Intensive care unit readmissions after lung transplantation: epidemiology and outcome

Introduction

Significant improvement of short-term and long-term survival after lung transplantation (LT) has been observed. Nevertheless, a significant number of patients need to be readmitted to the ICU. The aim of our study was to analyse the epidemiology, outcome and risk factors for LT patients readmitted to the ICU after an initial discharge.

Methods

From February 1996 until May 2006 we studied all LT patients from a single centre initially discharged from the ICU who needed to be readmitted. Demographic data included the type and date of LT, best post-LT FEV₁, last pre-ICU readmission FEV₁, admission diagnosis, time from LT to ICU admission, mechanical ventilation (MV) use, rejection episodes and infections. Actuarial survival rates (ASR) were calculated with Kaplan–Meier curves.

Results

A total of 103 LT patients were discharged from the ICU, 41 patients (39.8%) were readmitted (males 53.6% (22 patients) with a mean age of 42 years (15–66)). Indications were emphysema in 13 patients (31.7%), idiopathic pulmonary fibrosis in eight patients (19.5%), bronchiectasis in five patients (12.2%), cystic fibrosis in five patients and others in seven patients (17%). Seventeen patients underwent bilateral LT, 11 patients right LT (26.8%) and eight patients left LT (19.5%), while five patients received a heart–lung transplantation. Respiratory failure was the principal ICU admission diagnosis (68.3%), followed by seizures (7%) and septic shock (4.8%). MV was required in 35 patients (85.3%). ICU mortality for readmitted patients was 68.3% with a 1-year, 3-year and 5-year ASR of 67.3%, 62.9% and 47.4%. The survival median was 1,761 days (1,134–2,388). In the MV patients, a 1-year, 3-year and 5-year ASR of 63.1%, 58.9% and 44.2% was found with a median survival of 1,618 days (132–3,104). The time to ICU admission was 1,303 (4–3,096 days). ICU admission timing was not found to be a predictor for early (<30 days; 53.8%) vs late (>30 days: 46.4%), P = 0.65. Deceased patients required significantly more MV (71.4% vs 38.5%; P = 0.044 (chi-square); OR: 4; 95% CI: 1–15.99). Emphysema was not more prevalent in the deceased patient group, and neither was the pre-ICU readmission FEV1 nor the occurrence of opportunistic infections. Steroid-resistant acute rejection was found to correlate with mortality.

Conclusion

ICU readmissions are frequent among LT patients. In our study group, respiratory failure was the more prevalent admission diagnosis. The need for MV was associated with a worse prognosis as well as steroid-resistant acute rejection episodes. Early or late ICU admission after LT has not influenced mortality.