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Clinical Characteristics and Outcomes of Patients With COVID-19–Associated Acute Respiratory Distress Syndrome Who Underwent Lung Transplant

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Key Points

Question  What were the clinical outcomes of patients who underwent a lung transplant after developing COVID-19–associated acute respiratory distress syndrome (ARDS) at a single center in the US?

Findings  In this retrospective case series involving 102 consecutive patients who underwent a lung transplant between January 21, 2020, and September 30, 2021, at a single center in Chicago, Illinois, patient survival was 100% for the 30 patients who had COVID-19–associated ARDS and 83% for the 72 patients without COVID-19, as of November 15, 2021.

Meaning  In this case series of patients who underwent a lung transplant, survival was 100% in patients who had COVID-19–associated ARDS as of November 15, 2021.

Abstract

Importance  Lung transplantation is a potentially lifesaving treatment for patients who are critically ill due to COVID-19–associated acute respiratory distress syndrome (ARDS), but there is limited information about the long-term outcome.

Objective  To report the clinical characteristics and outcomes of patients who had COVID-19–associated ARDS and underwent a lung transplant at a single US hospital.

Design, Setting, and Participants  Retrospective case series of 102 consecutive patients who underwent a lung transplant at Northwestern University Medical Center in Chicago, Illinois, between January 21, 2020, and September 30, 2021, including 30 patients who had COVID-19–associated ARDS. The date of final follow-up was November 15, 2021.

Exposures  Lung transplant.

Main Outcomes and Measures  Demographic, clinical, laboratory, and treatment data were collected and analyzed. Outcomes of lung transplant, including postoperative complications, intensive care unit and hospital length of stay, and survival, were recorded.

Results  Among the 102 lung transplant recipients, 30 patients (median age, 53 years [range, 27 to 62]; 13 women [43%]) had COVID-19–associated ARDS and 72 patients (median age, 62 years [range, 22 to 74]; 32 women [44%]) had chronic end-stage lung disease without COVID-19. For lung transplant recipients with COVID-19 compared with those without COVID-19, the median lung allocation scores were 85.8 vs 46.7, the median time on the lung transplant waitlist was 11.5 vs 15 days, and preoperative venovenous extracorporeal membrane oxygenation (ECMO) was used in 56.7% vs 1.4%, respectively. During transplant, patients who had COVID-19–associated ARDS received transfusion of a median of 6.5 units of packed red blood cells vs 0 in those without COVID-19, 96.7% vs 62.5% underwent intraoperative venoarterial ECMO, and the median operative time was 8.5 vs 7.4 hours, respectively. Postoperatively, the rates of primary graft dysfunction (grades 1 to 3) within 72 hours were 70% in the COVID-19 cohort vs 20.8% in those without COVID-19, the median time receiving invasive mechanical ventilation was 6.5 vs 2.0 days, the median duration of intensive care unit stay was 18 vs 9 days, the median post–lung transplant hospitalization duration was 28.5 vs 16 days, and 13.3% vs 5.5% required permanent hemodialysis, respectively. None of the lung transplant recipients who had COVID-19–associated ARDS demonstrated antibody-mediated rejection compared with 12.5% in those without COVID-19. At follow-up, all 30 lung transplant recipients who had COVID-19–associated ARDS were alive (median follow-up, 351 days [IQR, 176-555] after transplant) vs 60 patients (83%) who were alive in the non–COVID-19 cohort (median follow-up, 488 days [IQR, 368-570] after lung transplant).

Conclusions and Relevance  In this single-center case series of 102 consecutive patients who underwent a lung transplant between January 21, 2020, and September 30, 2021, survival was 100% in the 30 patients who had COVID-19–associated ARDS as of November 15, 2021.

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Article Information

Corresponding Author: Ankit Bharat, MD, Northwestern Medicine, 676 N Saint Clair St, Ste 650, Chicago, IL 60611 (ankit.bharat@nm.org).

Accepted for Publication: January 7, 2022.

Published Online: January 27, 2022. doi:10.1001/jama.2022.0204

Author Contributions: Mr Manerikar and Dr Kurihara had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Kurihara, Kim, Ho, Arunachalam, Budinger, Bharat.

Acquisition, analysis, or interpretation of data: Kurihara, Manerikar, Querrey, Felicelli, Yeldandi, Garza-Castillon, Lung, Ho, Tomic, Arunachalam, Pesce, Bharat.

Drafting of the manuscript: Kurihara, Manerikar, Querrey, Yeldandi, Garza-Castillon Jr, Arunachalam, Budinger, Bharat.

Critical revision of the manuscript for important intellectual content: Kurihara, Felicelli, Garza-Castillon Jr, Lung, Kim, Ho, Tomic, Arunachalam, Budinger, Pesce, Bharat.

Statistical analysis: Kurihara, Manerikar, Ho, Pesce, Bharat.

Obtained funding: Kurihara, Budinger, Bharat.

Administrative, technical, or material support: Kurihara, Manerikar, Felicelli, Yeldandi, Garza-Castillon Jr, Kim, Tomic, Budinger, Bharat.

Supervision: Kurihara, Kim, Arunachalam, Bharat.

Conflict of Interest Disclosures: None reported.

Funding/ Support: This study was supported by the National Institutes of Health (NIH HL145478, HL147290, and HL147575 to Dr Bharat).

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank Elena Susan, MA, Division of Thoracic Surgery, Northwestern University, for formatting and submission of the manuscript to the journal, for which she received no additional compensation.

References
1.
Geleris  J , Sun  Y , Platt  J ,  et al.  Observational study of hydroxychloroquine in hospitalized patients with COVID-19.   N Engl J Med. 2020;382(25):2411-2418. doi:10.1056/NEJMoa2012410PubMedGoogle ScholarCrossref
2.
Richardson  S , Hirsch  JS , Narasimhan  M ,  et al; the Northwell COVID-19 Research Consortium.  Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area.   JAMA. 2020;323(20):2052-2059. doi:10.1001/jama.2020.6775PubMedGoogle ScholarCrossref
3.
Horby  P , Lim  WS , Emberson  JR ,  et al; RECOVERY Collaborative Group.  Dexamethasone in hospitalized patients with COVID-19.   N Engl J Med. 2021;384(8):693-704. doi:10.1056/NEJMoa2021436PubMedGoogle Scholar
4.
Beigel  JH , Tomashek  KM , Dodd  LE .  Remdesivir for the treatment of COVID-19: preliminary report: reply.   N Engl J Med. 2020;383(10):994. doi:10.1056/NEJMoa2007764PubMedGoogle Scholar
5.
Bharat  A , Querrey  M , Markov  NS ,  et al.  Lung transplantation for patients with severe COVID-19.   Sci Transl Med. 2020;12(574):eabe4282. doi:10.1126/scitranslmed.abe4282PubMedGoogle Scholar
6.
van der Mark  SC , Hoek  RAS , Hellemons  ME .  Developments in lung transplantation over the past decade.   Eur Respir Rev. 2020;29(157):190132. doi:10.1183/16000617.0132-2019PubMedGoogle Scholar
7.
Bharat  A , Machuca  TN , Querrey  M ,  et al.  Early outcomes after lung transplantation for severe COVID-19: a series of the first consecutive cases from four countries.   Lancet Respir Med. 2021;9(5):487-497. doi:10.1016/S2213-2600(21)00077-1PubMedGoogle ScholarCrossref
8.
Machuca  TN , Cypel  M , Bharat  A .  Comment on “Let’s build bridges to recovery in COVID-19 ARDS, not burn them!”   Ann Surg. 2021;274(6):e870-e871. doi:10.1097/SLA.0000000000004623PubMedGoogle ScholarCrossref
9.
Fan  E , Del Sorbo  L , Goligher  EC ,  et al; American Thoracic Society, European Society of Intensive Care Medicine, and Society of Critical Care Medicine.  An official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine clinical practice guideline: mechanical ventilation in adult patients with acute respiratory distress syndrome.   Am J Respir Crit Care Med. 2017;195(9):1253-1263. doi:10.1164/rccm.201703-0548STPubMedGoogle ScholarCrossref
10.
Badulak  J , Antonini  MV , Stead  CM ,  et al; ELSO COVID-19 Working Group Members.  Extracorporeal membrane oxygenation for COVID-19: updated 2021 guidelines from the Extracorporeal Life Support Organization.   ASAIO J. 2021;67(5):485-495. doi:10.1097/MAT.0000000000001422PubMedGoogle ScholarCrossref
11.
Kurihara  C , Walter  JM , Karim  A ,  et al.  Feasibility of venovenous extracorporeal membrane oxygenation without systemic anticoagulation.   Ann Thorac Surg. 2020;110(4):1209-1215. doi:10.1016/j.athoracsur.2020.02.011PubMedGoogle ScholarCrossref
12.
Kurihara  C , Manerikar  A , Gao  CA ,  et al.  Outcomes after extracorporeal membrane oxygenation support in COVID-19 and non–COVID-19 patients.   Artif Organs. 2021. doi:10.1111/aor.14090PubMedGoogle Scholar
13.
Manerikar  A , Watanabe  S , Kandula  V ,  et al.  Indwelling central venous catheters drive bloodstream infection during veno-venous extracorporeal membrane oxygenation support.   ASAIO J. 2021. doi:10.1097/MAT.0000000000001575PubMedGoogle Scholar
14.
Ranieri  VM , Rubenfeld  GD , Thompson  BT ,  et al; ARDS Definition Task Force.  Acute respiratory distress syndrome: the Berlin Definition.   JAMA. 2012;307(23):2526-2533. doi:10.1001/jama.2012.5669PubMedGoogle Scholar
15.
Snell  GI , Yusen  RD , Weill  D ,  et al.  Report of the ISHLT Working Group on Primary Lung Graft Dysfunction, part I: definition and grading: a 2016 consensus group statement of the International Society for Heart and Lung Transplantation.   J Heart Lung Transplant. 2017;36(10):1097-1103. doi:10.1016/j.healun.2017.07.021PubMedGoogle ScholarCrossref
16.
Bellomo  R , Ronco  C , Kellum  JA , Mehta  RL , Palevsky  P ; Acute Dialysis Quality Initiative Workgroup.  Acute renal failure: definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group.   Crit Care. 2004;8(4):R204-R212. doi:10.1186/cc2872PubMedGoogle ScholarCrossref
17.
Bharat  A , Hoetzenecker  K , Machuca  TN .  Lung transplantation for COVID-19-associated ARDS: authors’ reply.   Lancet Respir Med. 2021;9(9):e90. doi:10.1016/S2213-2600(21)00288-5PubMedGoogle Scholar
18.
Verity  R , Okell  LC , Dorigatti  I ,  et al.  Estimates of the severity of coronavirus disease 2019: a model-based analysis.   Lancet Infect Dis. 2020;20(6):669-677. doi:10.1016/S1473-3099(20)30243-7PubMedGoogle ScholarCrossref
19.
Oran  DP , Topol  EJ .  Prevalence of asymptomatic SARS-CoV-2 infection: a narrative review.   Ann Intern Med. 2020;173(5):362-367. doi:10.7326/M20-3012PubMedGoogle ScholarCrossref
20.
Dmytriw  AA , Chibbar  R , Chen  PPY ,  et al.  Outcomes of acute respiratory distress syndrome in COVID-19 patients compared to the general population: a systematic review and meta-analysis.   Expert Rev Respir Med. 2021;15(10):1347-1354. doi:10.1080/17476348.2021.1920927PubMedGoogle ScholarCrossref
21.
Attaway  AH , Scheraga  RG , Bhimraj  A , Biehl  M , Hatipoğlu  U .  Severe COVID-19 pneumonia: pathogenesis and clinical management.   BMJ. 2021;372(n436):n436. doi:10.1136/bmj.n436PubMedGoogle Scholar
22.
Barbaro  RP , MacLaren  G , Boonstra  PS ,  et al; Extracorporeal Life Support Organization.  Extracorporeal membrane oxygenation support in COVID-19: an international cohort study of the Extracorporeal Life Support Organization registry.   Lancet. 2020;396(10257):1071-1078. doi:10.1016/S0140-6736(20)32008-0PubMedGoogle ScholarCrossref
23.
Huang  C , Wang  Y , Li  X ,  et al.  Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.   Lancet. 2020;395(10223):497-506. doi:10.1016/S0140-6736(20)30183-5PubMedGoogle ScholarCrossref
24.
Pickens  CO , Gao  CA , Cuttica  MJ ,  et al; NU COVID Investigators.  Bacterial superinfection pneumonia in patients mechanically ventilated for COVID-19 pneumonia.   Am J Respir Crit Care Med. 2021;204(8):921-932. doi:10.1164/rccm.202106-1354OCPubMedGoogle ScholarCrossref
25.
Budinger  GRS , Misharin  AV , Ridge  KM , Singer  BD , Wunderink  RG .  Distinctive features of severe SARS-CoV-2 pneumonia.   J Clin Invest. 2021;131(14):149412. doi:10.1172/JCI149412PubMedGoogle Scholar
26.
Weingarten  N , Schraufnagel  D , Plitt  G , Zaki  A , Ayyat  KS , Elgharably  H .  Comparison of mechanical cardiopulmonary support strategies during lung transplantation.   Expert Rev Med Devices. 2020;17(10):1075-1093. doi:10.1080/17434440.2020.1841630PubMedGoogle ScholarCrossref
27.
Bermudez  CA , Shiose  A , Esper  SA ,  et al.  Outcomes of intraoperative venoarterial extracorporeal membrane oxygenation versus cardiopulmonary bypass during lung transplantation.   Ann Thorac Surg. 2014;98(6):1936-1942. doi:10.1016/j.athoracsur.2014.06.072PubMedGoogle ScholarCrossref
28.
Moreno Garijo  J , Cypel  M , McRae  K , Machuca  T , Cunningham  V , Slinger  P .  The evolving role of extracorporeal membrane oxygenation in lung transplantation: implications for anesthetic management.   J Cardiothorac Vasc Anesth. 2019;33(7):1995-2006. doi:10.1053/j.jvca.2018.10.007PubMedGoogle ScholarCrossref
29.
Hashimoto  K , Hoetzenecker  K , Yeung  JC ,  et al.  Intraoperative extracorporeal support during lung transplantation in patients bridged with venovenous extracorporeal membrane oxygenation.   J Heart Lung Transplant. 2018;37(12):1418-1424. doi:10.1016/j.healun.2018.07.003PubMedGoogle ScholarCrossref
30.
Querrey  M , Kurihara  C , Manerikar  A ,  et al.  Lung donation following SARS-CoV-2 infection.   Am J Transplant. 2021;21(12):4073-4078. doi:10.1111/ajt.16777PubMedGoogle ScholarCrossref
31.
Bullard  J , Dust  K , Funk  D ,  et al.  Predicting infectious severe acute respiratory syndrome coronavirus 2 from diagnostic samples.   Clin Infect Dis. 2020;71(10):2663-2666. doi:10.1093/cid/ciaa638PubMedGoogle ScholarCrossref
32.
Todd  JL , Neely  ML , Kopetskie  H ,  et al.  Risk factors for acute rejection in the first year after lung transplant: a multicenter study.   Am J Respir Crit Care Med. 2020;202(4):576-585. doi:10.1164/rccm.201910-1915OCPubMedGoogle ScholarCrossref
33.
Bharat  A , Saini  D , Benshoff  N ,  et al.  Role of intra-islet endothelial cells in islet allo-immunity.   Transplantation. 2007;84(10):1316-1323. doi:10.1097/01.tp.0000288192.11396.70PubMedGoogle ScholarCrossref
34.
Fernandez  FG , Jaramillo  A , Ewald  G ,  et al.  Blood transfusions decrease the incidence of acute rejection in cardiac allograft recipients.   J Heart Lung Transplant. 2005;24(7 Suppl):S255-S261. doi:10.1016/j.healun.2004.07.009PubMedGoogle ScholarCrossref
35.
Bowe  B , Xie  Y , Xu  E , Al-Aly  Z .  Kidney outcomes in long COVID.   J Am Soc Nephrol. 2021;32(11):2851-2862. doi:10.1681/ASN.2021060734PubMedGoogle ScholarCrossref
36.
Cypel  M , Keshavjee  S .  When to consider lung transplantation for COVID-19.   Lancet Respir Med. 2020;8(10):944-946. doi:10.1016/S2213-2600(20)30393-3PubMedGoogle ScholarCrossref
37.
Barbaro  RP , MacLaren  G , Boonstra  PS ,  et al; Extracorporeal Life Support Organization.  Extracorporeal membrane oxygenation for COVID-19: evolving outcomes from the international Extracorporeal Life Support Organization Registry.   Lancet. 2021;398(10307):1230-1238. doi:10.1016/S0140-6736(21)01960-7PubMedGoogle ScholarCrossref
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