High Grade Primary Graft Dysfunction after Lung Transplantation is Associated with Acute Rejection but Not Chronic Allograft Dysfunction

Long-Term Survival Following Primary Graft Dysfunction Development in Lung Transplantation

INTRODUCTION

Primary graft dysfunction (PGD) is a known risk factor for early mortality following lung transplant (LT). However, the outcomes of patients who achieve long-term survival following index hospitalization are unknown. We aimed to determine the long-term association of PGD grade 3 (PGD3) in patients without in-hospital mortality.

METHODS

LT recipients were identified from the United Network for Organ Sharing Database. Patients were stratified based on the grade of PGD at 72 h (No PGD, Grade 1/2 or Grade 3). Groups were assessed with comparative statistics. Long-term survival was evaluated using Kaplan-Meier methods and a multivariable shared frailty model including recipient, donor, and transplant characteristics.

RESULTS

The PGD3 group had significantly increased length of stay, dialysis, and treated rejection post-transplant (P < 0.001). Unadjusted survival analysis revealed a significant difference in long-term survival (P < 0.001) between groups; however, following adjustment, PGD3 was not independently associated with long-term survival (hazard ratio: 0.972; 95% confidence interval: 0.862-1.096). Increased mortality was significantly associated with increased recipient age and treated rejection. Decreased mortality was significantly associated with no donor diabetes, bilateral LT as compared to single LT, transplant in 2015-2016 and 2017-2018, and no post-transplant dialysis.

CONCLUSIONS

While PGD3 remains a challenge post LT, PGD3 at 72 h is not independently associated with decreased long-term survival, while complications such as dialysis and rejection are, in patients who survive index hospitalization. Transplant providers should be aggressive in preventing further complications in recipients with severe PGD to minimize the negative association on long-term survival.

Baseline lung allograft dysfunction in primary graft dysfunction survivors after lung transplantation

BACKGROUND

Primary graft dysfunction (PGD) after lung transplantation has previously been associated with increased risk of death and chronic lung allograft dysfunction (CLAD), but the relationship to baseline lung allograft dysfunction (BLAD), where graft function fails to normalize, is not known.

METHODS

We reviewed all double lung transplant recipients transplanted in our program 2004-2016. We defined PGD and CLAD as per recent consensus definitions and BLAD as failure to achieve both FEV1 and FVC ≥80% predicted on 2 consecutive tests ≥3 weeks apart. We used logistic and proportional hazards regression to test the association between severe high-grade PGD (PGD3) with BLAD and CLAD respectively, adjusting for known and identified confounders.

RESULTS

446 patients met inclusion criteria and 76 (17%) developed PGD3 at 48- or 72-h post-transplant. PGD3 occurred more frequently in patients with interstitial lung disease or pulmonary vascular disease, those with higher BMIs and recipients of older donors. PGD3 was associated with more frequent (58% vs. 36%; p = 0.0008) and more severe BLAD (p < 0.0001) and increased BLAD risk in an adjusted model (OR 2.00 [95% CI 1.13-3.60]; p = 0.0182). PGD3 was not associated with CLAD frequency, severity or time to CLAD onset in an adjusted model (HR 1.10 (95% CI 0.64-1.78), p = 0.7226).

CONCLUSION

Severe PGD was associated with increased risk and severity of BLAD but not CLAD. The mechanisms via which PGD may mediate baseline function warrant further investigation.