Blood product transfusion and lung transplant outcomes: A systematic review

Donor Specific Antibodies in Extracorporeal Membrane Oxygenation-Bridged Lung Transplant Recipients

Background

Extracorporeal membrane oxygenation (ECMO) is increasingly used as a bridge to lung transplantation. Although other mechanical circulatory support devices have been associated with anti-human leukocyte antigen antibody formation, including de novo donor-specific antibodies (dnDSA), it is unknown whether ECMO is a sensitizing exposure.

Methods

This was a single-center retrospective cohort study of lung transplant recipients. We compared dnDSA development in ECMO-bridged and non-ECMO exposed recipients. We also assessed differences in chronic lung allograft dysfunction-free survival between ECMO-bridged recipients with and without dnDSA, and between those who developed dnDSA with and without ECMO bridge.

Results

Among 299 transplant recipients, 48 were ECMO-bridged and 251 were non-ECMO exposed. dnDSA developed in 33.3% of ECMO-bridged and 21.5% of non-ECMO exposed recipients. ECMO was associated with dnDSA development in bivariate (hazard ratio [HR], 2.08, 95% CI, 1.19-3.64, P = .01) but not multivariate analysis after adjusting for known confounders (HR, 1.10, 95% CI, 0.50-2.42, P = .82). Higher posttransplant transfusion volume was independently associated with dnDSA development (HR, 4.68, 95% CI, 2.25-9.72, P < .001). ECMO-bridged recipients with dnDSA did not have worse adjusted chronic lung allograft dysfunction-free survival than those without dnDSA (HR, 0.35, 95% CI, 0.07-1.87, P = .22) or compared to non-ECMO exposed recipients with dnDSA (HR, 0.40, 95% CI, 0.08-2.00, P = .27).

Conclusions

A more restrictive posttransplant transfusion threshold among ECMO-bridged lung transplant recipients may reduce the risk of dnDSA. Surveillance for dnDSA, at least among ECMO-bridged recipients, may only be necessary in the presence of allograft dysfunction.

Impact of blood donation biovigilance and transfusion-transmitted infections on organ transplantation

Over 118 million blood donations are collected globally each year. Recipients of blood products include those who experience major trauma or surgery, have acute blood loss and anemia, or impaired bone marrow function. Solid organ transplant recipients often require transfusion of blood products which places them at risk of transfusion-associated adverse events including transfusion-transmitted infection. National hemovigilance networks have documented low rates of transfusion-transmitted infection in the general population. Incidence transfusion-transmitted infection continues to occur in solid organ transplant patients and arises mainly from existing gaps in blood donor biovigilance processes. Emerging infectious diseases have highlighted existing gaps in the donor-recipient pathway to administering safe blood products. This article reviews the current process and regulatory oversight of blood donor biovigilance, including donor screening and microbiological testing, highlights cases of transfusion-transmitted infection documented in the literature, and addresses ways in which biovigilance may be improved, with a focus on the impact of solid organ transplantation.

ISHLT consensus statement on the perioperative use of ECLS in lung transplantation: Part II: Intraoperative considerations

The use of extracorporeal life support (ECLS) throughout the perioperative phase of lung transplantation requires nuanced planning and execution by an integrated team of multidisciplinary experts. To date, no multidisciplinary consensus document has examined the perioperative considerations of how to best manage these patients. To address this challenge, this perioperative utilization of ECLS in lung transplantation consensus statement was approved for development by the International Society for Heart and Lung Transplantation Standards and Guidelines Committee. International experts across multiple disciplines, including cardiothoracic surgery, anesthesiology, critical care, pediatric pulmonology, adult pulmonology, pharmacy, psychology, physical therapy, nursing, and perfusion, were selected based on expertise and divided into subgroups examining the preoperative, intraoperative, and postoperative periods. Following a comprehensive literature review, each subgroup developed recommendations to examine via a structured Delphi methodology. Following 2 rounds of Delphi consensus, a total of 39 recommendations regarding intraoperative considerations for ECLS in lung transplantation met consensus criteria. These recommendations focus on the planning, implementation, management, and monitoring of ECLS throughout the entire intraoperative period.

The Risk of Pretransplant Blood Transfusion for Primary Graft Dysfunction After Lung Transplant

Background

Primary graft dysfunction (PGD) is the leading cause of short- and long-term mortality associated with lung transplantation. The impact of pretransplantation blood transfusions for recipients is not fully elucidated.

Methods

This is a retrospective review of 206 consecutive lung transplantations performed at a single academic center (Northwestern University Feinberg School of Medicine, Chicago, IL) from January 2018 to July 2022. Data on patient characteristics, pretransplantation laboratory values, transfusion requirements, and intraoperative and postoperative outcomes were collected.

Results

PGD grade 3 (PGD 3) occurred in 13.2% of the cohort (n = 28). A total of 33 patients received a blood transfusion within 4 weeks, whereas 21 patients received a blood transfusion a week before their lung transplant. Pretransplantation transfusions were strongly associated with a higher incidence of PGD 3 (48.5% vs 6.9%; P < .001). There was no significant difference in 1-year survival between the pretransplantation transfused group and the nontransfused group (77.7% vs 88.0%; P = .478). The 1year survival was reduced in recipients with PGD 3 compared with recipients without PGD 3 (63.5% vs 89.9%; P = .0012). In univariate analysis, pretransplant and intratransplant predictors of PGD 3 included younger age (P < .01), pretransplant extracorporeal membrane oxygenation (ECMO) use (P < .001), higher lung allocation score (P < .001), coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome (P < .01), blood transfusion within 4 weeks (P < .001), longer operative time (P < .001), intratransplant blood transfusion (P < .001), and intratransplant venoarterial ECMO use (P < .001).

Conclusions

Pretransplantation blood transfusions could be associated with a higher rate of PGD. The findings indicated the potential risks of pretransplantation blood transfusions in lung transplant recipients.

The impact of bleeding on outcomes following lung transplantation: a retrospective analysis using the universal definition of perioperative bleeding

BACKGROUND

Lung transplantation (LT) represents a high-risk procedure for end-stage lung diseases. This study describes the outcomes of patients undergoing LT that require massive transfusions as defined by the universal definition of perioperative bleeding (UDPB).

METHODS

Adult patients who underwent bilateral LT at a single academic center were surveyed retrospectively. Patients were grouped by insignificant, mild, or moderate perioperative bleeding (insignificant-to-moderate bleeders) and severe or massive perioperative bleeding (severe-to-massive bleeders) based on the UDPB classification. Outcomes included 1-year survival and primary graft dysfunction (PGD) of grade 3 at 72 h postoperatively. Multivariable models were adjusted for recipient age, sex, body mass index (BMI), Lung allocation score (LAS), preoperative hemoglobin (Hb), preoperative extracorporeal membrane oxygenation (ECMO) status, transplant number, and donor status. An additional multivariable model was created to find preoperative and intraoperative predictors of severe-to-massive bleeding. A p-value less than 0.05 was selected for significance.

RESULTS

A total of 528 patients were included, with 357 insignificant-to-moderate bleeders and 171 severe-to-massive bleeders. Postoperatively, severe-to-massive bleeders had higher rates of PGD grade 3 at 72 h, longer hospital stays, higher mortality rates at 30 days and one year, and were less likely to achieve textbook outcomes for LT. They also required postoperative ECMO, reintubation for over 48 h, tracheostomy, reintervention, and dialysis at higher rates. In the multivariate analysis, severe-to-massive bleeding was significantly associated with adverse outcomes after adjusting for recipient and donor factors, with an odds ratio of 7.73 (95% CI: 4.27-14.4, p < 0.001) for PGD3 at 72 h, 4.30 (95% CI: 2.30-8.12, p < 0.001) for 1-year mortality, and 1.75 (95% CI: 1.52-2.01, p < 0.001) for longer hospital stays. Additionally, severe-to-massive bleeders were less likely to achieve textbook outcomes, with an odds ratio of 0.07 (95% CI: 0.02-0.16, p < 0.001). Preoperative and intraoperative predictors of severe/massive bleeding were identified, with White patients having lower odds compared to Black patients (OR: 041, 95% CI: 0.22-0.80, p = 0.008). Each 1-unit increase in BMI decreased the odds of bleeding (OR: 0.89, 95% CI: 0.83-0.95, p < 0.001), while each 1-unit increase in MPAP increased the odds of bleeding (OR: 1.04, 95% CI: 1.02-1.06, p < 0.001). First-time transplant recipients had lower risk (OR: 0.16, 95% CI: 0.06-0.36, p < 0.001), whereas those with DCD donors had a higher risk of severe-to-massive bleeding (OR: 3.09, 95% CI: 1.63-5.87, p = 0.001).

CONCLUSION

These results suggest that patients at high risk of massive bleeding require higher utilization of hospital resources. Understanding their outcomes is important, as it may inform future decisions to transplant comparable patients.

High Rate of Passenger Lymphocyte Syndrome after ABO Minor Incompatible Lung Transplantation

Rationale: Passenger lymphocyte syndrome (PLS) may complicate minor ABO mismatched lung transplantation (LuTX) via donor-derived red cell antibody-induced hemolysis.Objectives: To ascertain the incidence and specificity of PLS-relevant antibodies among the study population as well as the dynamics of hemolysis parameters and the transfusion requirement of patients with or without PLS.Methods: In this cohort study, 1,011 patients who received LuTX between January 2010 and June 2019 were studied retrospectively. Prospectively, 87 LuTX (July 2019 to June 2021) were analyzed. Postoperative ABO antibody and hemolytic marker determinations, transfusion requirement, and duration of postoperative hospital care were analyzed. Retrospectively, blood group A recipients of O grafts with PLS were compared with those without.Measurements and Main Results: PLS affected 18.18% (retrospective) and 30.77% (prospective) of A recipients receiving O grafts, 5.13% of B recipients of O grafts, and 20% of AB patients receiving O transplants. Anti-A and anti-A1 were the predominant PLS-inducing antibodies, followed by anti-B and anti-A,B. Significantly lower hemoglobin values (median, 7.4 vs. 8.3 g/dl; P = 0.0063) and an approximately twice as high percentage of patients requiring blood transfusions were seen in PLS. No significant differences in other laboratory markers, duration of hospital stay, or other complications after LuTX were registered.Conclusions: Minor ABO incompatible LuTX recipients are at considerable risk of developing clinically significant PLS. Post-transplant monitoring combining red cell serology and hemolysis marker determination appears advisable so as not to overlook hemolytic episodes that necessitate antigen-negative transfusion therapy.

Donor and recipient risk factors for the development of primary graft dysfunction following lung transplantation

Primary Graft Dysfunction (PGD) is a major cause of both short-term and long-term morbidity and mortality following lung transplantation. Various donor, recipient, and technical risk factors have been previously identified as being associated with the development of PGD. Here, we present a comprehensive review of the current literature as it pertains to PGD following lung transplantation, as well as discussing current strategies to mitigate PGD and future directions. We will pay special attention to recent advances in lung transplantation such as ex-vivo lung perfusion, thoracoabdominal normothermic regional perfusion, and up-to-date literature published in the interim since the 2016 ISHLT consensus statement on PGD and the COVID-19 pandemic.

Development of New Donor-Specific and Human Leukocyte Antigen Antibodies After Transfusion in Adult Lung Transplantation

OBJECTIVES

The development of new human leukocyte antigens (HLAs) and donor-specific antibodies (DSAs) in patients are associated with worse outcomes following lung transplantation. The authors aimed to examine the relationship between blood product transfusion in the first 72 hours after lung transplantation and the development of HLA antibodies, including DSAs.

DESIGN

A retrospective observational study.

SETTING

At a single academic tertiary center.

PARTICIPANTS

Adult lung transplant recipients who underwent transplantation between September 2014 and June 2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 380 patients were included in this study, and 87 (23%) developed de novo donor-specific antibodies in the first year after transplantation. Eighty-five patients (22%) developed new HLA antibodies that were not donor-specific, and 208 patients (55%) did not develop new HLA antibodies in the first year after transplantation. Factors associated with increased HLA and DSA development included donor pulmonary infection, non-infectious indication for transplant, increased recipient body mass index, and a preoperative calculated panel reactive antibody value above 0. Multivariate analysis identified platelet transfusion associated with an increased risk of de novo HLA antibody development compared to the negative group (odds ratio [OR; 95% CI] 1.18 [1.02-1.36]; p = 0.025). Cryoprecipitate transfusion was associated with de novo DSA development compared to the negative group (OR [95% CI] 2.21 [1.32-3.69] for 1 v 0 units; p = 0.002).

CONCLUSIONS

Increased perioperative transfusion of platelets and cryoprecipitate are associated with de novo HLA and DSA development, respectively, in lung transplant recipients during the first year after transplantation.

Utilization of machine learning to model the effect of blood product transfusion on short-term lung transplant outcomes

The objective of this study was to identify the relationship between blood product transfusion and short-term morbidity and mortality following lung transplantation utilizing machine learning. Preoperative recipient characterstics, procedural variables, perioperative blood product transfusions, and donor charactersitics were included in the model. The primary composite outcome was occurrence on any of the following six endpoints: mortality during index hospitalization; primary graft dysfunction at 72 h post-transplant or the need for postoperative circulatory support; neurological complications (seizure, stroke, or major encephalopathy); perioperative acute coronary syndrome or cardiac arrest; and renal dysfunction requiring renal replacement therapy. The cohort included 369 patients, with the composite outcome occurring in 125 cases (33.9%). Elastic net regression analysis identified 11 significant predictors of composite morbidity: higher packed red blood cell, platelet, cryoprecipitate and plasma volume from the critical period, preoperative functional dependence, any preoperative blood transfusion, VV ECMO bridge to transplant, and antifibrinolytic therapy were associated with higher risk of morbidity. Preoperative steroids, taller height, and primary chest closure were protective against composite morbidity.

Lung Retransplantation

Lung retransplantation remains the standard treatment of irreversible lung allograft failure. The most common indications for lung retransplantation are acute graft failure, chronic lung allograft dysfunction, and postoperative airway complications. Careful patient selection with regards to indications, anatomy, extrapulmonary organ dysfunction (specifically renal dysfunction), and immunologic consideration are of utmost importance. The conduct of the lung retransplantation operation is arduous with special considerations given to operative approach, type of surgery (single vs bilateral), use of extracorporeal circulatory support, and hematological management. Outcomes have improved significantly for most patients, nearing short and midterm outcomes of primary lung recipients in select cases.