The risk that a positive smoking history in lung donors
could adversely affect survival of transplant recipients causes
concern. Conversely, reduction of the donor pool by exclusion of donors
with positive smoking histories could compromise survival of patients
waiting to receive a transplant. We examined the consequences of donor
smoking on post-transplantation survival, and the potential effect of
not transplanting lungs from such donors.
Methods We
analysed the effect of donor smoking on 3 year survival after first
adult lung transplantation from brain-dead donors done between July 1,
1999, and Dec 31, 2010, by Cox regression modelling of data from the UK
Transplant Registry. We estimated the effect of acceptance of lungs from
donors with positive smoking histories on survival and compared it with
the effect of remaining on the waiting list for a potential transplant
from a donor with a negative smoking history donor, by analysing all
waiting-list registrations during the same period with a risk-adjusted
sequentially stratified Cox regression model.
Findings Of
1295 lung transplantations, 510 (39%) used lungs from donors with
positive smoking histories. Recipients of such lungs had worse 3 year
survival after transplantation than did those who received lungs from
donors with negative smoking histories (unadjusted hazard ratio [HR]
1·46, 95% CI 1·20–1·78; adjusted HR 1·36, 1·11–1·67). Independent
factors affecting survival were recipient's age, donor–recipient
cytomegalovirus matching, donor–recipient height difference, donor's
sex, and total ischaemic time. Of 2181 patients registered on the
waiting list, 802 (37%) died or were removed from the list without
receiving a transplant. Patients receiving lungs from donors with
positive smoking histories had a lower unadjusted hazard of death after
registration than did those who remained on the waiting list (0·79, 95%
CI 0·70–0·91). Patients with septic or fibrotic lung disease registered
in 1999–2003 had risk-adjusted hazards of 0·60 (95% CI 0·42–0·87) and
0·39 (0·28–0·55), respectively.
InterpretationIn
the UK, an organ selection policy that uses lungs from donors with
positive smoking histories improves overall survival of patients
registered for lung transplantation, and should be continued. Although
lungs from such donors are associated with worse outcomes, the
individual probability of survival is greater if they are accepted than
if they are declined and the patient chooses to wait for a potential
transplant from a donor with a negative smoking history. This situation
should be fully explained to and discussed with patients who are
accepted for lung transplantation.