The use of high-risk donors decreases one-year survival in high-risk lung recipients Matthew Mulligan, Pablo G Sanchez, Charles F Evans, Sina Rahimpour, Irina Timofte, Keshava Rajagopal, Aldo T Iacono, June Kim, James S Gammie, Bartley P Griffith, Si M Pham University of Maryland School of Medicine

Disclosure I have no conflicts of interest

56% of lung transplants used extended donors (Reyes 2010) Use not associated with reduced survival (Gabbay 1999; Bhorade 2000; Orens 2003; Meers 2010) Paucity of data on matching donor quality and recipient severity

Single Institutional review Use of extended donors not associated with reduced survival in extended recipients

High-Risk Donors & High-Risk Recipients Poor Outcomes Clinical Impression

We hypothesize that use of high-risk donors with high-risk recipients is associated with decreased 1-year survival

Methods Review of UNOS Database – –Post LAS 9,015 Transplant Recipients Inclusion: ≥18 years old Exclusion: ECMO, Re-transplants

High-Risk Donors Low-Risk Donors Low-Risk Recipients High-Risk Recipients Vs. Outcomes: 1-year transplant survival 1-year post registration survival

Donor Risk Stratification High-Risk Donors? Multivariable Cox- hazard regressions Deviations from ideal donor factors on 1-year transplant survival Bhorade et al. JHLT 2000 Standard Donor Criteria

Donor Risk Stratification Donor VariablesHR (95% CI) Age≥551.2 ( ) Cigarette Use ≥ 20 P-Y 1.2 ( ) Diabetes1.3 ( )

Donor Risk Stratification Donor VariablesHazard Ratio (95% CI) PaO2≤ ( ) Abnormal Chest X-Ray0.9 ( ) Purulent Secretions1.0 ( ) Blood Infection1.0 ( ) No association with 1-year survival

Donor Risk Stratification High-Risk Donors Age≥55 or Smoking ≥20 pack- years or Diabetes 24% (n=2,155) Low-Risk Donors Everyone else 76% (n=6,680)

Recipient Risk Stratification High-Risk Recipients? LAS≥60 associated with decrease in survival after transplant (Liu 2010)

Recipient Risk Stratification High-Risk Recipients LAS≥60 8% (n=679) Low-Risk Recipients LAS<60 92% (n=8,336)

OUTCOMES

1-Year Transplant Survival

Lower survival associated with high-risk donors in high-risk recipients Benefit of using high-risk donors over no transplantation? 1-year post registration survival

1-Year Post-Registration Survival Waitlist Mortality Candidates not transplanted

Summary Independent donor variables that affect 1-year survival – age≥55, smoking≥20 P-Ys, diabetes  High-risk Donor High-risk donors in recipients with LAS<60: marginal survival disadvantage High-risk donors in recipients with LAS≥60: markedly decreased survival Nevertheless high-risk donors into high-risk recipients: better survival than no transplant.

Conclusion First large database analysis demonstrating that matching donor quality with recipient status is critical to achieve optimal outcomes in lung transplantation

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