Abstract
Objective
End-stage lung disease from severe COVID-19 infection is an increasingly common indication for lung transplantation (LT), but there are limited data on outcomes. We evaluated 1-year COVID-19 LT outcomes.
Methods
We identified all adult US LT recipients January 2020 to October 2022 in the Scientific Registry for Transplant Recipients, using diagnosis codes to identify recipients transplanted for COVID-19. We used multivariable regression to compare in-hospital acute rejection, prolonged ventilator support, tracheostomy, dialysis, and 1-year mortality between COVID-19 and non-COVID-19 recipients, adjusting for donor, recipient, and transplant characteristics.
Results
LT for COVID-19 increased from 0.8% to 10.7% of total LT volume during 2020 to 2021. The number of centers performing LT for COVID-19 increased from 12 to 50. Recipients transplanted for COVID-19 were younger; were more likely to be male and Hispanic; were more likely to be on a ventilator, extracorporeal membrane oxygenation support, and dialysis pre-LT; were more likely to receive bilateral LT; and had higher lung allocation score and shorter waitlist time than other recipients (all P values < .001). COVID-19 LT had higher risk of prolonged ventilator support (adjusted odds ratio, 2.28; P < .001), tracheostomy (adjusted odds ratio 5.3; P < .001), and longer length of stay (median, 27 vs 19 days; P < .001). Risk of in-hospital acute rejection (adjusted odds ratio, 0.99; P = .95) and 1-year mortality (adjusted hazard ratio, 0.73; P = .12) were similar for COVID-19 LTs and LTs for other indications, even accounting for center-level differences.
Conclusions
COVID-19 LT is associated with higher risk of immediate postoperative complications but similar risk of 1-year mortality despite more severe pre-LT illness. These encouraging results support the ongoing use of LT for COVID-19–related lung disease.
Key Words: COVID-19, lung transplant, outcomes
Mortality after lung transplants for COVID-19 versus other indications in the United States, 2020-2022.
Central Message.
Recipients of lung transplants performed for COVID-19 had higher risk of postoperative complications but similar risk of 1-year mortality despite more severe illness before lung transplant.
Perspective.
Severe COVID-19 infection is an increasingly common indication for lung transplant, with 10% of lung transplants in the United States in 2021 performed for COVID-19. Recipients of lung transplants performed for an indication of COVID-19 have higher risk of immediate postoperative complications but similar risk of 1-year mortality despite more severe pretransplant illness.
See Commentary on page XXX.
End-stage lung disease due to severe COVID-19 infection is an increasingly common indication for lung transplant (LT),1 , 2 with 7% of LT between August 2020 and September 2021 performed for this indication.3 As COVID-19 transitions from a pandemic to an endemic disease, data regarding the outcomes of transplants for this indication are needed. The addition of COVID-19-specific diagnosis codes to national transplant registry data have assisted these efforts,4 allowing evaluation of COVID-19–related LT outcomes on a national scale.
Early data suggested that LT for sequelae of severe COVID-19, including COVID-19 acute respiratory distress syndrome (ARDS) and COVID-19 pulmonary fibrosis, were technically challenging due to severe pleural adhesions and transfusion requirements but had similar outcomes to LT performed for other indications.5 However, these reports were limited to case series,5, 6, 7, 8, 9 small national cohorts including fewer than 20 COVID-19-related LTs,10 , 11 or short follow-up time points.4 Florissi and colleagues4 published one of the most comprehensive comparisons to date, finding that recipients of LT for an indication of COVID-19 had similar 90-day survival to non–COVID-19 ARDS LT recipients. However, their use of a historical cohort of ARDS patients from 2009 to 2022 and low sample size resulted in limited power and comparability to current COVID-19 LT outcomes. Additionally, longer-term comparisons to the general LT recipient population are needed to confirm that LT is a safe treatment for these recipients, who often have more severe illness and pretransplant debilitation than other waitlist candidates, and that they have sufficiently acceptable outcomes to warrant use of the limited lung allograft supply.
Therefore, we used national registry data to evaluate trends in the uptake of LT for COVID-19–related disease and 1-year post-LT outcomes of recipients transplanted for COVID-19–related disease versus other indications. In addition to characterizing the population of recipients transplanted for COVID-19, we assessed both short-term outcomes - including acute rejection, post-LT ventilator support, and tracheostomy - and 1-year mortality risk.
Methods
Data Source
This study used data from the Scientific Registry of Transplant Recipients (SRTR). The SRTR data system includes data on all donor, wait-listed candidates, and transplant recipients in the United States, submitted by the members of the Organ Procurement and Transplantation Network (OPTN). The Health Resources and Services Administration, US Department of Health and Human Services provides oversight to the activities of the OPTN and SRTR contractors. This dataset has previously been described elsewhere.12
Study Population
Using SRTR data, we identified all adult (aged 18 years or older) LT recipients in the United States from January 1, 2020, through October 31, 2022. Data were administratively censored on November 1, 2022. We classified recipients as receiving LT for an indication of COVID-19 if their primary diagnosis code in SRTR was 1616 (COVID-19 ARDS) or 1617 (COVID-19 pulmonary fibrosis). These codes have been available in SRTR/OPTN since October 28, 2020.13 We excluded recipients of prior transplants, multiorgan transplants, or lobar LTs. This study was deemed exempt for the need for institutional review board approval by the Johns Hopkins Institutional Review Board (NA_00042871, approved September 14, 2013).
Temporal Trends in Performing LT for an Indication of COVID-19–Related Lung Disease
We quantified the number of LT performed for an indication of COVID-19–related disease in each year of the study period, as well as the percentage of annual LT that these transplants represented. We also quantified the number of centers performing LT for COVID-19–related disease in each year of the study period.
Donor, Recipient, and Transplant Characteristics
We assessed the normality of variables using Shapiro-Wilk testing and histogram visualization. We then compared the donor, recipient, and transplant characteristics of LT performed for COVID-19 versus other indications using χ2 and Wilcoxon rank-sum testing. We empirically included donor and recipient age, sex, and race as covariates in our multivariable models, which are described in greater detail below. Additional covariates were chosen by significance at a level of P < .1 on univariate analysis and included donor age, sex, race, and smoking history (≥20 pack-years vs <20 pack-years); recipient age, sex, race, primary diagnosis, lung allocation score (LAS); and procedure type (single vs bilateral LT). There were no missing values for donor age, sex, or race; recipient age, sex, race, diagnosis, or LAS; or for procedure type. Smoking history was missing for 161 donors (2.6%); recipients of these transplants were excluded from multivariable analyses. The same covariates were used for adjustment in all multivariable models. Additionally, we compared the donor, recipient, and transplant characteristics of LT performed for an indication of COVID-19, by year of transplant, to evaluate for secular trends in practice.
Posttransplant Outcomes
We studied incidence of posttransplant outcomes, including acute rejection (between transplant and hospital discharge), tracheostomy, prolonged ventilator support (>48 hours), length of stay, and mortality. In SRTR, mortality and graft loss are reported by individual transplant centers, and ascertainment is supplemented through linkage to the Social Security Master Death File (mortality) and the waiting list (graft loss).
For posttransplant outcomes available in SRTR as binary variables, including acute rejection, prolonged ventilator support, tracheostomy, and dialysis, we compared the proportion of recipients transplanted for COVID-19 versus other indications who experienced the outcome during the study period using χ2 or Fisher exact testing for univariate analysis and multivariable logistic regression, adjusted for donor, recipient, and transplant characteristics selected as described above. Goodness of fit of logistic regression models were evaluated with the Hosmer-Lemeshow test; all P values were >.05, so we did not reject the null hypothesis of an appropriate model fit. Posttransplant length of stay was analyzed as a continuous variable, with comparison of the distribution of length of stay between groups using Wilcoxon rank-sum testing. Given the highly skewed nature of the length of stay data, we did not perform multivariable linear regression on the length of stay data.
To evaluate post-LT mortality, we performed time-to-event analysis and visualized the incidence of this outcome using Kaplan-Meier curves. We used Cox regression to compare the time to death among recipients transplanted for COVID-19 versus other indications, adjusting for donor, recipient, and transplant characteristics chosen as described above. As a sensitivity analysis, we also performed multilevel modeling to account for center-level clustering. Finally, we used Cox regression to compare 30-day mortality risk among recipients transplanted for an indication of COVID-19, by transplant year. We followed recipients until the outcome of interest or administrative censorship on November 1, 2022. Cox regression models were evaluated for violations of the proportional hazards assumption using complementary log-log plots, smoothed hazard estimates, and global tests of proportional hazards on the basis of Schoenfeld residuals. No violations of the proportional hazards assumption were noted for the adjusted models. All analyses were performed using Stata 16.1/SE for Windows (StataCorp).
Sensitivity Analyses
To test model assumptions for our main outcome of posttransplant mortality, we performed multiple sensitivity analyses. These included restricting the control group to patients with restrictive disease, restricting analysis to patients on extracorporeal membrane oxygenation (ECMO) pretransplant, restricting analysis to patients on dialysis pretransplant, adding year of transplant to the model, and performing propensity matching instead of multivariable regression to ensure that appropriate controls were being used. For propensity score matching, the same covariates were used to generate the propensity score that were used for adjustment in the multivariable regression models. For analyses restricted to a smaller subpopulation (eg, those on pretransplant ECMO), fewer covariates were used for adjustment for some of these models due to the lower number of events to ensure an event-to-covariate ratio of no less than 20:1. When a different set of covariates was used in the model, this is noted in the text of the Results section. Because these additional analyses were performed to test model assumptions, no P value adjustments were required.
Results
Use of LT for Treatment of COVID-19–Related Disease
The number of LTs performed for COVID-19–related disease increased from 20 in 2020 to 258 in 2021, representing an increase from 0.8% to 10.7% of annual LTs (Figure 1 ). Through October of 2022, 138 LTs for COVID-19 had been performed, representing 9.4% of LT volume nationally for the year. The number of centers performing LT for COVID-19 similarly increased from 12 in 2020 to 50 in 2021; 48 centers have performed LT for COVID-19 in 2022 using data through July. The median (interquartile range [IQR]) number of LTs for COVID-19 performed at these centers was 3.5 (IQR, 1-7).
Figure 1.
Percentage of lung transplants performed for an indication of COVID-19, by year. ∗Only includes lung transplants performed January through October 2022.
Study Population
For the 6274 LTs represented in the dataset, recipients transplanted for COVID-19 were younger (median, 51 vs 63 years; P < .001); more likely to be men (75.5% vs 60.6%; P < .001), Hispanic (30.5% vs 11.6%; P > .001), on a ventilator pre-LT (45.2% vs 4.0%; P < .001), on ECMO pre-LT (56.5% vs 5.3%; P < .001), and on dialysis pre-LT (2.4% vs 0.3%; P < .001); and had a higher LAS (median, 88 vs 41; P < .001) than other recipients (Table 1 ). They were more likely to receive bilateral LT (92.1% vs 78.5%; P < .001) and had shorter waitlist times (median, 13 vs 37 days; P < .001).
Table 1.
Donor, recipient, and transplant characteristics by donor and recipient COVID-19 status
| Characteristic | Non-COVID | COVID | P value |
|---|---|---|---|
| N | 5858 | 416 | |
| Donor characteristics | |||
| Age (y) | 34 (25-47) | 34 (24-43) | .11 |
| Male sex | 61.1 | 61.3 | .95 |
| White race | 58.7 | 53.8 | .09 |
| Cause of death | .91 | ||
| Anoxia | 36.7 | 36.5 | |
| Stroke | 24.6 | 23.6 | |
| Head trauma | 36.3 | 38.0 | |
| Other | 2.4 | 2.9 | |
| Smoking history (>20 pack-years) | 7.4 | 6.0 | .30 |
| Recipient characteristics | |||
| Age (y) | 63 (56-68) | 51 (41-57) | <.001 |
| Male sex | 60.6 | 75.5 | <.001 |
| Race/ethnicity | <.001 | ||
| White | 73.7 | 54.3 | |
| Black | 10.2 | 6.5 | |
| Hispanic | 11.6 | 30.5 | |
| Other | 4.5 | 8.7 | |
| Diagnosis | <.001 | ||
| Obstructive | 19.9 | 0.0 | |
| Pulmonary vascular | 6.1 | 0.0 | |
| Cystic fibrosis and immunodeficiency | 2.1 | 0.0 | |
| Restrictive | 44.2 | 100.0 | |
| Other | 27.7 | 0.0 | |
| Blood type | .13 | ||
| O | 46.5 | 52.4 | |
| A | 38.4 | 34.1 | |
| B | 11.5 | 10.6 | |
| AB | 3.7 | 2.9 | |
| On ventilator pretransplant | 4.0 | 45.2 | <.001 |
| FEV1 (% predicted) | 44 (28-60) | 37 (27-54) | .02 |
| On ECMO pretransplant | 5.3 | 56.5 | <.001 |
| On dialysis pretransplant | 0.3 | 2.4 | <.001 |
| Waitlist time (d) | 37 (12-109) | 13 (6-27) | <.001 |
| Lung allograft ischemia time (h) | 5.7 (4.7-7.0) | 5.9 (5.1-7.1) | .01 |
| Donation after circulatory death | 7.8 | 5.3 | .06 |
| Procedure, bilateral transplant | 78.5 | 92.1 | <.001 |
| Lung allocation score | 41 (35-54) | 88 (80-91) | <.001 |
Values are presented as median (interquartile range) or %. FEV1, Forced expiratory volume in 1 second; ECMO, extracorporeal membrane oxygenation.
Over the study period, recipients undergoing LT for COVID-19 differed in the frequency of pre-LT ventilator use (2020: 55.0%, 2021: 52.3%, and 2022: 30.4%; P < .001), pre-LT ECMO use (2020: 65.0%, 2021: 62.8%, and 2022: 43.5%; P < .001), and waitlist time (median, 2020: 8 days, 2021: 11 days, and 2022: 18 days; P < .001). Recipients transplanted for COVID-19 had otherwise similar characteristics over the study period and received organs from donors of similar characteristics (Table 2 ). Median follow-up time was 1.02 years (IQR, 0.65-1.49 years) for recipients transplanted for COVID-19 and 1.36 years (IQR, 0.68-2.04 years) for all other recipients.
Table 2.
Donor, recipient, and transplant characteristics for lung transplants performed for an indication of COVID-19, by transplant year
| Characteristic | Transplant year |
P value | ||
|---|---|---|---|---|
| 2020 | 2021 | 2022∗ | ||
| N | 20 | 258 | 138 | |
| Donor characteristics | ||||
| Age (y) | 35 (28-41) | 33 (23-43) | 36 (25-43) | .47 |
| Male sex | 60.0 | 62.0 | 60.1 | .93 |
| White race | 50.0 | 53.5 | 55.1 | .96 |
| Cause of death | .25 | |||
| Anoxia | 50.0 | 36.0 | 35.5 | |
| Stroke | 10.0 | 21.3 | 29.7 | |
| Head trauma | 40.0 | 39.9 | 34.1 | |
| Other | 0.0 | 2.8 | 0.7 | |
| Smoking history (>20 pack-years) | 10.0 | 4.4 | 8.3 | .23 |
| Recipient characteristics | ||||
| Age (y) | 52 (46-57) | 51 (40-57) | 52 (42-57) | .65 |
| Male sex | 80.0 | 77.9 | 70.3 | .22 |
| Race/ethnicity | ||||
| White | 50.0 | 49.6 | 63.8 | |
| Black | 5.0 | 7.8 | 4.3 | |
| Hispanic | 45.0 | 32.2 | 25.4 | |
| Other | 0.0 | 10.5 | 6.5 | .08 |
| Diagnosis: restrictive disease | 100.0 | 100.0 | 100.0 | n/a |
| Blood type | .40 | |||
| O | 70.0 | 51.6 | 51.4 | |
| A | 30.0 | 33.3 | 36.2 | |
| B | 0.0 | 11.2 | 10.9 | |
| AB | 0.0 | 3.9 | 1.4 | |
| On ventilator pretransplant | 55.0 | 52.3 | 30.4 | <.001 |
| FEV1 (% predicted) | 38 (23-56) | 37 (26-54) | 38 (28-53) | .94 |
| On ECMO pretransplant | 65.0 | 62.8 | 42.5 | <.001 |
| On dialysis pretransplant | 10.0 | 2.3 | 1.4 | .065 |
| Waitlist time (d) | 8 (6-13) | 11 (6-23) | 18 (9-42) | <.001 |
| Lung allograft ischemia time (h) | ||||
| Donation after circulatory death | 0.0 | 6.6 | 3.6 | .25 |
| Procedure: Bilateral transplant | 100.0 | 91.1 | 92.8 | .34 |
| Lung allocation score | 89 (86-90) | 88 (83-90) | 90 (63-94) | .10 |
Values are presented as median (interquartile range) or %. FEV1, Forced expiratory volume in 1 secnod; ECMO, extracorporeal membrane oxygenation; n/a, not available.
Only includes transplants performed January through October 2022.
Transplant Hospitalization Outcomes
Recipients transplanted for COVID-19 were more likely to require prolonged ventilator support posttransplant (70.7% vs 38.0%; P < .001; adjusted odds ratio [aOR], 2.28; 95% CI, 1.76-2.96; P < .001) and tracheostomy (42.1% vs 2.8%; aOR, 5.30; 95% CI, 3.51-8.01; P < .001), and to have longer posttransplant length of stay (median, 27 days; IQR, 18-44 versus 19, IQR, 13-32; P < .001) (Figure 2 ). Recipients transplanted for COVID-19 were more likely to be on dialysis posttransplant (12.0% vs 7.6%; P = .001), even after restricting to recipients with new initiation of dialysis posttransplant (10.6% vs 7.5%; P = .02). However, risk of post-LT dialysis was similar between recipients transplanted for COVID-19 versus other indications after adjusting for donor, recipient, and transplant characteristics (aOR, 1.15; 95% CI, 0.78-1.69; P = .48).
Figure 2.
Hospital length of stay by lung transplant indication (COVID-19 vs other). The upper and lower borders of the box represent the 25th and 75th percentiles, whereas the horizontal line within the box represents the median (50th percentile). The upper and lower whiskers show the maximum and minimum values within the fences, which are defined as values within (median ± 1.5 × the interquartile range). The dots outside of the whiskers show values falling beyond the fences. IQR, Interquartile range.
Graft Rejection and Mortality
The proportion of recipients experiencing acute rejection during the transplant hospitalization was similar among recipients transplanted for COVID-19 versus other indications (7.6% vs 5.8%; P = .15), including after adjusting for donor, recipient, and transplant characteristics (aOR, 0.99; 95% CI, 0.61-1.59; P = .95) (Table 3 ). The risk of mortality at 1 year post-LT was similar among recipients transplanted for COVID-19 versus other indications (adjusted hazard ratio [aHR], 0.73; 95% CI, 0.49-1.09; P = .12) (Table E1 and Figure 3 ). This remained true after accounting for center-level differences (aHR mortality, 0.71; 95% CI, 0.43-1.17; P = .18).
Table 3.
Posttransplant outcomes of recipients transplanted for an indication of COVID-19 versus for other indications
| Outcome | Estimate | COVID-19 vs non-COVID-19 | 95% CI | P value |
|---|---|---|---|---|
| Prolonged ventilator support∗ | aOR | 2.08 | 1.61-2.67 | <.001 |
| Tracheostomy | aOR | 4.15 | 3.03-5.68 | <.001 |
| Length of stay | Median (IQR) | 27 (18-44) vs 19 (13-32) | n/a | <.001 |
| Posttransplant dialysis | aOR | 0.97 | 0.68-1.39 | .87 |
| Acute rejection before discharge | aOR | 1.01 | 0.64-1.59 | .97 |
| 1 y posttransplant mortality | aHR | 0.73 | 0.49-1.09 | .12 |
CI, Confidence interval; aOR, adjusted odds ratio; IQR, interquartile range; n/a, not available; aHR, adjusted hazard ratio.
More than 48 hours posttransplant.
Figure 3.
Mortality after lung transplants performed for COVID-19 versus other indications in the United States, 2020-2022. aHR, Adjusted hazard ratio; CI, confidence interval.
In sensitivity analyses, the risk of mortality was similar for patients transplanted for COVID-19 and for other indications when restricting to recipients transplanted for restrictive disease (aHR, 0.80; 95% CI, 0.52-1.25; P = .33), when restricting to recipients on pretransplant dialysis (HR, 0.15; 95% CI, 0.02-1.18; P = .07; unadjusted due to low number of events), and when adding transplant year to the model (aHR, 0.80; 95% CI, 0.54-1.21; P = .29). The risk of mortality for recipients transplanted for COVID-19 and for other indications also remained similar when using propensity score matching instead of multivariable Cox regression (P = .08). In a sensitivity analysis restricted to recipients on pretransplant ECMO, recipients transplanted for COVID-19 had lower mortality risk than those transplanted for other indications (aHR, 0.53; 95% CI, 0.32-0.87; P = .01). However, this model could only be adjusted for LAS due to the small sample size and number of events. By transplant year, we identified no significant differences in 30-day mortality among recipients who were transplanted for an indication of COVID-19, even after accounting for donor, recipient, and transplant characteristics (aHR mortality, 1.00; 95% CI, 0.30-3.29; P > .99).
Discussion
In this national study of utilization of LT for treatment of COVID-19–related lung disease and outcomes of these transplants, we found that COVID-19 is now the primary diagnosis for approximately 10% of LT recipients. Recipients transplanted for an indication of COVID-19 had more severe illness pretransplant than other recipients, including higher likelihood of ventilator dependence and ECMO use. Although these recipients were more likely to require prolonged posttransplant ventilation and tracheostomy, likely due to debilitation from their pretransplant disease, their 1-year post-LT survival was similar to that of other candidates.
Whereas literature on LTs for an indication of COVID-19 remains limited due to the novelty of this indication, several leading LT centers have raised concerns about whether some candidates truly have irreversible disease and are undergoing transplantation too soon.14, 15, 16 We found that the median waitlist times for recipients transplanted for COVID-19 was <2 weeks, consistent with previous reports of short waitlist times for these recipients6; unfortunately, the time since COVID-19 diagnosis was not available in this dataset. Regardless, the increasing use of LT as treatment for patients who experienced severe COVID-19 suggests that clear guidelines are needed for when to list these patients for transplant, potentially including a length of time since COVID-19 diagnosis and methods to improve assessment of irreversibility of damage.
An additional concern is the accuracy of tracking patients receiving LT for an indication of COVID-19. The United Network for Organ Sharing data collection forms collect only a primary diagnosis for LT candidates, in contrast with the collection of both primary and secondary diagnoses for liver transplant candidates.17 On review of LT recipients with COVID-19 at our own center, we confirmed that only recipients with a primary diagnosis of COVID-19 were coded with this indication in the national registry. Other recipients who had both COVID-19 infection and other underlying lung disease, which anecdotally is becoming a greater proportion of severe COVID-19 cases now that many LT candidates are vaccinated, are therefore not captured by this coding system. This lack of ability to track recipients with COVID-19 superimposed on other lung disease will limit our ability to evaluate the outcomes of these recipients.
As noted above, our ability to study national LT patterns and outcomes for an indication of COVID-19 was limited by the information available in the national registry database. Therefore, there might be unmeasured confounding influencing our estimates. The relative novelty of LT for COVID-19 also limited the number of recipients who have received LT for this indication, as well as the available follow-up time. Although 1-year outcomes are encouraging, longer-term outcomes must be monitored to ensure the safety and efficacy of this treatment strategy. Finally, we recognize that complications might be underreported due to lag of entry into the registry; this would bias our findings toward the null hypothesis of no difference between groups. However, this is a limitation of all registry data analysis.
Conclusions
We found that LT for an indication of COVID-19 increased in frequency, was performed for candidates with more severe pretransplant disease, and was associated with a higher risk of posttransplant prolonged ventilation and tracheostomy. However, these recipients had similar 1-year outcomes to recipients of LT for other indications. Therefore, the use of LT for treatment of severe COVID-19–related disease appears to be safe and efficacious, but longer-term outcomes should be monitored.
Conflict of Interest Statement
Dr Segev reports consulting and speaking honoraria from Sanofi, Novartis, CLS Behring, Jazz Pharmaceuticals, Veloxis, Mallinckrodt, and ThermoFisher Scientific. All other authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
Footnotes
Supported by grant No. F32-AG067642091A1 (to Dr Ruck) from the National Institute of Aging and No. K24-AI144954 to 08 (to Dr Segev) from The National Institute of Allergy and Infectious Disease. The analyses described here are the responsibility of the authors alone and do not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US government.
The data reported here have been supplied by the Hennepin Healthcare Research Institute as the contractor for the Scientific Registry of Transplant Recipients (SRTR). The interpretation and reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy of or interpretation by the SRTR or the US government.
IRB Number: NA_00042871.
Appendix E1
Table E1.
Multivariable Cox regression model for 1-year postlung transplant mortality risk by indication for transplant (COVID-19 vs other)
| Covariate | aHR (95% CI) | P value |
|---|---|---|
| Indication for transplant∗ | 0.73 (0.49-1.09) | .12 |
| Donor characteristics | ||
| Age, per year | 1.004 (0.998-1.010) | .23 |
| Sex, female vs male | 1.09 (0.91-1.31) | .36 |
| Race | ||
| White | Ref | |
| Black | 1.38 (1.13-1.69) | .002 |
| Other | 1.06 (0.86-1.30) | .60 |
| Smoking history, >20 pack-years vs less | 1.10 (0.81-1.50) | .53 |
| Recipient characteristics | ||
| Age, per year | 1.009 (0.999-1.018) | .06 |
| Sex, female vs male | 1.15 (0.96-1.39) | .13 |
| Race | ||
| White | Ref | |
| Black | 1.27 (0.98-1.63) | .07 |
| Other | 1.16 (0.81-1.65) | .42 |
| Diagnosis | ||
| Obstructive | Ref | |
| Pulmonary vascular | 1.26 (0.84-1.88) | .26 |
| Cystic fibrosis and immunodeficiency | 1.08 (0.52-2.23) | .84 |
| Restrictive | 1.08 (0.83-1.39) | .58 |
| Lung allocation score, per unit | 1.01 (1.00-1.02) | <.001 |
| Single vs bilateral lung transplant | 1.28 (1.05-1.57) | .02 |
COVID-19 versus other.
References
- 1.Cypel M., Keshavjee S. When to consider lung transplantation for COVID-19. Lancet Respir Med. 2020;8:944–946. doi: 10.1016/S2213-2600(20)30393-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Shah P., Neujahr D.C. Lung transplantation: candidate selection and timing of transplant. Curr Opin Organ Transplant. 2021;26:302–308. doi: 10.1097/MOT.0000000000000879. [DOI] [PubMed] [Google Scholar]
- 3.Roach A., Chikwe J., Catarino P., Rampolla R., Noble P.W., Megna D., et al. Lung transplantation for COVID-19–related respiratory failure in the United States. N Engl J Med. 2022;386:1187–1188. doi: 10.1056/NEJMc2117024. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Florissi I.S., Etchill E.W., Barbur I., Verdi K.G., Merlo C., Bush E.L. Lung transplantation in patients with COVID-19-the early national experience. Semin Thorac Cardiovasc Surg. August 28, 2022 doi: 10.1053/j.semtcvs.2022.08.008. [Epub ahead of print] [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Bharat A., Machuca T.N., Querrey M., Kurihara C., Garza-Castillon R.Jr, Kim S., et al. Early outcomes after lung transplantation for severe COVID-19: a series of the first consecutive cases from four countries. Lancet Respir Med. 2021;9:487–497. doi: 10.1016/S2213-2600(21)00077-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Kurihara C., Manerikar A., Querrey M., Felicelli C., Yeldandi A., Garza-Castillon R., Jr, et al. Clinical characteristics and outcomes of patients with COVID-19-associated acute respiratory distress syndrome who underwent lung transplant. JAMA. 2022;327:652–661. doi: 10.1001/jama.2022.0204. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Palleschi A., Crotti S., Scandroglio A.M., Lissoni A., Fominskiy E., Rosso L., et al. Lung transplant for ARDS after COVID-19: long-term outcomes and considerations about detrimental issues. J Clin Med. 2022;11:4754. doi: 10.3390/jcm11164754. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Bharat A., Querrey M., Markov N.S., Kim S., Kurihara C., Garza-Castillon R., et al. Lung transplantation for patients with severe COVID-19. Sci Transl Med. 2020;12:eabe4282. doi: 10.1126/scitranslmed.abe4282. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Wang B., Huang J., Hsin M., Chen J., Lin H. First lung transplant in Wuhan for a critical and elderly COVID-19 patient. Immun Inflam Dis. 2021;9:1500–1507. doi: 10.1002/iid3.501. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Ko R.E., Oh D.K., Choi S.M., Park S., Park J.E., Lee J.G., et al. Lung transplantation for severe COVID-19-related ARDS. Ther Adv Respir Dis. 2022;16 doi: 10.1177/17534666221081035. 17534666221081035. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Lang C., Ritschl V., Augustin F., Lang G., Moser B., Taghavi S., et al. Clinical relevance of lung transplantation for COVID-19 ARDS: a nationwide study. Eur Respir J. 2022;60:2102404. doi: 10.1183/13993003.02404-2021. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Massie A.B., Kuricka L.M., Segev D.L. Big data in organ transplantation: registries and administrative claims. Am J Transplant. 2014;14:1723–1730. doi: 10.1111/ajt.12777. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.United Network for Organ Sharing COVID-19 organ failure diagnosis codes for heart and lung candidate listings in UNet now available. https://unos.org/news/covid-19-organ-failure-diagnosis-codes-for-heart-and-lung-candidate-listings-in-unet-now-available
- 14.Rudym D., Chang S.H., Angel L.F. Characteristics and outcomes of patients with COVID-19-associated ARDS who underwent lung transplant. JAMA. 2022;327:2454. doi: 10.1001/jama.2022.6634. [DOI] [PubMed] [Google Scholar]
- 15.Manerikar A., Budinger G.R.S., Bharat A. Characteristics and outcomes of patients with COVID-19-associated ARDS who underwent lung transplant-reply. JAMA. 2022;327:2454–2455. doi: 10.1001/jama.2022.6637. [DOI] [PubMed] [Google Scholar]
- 16.King C.S., Mannem H., Kukreja J., Aryal S., Tang D., Singer J.P., et al. Lung transplantation for patients with COVID-19. Chest. 2022;161:169–178. doi: 10.1016/j.chest.2021.08.041. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.United Network for Organ Sharing UNOS Data Collection Forms. https://unos.org/data/data-collection/