Lung transplantation during acute exacerbations of interstitial lung disease and post-transplant survival

Acute exacerbations of interstitial lung disease (AE-ILD) cause severe respiratory failure, and mortality is high despite treatment. Lung transplantation is an effective therapy for progressive and late-stage interstitial lung disease (ILD), but it is a limited resource. Prior studies are conflicting on if patients transplanted during an AE-ILD can have acceptable post-transplant outcomes. To compare one-year survival for patients transplanted during an AE-ILD with that for other ILD transplant recipients. We performed a retrospective evaluation of all first-time lung transplant recipients for ILD performed at our institution between 1 May 2005 and 1 April 2019. Patients were stratified according to a published consensus definition into AE-ILD recipients, other inpatients, or outpatients. One-year survival was compared with a Cox proportional hazards model. Subset analysis was performed on those with idiopathic pulmonary fibrosis. Patients were also assessed for survival free of long-term chronic lung allograft dysfunction (CLAD). We identified 717 patients with ILD who received a first-time lung transplant: 41 inpatients with an AE-ILD, 31 other inpatients, and 645 outpatients. One-year survival was 93% for AE-ILD recipients, 61% for other inpatient recipients, and 82% for outpatient recipients. Those transplanted during an AE-ILD had a lower hazard of death or retransplantation compared to other inpatients (hazard ratio [HR] 0.16, 95% confidence interval [CI] 0.04-0.56) and outpatients (HR 0.29, CI 0.09-1.00). Results were similar among the subset of patients with IPF, but differences were not significant. For those transplanted during AE-ILD, rates of CLAD were not significantly different compared to other inpatients (HR 1.34, CI 0.51-3.54) or to outpatients (HR 1.05, CI 0.52-2.13). With careful selection, patients with AE-ILD can be transplanted and have acceptable one-year outcomes without an increased risk of long-term graft dysfunction.