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Survival After Bilateral Versus Single-Lung Transplantation for Idiopathic Pulmonary Fibrosis

Gabriel Thabut, MD, PhD; Jason D. Christie, MD, MS; Philippe Ravaud, MD, PhD; Yves Castier, MD, PhD; Gaëlle Dauriat, MD; Gilles Jebrak, MD; Michel Fournier, MD, PhD; Guy Lesèche, MD, PhD; Raphaël Porcher, PhD; and Hervé Mal, MD
[+] Article and Author Information

From Hôpital Bichat, APHP et Université Paris-Diderot Paris-7, INSERM U738, INSERM U717, and Hôpital Saint-Louis, Paris, France, and the University of Pennsylvania, Philadelphia, Pennsylvania.


Disclaimer: The data reported here have been supplied by UNOS as the contractor for the Organ Procurement and Transplantation Network. The interpretation and reporting of these data are the responsibility of the authors and should in no way be seen as an official policy of or interpretation by the Organ Procurement and Transplantation Network or the U.S. government.

Potential Conflicts of Interest: None disclosed.

Reproducible Research Statement:Study protocol and statistical code: Available from Dr. Thabut (gabriel.thabut@bch.aphp.fr). Data set: Available on request from UNOS (www.unos.org).

Requests for Single Reprints: Gabriel Thabut, MD, PhD, Service de Pneumologie B et Transplantation Pulmonaire, Hôpital Bichat, 46 rue Henri Huchard, 75018 Paris, France; e-mail, gabriel.thabut@bch.aphp.fr.

Current Author Addresses: Drs. Thabut, Dauriat, Jebrak, Fournier, and Mal: Service de Pneumologie B et Transplantation Pulmonaire, Hôpital Bichat, 46 rue Henri Huchard, 75018 Paris, France.

Dr. Christie: Division of Pulmonary and Critical Care Medicine, Department of Medicine, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, 8th Floor, Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104.

Dr. Ravaud: Département d'Épidémiologie, de Biostatistiques, et de Recherche Clinique, Hôpital Bichat, 46 rue Henri Huchard, 75018 Paris, France.

Drs. Castier and Lesèche: Service de Chirurgie Thoracique et Vasculaire, Hôpital Bichat, 46 rue Henri Huchard, 75018 Paris, France.

Dr. Porcher: Département de Biostatistique et Informatique Médicale, Hôpital Saint-Louis, 1 avenue Claude Vellefaux, 75010 Paris, France.

Author Contributions: Conception and design: G. Thabut, J.D. Christie, P. Ravaud, M. Fournier, G. Lesèche, H. Mal.

Analysis and interpretation of the data: G. Thabut, J.D. Christie, P. Ravaud, Y. Castier, M. Fournier, G. Lesèche, R. Porcher, H. Mal, G. Dauriat.

Drafting of the article: G. Thabut, J.D. Christie, Y. Castier, H. Mal.

Critical revision of the article for important intellectual content: J.D. Christie, P. Ravaud, Y. Castier, M. Fournier, G. Lesèche, R. Porcher, H. Mal, G. Dauriat.

Final approval of the article: J.D. Christie, P. Ravaud, Y. Castier, M. Fournier, R. Porcher, H. Mal, G. Dauriat.

Provision of study materials or patients: J.D. Christie, G. Jebrak, G. Lesèche.

Statistical expertise: G. Thabut, J.D. Christie, R. Porcher.

Administrative, technical, or logistic support: P. Ravaud, G. Jebrak, M. Fournier, G. Dauriat.

Collection and assembly of data: G. Jebrak.


Ann Intern Med. 2009;151(11):767-774. doi:10.7326/0003-4819-151-11-200912010-00004
Text Size: A A A

Background: Patients with end-stage idiopathic pulmonary fibrosis (IPF) are increasingly having bilateral rather than single-lung transplantation.

Objective: To compare survival after single and bilateral lung transplantation in patients with IPF.

Design: Analysis of data from the United Network of Organ Sharing registry.

Setting: Transplantation centers in the United States.

Patients: 3327 patients with IPF who had single (2146 patients [64.5%]) or bilateral (1181 patients [35.5%]) lung transplantation between 1987 and 2009.

Measurements: Survival times and causes of death after lung transplantation. Selection bias was accounted for by multivariate risk adjustment, propensity score risk adjustment, and propensity-based matching.

Results: Median survival time was longer after bilateral lung transplantation than single-lung transplantation (5.2 years [CI, 4.3 to 6.7 years] vs. 3.8 years [CI, 3.6 to 4.1 years]; P < 0.001). However, survival times for the 2 procedures did not differ after adjustment for baseline differences, with adjusted hazard ratios (HRs) for mortality with bilateral transplantation ranging from 0.89 (95% CI, 0.79 to 1.02) to 0.96 (CI, 0.77 to 1.20) in different analyses. Bilateral lung transplantation seemed to result in harm within the first year (HR, 1.18 [CI, 0.98 to 1.42]) but survival benefit thereafter (HR, 0.72 [CI, 0.59 to 0.87]). Primary graft failure was a more common cause of death among patients who had bilateral rather than single-lung transplantation (3.7% vs. 1.9%; P = 0.002). Cancer was a more common cause of death among patients who had single rather than bilateral lung transplantation (unadjusted HR for death among single vs. bilateral transplant recipients, 3.60 [CI, 2.16 to 6.05]; P <0.001).

Limitation: Causes of death were ascertained without an adjudication committee and must be interpreted cautiously.

Conclusion: Survival did not differ between patients who had single and bilateral lung transplantation. Single-lung transplantation confers short-term survival benefit but long-term harm, whereas bilateral transplantation confers short-term harm but long-term survival benefit.

Primary Funding Source: None.

Figures

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Appendix Figure 1.
Rates of single and bilateral lung transplantation over time in patients with idiopathic pulmonary fibrosis.

Data are from the United Network for Organ Sharing registry.

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Appendix Figure 2.
Proportion of bilateral lung transplantations, by center volume.

IPF = idiopathic pulmonary fibrosis.

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Figure 1.
Kaplan–Meier estimates for survival after lung transplantation.

LT = lung transplantation. Top. For 3327 patients with idiopathic pulmonary fibrosis. Bottom. For 795 pairs of patients who were matched by propensity score.

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Appendix Figure 3.
Hazard ratios for death associated with bilateral lung transplantation, by recipient mean pulmonary artery pressure at transplantation.

We adjusted the ratios for recipient age, body mass index, functional status, and mean pulmonary pressure; donor body mass index and cytomegalovirus status; transplantation year; and lung transplantation center and center volume.

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Figure 2.
Estimate of the hazard ratio for death associated with bilateral lung transplantation as a function of time after lung transplantation.

This plot is a smoothing of the scaled Schoenfeld residuals as described in reference (18).

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Appendix Figure 4.
Cumulative incidence of cancer, by type of lung transplantation.

LT = lung transplantation.

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