Abstract
To compare outcomes of single(SLT) versus bilateral(BLT) lung transplantation among dually listed recipients hypothetically eligible for either treatment.
Considerable debate remains regarding the added benefit of BLT versus SLT. Prior analyses were confounded by significant selection bias or limited in generalizability to the contemporary era; a randomized trial remains unlikely due to ethical concerns.
Within the Organ Procurement and Transplantation Network, we considered all adults who were dually listed for SLT and BLT and underwent first-time lung allograft transplantation for idiopathic pulmonary fibrosis(IPF) or chronic obstructive pulmonary disease(COPD) in the US between 2017-2024. We applied target trial emulation and clone-censor weight methodology to emulate a prospective randomized trial comparing SLT versus BLT.
We tabulated 3,274 dually listed lung allograft recipients, of whom 1,026 were transplanted for COPD and 2,248 for IPF. Median follow-up was 24.5 months. COPD patient survival at five years was superior following BLT (61%[55-66%]) versus SLT (52%[46-58%, P=0.009). Meanwhile, among IPF patients, five year survival was 59%[54-63%] following BLT versus 56%[51-61%], P=0.009) after SLT. In a target trial emulation, among COPD patients, BLT remained associated with reduced mortality hazard (HR 0.67, CI 0.50-0.88). However, stratifying by age, SLT and BLT yielded comparable outcomes among patients ≥70years (HR 0.75, Credible Interval 0.38-1.37). Evaluating IPF recipients, after adjustment, BLT remained associated with comparable mortality hazard (HR 1.04, CI 0.85-1.26). No age-related effect was noted.
Our findings suggest SLT could yield acceptable post-transplantation survival in select patients, while expanding access to this invaluable resource.