Long-Term Outcomes are Worse in Patients Hospitalized Prior to Lung Transplantation

Purpose While recipients who are critically ill at the time of lung transplantation are at increased risk of post-transplant mortality and complications, it is unclear whether outcomes for inpatient recipients without critical care needs are any worse than those of patients who are admitted from home prior to transplant. Methods The United Network for Organ Sharing database was queried for adult lung transplants between 2005 and 2017. Patients were classified as either inpatient or outpatient at the time of transplant. Patients requiring life support or critical care were excluded. Patients were stratified by Lung Allocation Score (LAS) and functional status, and propensity score matching was performed on demographics and risk factors. Post-transplant survival, graft function, forced expiratory volume (FEV1), and functional status were analyzed with the Kaplan-Meier method and Cox proportional hazard, linear, and logistic regression. Results Of the 12,198 patients included in the study, 6140 were inpatient at the time of transplant (50.3%). Stratification and propensity score matching yielded 4760 well-matched pairs. Post-transplant survival was 85.6% at 1 year and 68.5% at 3 years for outpatients and 85.8% at 1 year and 67.3% at 3 years for inpatients (p = 0.700 by log-rank test). Graft function was 73.1% at 1 year and 39.0% at 3 years for outpatients and 72.0% at 1 year and 31.5% at 3 years for inpatients (p = 0.001). In Cox regression, inpatient status was not associated with post-transplant mortality (hazard ratio: 1.00, p = 0.892), but was associated with increased risk of graft failure (HR = 1.16, p = 0.005). In logistic regression, inpatient status was associated with increased risk of graft failure at 3 years (odds ratio: 1.39, p = 0.003) and worse FEV1 (p < 0.001) and functional status (p < 0.001) on follow-up. Conclusion When controlling for LAS score, functional status, and risk factors, patients who required hospitalization prior to lung transplant had similar survival, but worse long-term outcomes. While recipients who are critically ill at the time of lung transplantation are at increased risk of post-transplant mortality and complications, it is unclear whether outcomes for inpatient recipients without critical care needs are any worse than those of patients who are admitted from home prior to transplant. The United Network for Organ Sharing database was queried for adult lung transplants between 2005 and 2017. Patients were classified as either inpatient or outpatient at the time of transplant. Patients requiring life support or critical care were excluded. Patients were stratified by Lung Allocation Score (LAS) and functional status, and propensity score matching was performed on demographics and risk factors. Post-transplant survival, graft function, forced expiratory volume (FEV1), and functional status were analyzed with the Kaplan-Meier method and Cox proportional hazard, linear, and logistic regression. Of the 12,198 patients included in the study, 6140 were inpatient at the time of transplant (50.3%). Stratification and propensity score matching yielded 4760 well-matched pairs. Post-transplant survival was 85.6% at 1 year and 68.5% at 3 years for outpatients and 85.8% at 1 year and 67.3% at 3 years for inpatients (p = 0.700 by log-rank test). Graft function was 73.1% at 1 year and 39.0% at 3 years for outpatients and 72.0% at 1 year and 31.5% at 3 years for inpatients (p = 0.001). In Cox regression, inpatient status was not associated with post-transplant mortality (hazard ratio: 1.00, p = 0.892), but was associated with increased risk of graft failure (HR = 1.16, p = 0.005). In logistic regression, inpatient status was associated with increased risk of graft failure at 3 years (odds ratio: 1.39, p = 0.003) and worse FEV1 (p < 0.001) and functional status (p < 0.001) on follow-up. When controlling for LAS score, functional status, and risk factors, patients who required hospitalization prior to lung transplant had similar survival, but worse long-term outcomes.