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ICU Admission of the Lung Transplant Recipient Following Hospital Discharge

Chicago, IL
Chicago, IL
Chicago, IL
Dr. Massad is Associate Professor of Surgery and Surgical Director of Thoracic Organ Transplantation, Dr. Kpodonu is a cardiothoracic surgery fellow in training, and Dr. Jaffe is Associate Professor of Medicine and Medical Director of the Lung Transplantation Program, The University of Illinois at Chicago.

Correspondence to: Malek G. Massad, MD, FCCP, The University of Illinois at Chicago, Division of Cardiothoracic Surgery, 840 S. Wood St, CSB Suite 417 (MC 958), Chicago, IL 60612; e-mail: mmassad{at}uic.edu

In this issue of CHEST (see page 1040), Hadjiliadis and associates report on the outcome of lung transplant recipients who required admission to medical ICUs (MICUs) after their initial discharge following transplantation. Fifty-one patients who underwent lung transplantation at Duke University after 1999 required admission to the MICU after they were discharged. Of those 51 patients, 27 required intubation and mechanical ventilation, and 16 of those 27 patients (59%) died during that admission. The study emphasizes the important observation that admission to the MICU after initial discharge of a lung transplant recipient is associated with a high hospital mortality (37%) and, more importantly, that the need of these patients for mechanical ventilation carries more than a one in two chance of death prior to discharge from the hospital. A careful look at the Kaplan-Meier survival statistics for all lung transplant patients requiring readmission to a MICU reveals that the actuarial 1-year survival rate falls from an expected 77% to 43.1%.¹

Hadjiliadis and colleagues have made an important contribution in defining at-risk characteristics for survival of lung transplant patients admitted to the MICU after their initial discharge. While prior studies have evaluated such risks retrospectively,² theirs is the first prospective analysis of the outcome of these patients. MICU admission after lung transplant is not rare. In their cohort, 23.8% of the recipients were admitted over the surveillance time period; of that subgroup, 27.5% were admitted more than once. The most frequent causes for MICU admission were respiratory failure (69.9%) and sepsis (6.8%). The overall discharge from the hospital following the MICU admission was 62.7%. Lung transplant recipients at higher risk of death after MICU admission were those requiring mechanical ventilation. Of the patients who required mechanical ventilation and died (16 patients), 11 died in the MICU and 5 died after discharge from the MICU during the same hospitalization. Logistic regression analysis suggested that both lower last FEV₁/best posttransplant FEV₁ ratio and mechanical ventilation were independently associated with higher risk of death. APACHE (acute physiology and chronic health evaluation) III scores did not independently predict a poorer outcome. The presence of bronchiolitis obliterans syndrome was, likewise, not independently associated with death, but the small numbers of such defined recipients may have rendered the subpopulation inadequate to reach statistical significance.

Unavailable for evaluation in the patient cohort reported by Hadjiliadis and colleagues was the potentially independently associated factor of blood- stream infection (BSI). Palmer et al,³ reporting from the same institution, in a cohort evaluated few years earlier, showed that BSI after transplant was a significant predictor of posttransplant death independent of other pretransplant and posttransplant factors. In that cohort, BSI occurred in 25% of 176 lung transplant recipients over a 6-year period. Importantly, BSI was associated with significantly worse survival with 3-year survival of only 44% vs 71% in recipients without BSI. BSI in that group remained a significant predictor of death in all bivariant analyses, including analysis in conjunction with mechanical ventilation, and was the strongest of all predictors in a multivariant analysis.³

Analyses of the International Society for Heart and Lung Transplantation regarding the cause of death among lung transplant recipients indicate that between 2% and 5% of the deaths after transplant are directly related to rejection, whereas between 20% and 40% of the deaths are caused by infections.⁴ These statistics are alarming and imply that in the most critical of outcome analyses, ie, death and cause of death, lung transplant recipients may be overimmunosuppressed. In this context, it is rational to suggest that gentler, kinder, and less immunosuppressive drug protocols should be considered. In addition, other variables such as use of marginal donors, recipient weight, ethnicity, gender, nutritional status, perioperative blood albumin levels, cytomegalovirus status, and the presence or absence of diabetes among other recipient risks factors for transplant also need to be addressed in similar prospective studies to help determine if these variables may impact MICU readmission rates and survival after transplant.

In the study of Hadjiliadis et al, and as noted above, the overall 1-year actuarial survival after MICU admission dropped from 73% (United Network for Organ Sharing expected 1-year survival) to 43.1%. Hadjiliadis and colleagues note that admission to the MICU is associated with significant short-term morbidity and mortality. They have shown prospectively that along with the previously studied BSI, respiratory failure and the need for mechanical ventilation harbor a significantly greater risk of death after lung transplant. These data will help in assessing the risks and benefits of both MICU admission and support with mechanical ventilation. Also, these data are helpful for providing patients and their families with realistic expectations regarding the prognosis. The authors have made an important contribution in moving the basis of patient and family counseling in the setting of critical illness from experience- to evidence-based practice. Further prospective analyses of this type are needed.

References

1. United Network for Organ Sharing. Lung transplant national survival statistics, 1996–2001. Available at: http://www.optn. org/latestData/rptStrat.asp. Accessed October 1, 2003
2. Pietrantoni, C, Minai, OA, Yu, NC, et al Respiratory failure and sepsis are the major causes of ICU admissions and mortality in survivors of lung transplants. Chest 2003;123,504-509[Abstract/Free Full Text]
3. Palmer, SM, Alexander, BD, Sanders, LL, et al Significance of blood stream infection after lung transplantation: analysis in 176 consecutive patients. Transplantation 2000;69,2360-2366[CrossRef][ISI][Medline]
4. Trulock, EP, Edwards, LB, Taylor, DO, et al The Registry of the International Society for Heart and Lung Transplantation: twentieth official adult lung and heart-lung transplant report. J Heart Lung Transplant 2003;22,625-635[CrossRef][ISI][Medline]

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