National Trends, Risk Factors, and Outcomes of Acute In-Hospital Stroke Following Lung Transplantation in the United States: Analysis of the United Network for Organ Sharing Registry

Benjamin L Shou; Christopher Wilcox; Isabella S Florissi; Aravind Krishnan; Bo Soo Kim; Steven P Keller; Glenn J R Whitman; Ken Uchino; Errol L Bush; Sung-Min Cho

doi:10.1016/j.chest.2023.04.007

National Trends, Risk Factors, and Outcomes of Acute In-Hospital Stroke Following Lung Transplantation in the United States: Analysis of the United Network for Organ Sharing Registry

Chest. 2023 Oct;164(4):939-951. doi: 10.1016/j.chest.2023.04.007. Epub 2023 Apr 11.

Authors

Affiliations

¹ Division of Cardiac Surgery, Johns Hopkins School of Medicine, Baltimore, MD.
² Division of Neurosciences Critical Care, Johns Hopkins School of Medicine, Baltimore, MD.
³ Department of Cardiothoracic Surgery, Stanford University, Stanford, CA.
⁴ Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD.
⁵ Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH.
⁶ Division of General Thoracic Surgery, Johns Hopkins School of Medicine, Baltimore, MD.
⁷ Division of Cardiac Surgery, Johns Hopkins School of Medicine, Baltimore, MD; Division of Neurosciences Critical Care, Johns Hopkins School of Medicine, Baltimore, MD. Electronic address: csungmi1@jhmi.edu.

PMID: 37054775
PMCID: PMC10567928 (available on 2024-10-01)
DOI: 10.1016/j.chest.2023.04.007

Abstract

Background: Lung transplantation (LTx) is the definitive treatment for end-stage lung failure. However, there have been no large, long-term studies on the impact of acute in-hospital stroke in this population.

Research question: What are the trends, risk factors, and outcomes of acute stroke in patients undergoing LTx in the United States?

Study design and methods: We identified adult first-time isolated LTx recipients from the United Network for Organ Sharing database, which comprehensively captures every transplant in the United States, between May 2005 and December 2020. Stroke was defined as occurring at any time after LTx but prior to discharge. Multivariable logistic regression with stepwise feature elimination was used to identify risk factors for stroke. Freedom from death in patients with a stroke vs those without a stroke was evaluated with Kaplan-Meier analysis. Cox proportional hazards analysis was used to identify predictors of death at 24 months.

Results: Of 28,564 patients (median age, 60 years; 60% male), 653 (2.3%) experienced an acute in-hospital stroke after LTx. Median follow-up was 1.2 (stroke) and 3.0 (non-stroke) years. Annual incidence of stroke increased (1.5% in 2005 to 2.4% in 2020; P for trend = .007), as did lung allocation score and utilization of post-LTx extracorporeal membrane oxygenation (P = .01 and P < .001, respectively). Compared with those without stroke, patients with stroke had lower survival at 1 month (84% vs 98%), 12 months (61% vs 88%), and 24 months (52% vs 80%) (log-rank test, P < .001 for all). In Cox analysis, acute stroke conferred a high hazard of mortality (hazard ratio, 3.01; 95% CI, 2.67-3.41). Post-LTx extracorporeal membrane oxygenation was the strongest risk factor for stroke (adjusted OR, 2.98; 95% CI, 2.19-4.06).

Interpretation: Acute in-hospital stroke post-LTx has been increasing over time and is associated with markedly worse short- and long-term survival. As increasingly sicker patients undergo LTx as well as experience stroke, further research on stroke characteristics, prevention, and management strategies is warranted.

Keywords: UNOS; lung transplant; stroke.

Abstract

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