Prognosis Factors in Lung Transplant Recipients Readmitted to the Intensive Care Unit

doi:10.1016/j.transproceed.2007.06.058

Transplantation Proceedings

Volume 39, Issue 7, September 2007, Pages 2420-2421

https://doi.org/10.1016/j.transproceed.2007.06.058 Get rights and content

Abstract

Objective

To identify outcome predictors and prognostic factors for survival among lung transplant recipients on readmission to the intensive care unit (ICU).

Methods

This was a retrospective study of all lung transplant recipients during a 10-year period from 1997 to 2006. Data collection included age, gender, reason, and type of lung transplantation. Variables specific to individual ICU admissions included admission diagnosis, length of stay, duration of mechanical ventilation, interval from transplantation, Acute Physiology and Chronic Health Evaluation (APACHE) II score on ICU admission, and the identification of systemic organ dysfunction. We used Student t test (or where appropriate, its nonparametric equivalent) or the χ² test for comparisons among the patients who died and those who survived their ICU readmissions.

Results

Among 144 lung transplant patients 28 were later readmitted to the ICU after at least 1 week. The admission diagnosis was sepsis in 20 cases (71.4%). Seventeen patients died during their ICU stay (60.7%). A higher APACHE II score (P = .008), the presence of three or more dysfunctional organs upon readmission (P = .016), and the need for mechanical ventilation (P = .022) were risk factors for mortality. The mortality risk was also higher among the group with a longer delay to ICU readmission (P = .003).

Discussion

Readmission to the ICU, which is common among lung transplant recipients, was associated with a high mortality. Sepsis was the main cause of ICU readmission and the most frequent cause of death. APACHE II score, need for mechanical ventilation, number of dysfunctional organs, and delay in ICU readmission were important prognostic factors.

Section snippets

Methods

We retrospectively reviewed the records of lung transplant recipients who subsequently required readmission to the ICU. Readmission was considered to occur at least 1 week after ICU discharge. Data collection included age, gender, reason and type of lung transplantation. Variables specific to individual ICU admissions included diagnosis, time from discharge, length of stay, duration of mechanical ventilation, interval from transplantation, Acute Physiology and Chronic Health Evaluation (APACHE)

Results

During 1997 to 2006, we performed 144 lung transplants including 28 patients readmitted to the ICU after discharge. The characteristics of the population are presented in Table 1. There were no demographic differences between the survival and nonsurvival groups. The admission diagnosis was sepsis in 20 cases (71.4%). Seventeen patients died during the ICU stay (60.7%). Nonsurvivors showed a significantly higher need for mechanical ventilation (P = .022), higher APACHE II scores (P = .008), and

Discussion

Because ICU readmission after lung transplantation is associated with a high mortality rate, we sought to identify clinical factors to predict mortality, due to the few studies that examined ICU outcomes and predictors of mortality beyond the immediate peritransplant period.³

Sepsis was the most frequent diagnosis among lung transplants recipients readmitted to the ICU in our institution, consistent with previous studies. Logically, the use of immunosuppressive drugs and the continuous exposure

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Cited by (18)

Consequences of ICU Readmission After Lung Transplantation: Beyond the Early Postoperative Period
2022, Archivos de Bronconeumologia
Intensive care readmissions in the first year after lung transplantation: Incidence, early risk factors and outcome
2021, Anaesthesia Critical Care and Pain Medicine
Citation Excerpt :
In our study, ICU readmission was associated with a high mortality rate. Earlier studies have reported similar mortality rates, estimated between 25 and 62.5% [3,5,7,11], including 20–40% that are linked to sepsis [7]. These variable results are probably related to differences in the studied cohorts (pathology leading to LT, immunosuppression protocols, microbiological ecology).
Predictive factors of intensive care readmissions after lung transplantation (LT) have not been established. The main objective of this study was to assess early risk factors for ICU readmission during the first year after LT.
This retrospective, observational, single-centre study included all consecutive patients who underwent LT in our institution between January 2016 and November 2019. Patients who died during the initial hospitalisation in the ICU were excluded. Surgical and medical ICU readmissions were collected during the first year. The results are expressed as medians, interquartile ranges, absolute numbers and percentages. Statistical analyses were performed using the chi-square test, Fisher’s exact test and Mann–Whitney U test as appropriate (p < 0.05 as significance). Multivariate analysis was performed to identify independent risk factors for readmission. The Paris-North-Hospitals Institutional Review Board reviewed and approved the study.
A total of 156 patients were analysed. Eighteen of them (12%) died during the initial ICU hospitalisation. During the first year after LT, ICU readmission was observed for 49/138 (36%) patients. Among these patients, 14/49 (29%) died during the study period. Readmission was mainly related to respiratory failure (35 (71%) patients), infectious diseases (28 (57%) patients), airway complications (11 (22%) patients), and immunologic complications (4 (8%) patients). In the multivariate analysis, ICU readmission was associated with the use of high doses of catecholamines during surgery, and the increased duration of initial ICU stay.
The initial severity of haemodynamic failure and a prolonged postoperative course seem to be key determinants of ICU readmissions after LT.
Emergency Department Visits Among Lung Transplant Patients: A 4-Year Experience
2021, Journal of Emergency Medicine
Citation Excerpt :
Our study suggests that the clinician should have a low threshold, not only to contact a transplant specialist, but also to seek a higher level of care given the possibility of decompensation in the setting of these abnormal vital signs. One study of mortality rates among lung transplant recipients readmitted to the ICU suggested that higher Acute Physiology and Chronic Health Evaluation II scores, presence of three or more dysfunctional organs at readmission, and the need for mechanical ventilation were all important prognosticators (22). Another study of lung transplant patients in the ICU suggested that severe hypoxemia and high procalcitonin levels are associated with higher mortality rates (23).
Emergency department (ED) visits by lung transplant (LT) patients have not been well documented in the literature.
To analyze outcomes among LT recipients with ED visits, to better inform clinicians regarding evaluation and treatment.
This was a retrospective cohort study of LT patients at our ED (2015–2018). Demographics, transplant indication, laboratory studies, ED interventions, disposition, death, and revisit data were collected. Logistic regression models were used to identify univariable and multivariable predictors of ED revisit, intensive care unit (ICU) admission, or death.
For 505 ED visits among 160 LT recipients, respiratory-related concerns were most frequent (n = 152, 30.1%). Infection was the most common ED diagnosis (n = 101, 20.0%). Many patients were sent home from the ED (n = 235, 46.5%), and 31.3% (n = 158) returned to the ED within 30 days. Fourteen patients (2.8%) needed advanced airway measures. One patient died in the ED, and 18 died in the hospital. On multivariable analysis, more previous ED visits significantly increased the probability of 30-day ED revisit. Heart rate faster than 100 beats/min and systolic blood pressure < 90 mm Hg were significantly associated with ICU admission or death.
Infection should be prominent on the differential diagnosis for LT patients in the ED. A large proportion of patients were discharged from the ED, but a higher number of previous ED visits was most predictive of ED revisit within 30 days. Mortality rate was low in our study, but higher heart rate and lower systolic blood pressure were associated with ICU admission or death.
Timing and Frequency of Unplanned Readmissions After Lung Transplantation Impact Long-Term Survival
2016, Annals of Thoracic Surgery
Citation Excerpt :
This increase in LT recipients is associated with a concomitant increase in post-LT adverse events that often result in unplanned hospital readmissions. Although a few studies have investigated readmissions of LT recipients to the ICU [11–13] or readmissions within 3 months after discharge [14], to the best of our knowledge this is the first study that assesses overall long-term unplanned readmissions after lung transplantation. Our institutional experience demonstrated a readmission rate of 5.3 during a median follow-up time of 38 months.
Adverse events that require hospital readmission frequently occur long after lung transplantation (LT) that has been successfully performed. We sought to identify the causes and rate of unplanned readmissions after LT and to determine whether unplanned readmissions have a significant impact on post-LT survival.
We retrospectively reviewed the outcomes in 174 LT recipients who underwent LT at our center from June 2005 to May 2014. The median follow-up period was 38 months (range, 17 to 72 months).
One hundred sixty (92%) of the 174 recipients were readmitted 854 times (5.3 times per patient). The median time to first readmission was 71 days (interquartile range [IQR], 28 to 240 days), and the median hospital length of stay at readmission was 3 days (IQR, 2 to 6 days). Freedom from first readmission was observed for 65% of patients at 1 month, 48% at 3 months, 43% at 6 months, and 26% at 12 months. Gender, lung allocation score, body surface area, year of transplantation, air leak longer than 5 days after operation, and allograft function were risk factors for readmission. The causes of readmission included infections (33%), respiratory adverse events (18%), rejection (15%), gastrointestinal events (15%), renal dysfunction (5%), and cardiac events (4%). Patients who died were found to have had early readmissions (p = 0.04) and more frequent readmissions (p = 0.001).
The first year after LT remains a high-risk period for unplanned readmissions regardless of pretransplantation diagnosis. Readmissions soon after discharge at index hospitalization and multiple readmissions are associated with an increased risk of mortality.
Characteristics and outcomes of patients with lung transplantation requiring admission to the medical ICU
2014, Chest
Citation Excerpt :
Although the 6-month survival appeared to remain better for patients with double LT (59.2%) as compared with single LT (50%), the difference was statistically not significant (0.35 by Kaplan Meier) Earlier studies reporting on the patients with LT needing MICU admission are compared inTable 6.4–7 Patients included in the studies appear to have similar demographic profile as well as consistency in the indication for LT, which is reflective of uniform policies in candidate selection for LT. Despite idiopathic pulmonary fibrosis being the most common indication for transplantation in the post lung allocation score era,8 the pool of patients with LT with COPD as the underlying diagnosis is still the largest.9
There are few data on characteristics and outcomes among patients with lung transplantation (LT) requiring admission to the medical ICU (MICU) beyond the perioperative period.
We interrogated the registry database of all admissions to the MICU at Cleveland Clinic (a 53-bed closed unit) to identify patients with history of LT done > 30 days ago (n = 101; mean age, 55.4 ± 12.6 years; 53 men, 48 women). We collected data regarding demographics, history of bronchiolitis obliterans syndrome, preadmission FEV₁, clinical and laboratory variables at admission, MICU course, length of stay, hospital survival, and 6-month survival.
The most common indication for MICU admission was acute respiratory failure (n = 51, 50.5%). Infections were most frequently responsible for respiratory failure, whereas acute rejection (cellular or humoral) was less likely (16%). Nearly one-fourth of the patients required hemodialysis (24.1%), and more than one-half required invasive mechanical ventilation (53.5%). Despite excellent hospital survival (88 of 101), 6-month survival was modest (56.4%). APACHE (Acute Physiology and Chronic Health Evaluation) III score at admission and single LT were independent predictors of hospital survival but did not predict outcome at 6 months. Functional status at discharge was the only independent predictor of 6-month survival (adjusted OR, 5.1; 95% CI, 1.1-22.7;P= .035).
Acute rejection is an infrequent cause of decompensation among patients with LT requiring MICU admission. For patients admitted to the MICU, 6-month survival is modest. Functional status at the time of discharge is an independent predictor of survival at 6 months.
Lung transplant: An emerging challenge in the ICU
2012, Medicina Intensiva

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Lung transplantationPrognosis Factors in Lung Transplant Recipients Readmitted to the Intensive Care Unit

Abstract

Objective

Methods

Results

Discussion

Section snippets

Methods

Results

Discussion

Am J Transplant

Chest

Transplant Proc

Med Intensiva

Lung transplantation
Prognosis Factors in Lung Transplant Recipients Readmitted to the Intensive Care Unit