Introduction
Materials and methods
Study population
Data collection
Definitions
Perioperative care of the recipients
Statistical analysis
Results
General characteristics of the study population
General characteristics of the grafts depending on recipient’s pretransplantation BMI
Recipient BMI | Donor BMI | ||||||||
---|---|---|---|---|---|---|---|---|---|
Underweight N = 41 (13%) | Normal weight N = 130 (43%) | Overweight/obesity N = 133 (44%) | p | Underweight, N = 10 (3.6%) | Normal weight, N = 128 (46%) | Overweight, N = 95 (34%) | Obesity, N = 46 (16%) | p | |
Male gender, n (%) | 11 (27) | 72 (55) | 75 (56) | 0.002 | 6 (60) | 61 (48) | 56 (59) | 25 (54) | 0.38 |
Duration of MV, donor, med [IQR] | 2 [1, 4] | 2 [1, 3] | 2 [1, 3] | 0.75 | 2 [1–3] | 2 [1–3] | 2 [2–4] | 2 [1–3] | 0.21 |
PaO2/FiO2, donor, med [IQR] | 402 [350–470] | 380 [326–450] | 390 [334- 464] | 0.38 | 482 [401–499] | 425 [351–481] | 379 [326–446] | 345 [302–380] | < 0.001 |
Age, donor, med [IQR] | 51 [44–57] | 52 [35–62] | 54 [42–63] | 0.56 | 45 [27–50] | 49 [35–60] | 55 [47–65] | 55 [46–59] | 0.002 |
Tobbaco use, donor, n (%) | 18 (45) | 35 (28) | 65 (50) | 0.001 | 2 (20) | 52 (42) | 33 (35) | 20 (43) | 0.43 |
Transfusion, donor, n (%) | 11 (27) | 37 (29) | 33 (26) | 0.84 | 1 (10) | 38 (30) | 24 (26) | 8 (18) | 0.31 |
Characteristics of the recipients before and during surgical procedure depending on their recipients and donors BMI
All cohort, N = 304 (100) | Recipient underweight, N = 41 (13%) | Recipient normal weight, N = 130 (43%) | Recipient overweight/obesity, N = 33 (44%) | p | |
---|---|---|---|---|---|
Characteristics of the recipients | |||||
Age, recipient, years, | 57[50–62] | 51 [30–58] | 57 [51–62] | 57 [52–62] | < 0.001 |
Male gender, n (%) | 197 (65) | 17 (41) | 82 (63) | 98 (74) | < 0.001 |
Height, cm, med [IQR] | 170 [163–176] | 162 [158–170] | 170 [163–176] | 172 [166–178] | < 0.001 |
Weight, Kg, med [IQR] | 70 [58–80] | 45 [43–50] | 63 [56–70] | 80 [75–89] | < 0.001 |
BMI, Kg/m2, med [IQR] | 24 [21–27] | 17 [16–18] | 22 [20.9–24] | 27.7 [9, 26–29] | < 0.001 |
Smoking history, recipient, n (%) | 208 (68) | 22 (54) | 89 (68) | 97 (73) | 0.068 |
Underlying disease | |||||
Pulmonary fibrosis, n (%) | 136 (45) | 9 (22) | 50 (38) | 77 (58) | < 0.001 |
COPD, n (%) | 92 (30) | 11 (27) | 45 (35) | 36 (27) | 0.36 |
Comorbidities | |||||
Diabetes mellitus, n (%) | 33 (11) | 7 (17) | 9 (7) | 17 (13) | 0.097 |
High blood pressure, n (%) | 77 (25) | 7 (17) | 24 (18) | 46 (35) | 0.005 |
Hypercholesterolemia, n (%) | 65 (21) | 5 (12) | 22 (17) | 38 (29) | 0.021 |
Chronic ischaemic heart disease, n (%) | 27 (9) | 1 (2) | 5 (4) | 21 (16) | 0.001 |
Peripheral arterial disease, n (%) | 13 (4) | 1 (3) | 4 (3) | 8 (6) | 0.53 |
Preoperative assessment | |||||
Pulmonary hypertension, n (%) | 149 (50) | 16 (42) | 65 (50) | 68 (52) | 0.57 |
Dilatation of the right ventricle, n (%) | 82 (27) | 8 (20) | 37 (29) | 37 (28) | 0.50 |
Left ventricular ejection fraction, %, med [IQR] | 63 [58–68] | 62 [58–66] | 64 [60–69] | 62 [58–67] | 0.47 |
Serum creatinin, µmol/L, med [IQR] | 68 [56–80] | 53 [49–62] | 68 [55–80] | 72 [62–87] | < 0.001 |
Clinical characteristics before surgery | |||||
High flow oxygenotherapy before surgery, n (%) | 50 (16) | 7 (17) | 18 (14) | 25 (19) | 0.55 |
ECMO as bridge to LT, n (%) | 23 (8) | 5 (12) | 5 (4) | 13 (10) | 0.075 |
High emergency LT, n (%) | 59 (19) | 11 (27) | 22 (17) | 26 (20) | 0.38 |
Characteristics of intra-operative period | |||||
Bilateral LT, n (%) | 210 (69) | 30 (73) | 94 (72) | 86 (65) | 0.34 |
Retransplantation, n (%) | 9 (3) | 3 (7) | 5 (4) | 1 (1) | 0.048 |
Duration of surgical procedure, med [IQR] | 420 [315–490] | 420 [315–500] | 420 [380–480] | 420 [350–505] | 0.78 |
Peridural anesthesia, n (%) | 197 (66) | 24 (60) | 88 (69) | 85 (64) | 0.55 |
ECMO support during surgery, n (%) | 220 (72) | 27 (66) | 86 (66) | 107 (80) | 0.021 |
ECMO weaned in operating room, n (%) | 130 (59) | 18 (67) | 54 (63) | 58 (54) | 0.34 |
Cathecholamine support during surgery, n (%) | 295 (97) | 41 (100) | 123 (95) | 131 (98) | 0.12 |
Transfusion during surgery, n (%) | |||||
RBC transfusion | 204 (68) | 32 (78) | 89 (69) | 83 (63) | 0.17 |
0 RBC unit | 98 (32) | 9 (22) | 42 (33) | 47 (36) | 0.30 |
1–4 RBC units | 148 (49) | 20 (49) | 64 (50) | 64 (48) | |
≥ 5 RBC units | 56 (19) | 12 (29) | 23 (18) | 21 (16) | |
FFP transfusion | 188 (62) | 30 (73) | 74 (57) | 84 (63) | 0.16 |
Platelet transfusion | 64 (21) | 11 (27) | 31 (24) | 22 (17) | 0.22 |
Vascular filling ≥ 2500 mL during surgery, n (%) | 260 (86) | 35 (85) | 114 (88) | 111 (85) | 0.78 |
Overall, N = 279 (100%) | Donor underweight, N = 10 (3.6%) | Donor normal weight, N = 128 (46%) | Donor overweight, N = 95 (34%) | Donor obesity, N = 46 (16%) | p-value | |
---|---|---|---|---|---|---|
Before surgery | ||||||
Age, recipient, n (%) | 57 [51–62] | 56 [45–59] | 57 [50–62] | 57 [51–62] | 58 [53–63] | 0.46 |
Male gender, recipient, n (%) | 179 (64) | 5 (50) | 83 (65) | 62 (65) | 29 (63) | 0.81 |
Height, cm, med [IQR] | 170 [163–176] | 166 [159–175] | 171 [164–176] | 170 [163–177] | 170 [164–177] | 0.81 |
Weight, Kg, med IQR] | 69 [58- 80] | 57 [46–78] | 71 [59–82] | 67 [57–79] | 70 [60–80] | 0.27 |
BMI, Kg/m2, med[IQR] | 24 [21–27] | 21 [18–24] | 24 [21–27] | 23.9 [19–27] | 24 [22–28] | 0.19 |
Diabetes mellitus, n (%) | 30 (11) | 3 (30) | 15 (12) | 10 (11) | 2 (4) | 0.12 |
High blood pressure, n (%) | 70 (25) | 5 (50) | 29 (23) | 23 (24) | 13 (28) | 0.27 |
Dyslipidemia, n (%) | 57 (20) | 3 (30) | 27 (21) | 19 (20) | 8 (17) | 0.79 |
Ischc cardiopathy | 27 (10) | 1 (10) | 11 (9) | 10 (11) | 5 (11) | 0.91 |
Underlying disease | ||||||
COPD, n (%) | 86 (31) | 1 (10) | 37 (29) | 34 (36) | 14 (30) | 0.37 |
PF, n (%) | 130 (47) | 7 (70) | 65 (51) | 35 (37) | 23 (50) | 0.071 |
Other, n (%) | 55 (20) | 2 (20) | 21 (16) | 22 (23) | 10 (22) | 0.59 |
High flow oxygenotherapy before surgery, n (%) | 46 (16) | 3 (30) | 22 (17) | 15 (16) | 6 (13) | 0.59 |
MV before surgery, n (%) | 4 (1.4) | 0 (0) | 1 (1) | 3 (3.2) | 0 (0) | 0.47 |
ECMO support before surgery, n (%) | 21 (8) | 2 (20) | 8 (6) | 8 (8) | 3 (7) | 0.38 |
Tobacco use, n (%) | 190 (68) | 5 (50) | 84 (66) | 70 (74) | 31 (67) | 0.34 |
Peripheral arterial disease, n (%) | 12 (4) | 0 (0) | 7 (6) | 5 (5) | 0 (0) | 0.41 |
Pulmonary arterial hypertension, n (%) | 134 (49) | 5 (50) | 63 (50) | 44 (47) | 22 (49) | 0.97 |
Dilatation of the right ventricle, n (ù° | 77 (28) | 3 (30) | 32 (25) | 32 (34) | 10 (22) | 0.36 |
Ejection fraction of the left ventricle, %, med [IQR] | 62 [58–68] | 60 [58–64] | 63 [58–69] | 61 [60–65] | 63 [55–68] | 0.15 |
Serum creatinine, med [IQR] | 69 [56–80] | 57 [54–76] | 72 [56–84] | 65 [53–78] | 71 [59–83] | 0.083 |
High emergency LT, n (%) | 53 (19) | 3 (30) | 23 (18) | 19 (20) | 8 (17) | 0.74 |
Retransplantation | 7 (2.5) | 1 (10) | 4 (3) | 0 (0) | 2 (4.3) | 0.067 |
Redux | 27 (9.9) | 2 (22) | 16 (13) | 4 (4.3) | 5 (11) | 0.066 |
During surgery | ||||||
Bilateral LT, n (%) | 193 (69) | 6 (60) | 88 (69) | 70 (74) | 29 (63) | 0.52 |
Duration of cold ischemia, min, first lung, med [IQR] | 277 [240–334] | 355 [285–420] | 280 [240–342] | 270 [226–330] | 278 [240–340] | 0.25 |
Duration of cold ischemia, min, second lung, med [IQR] | 375 [308–427] | 428 [332–434] | 390 [315–448] | 360 [300–408] | 365 [300–420] | 0.20 |
Duration of anesthesia, min, med [IQR] | 420 [360–500] | 390 [360–420] | 420 [370–500] | 420 [360–500] | 410 [353–498] | 0.66 |
Peridural anesthesia, n (%) | 185 (67) | 4 (40) | 86 (68) | 62 (67) | 33 (73) | 0.26 |
ECMO support during surgery, n '(%) | 202 (72) | 7 (70) | 96 (75) | 62 (65) | 37 (80) | 0.23 |
Catecholamine support during surgery, n (%) | 273 (98) | 10 (100) | 126 (98) | 92 (97) | 45 (98) | 0.89 |
RBC transfusion during surgery, n (%) | 188 (68) | 9 (90) | 85 (67) | 66 (69) | 28 (62) | 0.40 |
0 RBC unit, n (%) | 88 (32) | 1 (10) | 42 (33) | 29 (31) | 16 (36) | |
1–4 RBC units, n (%) | 137 (49) | 7 (70) | 64 (50) | 45 (47) | 21 (47) | |
≥ 5 RBC units, n (%) | 52 (19) | 2 (20) | 21 (17) | 21 (22) | 8 (18) | |
Fresh frozen plasma transfusion, n (%) | 175 (63) | 6 (60) | 79 (62) | 61 (64) | 29 (63) | 0.98 |
Platelet transfusion n (%) | 56 (20) | 5 (50) | 24 (19) | 16 (17) | 11 (24) | 0.094 |
Vascular filling > 2500 mL, n (%) | 236 (85) | 10 (100) | 104 (83) | 84 (88) | 38 (83) | 0.37 |
Early postoperative complications of the recipients depending on recipients and donors BMI
Overall, N = 304 (100%) | Recipient underweight N = 41 (13%) | Recipient normal weight N = 130 (43%) | Recipient overweight/obesity, N = 133 (44%) | p value | |
---|---|---|---|---|---|
At admission in ICU | |||||
SAPS II score, med [IQR] | 44 [39–53] | 44 [37–50] | 44 [38–52] | 44 [39–54] | 0.28 |
SOFA score, med [IQR] | 8 [6–10] | 8 [6–9] | 8 [6–10] | 8 [7–10] | 0.23 |
Lactatemia > 3 mmol/L, n (%) | 108 (36) | 16 (39) | 42 (32) | 50 (38) | 0.59 |
Lactatemia > 2 mmol/L, n (%) | 185 (61) | 29 (71) | 76 (58) | 80 (60) | 0.36 |
Hemodynamic status during hospitalization in ICU | |||||
Duration of catecholamine administration, days, med [IQR] | 2 [1–4] | 2 [1–3.5] | 2 [1–4] | 2 [1–5] | 0.28 |
ECMO support after surgery, n (%) | 64 (21) | 9 (22) | 21 (16) | 34 (26) | 0.17 |
Duration of ECMO support, days, med [IQR] | 0 [0–2] | 0 [0–1] | 0 [0–2] | 0 [0–2] | 0.15 |
Atrial fibrilation, n (%) | 114 (38) | 12 (29) | 46 (36) | 56 (43) | 0.25 |
MOF syndrome, n (%) | 100 (33) | 14 (34) | 39 (30) | 47 (36) | 0.59 |
Respiratory complications | |||||
Duration of MV, med [IQR] | 3 [1–17] | 3[1–12] | 3 [1–10] | 4 [1–26] | 0.091 |
PGD, n (%) | 161 (53) | 17 (41) | 60 (46) | 84 (63) | 0.006 |
Grade 3 PGD | 117 (38) | 14 (34) | 40 (31) | 63 (47) | 0.018 |
NBA during hospitalization in ICU, n (%) | 89 (29) | 8 (20) | 30 (23) | 51 (39) | 0.008 |
Duration of NBA administration, days, med [IQR] | 0 [0–1] | 0 [0–0] | 0 [0–1] | 0 [0–2] | 0.020 |
Prone positionning, n (%) | 43 (14) | 2 (5) | 13 (10) | 28 (21) | 0.007 |
Number of sessions of prone positionning, med [IQR] | 0 [0–0] | 0 [0–0] | 0 [0–0] | 0 [0–0] | 0.011 |
Extubation failure, n (%) | 55 (22) | 9 (27) | 27 (25) | 19 (18) | 0.43 |
Tracheostomy for ventilation weaning, n (%) | 85 (28) | 9 (22) | 27 (21) | 49 (37) | 0.008 |
Infectious complications | |||||
Septic shock, n (%) | 90 (30) | 9 (22) | 35 (27) | 46 (35) | 0.19 |
Number of pneumonias, med [IQR] | 1 [1, 2] | 1 [1, 2] | 1 [1, 2] | 1 [1, 2] | 0.41 |
Renal complications | |||||
AKI, n (%) | 145 (48) | 21 (51) | 59 (46) | 65 (49) | 0.82 |
KDIGO score, med [IQR], n (%) | 1 [0–2] | 1 [0–2] | 1 [0–2] | 1 [0–3] | 0.29 |
KDIGO 3, n (%) | 60 (20) | 9 (22) | 17 (13) | 34 (26) | 0.036 |
Renal replacement therapy, n (%) | 48 (16) | 7 (17) | 14 (11) | 27 (20) | 0.11 |
Surgical complications | |||||
Thoracic surgical reintervention, n (%) | 61 (20) | 7 (17) | 25 (19) | 29 (22) | 0.77 |
Abdominal surgery, n (%) | 31 (10) | 6 (15) | 8 (6) | 17 (13) | 0.10 |
Other complications | |||||
Bonchial anastomotic dehiscence, n (%) | 40 (16) | 2 (6) | 14 (13) | 24 (21) | 0.072 |
Antibody-mediated rejection, n (%) | 81 (27) | 10 (24) | 32 (25) | 39 (30) | 0.62 |
Acute cellular rejection, n (%) | 40 (13) | 5 (12) | 13 (10) | 22 (17) | 0.28 |
Outcome | |||||
Duration of ICU stay, days, med [IQR] | 17 [9–31] | 18 [10–28] | 15 [10–26] | 18 [11–41] | 0.15 |
Death on day-90, n (%) | 52 (17) | 5 (12) | 24 (18) | 23 (17) | 0.65 |
Death at one year, n (%) | 86 (28) | 9 (22) | 37 (28) | 40 (30) | 0.60 |
Overall, N = 279 (100%) | Donor underweight, N = 10 (3.6%) | Donor normal weight, N = 128 (46%) | Donor overweight, N = 95 (34%) | Donor obesity, N = 46 (16%) | p value | |
---|---|---|---|---|---|---|
At admission in the ICU | ||||||
SAPS II at admission in ICU, med [IQR] | 44 [39–53] | 40 [36–48] | 45 [39–53] | 44 [39–53] | 45 [41–52] | 0.41 |
SOFA score at admission in ICU, med [IQR] | 8 [7–10] | 6 [6–9.3] | 8 [7–10] | 8 [7–10] | 7.5 [6–10] | 0.30 |
Serum lactate > 3 mmol/L | 101 (36) | 3 (30) | 46 (36) | 35 (37) | 17 (37) | 0.99 |
Serum lactate > 2 mmol/L | 170 (61) | 8 (80) | 77 (60) | 62 (65) | 23 (50) | 0.22 |
Hemodynamic status during hospitalization in ICU | ||||||
Duration of catecholamine support, med [IQR] | 2 [1–4] | 2 [1–7] | 2 [1–4] | 2 [1–4] | 2 [1–3] | 0.75 |
Atrial fibrillation, n (%) | 103 (37) | 7 (70) | 39 (31) | 43 (45) | 14 (32) | 0.020 |
MOF syndrome, n (%) | 94 (34) | 4 (40) | 42 (33) | 36 (38) | 12 (26) | 0.54 |
Duration of ECMO support | 0 [0–2] | 0 [0–0] | 0 [0–2] | 1 [0–3] | 0 [0–0] | 0.004 |
Respiratory complications | ||||||
Duration of MV, med [IQR] | 3 [1–19] | 5 [1–24] | 3 [1–17] | 3 [1–18] | 3 [1–20] | 0.98 |
PGD, n (%) | 147 (53) | 4 (40) | 66 (52) | 55 (58) | 22 (48) | 0.54 |
Grade 3 PGD, n (%) | 74 (27) | 2 (20) | 36 (28) | 30 (32) | 6 (13) | 0.10 |
NBA administration, n (%) | 85 (31) | 4 (40) | 36 (29) | 32 (34) | 13 (28) | 0.73 |
Duration of NBA administrationn, med [IQR] | 3 [1–5] | 5 [4–8] | 3 [1–4] | 3 [1–5] | 2 [1–5] | 0.45 |
Prone positionning, n (%) | 41 (15) | 3 (30) | 17 (13) | 16 (17) | 5 (11) | 0.37 |
Reintubation | 50 (22) | 2 (22) | 26 (25) | 11 (15) | 11 (28) | 0.28 |
Tracheostomy for ventilation weaning, n (%) | 80 (29) | 3 (30) | 38 (30) | 27 (28) | 12 (26) | 0.97 |
Infectious complications | ||||||
Bacteriemia, n (%) | 44 (16) | 3 (30) | 18 (14) | 17 (18) | 6 (13) | 0.50 |
Mediastinitis, n (%) | 15 (5.4) | 1 (10) | 6 (4.7) | 5 (5.3) | 3 (6.5) | 0.67 |
Septic shock | 83 (30) | 2 (20) | 36 (28) | 32 (34) | 13 (29) | 0.76 |
Number of pneumonia, med [IQR] | 1 [1, 2] | 1 [1–1.75] | 1 [1, 2] | 1 [1, 2] | 1 [1, 2] | 0.86 |
Surgical complications | ||||||
Surgical thoracic reintervention, n (%) | 54 (19) | 1 (10) | 23 (18) | 22 (23) | 8 (17) | 0.71 |
Abdominal surgery, n (%) | 29 (10) | 2 (20) | 13 (10) | 11 (12) | 3 (6.5) | 0.50 |
Renal complications | ||||||
AKI, n (%) | 133 (48) | 4 (40) | 62 (49) | 43 (45) | 24 (52) | 0.84 |
KDIGO stage, med [IQR] | 1 [0–2] | 0 [0–1] | 1 [0–2] | 1 [0–2] | 1 [0–2] | 0.50 |
Renal replacement therapy, n(%) | 44 (16) | 0 (0) | 19 (15) | 19 (20) | 6 (13) | 0.39 |
Other complications | ||||||
Bronchial anastomotic dehiscence, n(%) | 38 (16) | 2 (25) | 17 (15) | 9 (11) | 10 (24) | 0.17 |
Antibody mediated rejection, n (%) | 75 (27) | 2 (20) | 36 (28) | 27 (29) | 10 (22) | 0.83 |
Acute cellular rejection, n (%) | 33 (12) | 1 (10) | 17 (13) | 10 (11) | 5 (11) | 0.94 |
Outcome | ||||||
Duration of ICU stay, med IQR] | 17 [9–32] | 20 [9, 11–32] | 17 [10–35] | 18 [12–28] | 15 [9–31] | 0.77 |
Death on day-90, n (%) | 49 (18) | 0 (0) | 21 (16) | 20 (21) | 8 (17) | 0.45 |
Short-term outcome according to the pretransplantation BMI of the recipients
OR | 95%CI | p | |
---|---|---|---|
Tobbacco use (donor) | 0.53 | 0.23 – 1.22 | 0.13 |
PaO2/FiO2 (donor) | 0.97 | 0.92 – 1.01 | 0.13 |
Preoperative BMI ≥ 25 kg/m2 | 0.66 | 0.28 – 1.51 | 0.33 |
ECMO support during surgery | 1.42 | 0.48 – 4.88 | 0.55 |
Dobutamine administration during surgery | 7.52 | 0.75 – 137.47 | 0.12 |
Vascular filling ≥ 2500 mL | 1.41 | 0.38 – 7.14 | 0.64 |
SAPS II score at ICU admission | 1.16 | 1.11 – 1.21 | < 0.001 |