Survival benefit of lung transplantation compared with medical management and pulmonary rehabilitation for patients with end-stage COPD

Irina Timofte; Marniker Wijesinha; Roumen Vesselinov; June Kim; Robert Reed; Pablo G Sanchez; Nicholas Ladikos; Si Pham; Zachary Kon; Keshava Rajagopal; Steven M Scharf; Robert Wise; Alice L Sternberg; David Kaczorowski; Bartley Griffith; Michael Terrin; Aldo Iacono

doi:10.1183/23120541.00177-2019

Survival benefit of lung transplantation compared with medical management and pulmonary rehabilitation for patients with end-stage COPD

ERJ Open Res. 2020 Apr 27;6(2):00177-2019. doi: 10.1183/23120541.00177-2019. eCollection 2020 Apr.

Authors

Irina Timofte¹, Marniker Wijesinha², Roumen Vesselinov², June Kim¹, Robert Reed¹, Pablo G Sanchez³, Nicholas Ladikos⁴, Si Pham⁵, Zachary Kon⁶, Keshava Rajagopal⁷, Steven M Scharf¹, Robert Wise⁸, Alice L Sternberg⁹, David Kaczorowski¹⁰, Bartley Griffith¹⁰, Michael Terrin², Aldo Iacono¹¹

Affiliations

¹ Dept of Medicine, University of Maryland Medical Center, Baltimore, MD, USA.
² Dept of Epidemiology and Public Health, University of Maryland Medical Center, Baltimore, MD, USA.
³ Dept of Cardio Thoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
⁴ Dept of Pharmacy, Suburban Hospital/Johns Hopkins Medicine, Bethesda, MD, USA.
⁵ Dept of Cardio Thoracic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA.
⁶ Dept of Thoracic Surgery, New York University, New York, NY, USA.
⁷ Dept of Cardio Thoracic Surgery, University of Texas Health Science Center at Houston, Houston, TX, USA.
⁸ Dept of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁹ Dept of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
¹⁰ Dept of Cardio Thoracic Surgery, University of Maryland Medical Center, Baltimore, MD, USA.
¹¹ R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, USA.

Abstract

Background: COPD patients account for a large proportion of lung transplants; lung transplantation survival benefit for COPD patients is not well established.

Methods: We identified 4521 COPD patients in the United Network for Organ Sharing (UNOS) dataset transplanted from May 2005 to August 2016, and 604 patients assigned to receive pulmonary rehabilitation and medical management in the National Emphysema Treatment Trial (NETT). After trimming the populations for NETT eligibility criteria and data completeness, 1337 UNOS and 596 NETT patients remained. Kaplan-Meier estimates of transplant-free survival from transplantation for UNOS, and NETT randomisation, were compared between propensity score-matched UNOS (n=401) and NETT (n=262) patients.

Results: In propensity-matched analyses, transplanted patients had better survival compared to medically managed patients in NETT (p=0.003). Stratifying on 6 min walk distance (6 MWD) and FEV₁, UNOS patients with 6 MWD <1000 ft (∼300 m) or FEV₁ <20% of predicted had better survival than NETT counterparts (median survival 5.0 years UNOS versus 3.4 years NETT; log-rank p<0.0001), while UNOS patients with 6 MWD ≥1000 ft (∼300 m) and FEV₁ ≥20% had similar survival to NETT counterparts (median survival, 5.4 years UNOS versus 4.9 years NETT; log-rank p=0.73), interaction p=0.01.

Conclusions: Overall survival is better for matched lung transplant patients compared with medical management alone. Patients who derive maximum benefit are those with 6 MWD <1000 ft (∼300 m) or FEV₁ <20% of predicted, compared with pulmonary rehabilitation and medical management.

Grants and funding

T32 AG000262/AG/NIA NIH HHS/United States