Novel Association Between AMR and Airway Complications Among Lung Transplant Recipients

Airway complications (AC) such as stenosis and dehiscence are major challenges following lung transplantation, occurring in 1.4% to 44% of recipients and often linked to donor bronchial ischemia. Despite advances in surgical and bronchoscopic techniques, predictors for AC still remain unclear. This study aimed to evaluate the prevalence of AC and identify potential risk factors in a contemporary cohort.

We retrospectively analyzed 220 lung transplant recipients (2020-2023) at a high-volume center. Airway complications were categorized (stenosis, dehiscence, ischemia/necrosis, malacia) per ISHLT guidelines. Baseline characteristics and outcomes were compared between patients with and without AC using chi-squared and Wilcoxon rank-sum tests. Multivariate logistic regression evaluated associations with factors such as antibody-mediated rejection (AMR), microbial colonization, surgical techniques, and clinical outcomes.

Airway complications were observed in 17.2% of patients, with stenosis (12.7%) being the most common. Among those with stenosis, 18 patients (8.2% of the total cohort) had preceding ischemia/necrosis noted on earlier surveillance bronchoscopy. Malacia occurred in 3.1% of the patients. A combination of 2 or more complications was identified in 1.3% of patients. Multivariate analysis revealed that AMR significantly increased the risk of AC (adjusted odds ratio [aOR] 5.554, P = .013). Additional risk factors included Pseudomonas colonization (aOR 2.728, P = .014), Aspergillus colonization (aOR 3.623, P = .026), and the telescoping surgical technique (P = .038) in the comparative analysis.

Airway complications remain prevalent despite advancements in lung transplantation. AMR, microbial colonization, and the telescoping technique are significant contributors to AC. These findings underscore the need for early intervention and further research into immunological mechanisms to improve patient outcomes.