Outcomes of staged single versus bilateral lung transplantation in the modern era

Staged single-lung transplantation (SSLT) has been proposed as a strategy for high-risk patients amid donor organ shortages. We aimed to compare modern SSLT versus bilateral lung transplantation (BLT) outcomes and identify factors associated with SSLT long-term survival.

We retrospectively analyzed the United Network for Organ Sharing registry for all adult lung transplants from 2005 to 2021. Propensity-matched outcomes of SSLT (2 sequential, contralateral single-lung transplants) were compared with BLT. Kaplan-Meier methods were used to assess survival, and multivariable analysis identified independent predictors of mortality after SSLT.

Among 188 recipients of SSLT and 2948 recipients of BLT, recipients of SSLT were older and more likely to have interstitial lung disease. Despite greater 1-year survival among recipients of SSLT (92.0% vs 87.5%), median overall survival was significantly shorter compared with the BLT cohort (5.8 vs 7.1 years), and both 5-year (54.8% vs 63.8%) and 10-year (27.4% vs 43.6%) survival estimates were lower (P < .001). Thirty-day mortality after the second transplant was also greater in SSLT (4.7% vs 2.7%, P = .04). On multivariable analysis, SSLT was associated with greater 3-year mortality (hazard ratio, 1.72; 95% CI, 1.03-2.84), although on subgroup analysis, those with a diagnosis of interstitial lung disease, age ≥65 years, or body mass index ≥30 and duration between staged lung transplantation ≥5 years at time of listing showed similar outcomes.

In the modern era, BLT is associated with superior long-term survival compared with SSLT. SSLT can achieve acceptable early outcomes in select patients or donor-scarce situations, but BLT should remain the preferred approach when feasible.