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BACKGROUND Induction immunosuppression regimens for kidney transplants in lung transplant recipients vary widely. We studied the impact of induction types for kidney after lung transplant recipients. METHODS Using the Scientific Registry of Transplant Recipients database between 1994 and 2015, we studied outcomes of patients and kidney grafts for 330 kidney after lung transplant recipients for whom induction before kidney transplant included depletional (n = 115), non-depletional (n = 170), or no induction (steroids only; n = 45). We studied risk factors for recipient and graft survival using Cox proportional hazards model adjusted for kidney and lung induction, kidney donor type, dialysis status, recipient and donor ages, time from lung to kidney transplant, cause of lung disease, bilateral vs single lung transplant, diabetes, and human leukocyte antigen mismatches before kidney transplant, with transplant center as a random effect. RESULTS There was no difference between groups in patient survival or death-censored kidney allograft survival. The 1-year kidney acute rejection rates were 15.5%, 7.14%, and 0% in depletional, non-depletional, and no induction groups, respectively. In the Cox model for patient survival, living kidney donor recipients and bilateral lung transplant recipients were favorable predictors. For death-censored graft survival, kidney induction type did not predict graft survival. Results did not change when models only included recipients on tacrolimus and mycophenolate based maintenance. CONCLUSIONS The type of kidney induction did not influence patient or kidney graft survival following kidney transplants for those with previous lung transplants. No induction may be the preferred choice for kidney after lung transplant because of the lack of benefits from biologic induction in this large cohort.

BACKGROUND: This study aimed to examine intermediate-term outcomes of lung transplantation (LTx) recipients from donors after circulatory death (DCD).METHODS: We examined the International Society for Heart and Lung Transplantation (ISHLT) Thoracic Transplant Registry data for patients transplanted between January 2003 and June 2017 at 22 centers in North America, Europe, and Australia participating in the DCD Registry. The distribution of continuous variables was summarized as median and interquartile range (IQR) values. Wilcoxon rank sum test was used to compare distribution of continuous variables and chi-square or Fisher's exact test for categorical variables. Kaplan-Meier survival rates after LTx from January 2003 to June 2016 were compared between DCD-III (Maastricht category III withdrawal of life-sustaining therapy [WLST]) only and donors after brain death (DBD) using the log-rank test. Risk factors for 5-year mortality were investigated using Cox multivariate proportional-hazards model.RESULTS: The study cohort included 11,516 lung transplants, of which 1,090 (9.5%) were DCD lung transplants with complete data. DCD-III comprised 94.1% of the DCD cohort. Among the participating centers, the proportion of DCD-LTx performed each year increased from 0.6% in 2003 to 13.5% in 2016. DCD donor management included extubation in 91%, intravenous heparin in 53% and pre-transplant normothermic ex vivo donor lung perfusion in 15%. The median time interval from WLST to cardiac arrest was 15 minutes (IQR: 11-22 minutes) and to cold flush 32 minutes (IQR: 26-41minutes). Compared with DBD, donor age was higher in DCD-III donors (46 years [IQR: 34-55] vs 40 years [IQR: 24-52]), bilateral LTx was performed more often (88.3% vs 76.6%), and more recipients had chronic obstructive pulmonary disease and emphysema as their transplant indication. Five-year survival rates were comparable (63% vs 61%, p = 0.72). In multivariable analysis, recipient and donor ages, indication diagnosis, procedure type (single vs bilateral and double LTx), and transplant era (2003-2009 vs 2010-2016) were independently associated with survival (p CONCLUSION: This ISHLT DCD Registry report with 5-year follow-up demonstrated similar favorable long-term survival in DCD-III and DBD lung donor recipients at 22 experienced centers globally. These data indicate that more extensive use of DCD-LTx would increase donor organ availability and may reduce waiting list mortality. (C) 2019 International Society for Heart and Lung Transplantation. All rights reserved.

Prior coronary artery bypass grafting (CABG) has been considered a relative contraindication to lung transplantation due to the atherosclerotic disease burden and technical challenges. We hypothesized that lung transplant recipients with prior CABG have increased mortality compared to recipients without prior CABG. Further, the causes of death are different for lung transplant recipients with prior CABG vs without CABG. The Scientific Registry of Transplant Recipients database was queried to define the survival and causes of death of lung transplant recipients with or without CABG during the Lung Allocation Score era from May 5, 2005 to December 31, 2015. The primary end-points were all-cause mortality at 1 year and 5 years, as well as mortality due to major causes of death. This retrospective study cohort included a total of 13,064 lung transplant recipients, of whom 319 patients had previously undergone CABG, representing 2.4% of all transplants. Patients without prior CABG were more likely to have undergone bilateral lung transplantation compared to those with prior CABG (61.2 % vs 15.7%, P0.001). Among patients with prior CABG, single right lung transplant was most common. Overall patient survival at 1 year was 76.8% for lung transplant recipients with prior CABG and 85.4% for patients without prior CABG. Freedom from death due to graft failure at 1 and 5 years in patients with a prior CABG was 93.1% and 76.2% respectively, cardiac and/or cerebrovascular disease 96.2% and 88.5% respectively, and hemorrhage 97.9% and 97.5% respectively. In a multivariate Cox regression model utilizing time-dependent coefficients for recipient age, prior CABG, among several other risk factors, was associated with increased mortality within 1 year. Prior CABG is associated with short- and long-term mortality in lung transplant recipients with history of CABG despite the majority of these patients undergoing single lung transplantation vs bilateral lung transplantation. Graft failure and/or pulmonary causes are the most common cause of death regardless of whether or not the lung transplant recipient had prior CABG, but patients with prior CABG are at increased risk of death due to graft failure, cardiac or cerebrovascular disease, and hemorrhage.

BACKGROUND Tracheostomy is an important adjunct for lung transplant patients requiring prolonged ventilation. We explored the effects of post-transplant tracheostomy on survival and bronchiolitis obliterans syndrome after lung transplant. METHODS A retrospective, single center analysis was performed on all lung transplant recipients during the Lung Allocation Score (LAS) era. Risk factors for post-transplant tracheostomy or death within 30 days were assessed. Kaplan-Meier estimates and Cox proportional hazards models were used to examine the association between tracheostomy within 30 days after transplant and survival at 1 and 3 years. A total of 403 patients underwent single or bilateral lung transplant between May 2005 and February 2016 with complete data for 352 cases, and 35 patients (9.9%) underwent tracheostomy or died (N = 10, 2.8%) within 30 days. RESULTS In adjusted analyses, primary graft dysfunction grade 3 (PGD3) was associated with a composite end point of tracheostomy or death within 30 days (HR 3.11 (1.69, 5.71), P-value

Purpose To compare 5-year survival of lung transplant (LTx) recipients in donation after circulatory death (DCD) versus donation after brain-death (DBD) donors. Methods We examined the ISHLT Thoracic Transplant Registry data for LTx patients transplanted between 2003 and 06/2017 at 23 centers in North America, Europe and Australia participating in the DCD Registry. Distribution of continuous variables was summarized as median and interquartile (IQR) values. Mann-Whitney test was used to compare distribution of continuous variables and chi-square or Fisher's exact test for categorical variables. Kaplan-Meier survival rates after LTx during 2003-06/2016 were compared between DCD-III [Maastricht category III withdrawal of life sustaining therapy (WLST)] only and DBD using the log-rank test. Risk factors for 5-year mortality were investigated using Cox multivariate proportional-hazards model. Results The study cohort included 11,516 lung transplants, of which 1,090 (9.5%) were DCD transplants. DCD-III category comprised 94.1% of the DCD cohort. Among the participating centers, the proportion of DCD-LTx increased from 0.6% in 2003 to 15.2% in 2017. DCD donor management included extubation in 91%, intravenous heparin in 51% and pre-transplant normothermic ex-situ pulmonary allograft perfusion in 15%. Median time interval from WLST to cardiac arrest was 15 min [IQR: 11-22 min] and to cold flush 32 min [IQR: 26-41 min]. Compared to DBD, donor age was higher (47 [IQR: 34-55] vs 40 [IQR: 24-52] years), bilateral LTx was performed more often (88.3% vs 76.6%), more recipients had COPD/emphysema as transplant indication, and recipient hospital stay was longer (25 [IQR: 17-39] versus 18 [IQR: 12-29] days) in DCD-III (all p Conclusion This ISHLT DCD Registry report with 5-year follow-up demonstrated similar excellent long-term survival in DCD-III and DBD lung donor recipients in 23 experienced centers. These data support measures to implement and increase DCD LTx more widely.

A 53-year-old woman who underwent bilateral lung transplantation 14 months before presented with 2 to 3 weeks of severe exertional dyspnea. Workup revealed a complete embolic occlusion of her left main pulmonary artery related to a femoral deep venous thrombosis. The occlusion did not respond to systemic anticoagulation, and a trial of catheter-directed thrombolysis was pursued. Flow to the left lower lobe was restored after 2 days of thromobolytic therapy. The patient is alive and well at more than 1 year of follow-up.

BACKGROUND: The objective of this study was to review the international experience in lung transplantation using lung donation after circulatory death (DCD).METHODS: In this retrospective study, data from the International Society for Heart and Lung Transplantation (ISHLT) DCD Registry were analyzed. The study cohort included DCD lung transplants performed between January 2003 and June 2013, and reported to the ISHLT DCD Registry as of April 2014. The participating institutions included 10 centers in North America, Europe and Australia. The control group was a cohort of lung recipients transplanted using brain-dead donors (DBDs) during the same study period. The primary end-point was survival after lung transplantation.RESULTS: There were 306 transplants performed using DCD donors and 3,992 transplants using DBD donors during the study period. Of the DCD transplants, 94.8% were Maastricht Category whereas 4% were Category IV and 1.2% Category V (euthanasia). Heparin was given in 54% of the cases, donor extubation occurred in 90% of the cases, and normothermic ex vivo lung perfusion (EVLP) was used in 12%. The median time from withdrawal of life support therapy (WLST) to cardiac arrest was 15 minutes (5th to 95th percentiles of 5 to 55 minutes), and from WLST to cold flush was 33 minutes (5th to 95th percentiles of 19.5 to 79.5 minutes). Recipient age and medical diagnosis were similar in DCD and DBD groups (p = not significant ENS]). Median hospital length of stay was 18 days in DCD lung transplants and 16 days in DBD transplants (p = 0.016). Thirty-day survival was 96% in the DCD group and 97% in the DBD group. One-year survival was 89% in the DCD group and 88% in the DBD group (p = NS). Five-year survival was 61% in both groups (p = NS). The mechanism of donor death within the DCD group seemed to influence recipient early survival. The survival rates through 30 days were significantly different by donor mechanism of death (p = 0.0152). There was no significant correlation between the interval of WLST to pulmonary flush with survival (p = 0.11).CONCLUSION: This large study of international, multi-center experience demonstrates excellent survival after lung transplantation using DCD donors. It should be further evaluated whether the mechanism of donor death influences survival after DCD transplant. (C) 2015 International Society for Heart and Lung Transplantation. All rights reserved.

We enthusiastically present the 2011 Annual Reports of the Scientific Registry (the Registry) of the International Society for Heart and Lung Transplantation (ISHLT). The Registry has now collected, analyzed, and reported data for more than 142,000 heart, heart-lung, and lung transplants. We are delighted to announce a new reporting relationship with L’agence de la Biomedicine, which allows us, for the first time, to add to the Registry data related to more than 13,000 heart, heart-lung, and lung transplants performed in France between April 1968 and December 2009. The addition of the French data, in combination with continued participation of more than 200 other centers worldwide (Appendix), has resulted in the past year being our most active to date (Table 1). We also note a transition in Registry report authorship: Dr Christian Benden is the first author of this year’s Pediatric Lung and Heart-Lung Transplant report, and will assume the position of Associate Medical Director from Dr Paul Aurora, who has served extremely ably in that capacity since 2007. There are many ways to access the Transplant Registry data. As in past years, all of the data figures and tables included in the Registry reports are also available on the ISHLT Web site (www.ishlt.org/registries) in the Microsoft PowerPoint (Microsoft Corp, Redmond, WA) format. The Web site also contains many additional data slides that are not included in the published reports. Those who wish to

Lungs are allocated to adult and adolescent transplant candidates (aged ⩾ 12 years) on the basis of age, geography, blood type compatibility, and the lung allocation score (LAS), which reflects risk of waitlist mortality and probability of posttransplant survival. In 2013, the most adult candidates, 2394, of any year were added to the list. Overall median waiting time for candidates listed in 2013 was 4.0 months. The preferred procedure remained bilateral lung transplant, representing approximately 70% of lung transplants in 2013. Measures of short-term and longterm survival have plateaued since the implementation of the LAS in 2005. The number of new child candidates (aged 0-11 years) added to the lung transplant waiting list increased to 39 in 2013. A total of 28 lung transplants were performed in child recipients, 3 for ages younger than 1 year, 9 for ages 1 to 5 years, and 16 for ages 6 to 11 years. The diagnosis of pulmonary hypertension was associated with higher survival rates than cystic fibrosis or other diagnosis (pulmonary fibrosis, bronchiolitis obliterans, bronchopulmonary dysplasia). For child candidates, infection was the leading cause of death in year 1 posttransplant and graft failure in years 2 to 5.

Background Idiopathic pulmonary fibrosis (IPF) is a progressive and fatal disease. Lung transplantation is the only therapy associated with prolonged survival. The ideal transplant procedure for IPF is unclear. Outcomes after single transplantation (SLTx) versus bilateral lung transplantation (BLTx) in IPF patients after introduction of the Lung Allocation Score were examined. Methods Records of patients undergoing lung transplantation for IPF at our institution between May 2005 and March 2017 were reviewed to examine the effect of transplant laterality. Primary outcomes were overall, rejection-free, and bronchiolitis obliterans (BOS)-free survival at 1 and 5 years post-transplant. Results Lung transplantation was performed in 151 IPF patients post-Lung Allocation Score. Most recipients were male with average age 59 ± 8 years. SLTx was performed in 94 patients (62%). In the overall cohort, comparative survival between SLTx and BLTx was similar at 1 and 5 years before and after adjusting for age and pulmonary hypertension (PH). SLTx was associated with shorter ventilator time and intensive care unit stay and trended toward improved survival over BLTx in patients without PH. Conclusions The use of SLTx versus BLTx in IPF did not correspond to significantly different survival adjusting for age and PH. BLTx was associated with prolonged postoperative ventilation and length of stay compared with SLTx. Patients without PH, all older patients, and patients with PH and advanced disease should be considered for SLTx for IPF.

Background With the relative paucity of acceptable donors for lung transplantation, criteria for extended donor consideration are being explored. We sought to evaluate the suitability of donors whose cause of death was asphyxiation or drowning (A/D) as a potential option to enlarge the donor pool. Methods We queried the United Network for Organ Sharing (UNOS) Standard Transplant Analysis and Research registry for lung transplantation from 1987 to 2010 to assess associations between cause of death and recipient survival using the Kaplan-Meier method. To adjust for potential confounders, we used a Cox proportional hazards model and a logistic regression model to evaluate incidence of rejection within the first year. Results There were 18,250 adult primary lung transplantations performed, with 309 A/D donors. There was no difference in survival between groups (log-rank, p = 0.52). There were no differences in demographics, length of stay, airway dehiscence, lung allocation score (LAS), or ischemic time in univariate analysis (all p > 0.05). The A/D lung recipients had fewer deaths from pulmonary causes (5.8% versus 9.5%; p = 0.02). Proportional hazards analysis was significant for double lung transplantation (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.8–0.9), height difference (HR, 1.002; 95% CI, 1.00–1.003), donor age greater than 50 years (HR, 0.89; 95% CI, 0.83–0.96), and recipient age greater than 55 years (HR, 0.8; 95% CI, 0.76–0.84). A/D cause of death did not impact survival in multivariate analysis. Conclusions A/D as a donor cause of death was not associated with poor long-term survival or incidence of rejection in the first year after transplantation. Donor cause of death by A/D, when carefully evaluated and selected, should not automatically exclude the organ from transplant consideration. These results provide important justification for potentially broadening the donor pool safely.

Purpose Donation after circulatory death (DCD) donors and ex-vivo lung perfusion (EVLP) both share the potential to attenuate lung shortage. We report the experience of the OCS Lung EXPAND trial on lung transplantation following EVLP for DCD pulmonary grafts. Methods OCS Lung EXPAND is an international multi-center clinical trial aiming to evaluate the safety and effectiveness of the OCS™ Lung to recruit, preserve and assess donor lungs that may not meet current standard donor lung acceptance criteria for transplantation. We performed a post-hoc analysis of the DCD donors. Data are reported as mean±standard deviation. Results Out of 93 OCS perfused donor lungs, 32 (34%) were DCD grafts of which 26 (81% utilization rate) were transplanted. Recipient age was 55±11 years; 18 male/ 8 female; indications were emphysema (n=11), fibrosis (n=5), cystic fibrosis (n=4), other (n=6); donor age was 40±14 years; 17 male/ 9 female. EVLP time was 389±127 min, final PO2/FiO2 was 403±84 mmHg. Pulmonary artery pressure (PAP), pulmonary vascular resistance (PVR) and peak airway pressure (PAWP) remained stable during EVLP (Figure 1). Intensive care unit and hospital stay was 12±8 and 31±25 days, respectively. Time until first extubation was 5±8 days. Ratio of primary graft dysfunction grade 3 at 24, 48 and 72 hours was 15%, 8% and 8%, respectively. With a follow-up of 1 year, no acute rejections occurred and 1 patient developed chronic lung allograft dysfunction. Two patients died at 73 and 139 days post-transplant due to hyperkalemia and esophageal perforation; 24 patients were alive, resulting in a 1-year patient survival of 92%. Conclusion Portable EVLP is a safe and effective modality to assess functional performance of DCD lungs prior to transplantation, resulting in a high utilization rate and good clinical outcome.

Background Clostridium difficile infection (CDI) and associated mortality in solid organ transplant recipients is rising, but data are scarce in lung transplant recipients. We aimed to characterize CDI and its effect on mortality in a large cohort of lung transplant recipients. Methods Lung transplant recipients were identified from our transplant database from 2000 to 2011. Cox proportional hazard models were used to calculate hazard ratios for CDI and death after adjusting for potential confounders identified from bivariate analysis. Results We identified 388 patients (196 female, 192 male), with a median age of 56 years (range, 8–75 years), during the study period. CDI developed after transplant in 89 (22.9%), with 27 (7.0%) developing CDI during the initial hospitalization at a mean diagnosis of 12.7 ± 11.4 days. Incidence varied widely each year (median, 24%; range, 5%–32%), with the highest rates in 2007 to 2008. Post-operative length of stay was identified as a significant predictor of CDI (hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.01–1.03). Early CDI was an independent significant predictor of death (HR, 1.96; 95% CI, 1.14–3.36) as well as CDI anytime after transplant (HR, 1.61; 95% CI, 1.02–2.52). Conclusions CDI rates varied widely from 2000 through 2011, with the highest rates in 2007 to 2008. Lung transplant recipients who developed CDI had a higher risk of death, especially when CDI occurred in the first 6 months after transplant.

Background Tacrolimus (FK506) has a superior immunosuppressive effect compared with cyclosporine (CSA) without a significant increase in generalized infectious complications. Differences in specific infections such as Clostridium difficile (CDI) have not been reported. We investigated the relationship between calcineurin inhibitors and CDI, hypothesizing that choice of calcineurin inhibitor (CSA or FK506) after lung transplantation would have no effect on the incidence of CDI. Methods We performed a retrospective chart review of lung transplant recipients between June 1, 2000, and December 31, 2005, at a single institution. Positive CDI assays through December 11, 2011, were also recorded. We used Student's t- and chi-squared tests (α = 0.05) to compare CSA and FK506 groups. We calculated adjusted hazard ratios for CDI using Cox proportional hazard models. Results We identified 217 lung transplant recipients: 106 patients in the CSA group and 111 patients in the FK506 group. A total of 31 patients (27.9%) in the FK506 group developed CDI postoperatively compared with 20 patients (18.9%) in the CSA group (P = 0.16). The adjusted hazard ratio for CDI in the FK506 group was not significantly higher (1.53; 95% confidence interval, 0.78-2.98). There was no significant difference in the intensive care unit or total length of stay, in-hospital incidence rate, time to first CDI episode, or recurrence rate between groups. Conclusions The CDI rates were not significantly higher in the FK506 group than the CSA group in our study. These data are consistent with previous studies on FK506 that show no increase in infectious complications over CSA, and demonstrate its continued safety in lung transplantation.

Background We sought to clarify the effect of donor age as a continuous variable on morbidity and mortality in a single-institution experience. Methods From 1986 to 2016, 882 adult lung transplants were performed, including 396 in the lung allocation score era. Kaplan-Meier curves and Cox proportional hazards models were used to evaluate the association of donor age with overall survival and bronchiolitis obliterans syndrome (BOS) score ≥1-free survival. Logistic regression was used to evaluate the association with primary graft dysfunction grade 3. Natural cubic splines were used to explore donor age in a continuous fashion to allow for nonlinear relationships. Results In the lung allocation score era, unadjusted 5-year survival was not significantly different between 3 a priori–defined donor age groups: age P = .8). Unadjusted 5-year freedom from BOS ≥1 was not significantly different (34%, 20%, and 33%, respectively, P = .1). After we adjusted for comorbidities, cubic spline analysis demonstrated no effect between donor age as a continuous variable and hazard for mortality at 5 years. Similarly, no interaction was seen between donor age and risk of BOS or primary graft dysfunction 3. Adjusted analysis of all 882 transplants pre- and postinception of the lung allocation score also showed no effect of age on 10-year survival. Conclusions Long-term survival of lung transplant recipients was not affected by the age of the donor. These findings support the notion that donor age could be relaxed.

On behalf of the Registry Executive Committee, I am pleased to present the 2012 Annual Reports of the Scientific Registry (the Registry) of the International Society for Heart and Lung Transplantation (ISHLT). The Registry has now collected, analyzed, and reported data regarding more than 150,000 heart, heart-lung, and lung transplants. We are delighted to report a new relationship with the Registro Espanol de Trasplante Cardiaco, which will allow us, for the first time, to add data to the Registry regarding more than 4,000 heart transplants performed in Spain between May 1984 and March 2012. The addition of the Spanish data, in combination with continued participation of more than 200 other centers worldwide (Appendix), has resulted in the past year being our most active to date, with 6,915 reported transplants (Table 1).

The Registry of the International Society for Heart and Lung Transplantation (ISHLT) has documented trends in clinical lung and heart-lung transplantation since the inception of these procedures. Detailed heart-lung transplantation data have been included in the Registry annual reports since 1984 and lung transplantation data since 1989. Through June 30, 2010, the Registry contains data on 4,248 heart-lung and 38,119 lung transplants from centers around the world. This 28th Lung and Heart-Lung Registry Report summarizes the current status of lung and heart-lung transplantation by reporting data on this international group of patients, focusing on adults. More detailed information is presented in the full set of more than 200 slides that can be found on the ISHLT Web site at www.ishlt.org/registries/.

This Twenty-eighth Report of the International Society for Heart and Lung Transplantation (ISHLT) Transplant Registry is based on data submitted by participating transplant centers worldwide. A total of 388 heart transplant centers have contributed information to the Registry. This year we have also achieved another important milestone: the 100,000 heart transplant recipient was registered in the database. This report reviews important statistics for the entire cohort of patients registered in the database. However, similar to prior reports, many of the more detailed analyses will focus on recent transplant recipients, exploring information relevant to contemporary heart transplantation practice. The first part of the report reviews important donor, recipient, and medical center demographics. The second part provides an overview of immunosuppressive therapies used after transplantation. The third part examines survival, mortality risk factors, and causes of death after adult heart transplantation. The last section focuses on quality of life after transplant.

Whitson BA, Shelstad RC, Hertz MI, Kelly RF, D’Cunha J, Shumway SJ. Lung transplantation after hematopoietic stem cell transplantation. Clin Transplant 2011 DOI: 10.1111/j.1399-0012.2011.01482.x. © 2011 John Wiley & Sons A/S. Abstract: Introduction: Pulmonary insufficiency following bone marrow transplant (BMT) is common and has significant associated mortality. Lung transplantation (LTX) is the only viable treatment for patients with end-stage pulmonary disease, but LTX after BMT is an uncommon event given the medical candidacy of the potential recipients. We sought to evaluate the short- and long-term outcomes of LTX in BMT recipients. Methods: We performed a retrospective evaluation of our institution’s longitudinal LTX and BMT databases. Demographic and outcomes variables were collected. Results: We identified 639 LTX from January 1, 1988, through December 31, 2009, and 5525 BMT from program inception, March 21, 1974, through December 31, 2009. From the cross-referenced cohort, we identified four patients who had BMT followed by LTX. Our series was composed of two men and two women, with a mean age of 32.3 yr (range, 20–59 yr). Single LTX were performed in two recipients (50%). All patients had significant and expected morbidities related to their transplant immunosuppression. Three patients (75%) required cardiopulmonary bypass at the time of LTX. The two recipients who underwent bilateral LTX required open chest management and subsequent tracheostomy. All patients are still alive at follow-up (range, 19–119 months, median 39.5). Conclusion: Our study demonstrates that LTX in the setting of BMT is a high-risk operation with the potential for a tumultuous perioperative course. Despite this, good outcomes and survival are obtainable in carefully selected patients. Selection factors include clinically stable patients without active sepsis and preoperative optimization of nutrition in anticipation of a prolonged recovery. An experienced multidisciplinary team approach and a protocol-driven management plan are paramount for successful outcomes in this challenging population.

This tenth official pediatric report of the International Society for Heart and Lung Transplantation (ISHLT) covers the international pediatric lung and heart-lung transplantation experience from 1982 to 2006. As of last year's report, pediatric lung and heart-lung transplant data are now reported separately from pediatric heart transplant data and adult lung transplant data. For the first time this year, Registry data are analyzed by geographic region in addition to the usual aggregate analyses. All figures and tables included in this report and additional supplementary slides are available from the ISHLT website (www.ishlt.org/registries).

ide the an b he rt r p f the I ep n of c ith t stry. C wn i tted t tively p ata v affiliorts f ort r be o est a lung t dies r of s w ete a d app ed a s stical s ing R req to d the s gory o ulty A SHLT R c of r ties. T e: to o rom t ning o in e art a ulty A MD, M evelo a P v e are pleased to present the 2008 annual repor he Scientific Registry of the International Society eart and Lung Transplantation (the Registry). This arks the 25th anniversary of the Registry; since 1 he Registry has collected and reported data regard ore than 80,000 heart transplants and more t 9,000 lung and heart–lung transplants ( Table 1). The ast year has also been our most active to date, ,276 transplants added to the Registry from more 00 centers worldwide. Much gratitude is owed the m eart and lung transplant surgeons and physicians, clin oordinators, data coordinators and organ-exchange or izations (OEOs) throughout the world, whose timely ccurate submission of data has made attaining th ilestones possible (see Appendix). We also report some transitions in Registry re uthorship. This year Dr Richard Kirk authored ediatric Heart Transplant report; we thank Dr M oucek, author of the first 10 Pediatric Heart Transp eports, for his singular contribution to the Regis uccess. We also welcome Anna Kucheryavaya to egistry data analysis team. There are many ways to access the the ISHLT Re ata. As in past years, all of the data figures and ncluded in the Registry reports are also available iewing and downloading from the ISHLT web www.ishlt.org/registries) in MS P OWERPOINT format. he website also contains many additional data sl hat are not included in the published reports. Fur hose wishing to view the published heart, lung eart–lung and pediatric reports online may do so ontacting www.cardiosource.com. In addition to t nformation available in the published Registry repo nd slide sets, continentand center-specific data

The development of severe primary graft dysfunction (PGD) is a risk factor for perioperative death following lung transplantation. Our goal is to improve the predictive value of the earliest Pao(2)/fraction of inspired oxygen (P/F) measurements that gauge PGD severity.We identified 96 patients with severe PGD (P/F200) at ICU arrival through a retrospective review of 431 lung transplants performed at our institution from 1992 to 2005. The P/F trend, represented as quartiles of the 12-h percentage change in P/F, was analyzed using multivariate logistic regression. Study outcomes were 90-day death and long-term survival.The median percentage change in P/F over 12 h was + 52% (interquartile range, +20 to 90%). We observed the highest early mortality among those in the lowest quartile of the P/F trend (an increase in P/For= 20%). Ninety-day death rates decreased across the quartiles (low quartile, 32%; low-mid quartile, 9%; high-mid quartile, 5%; high quartile, 5%; test for trend, p = 0.007). After adjustment for the use of cardiopulmonary bypass, those in the lowest quartile of P/F trend had 6.8 times the odds of early death vs patients with a more favorable trend (odds ratio, 6.80; 95% confidence interval, 1.73 to 0.51; p = 0.007). In the first 5 years after transplant, there were significantly more deaths within the low quartile group vs those with a more rapidly increasing P/F trend (log-rank test, p = 0.01).Among lung recipients with severe PGD at ICU arrival, an improvement in P/For= 20% in the first 12 h portends a poor outcome.

Background A simplified and consensus-based donor scoring process could improve donor lung use. Methods To develop the University of Minnesota Donor Lung Quality Index (UMN-DLQI), we used expert opinion to create an online survey that ranked 17 lung donor and recipient factors and graded their importance on a scale of 0 to 10. To arrive at consensus-based weights for each of the 17 factors, we used magnitude estimation (ME) methods. We performed receiver operating characteristic (ROC) analyses to evaluate predictive value. An application (app) was developed to simplify the scoring process. A second review process was instituted for every donor offer with an UMN-DLQI score greater than 40 as of September 2014 (post–donor score era). Results Worldwide, 11 transplantation centers (including ours) completed our survey. Results showed strong consensus among transplantation physicians across disparate practices. UMN-DLQI scores greater than 40 provided a sensitivity of 89%, a specificity of 55%, and a positive predictive value of 52% for donor offer acceptance. Number of transplants (63 versus 48) and donor lung use (15.1% versus 8.9%; p = 0.02) were significantly better in the post–donor score era without a penalty in transplantation outcomes. There was a trend toward a lower incidence of any primary graft dysfunction within 72 hours (40% versus 75%; p = 0.06) with a UMN-DLQI greater than 40 but no difference in 30-day or 1-year survival. Conclusions The UMN-DLQI scoring app is a simple tool for describing the attributes of a donor lung offer. More attention to scores greater than 40 safely improved donor lung use at a single institution.

4 he Scientific Registry of the International Society for eart and Lung Transplantation remains the world’s ost comprehensive record of heart and lung translant activity, practices and outcomes. At present, the egistry contains data regarding 73,000 heart translants, 3,154 heart–lung transplants and 21,264 lung ransplants. During the past year more than 4,600 ransplants from more than 200 centers were added to he Registry. We wish to extend our continued appreiation to the many heart and lung transplant surgeons nd physicians, data coordinators and organ exchange rganizations (OEOs) throughout the world, whose imely and accurate submission of data has made these nalyses possible.

Renal insufficiency is common after non-renal organ transplants. The predictors of long-term renal outcomes are not well established. A total of 219 lung and heart-lung transplant recipients surviving more than 6 months after transplantation were studied to determine predictors of time to doubling of serum creatinine and end-stage kidney disease (ESKD) with death as a competing risk. Median follow-up was 79 months (range 9-222 months). Baseline estimated glomerular filtration rate (GFR) was 96.3+/-34.5 mL/min/1.73 m2. One hundred twenty-two recipients (55%) doubled their serum creatinine, 16 (7.3%) progressed to ESKD and 143 (65%) died. The majority of recipients who survived >6 years had a GFR

A scoring system was recently proposed to grade the severity of primary graft dysfunction (PGD), a frequent early complication of lung transplantation. The purposes of this study are to: (1) validate the PGD grading system with respect to patient outcomes; and (2) compare the performance of criteria employing the arterial oxygenation to fraction of inspired oxygen (P/F) ratio to an alternative grading system employing the oxygenation index (OI).We retrospectively reviewed the medical records of 402 patients having undergone lung transplantation at our institution from 1992 through 2004. The ISHLT PGD grading system was modified and grades were assigned up to 48 hours post-transplantation as follows: Grade 1 PGD, P/F300; Grade 2, P/F 200 to 300; and Grade 3, P/F200. A worst score T(0-48) was also assigned, which reflects the highest grade recorded between T0 and T48.The prevalence of severe PGD (P/F Grade 3) declined after transplant, from 25% at T0 to 15% at T48. Grouping patients by P/F grade at T48 demonstrated the clearest differentiation of 90-day death rates (Grade 1, 7%; Grade 2, 12%; Grade 3, 33%) (p = 0.0001). T48 OI grade also differentiates 90-day death rates. There was no difference in longer-term survival between patients with PGD Grades 1 and 2. OI grade at T0 qualitatively improved differential mortality between Grades 1 and 2; however, the differences did not reach statistical significance. Patients with a worst score T(0-48) of Grade 3 PGD did have significantly decreased long-term survival, as well as longer ICU and hospital stay, when compared with Grades 1 and 2 PGD. Significant risk factors for short- and long-term mortality in our multivariate model were P/F Grade 3 [worst score T(0-48) as well as T0 grade], single-lung transplant, use of cardiopulmonary bypass and high pre-operative mean pulmonary artery pressure.There is an increased risk of short- and long-term mortality and length of hospital stay associated with severe (Grade 3) PGD. The proposed ISHLT grading system can rapidly identify patients with poor outcomes who may benefit from early, aggressive treatment. Refinement of the scoring system may further improve patient risk stratification.