Lung Transplant for COVID-19-Related Respiratory Failure Yields Good Outcomes

Patients receiving lung transplants due to COVID-19-related diagnoses of ARDS or pulmonary fibrosis had high rates of survival and low rates of graft failure.

Lung transplant was associated with positive outcomes among patients with COVID-19-related irreversible respiratory failure, yielding survival rates similar to other pretransplant etiologies, according to a study in JAMA Surgery.

Researchers assessed outcomes in patients who had lung transplant for COVID-19 and compared the outcomes with those of patients receiving lung transplantation that was unrelated to COVID-19, using the United Network for Organ Sharing (UNOS) registry.

Participants included adults who underwent lung transplant in the US due to COVID-19-related acute respiratory distress syndrome (ARDS) and COVID-19-related pulmonary fibrosis (PF), as well as their graft donors, from March 2020 to August 2022. The Kaplan-Meier method was used to estimate and plot overall survival and freedom from graft failure with use of deidentified time-to-event data.

The analysis included 195 patients (72.8% male; median age, 46 years [interquartile range {IQR}, 38-54] years) in the ARDS group and 190 (78.9% male; median age, 54 [IQR, 45-62] years) in the PF group. The median lung allocation score was 88.3 (IQR, 80.5-91.1) in the ARDS group and 78.5 (IQR, 47.7- 88.3) in the PF group.

The findings of this study suggest that lung transplant offers encouraging early results in patients with COVID-19-related ARDS and PF.

The median follow-up was 186 (IQR, 64-359) days in the ARDS group vs 181 (IQR, 40-350) days in the PF group. After the follow-up, 8.7% of patients in the ARDS cohort and 8.6% in the PF cohort had an acute rejection episode.

Freedom from graft failure during the 1-, 6-, and 12-month follow-up was 0.98 (95% CI, 0.96-0.99), 0.95 (95% CI, 0.90- 0.97), and 0.88 (95% CI, 0.79-0.93), respectively, in the ARDS group and 0.96 (95% CI, 0.92-0.98), 0.93 (95% CI, 0.87-0.96), and 0.85 (95% CI, 0.74-0.91), respectively, in the PF group.

Overall survival at 1, 6, and 12 months was 0.99 (95% CI, 0.96-0.99), 0.95 (95% CI, 0.91- 0.98), and 0.88 (95% CI, 0.80-0.94), respectively, for the ARDS group and 0.96 (95% CI, 0.92-0.98), 0.92 (95% CI, 0.86-0.96), and 0.84 (95% CI, 0.74-0.90), respectively, for the PF group.

Receiving a graft from a donor who had a heavy and prolonged history of smoking was associated with worse overall survival in the ARDS group in unadjusted and adjusted analyses. Female sex and high body mass index in recipients were associated with worse overall survival in the PF group, and receiving a graft from a female donor was associated with favorable overall survival in adjusted analyses.

When the investigators compared patients receiving lung transplant due to COVID-19-related lung diseases with those who received lung transplant for non-COVID-19 etiologies, they observed no significant difference in overall survival (unadjusted hazard ratio, 0.73; 95% CI, 0.51-1.06; P =.10 and adjusted hazard ratio, 0.79; 95% CI, 0.54-1.16; P =.23, respectively).

In citing limitations, the researchers noted they were unable to evaluate the interval from respiratory failure onset until the day of the transplant to further understand appropriate time intervals required before listing. In addition, the association of intraoperative variables with outcomes was not evaluated, and data were unavailable for the modalities used to diagnose COVID-19 or immunosuppressive agents used.

“The findings of this study suggest that lung transplant offers encouraging early results in patients with COVID-19-related ARDS and PF,” stated the study authors. “Comparable survival outcomes were noted between patients who underwent lung transplant for COVID-19 and non-COVID-19 etiologies.” The study authors further noted that “Organizing a multidisciplinary care team is of paramount importance to overcome the challenges that emerge due to the complexity of this treatment modality.”


Tasoudis P, Lobo LJ, Coakley RD, et al. Outcomes following lung transplant for COVID-19–related complications in the US. JAMA Surg. Published online August 16, 2023. doi:10.1001/jamasurg.2023.3489