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BackgroundPreformed donor-specific antibodies (DSAs) are associated with worse outcome after lung transplantation (LTx) and migvaht limit access to LTx. A virtual crossmatch (CXM)-based strategy for perioperative desensitisation protocol has been used for immunised LTx candidates since 2012 at Foch hospital. We compared the outcome of desensitised LTx candidates with high DSA mean fluorescence intensity (MFI) and those with low or no preformed DSAs, not desensitised.MethodsFor all consecutive LTx recipients (January-2012/March-2018), freedom from CLAD and graft survival were assessed by Kaplan–Meier analysis and Cox multivariate analysis.ResultsWe compared outcomes for desensitised patients with high preformed DSAs (n=39) and those with no (n=216) or low pre-formed DSAs (n=66). The desensitisation protocol decreased the level of immunodominant DSA (class I/II) at 1, 3, and 6 month post-LTx (p<0.001, p<0.01, p<0.001, respectively). Freedom from CLAD and graft survival at 3 years was similar in the desensitised group as a whole and other groups. Nevertheless, incidence of CLAD was higher with persistent high- than cleared high-level (p=0.044) or no DSAs (p=0.014). Conversely, graft survival was better with cleared high DSAs than persistent high-, low-level, and no pre-formed DSAs (p=0.019, p=0.025, and p=0.044, respectively). On multivariate analysis, graft survival was associated with cleared high DSAs (HR: 0.12 [95%CI: 0.02–0.85] versus no DSAs, p=0.035) and CLAD with persistent DSAs (HR: 3.04 [1.02–9.17] versus no preformed DSAs, p=0.048).ConclusionThe desensitisation protocol in LTx recipients with high preformed DSAs was associated with satisfactory outcome, with cleared high pre-formed DSAs after desensitisation identified as an independent predictor of graft survival.

Summary Inhaled nitric oxide (iNO) is usually used during lung transplantation despite controversial postoperative benefits. Our group chose to administer iNO systematically during the procedure and stop at the end of surgery. This study aims to describe the features of patients who cannot be weaned from iNO, the reasons for this and its impact on postoperative outcomes. This is a monocentric cohort study comprised all consecutive patients who underwent double‐lung transplantation (DLT) between 1 January 2012 and 1 January 2016. The impact of iNO dependency on postoperative outcomes was estimated using a boosted inverse probability of treatment weighting estimator. A total of 9.8% of the 173 patients included in the study could not be weaned from iNO at end‐surgery stage. Body mass index (OR = 2.03, 95% CI = 1.14–3.29, P = 0.02) and intraoperative extracorporeal membrane oxygenation (OR = 1.80, 95% CI = 1.02–2.72, P = 0.04) were risk factors for iNO dependency In the weighted population, iNO dependency was associated with an increased prevalence of grade 3 primary graft dysfunction (adjusted RR = 4.20, 95% CI = 1.75–10.09, P < 0.001) and decreased postoperative survival during the first 1500 days of follow‐up (adjusted HR = 5.0, 95% CI = 1.86–13.48, P < 0.001). Inhaled nitric oxide dependency is an early marker of a poor prognosis following DLT.

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