Survival decreases in high-risk lung recipients matched with high-risk donors

SEATTLE — High-risk lung transplant recipients were likelier to have an increased risk for death 1 year after transplantation from high-risk donors compared with transplants from low-risk donors, according to study results presented at the American Association for Thoracic Surgery Annual Meeting.

“We performed the first large database analysis demonstrating that matching donor quality with recipient status is critical to achieve optimal outcomes in lung transplantation,” Matthew Mulligan, BA, of the University of Maryland School of Medicine, said during a presentation. “I think this work will be important for surgeons to continue to triage donors to recipient risk factors in order to achieve optimal outcomes.”

Mulligan and colleagues analyzed 9,015 lung transplant recipients from May 2005 to December 2012 from the United Network for Organ Sharing database to investigate survival rates at 1 year after wait list registration. The researchers analyzed rates for high- and low-risk recipients who received lungs from low- or high-risk donors.

High-risk donors were identified as having a PaO₂ level of 300 or lower, smoking history of at least 20 pack-years and having diabetes, or being aged 55 years or older with a PaO₂ of no greater than 300. High-risk recipients were considered those with a lung allocation score of 60 or greater and being aged 55 years or older.

More than half (62.8%) of recipients underwent transplantation within 1 year of being placed on the wait list, and 11.5% received transplants from high-risk donors.

One-year survival was not significantly different in low-risk recipients who received transplants from either low- or high-risk (0.911 vs. 0.922) donors. One-year survival, however, was better when compared with not receiving a transplant (0.743; P = .001).

One year after wait-list registration, patient survival was reduced in high-risk recipients who received transplants from high-risk donors (0.522 vs. 0.823; P = .0001) compared with those who received organs from low-risk donors.

Although survival was reduced in high-risk recipients receiving high-risk donor transplants, it remained significantly better compared with not undergoing transplantation (0.031; P = .0001).

“Our data show that these high-risk donors and high-risk recipients are associated with a lower 1-year survival compared to low-risk donors,” Mulligan said. “However, these high-risk donors would improve the survival of the recipient compared to no transplant.”

Mulligan addressed the ethical implications of transplanting high-risk recipients with high-risk donors.

“Ethically, these patients serve to benefit through reduction in wait list mortality with the use of high-risk donors, however one must weigh the limitations of CMS and insurance companies potentially shutting down programs that don’t meet certain survival criteria,” he said. “Therefore there is a balance that each program must make to weigh patient survival on one hand with program survival on the other hand. This perhaps highlights the need for an ethical debate that should be discussed at a larger level.” – by Ryan McDonald

Reference:

Mulligan M, et al. Abstract 103. Presented at: the American Association for Thoracic Surgery Annual Meeting; April 25-29, 2015; Seattle.

Disclosure: Mulligan reports no relevant financial disclosures.