 1.023-1.059; P<0.001). Conclusion The results of this large contemporary cohort suggest that the relationship between graft ischemic time and 1 year all-cause survival is not uniform across lung transplant types. Ischemic time was significantly associated with risk of reduced survival in double lung but not single lung transplant recipients. Both graft type and ischemic time should be incorporated in the decision-making process. Currently accepted clinical guidelines recommend ischemic times of no longer than four to six hours. To maximize organ supply, ischemic times beyond this are sometimes necessitated. We sought to determine whether graft ischemic time is independently associated with all-cause survival in a large, contemporary cohort of single and double lung transplant recipients. Data from adults undergoing initial isolated lung transplantation in the UNOS (United Nation for Organ Sharing) registry from January 2010 to December 2017 were included and compared for all-cause mortality at 1 year. Within single lung transplants, patients were further stratified into 3 ischemic time groups: <3 hours (17%), 3-4.5 hours (45%), 4.5-6 hours (28%), and >6 hours (10%). Meanwhile, in the double lung transplant cohort, ischemic time subgroups were as follows: <4.5 hours (26%), 4.5-6 hours (39%), and >6 hours (35%). Ischemic time had no impact on survival following single lung transplantation whether defined categorically (P=0.546) or continuously (HR, 0.986; 95% CI, 0.960-1.011; P=0.272). However, ischemic time was associated with significantly reduced survival following DLT in both definitions (P<0.001). After adjustment for potential confounders, the difference remained significant (HR, 1.041; 95% CI, 1.023-1.059; P<0.001). The results of this large contemporary cohort suggest that the relationship between graft ischemic time and 1 year all-cause survival is not uniform across lung transplant types. Ischemic time was significantly associated with risk of reduced survival in double lung but not single lung transplant recipients. Both graft type and ischemic time should be incorporated in the decision-making process.

Comparative Performance Analysis of Donor-Derived Cell-Free DNA to Detect Acute Rejection in Single and Double Lung Transplant Recipients

<h3>Purpose</h3> Plasma donor-derived cell-free DNA (ddcfDNA) is a sensitive biomarker for acute rejection (AR). However, its performance remains unknown for single (SL) vs double lung (DL) transplant recipients, where differences in lung mass may affect interpretation. In this study, we aim to distinguish the performance characteristics of ddcfDNA to detect AR in SL vs DL transplant patients. <h3>Methods</h3> Lung transplant recipients (n=105) enrolled in two prospective cohort studies were adjudicated for acute cellular rejection (ACR) and antibody mediated rejection (AMR). <b>Measurement:</b> 337 serially-collected plasma samples were assayed for ddcfDNA by shotgun sequencing. <b>Analysis:</b> Area-under-the-receiver-operating-characteristic-curves (AUROC) of ddcfDNA and performance characteristics for the detection of AR were calculated separately for both DL and SL transplant recipients; cfDNA values were not doubled for SL transplant as in prior studies. <h3>Results</h3> The AUROC for ddcfDNA to detect AR was 0.86 and 0.89 in DL and SL transplants, respectively. The optimal ddcfDNA threshold of 0.54% for SL transplant showed a 92% sensitivity and 80% specificity for detecting AR. For DL transplant, the optimal threshold of 1.1% showed 78% sensitivity and 83% specificity for detecting AR. When ddcfDNA was doubled for single lung transplant, the 1.1% threshold showed 92% sensitivity and 80% specificity for detecting rejection. The AUROC for detection of AMR was 0.91 for both DL and SL transplants. However, the AUROC for detection of ACR was 0.73 for DL and 0.87 for SL transplants. <h3>Conclusion</h3> Plasma ddcfDNA showed similar accuracy to detect AR in both SL and DL transplant recipients, however, the accuracy of ddcfDNA for the detection of ACR appears higher in SL vs DL transplant recipients. Correcting ddcfDNA levels in SL transplant patients by doubling their value appears to be a reasonable method of preserving the performance characteristics of the test for the detection of acute rejection.

Molecular identification of Aspergillus fumigatus complex from lung transplant recipients using multilocus sequencing analysis (MLSA).

Aspergillus infection causes significant morbidity and mortality among lung transplant recipients (LTRs). It is primarily caused by Aspergillus fumigatus. Other closely related species belonging to the section Fumigati have also been found. These cryptic species are often misidentified as A. fumigatus. Thus, we used multilocus sequencing analysis (MLSA) of the calmodulin, β-tubulin, and hydrophobin gene sequences to identify these species and to determine the frequency with which they occur among LTRs. A total of 81 A. fumigatus isolates were initially isolated from bronchoalveolar lavage fluid or sputum specimens collected from lung transplant patients. These isolates were then sub-cultured and genotyped using MLSA. Of these isolates, 53, 17, and 11 were isolated from double LTRs, single LTRs, and pre-LTRs, respectively. All isolates (100%) carried DNA sequences identical to those of A. fumigatus reference strains and thus clustered in the same clade with A. fumigatus. Analysis of the MLSA data revealed that A. fumigatus species were the only species recovered in this population of LTRs. The MLSA results were consistent with those routinely obtained by conventional mycological procedures in the microbiology laboratory. A. fumigatus appears to be the primary causative agent of colonization or invasive aspergillosis among LTRs. No cryptic species were identified.

Acute worsening of native lung fibrosis after single lung transplantation for pulmonary fibrosis: two case reports

BackgroundIn patients receiving single lung transplantation for idiopathic pulmonary fibrosis, worsening of fibrosis of the native lung is usually progressive over time, with no significant effects on gas exchange.Case presentationHere, we describe the cases of two Caucasian male recipients of single lung transplants for idiopathic pulmonary fibrosis, 65 and 62 years of age, who exhibited acute worsening of lung fibrosis after an episode of serious viral infection (cytomegalovirus primo-infection in one case and COVID-19 in the other). In both cases, along with opacification of the native lung over several days, the patients presented acute respiratory failure that required the use of high-flow nasal oxygen therapy. Eventually, hypoxemic respiratory failure resolved, but with rapid progression of fibrosis of the native lung.ConclusionWe conclude that acute worsening of fibrosis on the native lung secondary to a severe viral infection should be added to the list of potential complications developing on the native lung after single lung transplantation for idiopathic pulmonary fibrosis.

A randomized controlled trial of liposomal cyclosporine A for inhalation in the prevention of bronchiolitis obliterans syndrome following lung transplantation

Long-term survival after lung transplantation is limited by chronic allograft dysfunction. The aim of this study was to investigate the effect of locally augmented immunosuppression with liposomal cyclosporine A for inhalation (L-CsA-i) for the prevention of bronchiolitis obliterans syndrome (BOS). In a randomized, double-blind, placebo-controlled, multi-center Phase 3study, 180LT recipients in BOS grade 0 were planned to receive L-CsA-i or placebo in addition to triple-drug immunosuppression. L-CsA-i was administered twice daily via an Investigational eFlow nebulizer to recipients of single (SLT) and bilateral lung transplants (BLT) within 6-32weeks posttransplant, and continued for 2years. The primary endpoint was BOS-free survival. 130 patients were enrolled before the study was prematurely terminated for business reasons. Despite a 2-year actuarial difference in BOS-free survival of 14.1% in favor of L-CsA-i in the overall study population, the primary endpoint was not met (p=.243). The pre-defined per protocol analysis of SLT recipients (n=24) resulted in a treatment difference of 58.2% (p=.053). No difference was observed in the BLT (n=48) subpopulation (p=.973). L-CsA-i inhalation was well tolerated. Although this study failed to meet its primary endpoint, the results warrant additional investigation of L-CsA-i in lung transplant recipients.

Life first and science respect: A commentary on current status and expectations of China's lung transplantation

Lung transplantation is the only effective method for the treatment of end-stage lung diseases. Lung transplantation has achieved rapid development in the world. At present, about 4 000 cases are carried out every year, and the long-term survival rate has gradually improved. With a high incidence of lung disease in China, at least ten thousand patients with respiratory failure need lung transplantation every year. In 2020, 29 lung transplantation centers in China has carried out more than 500 cases of lung transplantation. Idiopathic pulmonary interstitial fibrosis, chronic obstructive pulmonary disease, secondary pulmonary interstitial fibrosis and pneumoconiosis were the main primary diseases in lung transplantation recipients in China. Single-lung transplantation accounted for 57.6% and double-lung transplantation accounted for 42.4%, respectively. Peri-operation (<30 days), one-year, and three-year survival rates were 78.5%, 64.5% and 48.9%, respectively for double-lung transplant. The corresponding survival rates for single-lung transplant recipients were 83.0%, 69.9% and 46.8%, respectively. The Renmin Hospital of Wuhan University completed the first case of COVID-19 lung transplantation operation in Hubei Province in 2020, and the patients recovered and discharged successfully after the operation. Although China has made great progress in lung transplantation, it is still necessary to realize that the multi-disciplinary team cooperation mode and data registration management still need to be further strengthened, in order to provide more clinical guidelines and expert consensus and make the steady development and improvement of each lung transplantation center. The lung transplantation in China will be gradually promoted to the center of the organ transplantation stage in the world. © 2021, Editorial Board of Medical Journal of Wuhan University. All right reserved.

Single Lung Transplantation with a Rejected Contralateral Lung: Improved Assessment and Donor Lung Utilization in the Era of Ex Vivo Lung Perfusion

<h3>Purpose</h3> Single lung transplantation (SLT) is an option for certain lung transplant recipients and allows for maximal utility of a limited donor pool. However, whether a single lung should be transplanted when the contralateral donor lung is too injured for transplant is a challenging clinical scenario. The introduction of ex vivo lung perfusion (EVLP) has improved donor lung assessment and we hypothesize that it has improved SLT outcomes in this setting. We examined outcomes in SLT recipients with and without the use of EVLP. <h3>Methods</h3> A retrospective single-centre review of all SLT performed between 2000 and 2017 was performed. To account for the introduction of EVLP in our program in 2008, we considered the years 2000-2008 the "pre-EVLP era" and 2009-2017 the "EVLP era". SLT recipients were classified as Group 1 (Control) when both donor lungs were transplanted, Group 2 (Pre-EVLP era) when one lung was declined at the donor site and the other transplanted directly, Group 3a (EVLP era; non-EVLP) when one lung was declined at the donor site and the other transplanted directly, and Group 3b (EVLP era; EVLP utilized) when one lung was declined but the transplanted lung deemed acceptable using EVLP. The outcomes of interest were survival, time-to-extubation, and ICU and hospital stay. <h3>Results</h3> A total of 244 SLT were performed between 2000 and 2017. There were 143 SLT in Group 1, 21 in Group 2, 33 in Group 3a, and 47 in Group 3b. There was a significantly better 30-day mortality in the EVLP era (Table 1). Use of SLT increased from 12.7% of lung transplants pre-EVLP era to 16.8% in the EVLP era. <h3>Conclusion</h3> Though not every SLT with rejected contralateral lung necessitated evaluation by EVLP, the availability of EVLP allowed for additional evaluation of questionable single lungs. This has led to increased utilization rates and improved outcomes of SLT with a rejected contralateral lung in the EVLP era.

Native Lung Complications in Single Lung Transplant Recipients

Purpose Single lung transplants are performed less frequently around the world. Associated with better survival, bilateral lung transplantation is prefered. However, in the setting of scarce organ supply, single lung transplant is still a viable choice as it expands the donor pool.We aimed to describe native lung complications in single lung transplant recipients. Methods We performed a retrospective cohort study at a single lung transplant center in Buenos Aires, Argentina. We evaluated all single lung transplants performed from 2010 to 2019. Demographic characteristics and native lung complications, classified as infections, neoplasm and hyperinflation are presented. Results During the study period, 81 lung transplants were performed. 68% (n=55) were single lung transplants. 45% were performed in women. Mean age was 54 years.Cause of transplantation was as follow: COPD in 25 cases (45%), IPF in 22 cases (40%) and silicosis in 5 cases (9%).Native lung transplant complications were determined in 23 cases (36%). Infections were recorded in 13 ( 24%), neoplasm in 2 (4%) cases and hyperinflation in 8 (15%) cases. Both cases of neoplasm and one case of infection were determined as cause of death. Conclusion Native lung complications were common and were determined as cause of death in 15% of cases.

Phenotyping CLAD after Single Lung Transplant: Limits and Prognostic Assessment of the 2019 ISHLT Classification System

PurposePhenotyping chronic lung allograft dysfunction (CLAD) in single lung transplant (SLTX) recipients is challenging, due to the native lung contribution to pulmonary function tests (PFT). We aimed to assess the ISHLT CLAD classification and its prognostic performance in SLTX.MethodsIn this retrospective cohort of adult, first, SLTX from 2009 to 2017, patients with persistent drop in FEV1>20% were assessed by 2 independent reviewers to determine CLAD status and phenotype, specifically noting presence or absence of RAS-like opacities. Disagreements were resolved by a 3rd reviewer. Interobserver agreement (IOA) was calculated by Cohen's Kappa. Association of CLAD phenotypes with time to death/retransplant (ReTx), adjusted for age, sex, CMV mismatch and native lung condition, were assessed with Cox models.ResultsOut of 172 SLTX patients, 92 had a persistent drop in FEV1>20%, of whom 67 got a diagnosis of CLAD. We noted a moderate IOA for CLAD status (Kappa 0.69) and poor IOA for phenotype (Kappa 0.5). When applying the ISHLT criteria strictly (based on exact cut-offs for PFT, along with imaging), 34 patients had BOS (50.7%), 9 RAS/mixed (13.4%), 7 undefined (10.4%), and 17 unclassified (25.5%). We found no association of these strict phenotypes with death/ReTx (Fig A). When using adjudicated CLAD phenotypes, 31 patients had BOS (46.3%), 15 RAS/mixed (22.4%), 2 Undefined (3%), and 19 Unclassified (28.3%). Using these adjudicated phenotypes, RAS/mixed was significantly associated with higher risk of death/ReTx (HR 2.98, 95%CI [1.39-6.4]) (Fig B). Finally, the specific adjudication of RAS-like opacities had the best IOA (Kappa 0.73). Presence of RAS-like opacities was a strong predictor of death/ReTx (HR 2.3, 95%CI [1.2-4.5]) (Fig C).ConclusionPFT interpretation is challenging in SLTX. Using a classification relying more on imaging analysis that harboured good IOA, we obtained better prognostic performances than with a strict application of published physiologic cut-offs. Phenotyping chronic lung allograft dysfunction (CLAD) in single lung transplant (SLTX) recipients is challenging, due to the native lung contribution to pulmonary function tests (PFT). We aimed to assess the ISHLT CLAD classification and its prognostic performance in SLTX. In this retrospective cohort of adult, first, SLTX from 2009 to 2017, patients with persistent drop in FEV1>20% were assessed by 2 independent reviewers to determine CLAD status and phenotype, specifically noting presence or absence of RAS-like opacities. Disagreements were resolved by a 3rd reviewer. Interobserver agreement (IOA) was calculated by Cohen's Kappa. Association of CLAD phenotypes with time to death/retransplant (ReTx), adjusted for age, sex, CMV mismatch and native lung condition, were assessed with Cox models. Out of 172 SLTX patients, 92 had a persistent drop in FEV1>20%, of whom 67 got a diagnosis of CLAD. We noted a moderate IOA for CLAD status (Kappa 0.69) and poor IOA for phenotype (Kappa 0.5). When applying the ISHLT criteria strictly (based on exact cut-offs for PFT, along with imaging), 34 patients had BOS (50.7%), 9 RAS/mixed (13.4%), 7 undefined (10.4%), and 17 unclassified (25.5%). We found no association of these strict phenotypes with death/ReTx (Fig A). When using adjudicated CLAD phenotypes, 31 patients had BOS (46.3%), 15 RAS/mixed (22.4%), 2 Undefined (3%), and 19 Unclassified (28.3%). Using these adjudicated phenotypes, RAS/mixed was significantly associated with higher risk of death/ReTx (HR 2.98, 95%CI [1.39-6.4]) (Fig B). Finally, the specific adjudication of RAS-like opacities had the best IOA (Kappa 0.73). Presence of RAS-like opacities was a strong predictor of death/ReTx (HR 2.3, 95%CI [1.2-4.5]) (Fig C). PFT interpretation is challenging in SLTX. Using a classification relying more on imaging analysis that harboured good IOA, we obtained better prognostic performances than with a strict application of published physiologic cut-offs.