Original Translational Science
Center volume effect on acute cellular rejection and outcomes in pediatric lung transplant recipients

https://doi.org/10.1016/j.healun.2023.04.004Get rights and content

Background

Acute cellular rejection (ACR) is common after lung transplant (LTx). We sought to determine if transplant center volume affected ACR-related outcomes in children after LTx.

Methods

The United Network for Organ Sharing (UNOS) Registry was queried for patients <18-years-of-age who underwent LTx 1987-2020. Cohorts were children who survived the first-year post transplant and were treated for ACR within that first year (ACR group) and those not treated for ACR (non-ACR). LTx center volume was defined as: high volume center (HVC) (>5LTxs/year), medium volume center (MVC) (>1≤5 LTxs/year), and low volume center (LVC) (≤1LTxs/year).

Results

1320 patients were enrolled into the study; 269 (20.4%) did not experience ACR. The ACR cohort was older (median 14 [11-16] vs 13 [7-16] years, p < 0.001), female (65.3% vs 57.3%, p = 0.016), had cystic fibrosis (62.3% vs 45.5%, p < 0.001), and had a higher lung allocation score (37.3 [34.6-47.8] vs 35.8 [33-42.6], p = 0.029). The ACR cohort trended (p = 0.06) towards lower survival at 5-year (37% vs 47%) and 10-year (25% vs 34%) post-LTx. Among children at HVCs, ACR occurred in 17% of recipients (n = 98/574), compared to 18.5% (n = 73/395) at MVCs and 27% (n = 100/369) at LVCs. Children treated for ACR at HVCs had higher survival than LVCs at 5-years (52% vs 29%) and 10-years (36% vs 15%) (p < 0.001) but similar survival to MVCs at 5-years (52% vs 43%) and 10-years (36% vs 24%) (p = 0.081). No survival differences were detected in MVCs vs LVCs (p = 0.14).

Conclusions

ACR treated within the first post-LTx year influence survival of children. ACR incidence was lowest at higher volume centers whereas post-ACR treatment survival outcomes were also superior.

Section snippets

Methods

The study was approved by the Institutional Review Board at Cincinnati Children's Hospital Medical Center.

Patient and donor characteristics

A total of 1,320 pediatric LTx recipients ((1,272 double and 43 single LTx) were enrolled into our study, of which 269 (20.4%) (including 3 single LTx) survived the first post-LTx year and received treatment for ACR within that time period (Figure 1). Figure 2 illustrates the annual distribution over the last 30 years for pediatric LTx receiving vs not receiving treatment for ACR in the first post-LTx year. The incidence of ACR treatment peaked between 1998 and 2007, after which the number of

Discussion

The most important finding of the current study is that higher center volume positively impacts ACR outcomes in children after LTx. Although LTx may be the only treatment option for children with certain advanced lung diseases, the complexity of the surgical procedure and related clinical management suggests that the center where the LTx is performed is influencing outcomes for this high-risk patient population. A growing number of studies have demonstrated that greater LTx volume at adult

Disclosure statement

David L.S. Morales is a consultant for Abbot, Berlin Heart, CorMatrix/Azyio, Medtronic, and Syncardia Systems. This work was funded by National Institute of Health (NIH 1R01HL147957-01). The data used was obtained from OPTN. Therefore, the work was supported in part by Health Resources and Services Administration contract 234-2005-37011C. The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Health and Human Services,

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Amalia Guzman-Gomez and Hosam F. Ahmed are listed as co-first authors due to their equivalent contributions.

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