Trends in marginal lung allograft survival: Advanced-age donors improve

John James Miggins; Ross Michael Reul Jr; Gabriel Loor; Liam D Ferreira; Puneet S Garcha; John A Goss; Abbas A Rana

doi:10.1111/ctr.14777

Trends in marginal lung allograft survival: Advanced-age donors improve

Clin Transplant. 2022 Sep;36(9):e14777. doi: 10.1111/ctr.14777. Epub 2022 Jul 21.

Authors

John James Miggins¹, Ross Michael Reul Jr², Gabriel Loor³, Liam D Ferreira¹, Puneet S Garcha⁴, John A Goss⁵, Abbas A Rana⁵

Affiliations

¹ Office of Student Affairs, Baylor College of Medicine, Houston, Texas, USA.
² Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.
³ Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.
⁴ Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.
⁵ Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.

PMID: 35822915
DOI: 10.1111/ctr.14777

Abstract

Introduction: Although lung demand continues to outpace supply, 75% of potential donor lungs are discarded without being transplanted in the United States. To identify the discarded cohorts best suited to alleviate the lung shortage and reduce waitlist mortality, we explored changes in survival over time for five marginal donor definitions: age >60 years, smoking history >20 pack-years, PaO₂ /FiO₂ < 300 mmHg, purulent bronchoscopic secretions, and chest radiograph infiltrates.

Methods: Our retrospective cohort study separated 27 803 lung recipients in the UNOS Database into three 5-year eras by transplant date: 2005-2009, 2010-2014, and 2015-2019. Multivariable Cox proportional hazards regression and Kaplan-Meier analysis with log-rank test were used to compare survival across the eras.

Results: Three definitions-low PaO₂ /FiO₂ , purulent bronchoscopic secretions, and abnormal chest radiographs-did not bear out as truly marginal, demonstrating lack of significantly elevated risk. Advanced donor age demonstrated considerable survival improvement (HR (95% CI): 1.47 (1.26-1.72) in 2005-2009 down to 1.14 (.97-1.35) for 2015-2019), with protective factors being recipients <60 years, moderate recipient BMI, and low Lung Allocation Score (LAS). Donors with smoking history failed to demonstrate any significant improvement (HR (95% CI): 1.09 (1.01-1.17) in 2005-2009 increasing to 1.22 (1.08-1.38) in 2015-2019).

Conclusions: Advanced donor age, previously the most significant risk factor, has improved to near-benchmark levels, demonstrating the possibility for matching older donors to healthier non-elderly recipients in selected circumstances. Low PaO₂ /FiO₂ , bronchoscopic secretions, and abnormal radiographs demonstrated survival on par with standard donors. Significant donor smoking history, a moderate risk factor, has failed to improve.

Keywords: advanced-age; cigarette use; extended donor criteria; hazard ratio; marginal lung; organ allocation; risk assessment.

MeSH terms

Age Factors
Allografts
Humans
Lung
Lung Transplantation*
Middle Aged
Retrospective Studies
Tissue Donors
Tissue and Organ Procurement*
Treatment Outcome
United States / epidemiology