Natural History of Pleural Complications after Lung Transplantation

Background: Despite advances in lung transplantation, 5-year survival remains at 56%. Although focus has been on chronic lung allograft dysfunction and infection, pleural complications in some may contribute to adverse outcomes. Therefore, we determined 1) prevalence of, and risk factors for, pleural complications after lung transplant and 2) their association with allograft function and mortality.

Methods: From 2006 to 2017, 1,039 adults underwent primary lung transplant at Cleveland Clinic. Multivariable analyses were performed in the multiphase mixed longitudinal and hazard function domains to identify risk factors associated with allograft function and survival.

Results: 468 patients (45%) developed pleural complications, including pleural effusion in 271 (26%), pneumothorax in 152 (15%), hemothorax in 128 (12%), empyema in 47 (5%), and chylothorax in 9 (1%). Risk factors for pleural complications within the first 3 months included higher recipient/donor weight ratio, lower recipient albumin, and recipient-donor race mismatch; those extending beyond 3 months included older age, hypertension, smoking history, lower lung allocation score, and donor death from anoxia. Cardiopulmonary bypass and prior thoracic interventions were not risk factors in patients with pleural effusions who were treated with thoracentesis only, and forced expiratory volume in 1 second improved after drainage; however, repeat percutaneous or surgical interventions did not impart similar benefit. Pleural complications were associated with worse survival.

Conclusions: Pleural complications are common after lung transplant and are associated with worse allograft function and survival. They are likely secondary to other underlying clinical problems. Malnourishment and size mismatch are modifiable risk factors.