University of Groningen
Death after lung transplantation
Erasmus, Michiel E.; van der Bij, Wim
Published in:Transplant International DOI:
10.1111/tri.13553
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Publication date: 2020
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Erasmus, M. E., & van der Bij, W. (2020). Death after lung transplantation: improving long term survival despite perilous early postoperative years. Transplant International, 33(2), 128-129.
https://doi.org/10.1111/tri.13553
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INVITED COMMENTARY
Death after lung transplantation: improving long
term survival despite perilous early postoperative
years
Michiel E. Erasmus1 & Wim van der Bij2
1 Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands 2 Department of Pulmonary Diseases and Lung Transplantation, University Medical Center
Groningen, University of Groningen, Groningen, The Netherlands Correspondence
Michiel E. Erasmus, Department of Cardiothoracic Surgery, University Medical Center Groningen, Hanzeplein 1, Groningen 9700RB, The Netherlands.
Tel.: +31503613238;
e-mails: m.e.erasmus@umcg.nl and m.e.erasmus@thorax.umcg.nl
Transplant International 2020; 33: 128–129
Received: 31 October 2019; Accepted: 6 November 2019
Many centers showed that since they started a lung transplantation program, overall survival improved every 5- or 10-year cohort. This is also seen in com-bined international data [1]. Many changes in donor selection, organ preservation, and perioperative manage-ment improved short-term survival despite the usage of extended criteria donors. In parallel, also long-term sur-vival improved, likely because of gained experience and better anticipation on developing diseases after trans-plantation. A current relative standstill in the arsenal of medication directed on the prevention of (chronic) transplant dysfunction hampers further survival improvement. Lung transplant patients still have a shorter life expectancy than normal, especially caused by side effects of immunosuppression and our inability to stop chronic deterioration of the graft. Malignancies are an emerging cause of death besides the still persistent chronic lung allograft dysfunction (CLAD).
This, till now inevitable, downside of the success of lung transplantation is well described in the paper of Raskin et al. [2] in this issue. This paper focused on how death cause and death burden changed over the years in a program with improving results. Intriguing is that the patients that do die still die after a median per-iod of 3 years, across all primary diseases. This suggests that their death is not prevented by current anti-rejec-tion and infecanti-rejec-tion protocols that have hardly changed over the years in lung transplantation.
This paper suggests room for improvement and polishing of treatment protocols, preferentially in the first postoperative years. Moreover, by virtue of its descriptive nature, the paper inevitably raises a num-ber of questions to causes and variables that lead to mortality in this patient group. The influence of recipient age and type of immunosuppression is men-tioned in the discussion, but not extensively
ª 2019 The Authors. Transplant International published by John Wiley & Sons Ltd on behalf of Steunstichting ESOT This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. doi:10.1111/tri.13553 128
described. However, in a number of single-center studies an evident relation between type of immuno-suppressive drugs and long-term outcomes such as survival, renal function, and skin cancer, both in maintenance setting [3,4] or after conversion of drugs [4], has been described.
For this reason, the current paper justifies further study in European context, involving medium-to-large volume centers with state-of-the-art long-term results. Focus of interest may be:
• Incidence and type of cancer in relation to type and, particularly, target levels of immunosuppression
• Risk of lung cancer in relation to bilateral vs. unilat-eral lung transplantation
• Cardiovascular risk in relation to recipient age and pretransplant vascular condition
• The influence of primary disease on the mode of death. Especially, the high number of deaths by
infec-tion after transplantainfec-tion for fibrosis needs brother analysis.
Raskin et al. [2] show that the balance in protection and harm by the current used protocols in their pro-gram is not optimal as it is in all propro-grams. The devia-tion of the survival curves of the last two 5-year cohorts in their study might indicate that this improvement has started. For real improvement, focus of research on pro-tocols and new drugs should be aimed at preventing CLAD with less side effects.
Funding
The authors have declared no funding.
Conflicts of interest
The authors have declared no conflicts of interest.
REFERENCES
1. Chambers DC, Cherikh WS, Goldfarb SB, et al. The international thoracic organ transplant registry of the international society for heart and lung transplantation: thirty-fifth adult lung and heart-lung transplant report-2018; focus theme: multiorgan transplantation. J Heart Lung Transplant 2018;37: 1169.
2. Raskin J, Vanstapel A, Verbeken EK, et al. Mortality after lung transplantation: a single-center cohort analysis. Transpl Int 2020;33: 130. 3. Benazzo A, Schwarz S, Muckenhuber
M, et al. Alemtuzumab induction combined with reduced maintenance immunosuppression is associated with improved outcomes after lung
transplantation: a single centre experience. PLoS One 2019; 14: e0210443.
4. Vos M, Plasmeijer EI, van Bemmel BC, et al. Azathioprine to mycophenolate mofetil transition and risk of squamous cell carcinoma after lung transplantation. J Heart Lung Transplant 2018;37: 853.
Transplant International 2020; 33: 128–129 129
ª 2019 The Authors. Transplant International published by John Wiley & Sons Ltd on behalf of Steunstichting ESOT
