Long-Term Chronic Lung Allograft Dysfunction-Free Survival Following Lung Transplant in the Presence of...

Highly sensitized patients with advanced lung disease, who are more often Black and Hispanic women, are at increased risk for waitlist death. In 2012, we implemented a protocol to cross any pre-transplant donor-specific antibody (DSA), so long as a prospective complement-dependent cytotoxicity (CDC) crossmatch was negative. We report long-term outcomes, including overall survival and chronic lung allograft dysfunction (CLAD)-free survival.

This was a single-institution retrospective cohort study of lung transplant recipients between October 1, 2012-December 31, 2022. We compared overall retransplant-free survival and CLAD-free survival between recipients with and without pre-formed DSA. Secondary outcomes included freedom from acute cellular rejection (ACR) and antibody-mediated rejection (AMR).

The study cohort included 427 recipients with a median duration of follow-up of 4.3 years (IQR = 2.1-6.9). Thirty-three (7.7%) recipients had pre-transplant DSA with a peak historical mean fluorescence intensity (MFI) of 4200 (IQR = 3000-6600, total range 2100-23 000). The median number of DSA per patient was 1 (IQR = 1-2, total range 1-8). There was no difference in adjusted overall survival between recipients with and without pre-formed DSA (HR = 1.39, 95% CI = 0.82-2.36, p = 0.22) or adjusted CLAD-free survival between recipients with and without pre-formed DSA (HR = 1.07, 95% CI = 0.65-1.75, p = 0.79). Recipients with pre-formed DSA did not have increased adjusted hazard of ACR (HR = 0.71, 95% CI = 0.29-1.75, p = 0.45) but did have increased adjusted hazard of AMR (HR = 5.02, 95% CI = 2.11-11.95, p < 0.001).

In this moderately-sized cohort, a protocol of accepting donor offers for lung transplant candidates with pre-formed DSA but negative CDC crossmatch was not associated with worse overall or CLAD-free survival, within the limitations of the sample size.