Outcome of critically ill lung transplant candidates on invasive respiratory support

Lung transplantation (LTx) of patients on mechanical ventilation (MV) or extracorporeal support (ECS) is controversial because of impaired survival. Prognostic factors to predict survival should be identified.

A retrospective analysis was performed in a single centre of all ventilated LTx-candidates awarded an Eurotransplant (ET) high-urgency (HU) status between November 2004 and July 2009. Clinical data were collected on the first day of HU-status from intubated patients with an approved HU status. Single parameters as well as the lung allocation score (LAS), the Sequential Organ Failure Assessment score (SOFA) and the Simplified Acute Physiology Score (SAPS 2) were calculated. The association of these variables with survival was evaluated.

A total of 100 intubated patients (median age 38 years, 56 % female) fulfilled the inclusion criteria, of whom 60 also required ECS. The main indications were cystic fibrosis (25 %) and idiopathic pulmonary fibrosis (24 %). Median time with HU status was 12 days [interquartile range (IQR) 6-21 days]. Sixty patients were transplanted, five were weaned from mechanical ventilation and 38 died while on the wait list. One-year-survival rates were 57, 36 and 5 % for transplanted patients, all candidates and non-transplanted candidates, respectively (p < 0.001). A SAPS score >24 (median 30, IQR 27-35), a procalcitonin level of >0.5 µg/l (median 0.4, IQR 0.1-1.4 µg/l) and any escalation of bridging strategy were independently associated with mortality (p = 0.021, = 0.003, and < 0.001, respectively). The LAS (median 88, IQR 8-90) did not predict survival (p = 0.92).

High-urgency LTx improves survival in critically ill intubated candidates. Higher SAPS scores, escalating therapy and an abnormal procalcitonin level were associated with a poor outcome.