the use of high-risk donors decreases one-year survival in high-risk lung recipients matthew...

The use of high-risk donors decreases one-year survival in high-risk lung

recipients

Matthew Mulligan, Pablo G Sanchez, Charles F Evans, Sina Rahimpour, Irina Timofte, Keshava Rajagopal,

Aldo T Iacono, June Kim, James S Gammie, Bartley P Griffith, Si M Pham

University of Maryland School of Medicine

Disclosure• I have no conflicts of interest

• 56% of lung transplants used extended donors (Reyes 2010)

• Use not associated with reduced survival (Gabbay 1999; Bhorade 2000; Orens 2003; Meers 2010)

• Paucity of data on matching donor quality and recipient severity

• Single Institutional review

• Use of extended donors not associated with reduced survival in extended recipients

High-Risk Donors

&High-Risk Recipients

Poor Outcomes

Clinical Impression

We hypothesize that use of high-risk donors with high-risk recipients is associated with decreased 1-year survival

Methods• Review of UNOS Database

– 2005-2012– Post LAS

• 9,015 Transplant Recipients• Inclusion: ≥18 years old• Exclusion: ECMO, Re-transplants

High-Risk Donors

Low-Risk Donors Low-Risk Recipients

High-Risk Recipients

Vs.

Outcomes:• 1-year transplant survival• 1-year post registration survival

Donor Risk Stratification

• High-Risk Donors?

• Multivariable Cox-hazard regressions

• Deviations from ideal donor factors on 1-year transplant survival

Bhorade et al. JHLT 2000

Standard Donor Criteria

Donor Risk Stratification

Donor Variables HR (95% CI)

Age≥55 1.2 (1.1-1.5)

Cigarette Use ≥ 20 P-Y 1.2 (1.0-1.4)

Diabetes 1.3 (1.1-1.6)

Donor Risk Stratification

Donor Variables Hazard Ratio (95% CI)

PaO2≤300 1.0 (0.9-1.1)

Abnormal Chest X-Ray 0.9 (0.8-1.0)Purulent Secretions 1.0 (0.9-1.2)

Blood Infection 1.0 (0.8-1.2)

No association

with1-year

survival

Donor Risk Stratification

High-Risk Donors

Age≥55 or

Smoking ≥20 pack-years

orDiabetes

24% (n=2,155)

Low-Risk Donors

Everyone else

76% (n=6,680)

Recipient Risk Stratification• High-Risk Recipients?

• LAS≥60 associated with decrease in survival after transplant (Liu 2010)

Recipient Risk Stratification

High-Risk Recipients

LAS≥60

8% (n=679)

Low-Risk Recipients

LAS<60

92% (n=8,336)

OUTCOMES

1-Year Transplant Survival

• Lower survival associated with high-risk donors in high-risk recipients

• Benefit of using high-risk donors over no transplantation?

• 1-year post registration survival

1-Year Post-Registration Survival

• Waitlist Mortality

• Candidates not transplanted

Summary• Independent donor variables that affect 1-year survival

– age≥55, smoking≥20 P-Ys, diabetes High-risk Donor

• High-risk donors in recipients with LAS<60: marginal survival disadvantage

• High-risk donors in recipients with LAS≥60: markedly decreased survival

• Nevertheless high-risk donors into high-risk recipients: better survival than no transplant.

Conclusion• First large database analysis demonstrating

that matching donor quality with recipient status is critical to achieve optimal outcomes in lung transplantation

Thank You