Characteristics and outcomes among lung transplant patients with respiratory syncytial virus infection

Abstract

Background: To describe characteristics and outcomes among lung transplantation (LT) patients with respiratory syncytial virus (RSV) infection and elucidate the predictors of 1-year survival after RSV infection.Methods: This was a retrospective chart review study among LT patients with RSV infection between 2013 and 2018 (90 episodes among 87 patients; mean age 56.3 ± 13.1 years, M:F 52:35). A contemporaneous control group consisting of LT patients without RSV infection (n = 183) was included. One-year survival after the RSV infection was the primary endpoint.Results: Median time from LT to RSV infection was 30 (1-155) months. Before RSV infection, the median decline in forced vital capacity (FVC) was 9.7 cc (−17.8 to 83 cc) or 0.29% (−1.4% to 4.6%) per month, while the forced expiratory volume (FEV 1 ) decline was 7.5 cc (−8.8 to 58 cc) or 0.3% (−0.57% to 4.3%) per month with no statistically significant change after RSV infection. One-year survival among patients with RSV infection was 86.2% (75/87). Pre-infection diagnosis of chronic lung allograft dysfunction (CLAD; adjusted HR: 4.29, 1.08-17.0; P = .038) and FVC or FEV 1 decline >10% during 6 months post infection (adjusted HR: 35.1, 3.26-377.1; P = .003) were independently associated with worse survival. On propensity score matched analysis, RSV infection was not associated with worse post-transplant survival (HR with 95% CI: 0.79, 0.47-1.34; P = .38). Conclusions:A majority of LT patients in the current cohort did not experience an alteration in the trajectory of FVC or FEV 1 decline after developing RSV infection, and their post-transplant survival was not adversely impacted. Established CLAD at the time of RSV infection and post infection >10% decline in FVC or FEV 1 are independently associated with worse survival after RSV infection.

Post‐infection pulmonary sequelae after COVID‐19 among patients with lung transplantation

“…This variable has been found to be a useful pre-dictor of adverse outcomes after RVI among LT patients, although it has not been studied among patients with COVID-19. 17,18 In a large cohort of LT patients with RSV infection, an early decline in FEV 1 > 10% was noted among 13% of the patients and was an independent predictor of post-RSV mortality. 18 Similarly, our group found that more than a third of the LT patients suffered > 10% decline in FEV 1 or FVC during the 6 months after RSV infection and, along with pre-infection CLAD, was an independent predictor of mortality at one year after the RSV infection.…”

“…We defined the significant loss of lung functions as at least a 10% or more decline in either FVC or FEV 1 on post‐infection spirometry on two or more occasions. This variable has been found to be a useful predictor of adverse outcomes after RVI among LT patients, although it has not been studied among patients with COVID‐19 17,18 . In a large cohort of LT patients with RSV infection, an early decline in FEV 1 > 10% was noted among 13% of the patients and was an independent predictor of post‐RSV mortality 18 .…”

Elevated cell-free DNA in respiratory viral infection and associated lung allograft dysfunction

“…2,[12][13][14] Sustained FEV 1 decline in the months following RVI has been associated with CLAD development, but FEV 1 decline at the time of infection has not shown a similar CLAD association. 5,15 Finally, pre-viral CLAD has been assessed as a risk factor for further CLAD stage progression and, in LTRs with COVID-19 and RSV, pre-infection CLAD was associated with greater mortality, but has not been confirmed as a predictor for post-viral progression or allograft failure in other studies. 5,[15][16][17] Although antiviral agents have reduced acute mortality from respiratory viral infections, there is little evidence to suggest that associated CLAD rates have been reduced in response.…”

“…5,15 Finally, pre-viral CLAD has been assessed as a risk factor for further CLAD stage progression and, in LTRs with COVID-19 and RSV, pre-infection CLAD was associated with greater mortality, but has not been confirmed as a predictor for post-viral progression or allograft failure in other studies. 5,[15][16][17] Although antiviral agents have reduced acute mortality from respiratory viral infections, there is little evidence to suggest that associated CLAD rates have been reduced in response. 7,18 Thus, better approaches are needed to stratify LTR risk of long-term sequelae following RVI.…”

“…Histopathology, when available, has not always correlated with lung dysfunction or delineated subjects at greatest risk for allograft injury 2,12–14 . Sustained FEV 1 decline in the months following RVI has been associated with CLAD development, but FEV 1 decline at the time of infection has not shown a similar CLAD association 5,15 . Finally, pre‐viral CLAD has been assessed as a risk factor for further CLAD stage progression and, in LTRs with COVID‐19 and RSV, pre‐infection CLAD was associated with greater mortality, but has not been confirmed as a predictor for post‐viral progression or allograft failure in other studies 5,15–17 .…”