Outcomes in Patients with Severe Pulmonary Infections prior to Heart-Lung Transplantation

Background:

Existing literature on pulmonary infections prior to lung transplant are very limited and have been focused mainly on cystic fibrosis patients. We sought to assess the impact of multi-drug resistant pulmonary infections prior to heart-lung transplantation (HLT) on overall survival in the entire HLT population.

Objective:

To determine whether a history of pan-resistant bacterial lung infection (PBLI) prior to HLT  or history of more than two pulmonary sepsis episodes (PSE) treated with intravenous antibiotics in the last 12 months prior to transplantation have an impact on overall survival in HLT recipients.

Methods:

We did a post-hoc analysis of the limited access dataset of United Network for Organ Sharing (UNOS)/ Organ Procurement and Transplantation Network (OPTN). All adult HLT recipients with complete details on PBLI, PSE and follow-up (n = 10,092) were included in the analysis. Univariate analysis was done to determine the significant predictors of survival. In addition to the significant univariate predictors, potential risk factors were also adjusted as ‘a priori’ analysis in the multivariate Cox proportional hazards model (Table).

Results:

There were 10,092 patients included in the analysis. There were 1230 patients with recently treated PSE and 202 recipients with PBLI; of which 641 (52%) and 99 (48%) died respectively over a mean follow up of 5 years. Mean age was 50 ± 12 years; 51% were males, mean FEV1 and FVC at the time of transplant were 33% and 50% respectively. On multivariate analysis, both PSE (HR: 1.09, 95% CI: 0.91 to 1.27, p = 0.37) and PBLI (HR: 1.35, 95% CI: 0.84 to 2.17, p = 0.22) did not affect the overall survival of the patients. Other significant multivariate predictors are listed in the table.

Conclusions:

No significant difference in patient survival was noted based on the history of severe pulmonary infections in the year prior to HLT. Further research in this area would broaden the spectrum of the pool of the HLT candidates.

Table 1: Multivariate predictors of all-cause mortality in adjusted analysis*(n = 10,092)

Pre-Transplant Characteristics Hazard Ratio 95% C.I. P-Value Treated Pulmonary Episodes 1.01 0.85 to 1.20 0.89 Pan-resistant lung infection 1.34 0.83 to 2.15 0.24 Age of recipient 1.005 1.000 to 1.010 0.04 Age of the Donor 1.004 1.000 to 1.008 0.05 HLA Mismatch 1.06 1.01 to 1.11 0.01 FEV1 1.004 1.001 to 1.007 0.02 FVC 0.996 0.992 to 0.999 0.01 Cause of Transplant 1.17 1.03 to 1.32 0.01 Steroid Use 0.89 0.81 to 0.99 0.04 Hypertension 0.83 0.75 to 0.92 0.0003 O2 Requirement 1.04 1.01 to 1.06 0.01

* Analysis adjusted for age of the recipient and donor, ethnicity, ABO mismatch, HLA mismatch, cause of death, FEV1, FVC, diagnosis, malignancy, steroid use, transfusion history, peptic ulcer disease, diabetes, hypertension, receipient BMI, total bilirubin, creatinine and oxygen requirement.