Survival similar in lung transplantation for COVID-19-related ARDS, pulmonary fibrosis
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Key takeaways:
- Survival rates following transplantation did not differ between those with COVID-19 related ARDS or pulmonary fibrosis.
- Both groups also had similar rates of freedom from graft failure.
Patients with COVID-19-related acute respiratory distress syndrome undergoing transplantation had comparable, high survival rates to patients with COVID-19-related pulmonary fibrosis, according to results published in JAMA Surgery.
Further, survival rates from these patients did not differ from those of patients who underwent lung transplantation for a non-COVID-19-related reason, according to researchers.
“The findings of this study suggest that lung transplant offers encouraging early results in patients with COVID-19-related ARDS and [pulmonary fibrosis (PF)],” Panagiotis Tasoudis, MD, postdoctoral researcher in the department of cardiothoracic surgery at University of North Carolina at Chapel Hill, and colleagues wrote.
Using information from the U.S. United Network for Organ Sharing database, Tasoudis and colleagues analyzed 195 patients (median age, 46 years; 72.8% men; median allocation score, 88.3) who underwent a lung transplant for COVID-19 related ARDS and 190 patients (median age, 54 years; 78.9% men; median allocation score, 78.5) who underwent a lung transplant for COVID-19-related PF between March 2020 and August 2022 to evaluate survival and graft failure after the procedure in both sets of patients.
Researchers used the Kaplan-Meier method to figure out overall survival and Cox proportional regression models to find out which demographics/characteristics are linked to poor survival.
After transplantation, 15.3% of patients from the ARDS cohort needed dialysis, and this percentage was slightly lower (10.3%) for patients from the PF cohort.
Notably, hospitalization was extended among those from the ARDS cohort vs. the PF cohort (median, 30 days vs. 22 days), which might be due to the group’s higher prevalence of extracorporeal membrane oxygenation support needed on the third day after surgery (30.1% vs. 20%).
Both groups had comparable median times to follow-up, with 186 days among those who had ARDS and 181 days among those who had PF.
When comparing patients who received a transplant for PF with patients who received a transplant for ARDS, researchers observed similar high survival rates at 1 month (0.96; 95% CI, 0.92-0.98 vs. 0.99; 95% CI, 0.96-0.99), 6 months (0.92; 95% CI, 0.86-0.96 vs. 0.95; 95% CI, 0.91-0.98) and 12 months (0.84; 95% CI, 0.74-0.9 vs. 0.88; 95% CI, 0.8-0.94).
Further, both sets of patients had a comparable prevalence of acute rejection events (ARDS cohort, 16 instances; 8.7%; PF cohort, 15 instances; 8.6%).
Researchers additionally found little difference between both groups when assessing rates of freedom from graft failure at 1 month (ARDS cohort, 0.98; 95% CI, 0.96-0.99; PF cohort, 0.96; 95% CI, 0.92-0.98), 6 months (0.95; 95% CI, 0.9-0.97; 0.93; 95% CI, 0.87-0.96) and 12 months (0.88; 95% CI, 0.79-0.93; 0.85; 95% CI, 0.74-0.91) after transplantation.
Primary graft dysfunction following transplantation — represented through a partial pressure of oxygen/fraction of inspired oxygen ratio below 300 — was observed in both the ARDS cohort (median, 297) and the PF cohort (median, 279).
Factors linked to poor overall survival differed between both cohorts. Patients who previously had ARDS had unfavorable survival rates if they received a lung from someone with a heavy and prolonged smoking history. In contrast, those previously with PF faced lower rates of survival if they were a woman, had a high BMI and received a lung from a man.
In an additional analysis evaluating transplants given to patients with COVID-19-related lung diseases and transplants given to patients with non-COVID-19 etiologies, researchers found that survival did not significantly differ between both types of patients.
“Further evidence is warranted from high-quality studies in order to elucidate the role of lung transplant for irreversibly COVID-19-related lung injury, clarify its indications and contraindications and lead to a paradigm shift in the management of patients with and following COVID-19,” Tasoudis and colleagues wrote.
Perspective
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This paper is a retrospective review on the outcomes of lung transplant post-COVID illness. The patients are grouped into acute illness (ARDS) and post-COVID pulmonary comorbidity, primarily fibrosis. COVID-related acute pulmonary illness and post-acute illness survivors presenting with fibrosis are the most common indications for lung transplant.
This study shows that lung transplant can be a viable lifesaving option with good outcomes in carefully selected patients with minimal preexisting comorbidities with acute ARDS secondary to COVID illness. Post-COVID fibrosis is usually a disease secondary to acute illness, which is usually not a progressive illness like idiopathic pulmonary fibrosis. Lung transplant in patients who are acutely ill on extracorporeal membrane oxygenation and mechanical ventilation carries extensive post-transplant comorbidities such as renal failure requiring hemodialysis and a prolonged ICU and/or hospital stay. This translates into high costs of care when compared with historical cohorts. Most transplants happened in Southern states, as the Northeastern states were paralyzed during the first wave of the COVID pandemic, and many institutions had to close their operating rooms for elective surgeries.
Photo Credit: Mount Sinai Health System
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