17: A prospective study of a management algorithm to minimise lung transplant (LTx) primary graft dysfunction (PGD) (original) (raw)
The Effect of Primary Graft Dysfunction on Survival after Lung Transplantation
American Journal of Respiratory and Critical Care Medicine, 2005
Rationale: Primary graft dysfunction is a severe acute lung injury syndrome after lung transplantation. Long-term outcomes of subjects with primary graft dysfunction have not been studied. Objectives: We sought to test the relationship of primary graft dysfunction with both short-and long-term mortality using a large registry. Methods: We used data collected on 5,262 patients in the United Network for Organ Sharing/International Society of Heart and Lung Transplantation registry between 1994 and 2000. We assessed outcomes in all subjects; to assess potential bias from the effects of early mortality, we also evaluated subjects who survived at least 1 year, using Cox proportional hazards models with time-varying covariates. Main Results: The overall incidence of primary graft dysfunction was 10.2% (95% confidence intervals [CI], 9.2, 10.9). The incidence did not vary by year over the period of observation (p ϭ 0.22). All-cause mortality at 30 days was 42.1% for primary graft dysfunction versus 6.1% in patients without graft dysfunction (relative risk ϭ 6.95; 95% CI, 5.98, 8.08; p Ͻ 0.001); among subjects who died by 30 days, 43.6% had primary graft dysfunction. Among patients surviving at least 1 year, those who had primary graft dysfunction had significantly worse survival over ensuing years (hazard ratio, 1.35; 95% CI, 1.07, 1.70; p ϭ 0.011). Adjustment for clinical variables including bronchiolitis obliterans syndrome did not change this relationship. Conclusion: Primary graft dysfunction contributes to nearly half of the short-term mortality after lung transplantation. Survivors of primary graft dysfunction have increased risk of death extending beyond the first post-transplant year.
Outcome of lung transplanted patients with primary graft dysfunction
European Journal of Cardio-Thoracic Surgery, 2007
Objective: Primary graft dysfunction (PGD) causes significant mortality and morbidity after lung transplantation. The objectives of the study were to describe the clinical and histological sequelae of PGD. Methods: Histology of all patients receiving single-lung transplantation 1999-2004 (n = 181) was reviewed. PGD was defined as diffuse radiological infiltration of the lung allograft occurring within the first 72 h postoperatively. Results: One patient died intra-operatively. PGD was recorded in 63% (n = 113) of 180 consecutive transplant recipients. Patients with PGD had a worse 90-day postoperative mortality (14% versus 3%, p = 0.03) and 3-year survival (55% versus 77%, p = 0.003). Freedom from bronchiolitis obliterans syndrome was similar in both groups. The maximal FEV 1 was significantly lower in patients with PGD, median 54% (quartiles 48-61%) predicted; compared to patients without PGD, median 59% (quartiles 54-69%) predicted ( p = 0.003). There was a significant linear trend in the decline of maximal FEV 1 with the presence and increasing severity of radiographic infiltrate ( p = 0.004). During follow-up, patients with PGD were more likely to demonstrate diffuse alveolar damage or bronchiolitis obliterans organizing pneumonia ( p = 0.009 and p = 0.01, respectively). Histological findings of diffuse alveolar damage correlated closely with extent of radiological infiltration ( p < 0.0001). Conclusions: Transplant recipient survival, lung function, and histological findings of diffuse alveolar damage appear to be closely correlated with the appearance and severity of PGD. #
Risk factors for primary graft dysfunction after lung transplantation
2010
Objective: The International Society for Heart and Lung Transplantation has proposed a new grading system for primary graft dysfunction based on the ratio of arterial oxygen to fraction of inspired oxygen measured within 48 hours after lung transplantation. Worsening primary graft dysfunction grade is associated with increased operative mortality rates and decreased long-term survival. This study evaluated donor and recipient risk factors for postoperative International Society for Heart and Lung Transplantation grade 3 primary graft dysfunction.
Clinical Risk Factors for Primary Graft Dysfunction after Lung Transplantation
American Journal of Respiratory and Critical Care Medicine, 2013
Primary graft dysfunction (PGD) is a severe acute lung injury syndrome following lung transplantation. Previous studies of clinical risk factors, including a multicenter prospective cohort trial, have identified a number of recipient, donor, and operative variables related to Grade 3 PGD. The aim of this study was to validate these risk factors in a lung transplantation center with a low volume of procedures. We conducted a retrospective cohort study of 45 consecutive lung transplantations performed between January 2011 and September 2013. PGD was defined according to the International Society for Heart and Lung Transplantation grading scale. Risk factors were evaluated independently and the significant confounders entered into multivariable logistic regression models. The overall incidence of Grade 3 PGD was 35.5% at T24, 17.7% at T48, and 15.5% at T72. The following risk factors were associated with Grade 3 PGD at the indicated time points: recipient female gender at T24 (P ¼ .034), mixed diagnoses at T72 (P ¼ .047), ECMO bridge-to-lung transplantation at T24 (P ¼ .0004) and at T48 (P ¼ .038), donor causes of death different from stroke and trauma at T24 (P ¼ .019) and T72 (P ¼ .014), blood transfusions during surgery at T24 (P ¼ .001), intraoperative venoarterial ECMO T24 (P < .0001). Multivariate analysis at T24 identified recipient female gender and intraoperative venoarterial ECMO as risk factors (P ¼ .010 and P ¼ .018, respectively). This study demonstrated that risk factors for severe PGD in a low-volume center were similar to international reports in prevalence and type. ECMO bridge-to-lung transplantation emerged as a risk factor previously underestimated.
European Journal of Cardio-Thoracic Surgery, 2014
OBJECTIVES: Ex vivo lung perfusion (EVLP) is a novel technique used to evaluate and recondition marginal or rejected grafts. Primary graft dysfunction (PGD) is a major early complication after lung transplantation (LTx). The use of marginal or initially rejected grafts may increase its incidence and severity. The aim of this study is to evaluate the incidence of PGD after LTx using rejected grafts reconditioned with EVLP. METHODS: PGD has been evaluated immediately after LTx (t0) and after 72 h (t72) in patients receiving standard (Group A) or reconditioned (Group B) grafts. EVLP was performed using a controlled acellular perfusion according to the Toronto technique.