Advertisement

Decline in Functional Status While on the Waiting List Predicts Worse Survival After Lung Transplantation

Published:August 26, 2022DOI:https://doi.org/10.1053/j.jvca.2022.08.015

      Objectives

      To determine if decreases in the Karnofsky Performance Score (KPS) while on the waitlist predict decreased survival after lung transplantation (LTx).

      Design

      A retrospective evaluation of the United Network for Organ Sharing database. The KPS was evaluated at the time of listing for transplant and at the time of transplantation. Group I consisted of patients having a decrease in KPS during the time on the waiting list (from the time of listing to the time of transplant), and Group II consisted of patients whose KPS stayed the same or increased during the same period. The authors used propensity-score weighting for comparisons of these groups.

      Setting

      Retrospective observational database review.

      Participants

      Adult patients undergoing lung transplantation.

      Interventions

      None. Patients were stratified according to a change in their KPS.

      Measurements and Main Results

      Patient and graft survival of patients with decreasing or not decreasing KPS were compared. Of the 27,558 subjects included in the analysis, 17,986 (65%) had worsening KPS, which was associated with worse graft (p = 0.0003) and patient (p = 0.0019) survival after LTx. Using multivariate regression, a decrease in KPS of ≥40 was associated with decreased survival, and an increase of ≥40 was associated with improved survival (HR = 1.245, 95% CI [1.181-1.312], p < 0.0001 and HR = 0.866, 95% CI [0.785, 0.955], respectively). Among patients with a KPS <40 at the time of transplant, those with a decrease in KPS of ≥40 had decreased graft and patient survival compared with those with a smaller decrease (p = 0.0002 and p = 0.0021, respectively).

      Conclusions

      Deterioration of KPS on the waiting list for LTx is associated with significantly greater postoperative mortality in patients after LTx. These results should be taken into consideration when allocating organs. Strategies to increase or to prevent a decrease in KPS before LTx should be evaluated.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Cardiothoracic and Vascular Anesthesia
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Costa J
        • Benvenuto LJ
        • Sonett JR.
        Long-term outcomes and management of lung transplant recipients.
        Best Pract Res Clin Anaesthesiol. 2017; 31: 285-297
        • Yusen RD
        • Edwards LB
        • Kucheryavaya AY
        • et al.
        The registry of the International Society for Heart and Lung Transplantation: Thirty-first adult lung and heart-lung transplant report–2014; Focus theme: Retransplantation.
        J Heart Lung Transplant. 2014; 33: 1009-1024
        • Bos S
        • Vos R
        • Van Raemdonck DE
        • et al.
        Survival in adult lung transplantation: Where are we in 2020?.
        Curr Opin Organ Transplant. 2020; 25: 268-273
        • Hook JL
        • Lederer DJ.
        Selecting lung transplant candidates: Where do current guidelines fall short?.
        Expert Rev Respir Med. 2012; 6: 51-61
        • Shweish O
        • Dronavalli G.
        Indications for lung transplant referral and listing.
        J Thorac Dis. 2019; 11 (S1708-20)
        • Bottiger BA
        • Nicoara A
        • Snyder LD
        • et al.
        Frailty in the end-stage lung disease or heart failure patient: Implications for the perioperative transplant clinician.
        J Cardiothorac Vasc Anesth. 2019; 33: 1382-1389
        • Schag CC
        • Heinrich RL
        • Ganz PA.
        Karnofsky performance status revisited: Reliability, validity, and guidelines.
        J Clin Oncol. 1984; 2: 187-193
        • Grimm JC
        • Valero 3rd, V
        • Kilic A
        • et al.
        Preoperative performance status impacts perioperative morbidity and mortality after lung transplantation.
        Ann Thorac Surg. 2015; 99: 482-489
        • Leard LE
        • Holm AM
        • Valapour M
        • et al.
        Consensus document for the selection of lung transplant candidates: An update from the International Society for Heart and Lung Transplantation.
        J Heart Lung Transplant. 2021; 40: 1349-1379
      1. UNOS. Data Collection. Available at: https://unos.org/data/data-collection/. Accessed January 19, 2022.

        • Genao L
        • Whitson HE
        • Zaas D
        • et al.
        Functional status after lung transplantation in older adults in the post-allocation score era.
        Am J Transplant. 2013; 13: 157-166
        • Freiberger D
        • Gould Delaney A
        • Forbes P
        • et al.
        Pediatric lung transplant: Correlation of pretransplant condition with post-transplant outcomes.
        Pediatr Transplant. 2021; 25: e13889
        • Kilic A
        • Beaty CA
        • Merlo CA
        • et al.
        Functional status is highly predictive of outcomes after redo lung transplantation: An analysis of 390 cases in the modern era.
        Ann Thorac Surg. 2013; 96 (discussion 1811): 1804-1811
        • Bezinover D
        • Geyer NR
        • Dahmus J
        • et al.
        A decline in functional status while awaiting liver transplantation is predictive of increased post-transplantation mortality.
        HPB (Oxford). 2022; 24: 825-832
        • Soetanto V
        • Grewal US
        • Mehta AC
        • et al.
        Early postoperative complications in lung transplant recipients.
        Indian J Thorac Cardiovasc Surg. 2022; 22: 260-270
        • Singer JP
        • Diamond JM
        • Anderson MR
        • et al.
        Frailty phenotypes and mortality after lung transplantation: A prospective cohort study.
        Am J Transplant. 2018; 18: 1995-2004
        • Latham NK
        • Harris BA
        • Bean JF
        • et al.
        Effect of a home-based exercise program on functional recovery following rehabilitation after hip fracture: A randomized clinical trial.
        JAMA. 2014; 311: 700-708
        • Abizanda P
        • Lopez MD
        • Garcia VP
        • et al.
        Effects of an oral nutritional supplementation plus physical exercise intervention on the physical function, nutritional status, and quality of life in frail institutionalized older adults: The ACTIVNES study.
        J Am Med Dir Assoc. 2015; 16: e9-16
        • Rumer KK
        • Saraswathula A
        • Melcher ML.
        Prehabilitation in our most frail surgical patients: Are wearable fitness devices the next frontier?.
        Curr Opin Organ Transplant. 2016; 21: 188-193
        • Abdullah HR
        • Lien VP
        • Ong HK
        • et al.
        Protocol for a single-centre, randomised controlled study of a preoperative rehabilitation bundle in the frail and elderly undergoing abdominal surgery.
        BMJ Open. 2017; 7e016815
        • Szekely LA
        • Oelberg DA
        • Wright C
        • et al.
        Preoperative predictors of operative morbidity and mortality in COPD patients undergoing bilateral lung volume reduction surgery.
        Chest. 1997; 111: 550-558
        • Langer D.
        Rehabilitation in patients before and after lung transplantation.
        Respiration. 2015; 89: 353-362
        • Wickerson L
        • Mathur S
        • Brooks D.
        Exercise training after lung transplantation: A systematic review.
        J Heart Lung Transplant. 2010; 29: 497-503
        • Hoffman M
        • Chaves G
        • Ribeiro-Samora GA
        • et al.
        Effects of pulmonary rehabilitation in lung transplant candidates: A systematic review.
        BMJ Open. 2017; 7e013445
        • Baldwin MR
        • Singer JP
        • Huang D
        • et al.
        Refining low physical activity measurement improves frailty assessment in advanced lung disease and survivors of critical illness.
        Ann Am Thorac Soc. 2017; 14: 1270-1279
        • Blumenthal NP
        • Petty MG
        • McCorkle R.
        Missing domains of lung transplant patient selection.
        Prog Transplant. 2017; 27: 90-97
        • Singer JP
        • Diamond JM
        • Gries CJ
        • et al.
        Frailty phenotypes, disability, and outcomes in adult candidates for lung transplantation.
        Am J Respir Crit Care Med. 2015; 192: 1325-1334
        • Schaenman JM
        • Diamond JM
        • Greenland JR
        • et al.
        Frailty and aging-associated syndromes in lung transplant candidates and recipients.
        Am J Transplant. 2021; 21: 2018-2024
        • Wilson ME
        • Vakil AP
        • Kandel P
        • et al.
        Pretransplant frailty is associated with decreased survival after lung transplantation.
        J Heart Lung Transplant. 2016; 35: 173-178
        • Rozenberg D
        • Mathur S
        • Wickerson L
        • et al.
        Frailty and clinical benefits with lung transplantation.
        J Heart Lung Transplant. 2018; 37: 1245-1253
        • Montgomery E
        • Macdonald PS
        • Newton PJ
        • et al.
        Frailty as a predictor of mortality in patients with interstitial lung disease referred for lung transplantation.
        Transplantation. 2020; 104: 864-872
        • Ward RA
        • Brier ME.
        Retrospective analyses of large medical databases: What do they tell us?.
        J Am Soc Nephrol. 1999; 10: 429-432