Key Point

Primary graft dysfunction occurring after lung transplantation has a significant, negative effect on 30-day as well as overall survival.

PHILADELPHIA—Researchers at the University of Pennsylvania School of Medicine in Philadelphia used the United Network for Organ Sharing/International Society of Heart and Lung Transplantation (UNOS/ISHLT) registry to evaluate short- and long-term mortality after primary graft dysfunction in lung transplant recipients.¹ In addition to the registry, the investigators also evaluated 188 transplant procedures that were performed at their institution between 1994 and 2000.

For comparison with the database’s definition of primary graft dysfunction, the University of Pennsylvania group developed their own criteria for a diagnosis of primary graft dysfunction. To be defined as having primary graft dysfunction, patients had to meet the following¹:

• The presence within 72 hours of transplantation of a diffuse alveolar infiltrate involving lung allografts, sparing the native lung in the case of single lung transplant.
• A PaO₂/FIO₂ ratio of less than 200 persisting beyond 48 hours after surgery.
• No other secondary cause of graft dysfunction, including cardiogenic pulmonary edema, pathologic evidence of rejection, pneumonia, and pulmonary venous outflow obstruction.
• In the event of death prior to day 3, the patients must have fulfilled the above criteria at the time of death and must have demonstrated diffuse alveolar damage as the predominant process on histologic examination of the lung.

Outcomes included mortality at 30 days and one year, plus overall survival. A total of 5,262 patients were available for analysis. In the UNOS/ISHLT registry, of 305 patients who died within the first 30 days, only 28 (9.1%) had primary graft failure listed as the cause of death. In the University of Pennsylvania cohort, 12 of 188 patients were coded as having prolonged graft dysfunction during the initial hospital stay, according to the UNOS/ISHLT registry. All 12 patients met the investigators’ strict criteria for primary graft dysfunction based on individual chart review.

All-cause mortality at 30 days postsurgery was 42.1% for those with primary graft dysfunction versus 6.1% for those without. Of the 509 patients who died by 30 days, 43.6% had primary graft dysfunction. All-cause mortality at one year was 64.9% in patients with primary graft dysfunction compared to 20.4% in those without. Overall survival was significantly worse for patients who had primary graft dysfunction.

Although mortality is undeniably increased in lung transplant recipients with primary graft dysfunction, the reasons for this are not known. The investigators speculated that prolonged critical illness in survivors of primary graft dysfunction, as well as the potential for increased immunogenicity of the allograft after earlier severe lung injury, may both play a role. They added that their findings reinforce the importance of efforts aimed at preventing primary graft dysfunction and understanding the risk factors for the observed increase in long-term mortality among survivors.

—Gale Jurasek

Reference
1. Christie JD, Kotloff RM, Ahya VN, et al. The effect of primary graft dysfunction on survival after lung transplantation. Am J Respir Crit Care Med. 2005;171:1312-1316.

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