Acute flares before lung transplant put ILD patients at higher risk

Acute exacerbations may be independent risk factor for mortality: Study

Patricia Inácio, PhD avatar

by Patricia Inácio, PhD |

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Various gauges of risk indicate high risk.

Acute exacerbations, or sudden bouts of symptom worsening, increase the mortality risk after lung transplantation in people with interstitial lung diseases (ILDs), including idiopathic pulmonary fibrosis (IPF), a study reports.

While a lung transplant is considered an effective treatment for ILDs, these findings “suggest that caution is required during decision-making, especially in patients requiring pre-transplant mechanical respiratory support,” researchers wrote.

The study, “Clinical impact of pre-existing acute exacerbation in patients with interstitial lung disease who underwent lung transplantation,” published in the journal Respiratory Research.

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Lung transplant can be life-saving option for people with advanced ILD

A lung transplant can be a life-saving option for people with advanced ILD, helping to boost survival and improve quality of life. However, survival outcomes are unclear in patients who experience acute exacerbations before the procedure, with past studies reporting conflicting results.

To know more, researchers in South Korea reviewed clinical data from ILD patients who underwent a double lung transplant at the Asan Medical Center from October 2008 to January 2022. Patients were followed for a minimum of one year after the procedure.

All patients received immunosuppressive therapy before the surgery and also afterward, along with medications to prevent the risk of infections.

The study’s main goal was to assess and compare the overall post-transplant survival in ILD patients who had experienced acute exacerbations and in those who had not.

In total, data from 108 patients (71.3% men; mean age of 57.5 years) were included in the analyses. From these, 70 had IPF, while the remaining patients met the criteria for progressive pulmonary fibrosis.

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75% of patients required mechanical ventilation before transplant

Three-quarters of the patients (75%) required mechanical ventilation before the transplant.

Patients with IPF were significantly older than those without IPF (mean age of 59.8 vs. 53.3 years), were more likely male (81.4% vs. 52.6%), and were smokers or had been in the past (65.7% vs. 39.5%).

No differences in the rate of pre-existing acute exacerbations were seen between patients with and without IPF (52.9% vs. 39.5%). The two groups also did not differ significantly in their use of steroids or their need for mechanical ventilation or extracorporeal membrane oxygenation (ECMO), a type of artificial lung support, before the surgery. However, the use of Esbriet (pirfenidone) was significantly more common among IPF patients than in those without IPF (51.4% vs. 2.6%).

Among the 70 patients with IPF, 37 had acute exacerbations, with the majority (32 patients) requiring treatment with steroids.

At the time of the surgery, 52 patients (48.1%) experienced acute exacerbations. ILD patients with pre-existing acute exacerbations required mechanical ventilation during the transplant significantly more often than those who had no exacerbations (96.2% vs. 55.4%). They also required more preoperative ECMO (84.6% vs. 44.6%).

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Mortality rate higher in patients with acute exacerbations before transplant

A total of 36 patients (33.3%) died during the study, with the majority having acute exacerbations (23 patients). The mortality rate was significantly higher among patients with acute exacerbations. After three years, the cumulative mortality rate was 39.9% among those with acute exacerbations and 20.4% in those without them.

The leading cause of death was infections (61.1%), followed by rejection of the transplanted lungs (8.3%), and postoperative complications (8.3%).

Statistical analyses revealed pre-existing acute exacerbations were linked to a twofold higher risk of death after the transplant. This association remained significant, even after adjusting data to account for patients’ age, preoperative steroid use, and the number of days in intensive care after the surgery.

These findings demonstrate acute exacerbations are “an independent prognostic factor for mortality in patients who received lung transplantation,” the researchers wrote.