Single vs bilateral, sequential lung transplantation for end-stage emphysema: Influence of recipient age on survival and secondary end-points

Background: The appropriate age to perform bilateral, sequential lung trans plants (BSLT) in patients with chronic obstructive pulmonary disease (COPD) remains controversial. Although single lung transplant (SLT) offers an adv antage in terms of organ availability, the long-term survival may not warra nt this strategy in all age groups. Methods: We analyzed 2,260 lung transplant recipients (1835 SLT, 425 BSLT) with COPD recorded in the International Society for Heart and Lung Transpla ntation/United Network for Organ Sharing thoracic registry between January 1991 and December 1997. To assess mortality, we performed univariate (Kapla n-Meier method and the chi-square statistic) and multivariate analyses (pro portional hazards method). Because of incomplete morbidity data in the inte rnational registry, only data from U.S. centers (n = 1778, 1467 SLT, 311 BS LT) were used in the morbidity analysis. Results: Survival rates (%) computed using the Kaplan-Meier method at 30 da ys, I year, and 5 years for the patients aged < 50 years were 93.6, 80.2, a nd 43.6, respectively, for the SLT patients, and 94.9, 84.7, and 68.2, resp ectively, for the BSLT patients. For patients aged 50 to 60 years, survival rates (%) were 93.5, 79.4, and 39.8 for the SLT patients compared with 93. 0, 79.7, and 60.5 for the BSLT patients. For those aged > 60 years, SLT sur vival (%) wits 93.0, 72.9, and 36.4, compared with 77.8 and 66.0 for the BS LT group (a 5-year rate could not be completed in this group). The multivar iate model showed a higher risk ratio for mortality in patients aged 40 to 57 years who received SLT vs BSLT. Recipient age and procedure type did not appear to affect the development of rejection, bronchiolitis obliterans, b ronchial stricture, or lung infection. Conclusions: Single lung transplant may offer acceptable early survival for patients with end-stage respiratory failure. However, long-term survival d ata favors BSLT in recipients until approximately age 60 years. These data suggest that a BSLT approach offers a significant survival advantage to rec ipients younger than 60 years of age.