Improved outcomes in adult lung transplantation: a two-decade national analysis

Lung transplantation has undergone substantial policy and clinical changes in the past two decades. While short-term improvements have been observed, longitudinal outcomes into recent years remain incompletely characterized.

To evaluate trends in lung transplantation across allocation eras in the United States.

We identified adult lung transplant recipients (n = 38,512) and candidates (n = 48,527) in the OPTN Thoracic Database over four eras: 2005-2009, 2010-2017, 2017-2019, 2020-2024. Primary outcomes included 1-year survival, 90-day survival, length of stay (LOS), graft failure, and waitlist survival. Kaplan-Meier, Cox proportional hazards, and logistic regression were used.

The 2020-2024 era was associated with decreased risk of 1-year mortality (odds ratio [OR], 0.76; 95% confidence interval [CI], 0.70-0.83, P < 0.001), 90-day mortality (OR, 0.77; 95% CI, 0.68-0.88, P < 0.001), and waitlist mortality (HR, 0.38; 95% CI, 0.36-0.39, P < 0.001), with no significant difference in time-to-event graft failure risk (hazard ratio [HR], 1.00; 95% CI, 0.95-1.06, P = 0.92) compared to 2010-2017. Despite increasing recipient clinical complexity, 1-year survival rose from 83.6% in 2005-2009 to 88.6% in 2020-2024 (difference in proportions, 4.8%; 95% CI, 3.6%-5.9%; P < 0.001) and waitlist survival increased from 72.3% to 77.9% (difference in proportions, 5.6%; 95% CI, 3.3%-7.9%; P < 0.001). However, LOS increased across eras, with 2020-2024 being a significant predictor of prolonged LOS greater than 30 days (OR, 1.29; 95% CI, 1.20-1.37, P < 0.001).

Lung transplant outcomes have improved steadily over the past two decades. Future studies are needed to elucidate the causes of increasing LOS and persisting disparities.