Lung Transplantation from ICU does not affect long-term patient and allograft survival

R.A.S. Hoek, L. Seghers, E. Mahtab, J.A. Bekkers, R.J. van Thiel, D. Dos Reis Miranda, H.C. Hoogsteden, M.E. Hellemons

Friday 16 march 2018

11:20 - 11:30h at Willem Burger Zaal

Categories: Clinical, Session (parallel)

Parallel session: Parallel session 13: Clinical

Introduction

Lung transplantation (LuTx) is the last remaining therapy for selected patients with end-stage pulmonary disease. ICU treatment and ventilatory support before LuTx increases the risk of death within 1 year after LuTx by 58%. Due to donor organ shortage as well as the introduction of the Lung Allocation Score (LAS) LuTx from ICU (ICLT) is increasing, up to 14% in 2016 in the US. As in our center the number of ICLT is likewise increasing, we aimed to see if outcomes are sufficient to justify this practice, and secondly if differences exist between ICLT from mechanical ventilation (MV) and extra corporal life support (ECLS).

MethodstWe retrospectively assessed all lung transplantations performed from ICU at our center from 2002-2017. We collected patients characteristics, MV or ECLS support and compared outcome to our non-ICU cohort regarding ICU and hospital stay, number of surgical complications as well as patient and graft survival using survival analyses..

Results

We performed 171 non ICU LuTx and 21 ICLT: 10 from MV (5 patients with CF, 3 with COPD and 2 with ILD) and 11 on ECLS (1 with CF, 2 with COPD and 8 with ILD). Mean duration of ICU admission prior to ICLT was 42±26 days, all patients were awake and ambulated and underwent active rehabilitation prior to LuTx. Mean age of the patients that underwent ICLT was similar to non ICU LuTx. Post-ICLT ICU admission duration as well as total hospital admission duration was significantly longer in ICLT versus non ICU LuTx (median 32 [IQR 14-58] versus 7 [4-27] days, P=0.01 and 61 [35-110] versus 35 [25-60] days, P=0.01 respectively). Number of re-thoracotomies was also significantly higher in ICLT versus non ICU LuTX (69 versus 24%,P<0.01), especially in patients on ECLS (89%) compared to MV (43%). Patient survival in the ICLT group was similar at 1 and 5 years (90,5% vs 83,7 and 90,5% vs 71,9% respectively, P=0.61). In the ECLS group, survival at 1 and 5 year was 80%. In the MV group, survival at 1 and 5 year was 100%. Also the development of chronic lung allograft dysfunction was comparable in both groups (P=0.33).

Conclusion

Despite increased number of complications early post-LuTx, especially in ECLS, and extended ICU and hospital admission duration, outcomes regarding long-term patient and graft survival are similar to our non-ICU cohort. Our centers opinion therefore is that ICLT in carefully selected, awake patients is feasible.