- Email: [email protected]
Results of Lung Transplantation in Idiopathic Pulmonary Fibrosis Patients
Results of Lung Transplantation in Idiopathic Pulmonary Fibrosis Patients F.J. Algar, D. Espinosa, P. Moreno, J. Illana, F. Cerezo, A. Alvarez, C. Baamonde, J. Redel, J.M. Vaquero, F. Santos, and A. Salvatierra ABSTRACT Lung transplantation (OLT) remains the only available therapy for patients with end-stage idiopathic pulmonary fibrosis (IPF). The objective of this study was to review our experience of OLT for end-stage IPF (IPFLT) patients, seeking to identify variables associated with survival for comparison with outcomes of other indications for LT (OILT). From October 1993 to December 2009, we performed 310 consecutive OLT in 301 patients for treatment of various end-stage pulmonary conditions. The indications for OLT were: IPF (n ⫽ 89, 30.5%) chronic obstructive pulmonary disease (n ⫽ 82), cystic fibrosis (n ⫽ 80), bronchiectasis (n ⫽ 12), alfa-1-antitrypsin deficit (n ⫽ 6), primary pulmonary hypertension (n ⫽ 4), bronchiolitis obliterans (n ⫽ 4), other conditions (n ⫽ 15). We observed significant differences in the actuarial survival between the IPFLT and the OILT groups particularly at the expense of worse perioperative 30-day and early 1-year mortality in the IPFLT group. Upon univariate and multivariate analyses, the need for cardiopulmonary bypass, previous recipient ventilator dependence, and donor age ⬎50 years were all associated with poorer survival rates among IPF patients. In our experience, survival did not differ between patients who underwent a single versus a bilateral sequential lung transplant (BSLT); however, BSLT cases were associated with short-term damage but long-term survival. The functional results in the IPFLT group were excellent. We observed significant improvements in the values of arterial oxygen pressure (PaO2), arterial carbon dioxide pressure (PaCO2), forced vital capacity (FVC%) and forced expiratory volume in 1 second (FEV1%) at 6, 12, and 36 months compared to their pretransplant baseline results. DIOPATHIC PULMONARY FIBROSIS (IPF) is the most common adult form of diffuse parenchymal lung diseases of unknown origin.1 Lung transplantation (OLT) has been shown to be a viable option in these patients. However, transplant outcomes are believed to be worse for IPF patients than for OLT patients with other indications.2,3 The objective of this study was to review our experience of OLT for end-stage IPF (IPFLT) patients, seeking to identify risk factors for death after OLT for IPF, and to compare these results with other indications for LT (OILT).
I
PATIENTS AND METHODS From October 1993 to December 2009, we performed 310 consecutive OLTs in 301 patients for treatment of various end-stage pulmonary conditions. The indications for OLT were: IPF (n ⫽ 89, 30.5%) chronic obstructive pulmonary disease (n ⫽ 82), cystic
fibrosis (n ⫽ 80), bronchiectasis (n ⫽ 12), alfa-1-antitrypsin deficit (n ⫽ 6), primary pulmonary hypertension (n ⫽ 4), bronchiolitis obliterans syndrome (BOS n ⫽ 4), and other conditions (n ⫽ 15). Nine patients with cystic fibrosis and BOS required retransplantations. The IPF study group (IPFLT) comprised 25 women and 64 men, of overall mean of age 51 ⫾ 11 years (range ⫽ 13– 67). Antegrade (60 mL/kg) and retrograde (20 mL/kg) perfusion of the donor’s bipulmonary block was performed using modified Eurocollins or Perfadex (from 2004 onward) preservative solution.4 We performed 73 single-lung transplants (SLT; 46 right, 27 left) and From the Divisions of Thoracic Surgery and Pulmonary Medicine, Lung Transplantation Unit, Hospital Universitario Reina Sofía, University of Cordoba, Cordoba, Spain. Address reprint requests to F. Javier Algar Algar, Divisions of Thoracic Surgery, Lung Transplantation Unit, Hospital Universitario Reina Sofía, Avda Menéndez Pidal s/n, 14004 Córdoba, Spain. E-mail: [email protected]
© 2010 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/–see front matter doi:10.1016/j.transproceed.2010.05.046
Transplantation Proceedings, 42, 3211–3213 (2010)
3211
3212 sixteen bilateral sequential lung transplants (BSLT). Cardiopulmonary bypass (CB) was needed in 8 (9%) patients, and pulmonary tailoring to adapt the size of the lungs to that of the thoracic cavity, in 8.2%. In all cases, we used immunosuppressive therapy with cyclosporine or tacrolimus, azathioprine or mycophenolate mofetil, and steroids. Antibiotic treatment was based on previously determined sensitivities from recipient sputum cultures and donor bronchial aspirates.
Data Analysis We collected data on donors—age, gender, duration of intubation; PaO2/FiO2 recipients—age, gender, previous diagnoses, urgency code-mechanical ventilation, posttransplant PaO2/FiO2, posttransplant intubation time, posttransplant intensive care unit stays; surgical data—type of OLT, duration of ischemia, CB, pulmonary tailoring; and postoperative data early and perioperative mortality, surgical and medical complications, incidence of acute and chronic rejection as well as, survival. The objective of the data analysis was to review our IPFLT experience to identify variables associated with survival. The two groups (IPFLT and OILT) were compared using SPSS 12.0 statistical software package for chi-square, Student t and log-rank tests as well as Kaplan-Meier analyses. Values of P ⬍ .05 were considered to be significant. Cox proportional hazards regression was used to assess variables that predicted a high risk of mortality after OLT among IPF patients.
RESULTS
Eighty-nine OLTs were performed in IPF patients, most of whom were ambulatory. Four (4.5%) subjects received transplants under an urgency code, which gave them priority over elective patients due to the onset of an irreversible respiratory crisis that required mechanical ventilation. In most cases (82%), we performed an SLT. CB was needed more frequently in BSLT cases (25% vs 5.5%, P ⫽ .013). The ischemia times of the first and the second lung were 324 ⫾ 64 (175–520) and 489 ⫾ 62 (345–570) minutes, respectively. Early 24-hour and perioperative 30-days mortality rates were 5.6% and 28.1%, respectively. BSLT (56.3% vs 21.9%, P ⫽ .006), CB (75% vs 23.5%, P ⫽ .002), and OLT under an urgency code (75% vs 25.9%, P ⫽ .033) were related to higher perioperative mortality rates. There were surgical complications in 33.7% of cases, and bronchial complications in 5.6%. Eleven patients (12.4%) developed BOS. Survival rates at 1, 3, 5, and 12 years were 52.62%, 39.70%, 32.55%, and 29.20%, respectively in the IPFLT group (mean: 1804 [standard error ⫽ 244] days) and 68.71%, 61.01%, 54.75%, and 38.98% in the OILT group (mean: 2829 [standard error ⫽ 191] days), with a significant difference between the groups (P ⫽ .0009). Following transplantation, IPF patients displayed significant improvements arterial oxygen pressure (PaO2), arterial carbon dioxide pressure (PaCO2), forced vital capacity (FVC%) and forced expiratory volume in 1 second (FEV1%) at 6, 12, and 36 months compared to the pretransplant baseline situation. Donor age ⬎50 years (P ⫽ .0332), CB (P ⬍ .001), and OLT under urgency code (P ⫽ .0367) were all associated with poorer survival rates upon univariate analysis. BSLT performed in IPF showed no significant differences
ALGAR, ESPINOSA, MORENO ET AL Table 1. Differences Obtained From the Comparison Between Both Groups IPFLT (n ⫽ 89)
Donor data Age (y) 36 ⫾ 14 Gender (female/male; %) 54.3/45.7 PaO2/FiO2 (mm Hg) 461 ⫾ 77 Intubation time (h) 54 ⫾ 58 Recipient data Age (y) 51 ⫾ 11 Gender (female/male; %) 28.1/71.9 PaO2/FiO2 (mm Hg) in ICU 286 ⫾ 133 Intubation time (h) 120 ⫾ 262 Surgical data Ischemia time (first lung) (min) 324 ⫾ 64 Ischemia time (second lung) 489 ⫾ 62 (min) CB (%) 9 Pulmonary tailoring (%) 8.2 Urgency code (mechanical 4.5 ventilation) Posttrasplant data Surgical complications (%) 33.7 Bronchial complications (%) 5.6 Acute rejection episodes (n°) 1.09 ⫾ 1.20 Chronic rejection BOS (%) 12.4 Pneumonia episodes (first 0.45 ⫾ 0.50 month) Early mortality (24 h, %) 5.6 Perioperative mortality (30 d, %) 28.1
OILT (n ⫽ 203)
29 ⫾ 14 43.7/56.3 484 ⫾ 83 39 ⫾ 32
P
.001* .108 .040* .008*
38 ⫾ 18 ⬍.001* 34.5/65.5 .283 299 ⫾ 154 .577 96 ⫾ 228 .557 326 ⫾ 63 461 ⫾ 78
.817 .200
23.6 9 13.3
.003* .835 .031*
36 10.8 1.12 ⫾ 1.07 22.2 0.39 ⫾ 0.49
.922 .171 .866 .228 .494
6.4 19.2
.797 .091
CB, cardiopulmonary by pass; ICU, intensive care unit; IPFLT, idiopatic pulmonary fibrosis lung transplantation; OILT, others indications lung transplantation; BOS, bronchiolitis obliterans syndrome; PaO2, arterial oxygen pressure; FiO2, inspiratory oxygen fraction. *Significant P value.
compared with SLT with respect to long-term survival (P ⫽ .2861); however, BSLT performed with a donor age over 50 years was associated with worse survival rates (P ⫽ .0005). No survival differences were found with respect to recipient age (P ⫽ .1286). Table 1 compares some of the variables between the IPFLT group and the OILT group. Variables predicting survival in the multivariate analysis are shown in Table 2. DISCUSSION
OLT remains the only available therapy for patients with end-stage IPF lung disease. Transplant outcomes are believed to be worse for IPF patients than those transplanted for other indications, although there is no explanation for this difference.2,3 However, the largest observational studies demonstrating a high early mortality after OLT for IPF were not well controlled for donor, recipient, and transplant variables.5 In our series, we observed significant differences in the actuarial survival between the IPFLT group and the OILT group, mainly at the expense of worse perioperative 30-day and early 1-year mortality among the IPF patients. In the IPFLT group the need for CB, previous recipient ventilator dependence, and donor age over 50 years were all
IDIOPATHIC PULMONARY FIBROSIS
3213
Table 2. Independent Variables of Survival in the IPFLT Group by Multivariate Analysis (Cox Regression) Variables

SE
P Value
OR
Donor age ⬎ 50 y* OLT under UC* Cardiopulmonary bypass*
0.653 1.013 2.092
0.337 0.546 0.472
.053 .063 ⬍.001
1.92 2.75 8.13
, beta coefficient; SE, standar error; OR, odds ratio (e); IPFLT, idiopathic pulmonary fibrosis lung transplantation; OLT, lung transplantation; UC, urgency code. *0 ⫽ no; 1 ⫽ yes.
associated in univariate and multivariate analyses with worse survival rates. The use of CB has been related to higher mortality rates and was needed in 9% of OLT performed in IPF patients. Ventilator dependence has traditionally been regarded as a relative contraindication to OLT because it may increase mortality after transplantation. In our series, four patients (4.5%) in the IPFLT group and 27 patients (13.3%) in the OILT group were ventilatordependent before OLT. We found that OLT performed under urgency code (mechanical ventilation) in IPF patients was associated with mortality in the early postoperative period. However, in selected cystic fibrosis patients on mechanical ventilation, OLT permited acceptable longterm survival rates with no increase in early or perioperative mortality.6 Although advanced recipient age has been considered to be a risk factor for OLT, we did not observe it to be associated with a significantly increased mortality. However, in our experience, the advanced age of the lung donor (⬎50 years) was associated with increased mortality rates and worse long-term survival in the IPF group. The decision to perform SLT or BSLT in patients with pulmonary fibrosis is controversial. Some centers use recipient age (⬍50 years) as a criterion to select BSLT over SLT, but the rationale for this approach is not well established.7–9 Previous reports have confirmed a survival benefit of BSLT over SLT in high-risk IPF patients,8 whereas patients younger than 60 years of age who were recipients of transplants for pulmonary fibrosis appear to have better survival rates with SLT than with BSLT.7 Although the basis for this observation is unclear, events occurring in the early first-month period after transplantation may play a role. In our experience, survival did not differ between patients who underwent SLT versus BSLT, though BSLT conferred short-term damage but a long-term survival benefit. Previous mechanical ventilation (in all cases BSLT was performed) and the greater need for CB in BSLT may
explain the higher observed perioperative and 1-year mortality rates. BOS is the main limitation to long-term survival after OLT. The incidence of BOS after OLT in IPF patients was comparable to that seen among patients with other indications for OLT. As we have reported previously,4 improved lung preservation by using antegrade and retrograde flush perfusion might play roles in the low incidences of both BOS and bronchial anastomosis complications. The functional results in the IPFLT group were excellent. We observed significant improvements in values of PaO2, PaCO2, FVC%, and FEV1% at 6, 12, and 36 months compared to the pretransplant baseline situation. In conclusion, OLT remains the treatment of choice for IPF patients with end-stage respiratory disease despite the higher perioperative and 1-year mortality rates. BSLT confers shortterm damage (higher perioperative and 1-year mortality rates) but a long-term survival benefit. Advanced donor age and OLT under mechanical ventilation should to be advised in IPF patients, especially if a BSLT is likely. REFERENCES 1. Idiopathic pulmonary fibrosis: diagnosis and treatment. International consensus statement. American Thoracic Society (ATS) and the European Respiratory Society (ERS). American Thoracic Society. Am J Respir Crit Care Med 161:646, 2000 2. Orens JB, Shearon TH, Freudenburger RS, et al: Thoracic organ transplantation in the United States, 1995–2004. Am J Transplant 6:1188, 2006 3. Mason DP, Brizzio ME, Alster JM, et al: Lung transplantation for idiopathic pulmonary fibrosis. Ann Thorac Surg 84:1121, 2007 4. Alvarez A, Salvatierra A, Lama R, et al: Preservation with a retrograde second flushing of Eurocollins in clinical lung trasplantation. Trasplant Proc 31:1088, 1999 5. Whelan TP, Dunitz JM, Kelly RF, et al: Effect of preoperative pulmonary artery pressure on early survival after lung transplantation for idiopathic pulmonary fibrosis. J Heart Lung Transplant 24:1269, 2005 6. Algar FJ, Moreno P, Cano JR, et al: Urgency-code lung transplantation for cystic fibrosis: experience and results. Trasplant Proc 40:3067, 2008 7. Meyer DM, Edwards LB, Torres F, et al: Impact of recipients age and procedure type on survival after lung transplantation for pulmonary fibrosis. Ann Thorac Surg 79:950, 2005 8. Weiss ES, Allen JG, Merlo CA, et al: Survival after single versus bilateral lung transplantation for high-risk patients with pulmonary fibrosis. Ann Thorac Surg 88:1616, 2009 9. Thabut G, Christie JD, Ravaud PH, et al: Survival after bilateral versus single-lung transplantation for idiopathic pulmonary fibrosis. Ann Intern Med 151:767, 2009
I
PATIENTS AND METHODS From October 1993 to December 2009, we performed 310 consecutive OLTs in 301 patients for treatment of various end-stage pulmonary conditions. The indications for OLT were: IPF (n ⫽ 89, 30.5%) chronic obstructive pulmonary disease (n ⫽ 82), cystic
fibrosis (n ⫽ 80), bronchiectasis (n ⫽ 12), alfa-1-antitrypsin deficit (n ⫽ 6), primary pulmonary hypertension (n ⫽ 4), bronchiolitis obliterans syndrome (BOS n ⫽ 4), and other conditions (n ⫽ 15). Nine patients with cystic fibrosis and BOS required retransplantations. The IPF study group (IPFLT) comprised 25 women and 64 men, of overall mean of age 51 ⫾ 11 years (range ⫽ 13– 67). Antegrade (60 mL/kg) and retrograde (20 mL/kg) perfusion of the donor’s bipulmonary block was performed using modified Eurocollins or Perfadex (from 2004 onward) preservative solution.4 We performed 73 single-lung transplants (SLT; 46 right, 27 left) and From the Divisions of Thoracic Surgery and Pulmonary Medicine, Lung Transplantation Unit, Hospital Universitario Reina Sofía, University of Cordoba, Cordoba, Spain. Address reprint requests to F. Javier Algar Algar, Divisions of Thoracic Surgery, Lung Transplantation Unit, Hospital Universitario Reina Sofía, Avda Menéndez Pidal s/n, 14004 Córdoba, Spain. E-mail: [email protected]
© 2010 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/–see front matter doi:10.1016/j.transproceed.2010.05.046
Transplantation Proceedings, 42, 3211–3213 (2010)
3211
3212 sixteen bilateral sequential lung transplants (BSLT). Cardiopulmonary bypass (CB) was needed in 8 (9%) patients, and pulmonary tailoring to adapt the size of the lungs to that of the thoracic cavity, in 8.2%. In all cases, we used immunosuppressive therapy with cyclosporine or tacrolimus, azathioprine or mycophenolate mofetil, and steroids. Antibiotic treatment was based on previously determined sensitivities from recipient sputum cultures and donor bronchial aspirates.
Data Analysis We collected data on donors—age, gender, duration of intubation; PaO2/FiO2 recipients—age, gender, previous diagnoses, urgency code-mechanical ventilation, posttransplant PaO2/FiO2, posttransplant intubation time, posttransplant intensive care unit stays; surgical data—type of OLT, duration of ischemia, CB, pulmonary tailoring; and postoperative data early and perioperative mortality, surgical and medical complications, incidence of acute and chronic rejection as well as, survival. The objective of the data analysis was to review our IPFLT experience to identify variables associated with survival. The two groups (IPFLT and OILT) were compared using SPSS 12.0 statistical software package for chi-square, Student t and log-rank tests as well as Kaplan-Meier analyses. Values of P ⬍ .05 were considered to be significant. Cox proportional hazards regression was used to assess variables that predicted a high risk of mortality after OLT among IPF patients.
RESULTS
Eighty-nine OLTs were performed in IPF patients, most of whom were ambulatory. Four (4.5%) subjects received transplants under an urgency code, which gave them priority over elective patients due to the onset of an irreversible respiratory crisis that required mechanical ventilation. In most cases (82%), we performed an SLT. CB was needed more frequently in BSLT cases (25% vs 5.5%, P ⫽ .013). The ischemia times of the first and the second lung were 324 ⫾ 64 (175–520) and 489 ⫾ 62 (345–570) minutes, respectively. Early 24-hour and perioperative 30-days mortality rates were 5.6% and 28.1%, respectively. BSLT (56.3% vs 21.9%, P ⫽ .006), CB (75% vs 23.5%, P ⫽ .002), and OLT under an urgency code (75% vs 25.9%, P ⫽ .033) were related to higher perioperative mortality rates. There were surgical complications in 33.7% of cases, and bronchial complications in 5.6%. Eleven patients (12.4%) developed BOS. Survival rates at 1, 3, 5, and 12 years were 52.62%, 39.70%, 32.55%, and 29.20%, respectively in the IPFLT group (mean: 1804 [standard error ⫽ 244] days) and 68.71%, 61.01%, 54.75%, and 38.98% in the OILT group (mean: 2829 [standard error ⫽ 191] days), with a significant difference between the groups (P ⫽ .0009). Following transplantation, IPF patients displayed significant improvements arterial oxygen pressure (PaO2), arterial carbon dioxide pressure (PaCO2), forced vital capacity (FVC%) and forced expiratory volume in 1 second (FEV1%) at 6, 12, and 36 months compared to the pretransplant baseline situation. Donor age ⬎50 years (P ⫽ .0332), CB (P ⬍ .001), and OLT under urgency code (P ⫽ .0367) were all associated with poorer survival rates upon univariate analysis. BSLT performed in IPF showed no significant differences
ALGAR, ESPINOSA, MORENO ET AL Table 1. Differences Obtained From the Comparison Between Both Groups IPFLT (n ⫽ 89)
Donor data Age (y) 36 ⫾ 14 Gender (female/male; %) 54.3/45.7 PaO2/FiO2 (mm Hg) 461 ⫾ 77 Intubation time (h) 54 ⫾ 58 Recipient data Age (y) 51 ⫾ 11 Gender (female/male; %) 28.1/71.9 PaO2/FiO2 (mm Hg) in ICU 286 ⫾ 133 Intubation time (h) 120 ⫾ 262 Surgical data Ischemia time (first lung) (min) 324 ⫾ 64 Ischemia time (second lung) 489 ⫾ 62 (min) CB (%) 9 Pulmonary tailoring (%) 8.2 Urgency code (mechanical 4.5 ventilation) Posttrasplant data Surgical complications (%) 33.7 Bronchial complications (%) 5.6 Acute rejection episodes (n°) 1.09 ⫾ 1.20 Chronic rejection BOS (%) 12.4 Pneumonia episodes (first 0.45 ⫾ 0.50 month) Early mortality (24 h, %) 5.6 Perioperative mortality (30 d, %) 28.1
OILT (n ⫽ 203)
29 ⫾ 14 43.7/56.3 484 ⫾ 83 39 ⫾ 32
P
.001* .108 .040* .008*
38 ⫾ 18 ⬍.001* 34.5/65.5 .283 299 ⫾ 154 .577 96 ⫾ 228 .557 326 ⫾ 63 461 ⫾ 78
.817 .200
23.6 9 13.3
.003* .835 .031*
36 10.8 1.12 ⫾ 1.07 22.2 0.39 ⫾ 0.49
.922 .171 .866 .228 .494
6.4 19.2
.797 .091
CB, cardiopulmonary by pass; ICU, intensive care unit; IPFLT, idiopatic pulmonary fibrosis lung transplantation; OILT, others indications lung transplantation; BOS, bronchiolitis obliterans syndrome; PaO2, arterial oxygen pressure; FiO2, inspiratory oxygen fraction. *Significant P value.
compared with SLT with respect to long-term survival (P ⫽ .2861); however, BSLT performed with a donor age over 50 years was associated with worse survival rates (P ⫽ .0005). No survival differences were found with respect to recipient age (P ⫽ .1286). Table 1 compares some of the variables between the IPFLT group and the OILT group. Variables predicting survival in the multivariate analysis are shown in Table 2. DISCUSSION
OLT remains the only available therapy for patients with end-stage IPF lung disease. Transplant outcomes are believed to be worse for IPF patients than those transplanted for other indications, although there is no explanation for this difference.2,3 However, the largest observational studies demonstrating a high early mortality after OLT for IPF were not well controlled for donor, recipient, and transplant variables.5 In our series, we observed significant differences in the actuarial survival between the IPFLT group and the OILT group, mainly at the expense of worse perioperative 30-day and early 1-year mortality among the IPF patients. In the IPFLT group the need for CB, previous recipient ventilator dependence, and donor age over 50 years were all
IDIOPATHIC PULMONARY FIBROSIS
3213
Table 2. Independent Variables of Survival in the IPFLT Group by Multivariate Analysis (Cox Regression) Variables

SE
P Value
OR
Donor age ⬎ 50 y* OLT under UC* Cardiopulmonary bypass*
0.653 1.013 2.092
0.337 0.546 0.472
.053 .063 ⬍.001
1.92 2.75 8.13
, beta coefficient; SE, standar error; OR, odds ratio (e); IPFLT, idiopathic pulmonary fibrosis lung transplantation; OLT, lung transplantation; UC, urgency code. *0 ⫽ no; 1 ⫽ yes.
associated in univariate and multivariate analyses with worse survival rates. The use of CB has been related to higher mortality rates and was needed in 9% of OLT performed in IPF patients. Ventilator dependence has traditionally been regarded as a relative contraindication to OLT because it may increase mortality after transplantation. In our series, four patients (4.5%) in the IPFLT group and 27 patients (13.3%) in the OILT group were ventilatordependent before OLT. We found that OLT performed under urgency code (mechanical ventilation) in IPF patients was associated with mortality in the early postoperative period. However, in selected cystic fibrosis patients on mechanical ventilation, OLT permited acceptable longterm survival rates with no increase in early or perioperative mortality.6 Although advanced recipient age has been considered to be a risk factor for OLT, we did not observe it to be associated with a significantly increased mortality. However, in our experience, the advanced age of the lung donor (⬎50 years) was associated with increased mortality rates and worse long-term survival in the IPF group. The decision to perform SLT or BSLT in patients with pulmonary fibrosis is controversial. Some centers use recipient age (⬍50 years) as a criterion to select BSLT over SLT, but the rationale for this approach is not well established.7–9 Previous reports have confirmed a survival benefit of BSLT over SLT in high-risk IPF patients,8 whereas patients younger than 60 years of age who were recipients of transplants for pulmonary fibrosis appear to have better survival rates with SLT than with BSLT.7 Although the basis for this observation is unclear, events occurring in the early first-month period after transplantation may play a role. In our experience, survival did not differ between patients who underwent SLT versus BSLT, though BSLT conferred short-term damage but a long-term survival benefit. Previous mechanical ventilation (in all cases BSLT was performed) and the greater need for CB in BSLT may
explain the higher observed perioperative and 1-year mortality rates. BOS is the main limitation to long-term survival after OLT. The incidence of BOS after OLT in IPF patients was comparable to that seen among patients with other indications for OLT. As we have reported previously,4 improved lung preservation by using antegrade and retrograde flush perfusion might play roles in the low incidences of both BOS and bronchial anastomosis complications. The functional results in the IPFLT group were excellent. We observed significant improvements in values of PaO2, PaCO2, FVC%, and FEV1% at 6, 12, and 36 months compared to the pretransplant baseline situation. In conclusion, OLT remains the treatment of choice for IPF patients with end-stage respiratory disease despite the higher perioperative and 1-year mortality rates. BSLT confers shortterm damage (higher perioperative and 1-year mortality rates) but a long-term survival benefit. Advanced donor age and OLT under mechanical ventilation should to be advised in IPF patients, especially if a BSLT is likely. REFERENCES 1. Idiopathic pulmonary fibrosis: diagnosis and treatment. International consensus statement. American Thoracic Society (ATS) and the European Respiratory Society (ERS). American Thoracic Society. Am J Respir Crit Care Med 161:646, 2000 2. Orens JB, Shearon TH, Freudenburger RS, et al: Thoracic organ transplantation in the United States, 1995–2004. Am J Transplant 6:1188, 2006 3. Mason DP, Brizzio ME, Alster JM, et al: Lung transplantation for idiopathic pulmonary fibrosis. Ann Thorac Surg 84:1121, 2007 4. Alvarez A, Salvatierra A, Lama R, et al: Preservation with a retrograde second flushing of Eurocollins in clinical lung trasplantation. Trasplant Proc 31:1088, 1999 5. Whelan TP, Dunitz JM, Kelly RF, et al: Effect of preoperative pulmonary artery pressure on early survival after lung transplantation for idiopathic pulmonary fibrosis. J Heart Lung Transplant 24:1269, 2005 6. Algar FJ, Moreno P, Cano JR, et al: Urgency-code lung transplantation for cystic fibrosis: experience and results. Trasplant Proc 40:3067, 2008 7. Meyer DM, Edwards LB, Torres F, et al: Impact of recipients age and procedure type on survival after lung transplantation for pulmonary fibrosis. Ann Thorac Surg 79:950, 2005 8. Weiss ES, Allen JG, Merlo CA, et al: Survival after single versus bilateral lung transplantation for high-risk patients with pulmonary fibrosis. Ann Thorac Surg 88:1616, 2009 9. Thabut G, Christie JD, Ravaud PH, et al: Survival after bilateral versus single-lung transplantation for idiopathic pulmonary fibrosis. Ann Intern Med 151:767, 2009