http://www.jhltonline.

org

The International Thoracic Organ Transplant

Registry of the International Society for Heart and
Lung Transplantation: 37th adult lung
transplantation report — 2020; focus on deceased
donor characteristics
Daniel C. Chambers, MD, FRACP, Andreas Zuckermann, MD,
Wida S. Cherikh, PhD, Michael O. Harhay, PhD, Don Hayes, Jr, MD,
Eileen Hsich, MD, Kiran K. Khush, MD, MAS, Luciano Potena, MD, PhD,
Aparna Sadavarte, MS, Tajinder P. Singh, MD, and Josef Stehlik, MD, MPH, for
the International Society for Heart and Lung Transplantation

From the International Thoracic Organ Transplant Registry, International Society for Heart and Lung Transplantation,
Dallas, Texas.

TTX Registry is undergoing an update in data acquisition,

Almost 70,000 adult lung transplant procedures have
been reported to the International Society for Heart and
Lung Transplantation (ISHLT) International Thoracic
Organ Transplant (TTX) Registry since its inception, each
one the result of the selfless kindness of a grieving donor
family. With each year’s report, we provide more detailed
analyses on a particular focus theme important to recipient
outcomes. Since 2013, these have been donor and recipient
age, retransplantation, early graft failure, indication for
transplant, allograft ischemic time, multiorgan transplanta-
tion, and donor and recipient size matching.1−7 The goal of
this year’s report is to focus entirely on changes in donor
factors over the past 3 decades and to identify important
donor characteristics and transplant processes that may
influence post-transplant outcomes. Because of small num-
bers, heart−lung donor characteristics and transplant out-
comes have not been included. This 37th annual adult lung
transplant report is based on data submitted to the ISHLT
TTX Registry on 67,493 adult recipients of deceased donor
transplants between January 1, 1992 and June 30, 2018. In
response to a changing regulatory environment, the ISHLT
Reprint requests: Josef Stehlik, MD, MPH, University of Utah Health,
Division of Cardiovascular Medicine, U.T.A.H. Cardiac Transplant Pro-
gram, 50 North Medical Drive, A100 SOM, Salt Lake City, Utah 84132.
Telephone: +1-801-585-2340. Fax: +1-801-581-7735.
E-mail address: josef.stehlik@hsc.utah.edu
and the patient cohort examined in this report is therefore
derived from the same data source or datasets as that exam-
ined in the 2019 annual reports.2,8−10 We refer the reader to
the 2019 report for the detailed description of the baseline
characteristics of the cohort and additional core analyses
not directly related to the focus explored in this year’s
report.
Data collection, conventions, and statistical
methods
National and multinational transplant collectives and individ-
ual transplant centers submit data to the ISHLT TTX Registry.
Since the Registry’s inception, 481 heart transplant centers,
260 lung transplant centers, and 184 centers that perform com-
bined heart−lung transplants have reported data to the ISHLT
TTX Registry.2,8−10 It is estimated that data submitted repre-
sents approximately three quarters of the worldwide thoracic
transplant activity. This report references specific online e-
slides when particular data are discussed but not shown
because of space limitations; e-slide numbers refer to the
online adult lung transplant slides, shortened to L(a), and
available at https://ishltregistries.org/registries/slides.asp. The
ISHLT web site also contains slide sets for previous annual
reports.
The TTX Registry website (https://ishlt.org/research-data/regis
tries/ttx-registry) provides detailed spreadsheets of the data

1053-2498/$ - see front matter Ó Published by Elsevier Inc.

https://doi.org/10.1016/j.healun.2020.07.009
Chambers et al. ISHLT 37th Adult Lung Transplantation Report
elements collected in the Registry. The Registry requires submis-
sion of core donor, recipient, and transplant procedure variables at
baseline (i.e., around the time of transplantation) and at annual fol-
low-up, and these variables therefore have low rates of missing-
ness. Nevertheless, data quality depends on the accuracy and
completeness of reporting. Rates of missingness may significantly
increase for Registry variables that depend on voluntary reporting.
The Registry uses various quality control measures to ensure
acceptable data quality and completeness before including data
for analyses.
Analytic conventions
Unless otherwise specified, analyses of lung transplants do not
include combined heart−lung transplant data. The Registry does
not capture the exact occurrence date for most secondary out-
comes (e.g., bronchiolitis obliterans syndrome [BOS]), but it does
capture the window of occurrence (e.g., the event occurred
between the first and the second year annual follow-up visits). For
the report’s analyses, we use the midpoint between the annual fol-
low-ups as a surrogate for the event date. Because deceased sub-
jects no longer contribute to the secondary outcomes, to reduce
the potential of underestimating event rates or other outcomes, we
restrict some analyses to include only surviving recipients. For
time-to-event analyses, we censor the follow-up of recipients who
have not yet experienced the event at the most recent annual fol-
low-up or the time of retransplantation. We truncate time-to-event
graphs (e.g., survival graphs) when the number of individuals at
risk becomes <10. Previous Registry report themes provide more
details regarding specific donor and recipient characteristics and
outcomes.1−7
Focus theme: Deceased donor characteristics
The ongoing disparity between the demand for transplan-
tation for potential recipients with end-stage lung disease
and the supply of donor organs has, over time, altered
perception of what constitutes an acceptable organ and,
hence, the characteristics of the accepted donor. How-
ever, aside from a more aggressive stance on organ
acceptance, other factors such as demographic changes
(aging population and declining smoking rates) have also
impacted donor characteristics over the past 30 years.
Against this background, we examine donor characteris-
tics by year of transplantation.
Adult lung transplant donor characteristics stratified by
era (1992−2000, 2001−2009, and 2010−2018) are pre-
sented in Table 1. The number of transplants performed has
gradually increased over time, with the proportion of proce-
dures performed in North America falling relative to the
rest of the world. Notably, overall median donor age has
steadily increased from 30 to 40 years and in Europe is now
51 years (Figure 1a, eSlide L(a) 6). The aging of the donor
population over time likely reflects an increased willingness
to accept older donor lungs in the setting of a limited donor
pool, general population aging, and changes in the mode of
death prompting consideration of organ donation, as dis-
cussed in more detail hereafter. In line with increasing
donor age, the prevalence of cytomegalovirus and Epstein-
Barr virus seropositivity have both increased slightly over
time, from 55.3% to 61.6% and 91.6% to 93.7%,
1017
respectively (Table 1). The proportion of lung donors who
are female has increased from 38.1% to 43.8% (Table 1,
eSlide L(a) 7), and median donor height has fallen slightly
in line with these changing demographics. Median lung
donor body mass index has increased in all geographic
regions, with a global increase from 23.3 kg/m2 in the 1992
−2000 era to 25.1 kg/m2 in the 2010−2018 era (Figure 1b,
eSlide L(a) 6), reflecting the overall rising prevalence of
obesity in the general population.11
The median donor arterial partial pressure of oxygen
(PO2) has declined slightly over the past 2 decades (data is
not available for the 1992−2000 era) from 424 to 409
mm Hg (p < 0.0001, Table 1 and Figure 1c). This trend
probably reflects both an increased appetite for perceived
risk when accepting donor organs in the face of a limited
donor pool and an increasing recognition that donor PO2
does not have a significant impact on post-transplant out-
comes, at least within the range where organ acceptance is
common (≥250 mm Hg) (see survival analyses hereafter).
Notably, in previous ISHLT TTX Registry Reports, donor
PO2 has not appeared in the list of variables that are inde-
pendently associated with either short or long-term
survival.2,3
The distribution of donors by blood type has been quite
stable, with approximately 39% of donors being blood type
A, 49% blood type O, 10% blood type B, and the remaining
2% blood type AB (Table 1). Donor cause of death varies
by geographic region and has changed significantly over
the past 3 decades (Figure 2), as also noted in the 2020 adult
heart report.12 In Europe, donors have predominantly died
from cerebrovascular accident/stroke, whereas the propor-
tion of donors who have died of head trauma has declined.
These observations likely reflect fewer overall deaths
related to motor vehicle accidents and gun violence. At the
same time, the aging donor population seen particularly in
Europe is more likely to succumb because of neurological
events. In contrast, in North America, head trauma remains
the most common cause of death (Figure 2, eSlide L(a) 8),
whereas deaths owing to anoxia have increased in number
and proportion, likely because of the opioid epidemic and
drug overdose deaths.
Interesting trends are apparent on examining changes
in donor substance use over time (Table 1). The propor-
tion of donors with a >20 pack year history of cigarette
smoking has declined dramatically from almost 35% to
10% (Figure 3a, eSlide L(a) 9) since the 1990s. The
proportion of adult lung donors with a history of alcohol
use (≥2 standard alcoholic drinks per day) has increased
slightly (Figure 3b). The proportion of donors with a
history of cocaine use has doubled from under 10% to
over 20% (Figure 3c), and there has been a dramatic
and troubling increase in the proportion of donors who
have ever abused or been dependent upon non-intrave-
nous street drugs (crack cocaine; marijuana; and pre-
scription narcotics, sedatives, hypnotics, and stimulants)
from 20% to almost 50% (Figure 3d). Unfortunately, it
is not possible to examine changes in donor substance
use by geographic region, because of constraints in data
collection and reporting.
1018 The Journal of Heart and Lung Transplantation, Vol 39, No 10, October 2020

Table 1 Adult Lung Transplant Donor Characteristics by Era (Transplants: January 1992−June 2018)

Characteristic Jan 1992−Dec 2000 Jan 2001−Dec 2009 Jan 2010−June 2018 p-value
(N = 11,796) (N = 21,806) (N = 33,891)
Geographic location <0.0001
Europe 3,751 (31.8)% 7,818 (35.9)% 12,414 (36.6)%
North America 7,324 (62.1)% 12,545 (57.5)% 18,594 (54.9)%
Other 721 (6.1)% 1,443 (6.6)% 2,883 (8.5)%
Age (years) 30 (15−54) 37 (16−60) 40 (17−65) <0.0001
Male 61.9% 56.9% 56.2% <0.0001
Height (cm) 173.0 (157.0−188.0) 172.7 (157.0−188.0) 172.0 (155.0−188.0) <0.0001
BMI (kg/m2) 23.3 (18.2−31.0)a 24.2 (18.8−33.1) 25.1 (19.2−35.5) <0.0001
Blood type 0.1946
A 39.1% 38.8% 38.5%
AB 2.3% 2.4% 2.3%
B 9.9% 10.0% 10.6%
O 48.6% 48.7% 48.6%
Cause of death
Anoxia 3.5% 7.9% 19.8% <0.0001
CVA/stroke 38.4% 44.7% 41.2%
Head trauma 49.7% 44.5% 36.0%
Other 8.3% 2.9% 3.0%
CMV antibody positive 55.3% 60.4% 61.6% <0.0001
EBV antibody positive — 91.6%b 93.7% <0.0001
Hep B antibody positive 2.4% 2.5% 2.6% 0.6759
Hep C antibody positive 0.6% 0.1% 0.6% <0.0001
Smoking history 31.7% 20.7% 12.1% <0.0001
Alcohol use — 12.8%b 14.6% 0.0001
Cocaine use — 10.8% 14.3% <0.0001
Other drugs use — 28.1% 40.7% <0.0001
Diabetes 2.3%a 4.6% 7.2% <0.0001
Hypertension 12.4%a 18.4% 24.0% <0.0001
PO₂ (mm Hg) — 424.0 (115.0−578.4)c 409.0 (109.0−563.0) <0.0001
Abbreviations: BMI, body mass index; CVA, cerebrovascular accident; CMV, cytomegalovirus; EBV, Epstein-Barr virus; Hep B, hepatitis B; Hep C, hepati-
tis C; PO2, partial pressure of oxygen.
Summary statistics excluded transplants with missing data.
Continuous factors are expressed as median (5th−95th percentiles).
Comparisons for categorical variables were made using the chi-square statistic.
Comparisons for continuous variables were made using the Wilcoxon test.
a
Based on April 1994−December 2000 transplants.
b
Based on April 2006−December 2009 transplants.
c
Based on July 2004−December 2009 transplants.

Figure 1 Donor age, body mass index, and PO2 by year and region (transplants from eras as shown). (a) Age. (b) Body mass index. (c)
PO2.
Chambers et al. ISHLT 37th Adult Lung Transplantation Report 1019

Figure 2 Donor cause of death by era and region (transplants: January 1992−June 2018). CVA, cerebrovascular accident.

Figure 3 Donor substance use by year (transplants from eras as shown). (a) Smoking. (b) Alcohol. (c) Cocaine. (d) Other.

Important changes in adult lung donor comorbidities Survival analyses

(Table 1) have occurred over the past 3 decades, with
the potential for significant, and perhaps unexpected,
impact on post-transplant outcomes (see survival analy-
ses hereafter). The proportion of adult lung donors with
a history of diabetes has tripled from 2% to 3% to
almost 10% (Figure 4a), and the proportion with a his-
tory of systemic hypertension has increased from 10%
to over 25% (Figure 4b). Multiple factors likely underlie
these changes, including the aging donor pool and rising
obesity rates.
We next examined associations between donor risk factors and
post-transplant survival. We present a number of stratified
unadjusted analyses. Multivariable analyses were not per-
formed; hence, it should be kept in mind that these analyses
have not been adjusted for potential confounders that may
account for some of the reported differences. All 5-year sur-
vival analyses are conditional on survival to 1 year. The impact
of ischemic time on outcomes was the focus of the 2017
Report3 and so has not received heavy focus in this Report.
1020 The Journal of Heart and Lung Transplantation, Vol 39, No 10, October 2020

Figure 4 Donor diabetes and hypertension by year (transplants: January 1995−June 2018). (a) Diabetes. (b) Hypertension.

Donor age
Older donor age was weakly associated with lower 12-
month post-transplant survival, as has been previously
noted.2,4 In unadjusted Kaplan−Meier analyses, survival
was lower in recipients of organs from donors aged
≥50 years at 12 months (Figure 5a, eSlide L(a) 13). How-
ever, when survival at 5 years conditional on survival to 1
year was considered, there was no difference (Figure 5b,
eSlide L(a) 26), suggesting that the effect of donor age on
post-transplant survival is transient. The impact of older
donor age on survival to 12 months post-transplant was
consistent across geographic regions (eSlide L(a) 15) and a
range of recipient ages (Figure 6, eSlide L(a) 14), although
the differences did not reach significance in recipients aged
18 to 39 years. Ischemic time did not modulate the effect of
older donor age on survival at 12 months (eSlide L(a) 21).
This interaction was examined in depth in the 2017 Report.3
In summary, this more focused analysis is consistent with
findings from previous reports suggesting a relatively weak
and short-lived impact of donor age on recipient survival.
Donor cause of death and PO2
Donor cause of death is not a core data element in the
ISHLT Registry and so is variably reported by contributing
transplant centers. Although this limitation must be kept in
mind, broad trends in the events leading to death and subse-
quent lung donation are evident from the available data.
Although transplant recipients who received organs from
donors with a history of cerebrovascular accident experi-
enced the lowest 12-month survival, and those with a his-
tory of donor anoxia or trauma the highest, none of these
differences were statistically significant (Figure 7a, eSlide

Figure 5 Kaplan−Meier survival for adult lung transplant recipients by donor age (transplants: January 2000−June 2017 and January
2000−June 2013, respectively). (a) 12 months. (b) 5 years conditional on survival to 1 year. NS, not significant.
Chambers et al. ISHLT 37th Adult Lung Transplantation Report 1021

Figure 6 Kaplan−Meier survival within 12 months for adult lung transplant recipients by donor and recipient age (transplants: January
2000−June 2017). NS, not significant.

L(a) 16). Any trends in survival may well relate to the older
age of donors who died of cerebrovascular accident. Fur-
thermore, there was no clinically meaningful impact of
donor cause of death on 5-year survival, conditional on sur-
vival to 1 year (Figure 7b, eSlide L(a) 29). One of the most
important pieces of information that is acquired during the
process of donor assessment is the PO2 measured while
100% oxygen is administered to the potential lung donor.
Despite its perceived importance, the donor PO2 was not
associated with transplant survival at 1 and 5 years
(Figure 8a and b, eSlides L(a) 16 and 29), as noted in previ-
ous reports,1,2 and as also noted in the 2020 pediatric lung
report.13 Notably, the number of transplants where the
donor PO2 was reported to the Registry as <250 mm Hg
was 6,133, approximately 25% of the total number for
whom PO2 was available. This large proportion suggests
that some of the PO2 values reported were not obtained on
100% fraction of inspired oxygen. Nevertheless, there was
no clinically significant association between donor PO2 and
post-transplant survival, even if the donors with PO2 < 250
mm Hg were to be disregarded.
Donor substance abuse
We next examined recipient survival by donor substance
abuse, with 12-month survival data shown in Figure 9 and
5-year survival conditional on survival to 1 year in
Figure 10. As shown in Figure 9a (eSlide L(a) 17), receipt
of lungs from a donor with a history of smoking (more than
20 pack years) was associated with 3% lower 12-month sur-
vival and a 1.5% lower 5-year conditional survival
(Figure 10a, eSlide L(a) 30). A history of donor alcohol use
(defined as 2 or more alcoholic drinks per day) was not
associated with survival at 12 months (Figure 9b, eSlide L
(a) 17) or at 5 years (Figure 10b, eSlide L(a) 30). Donor
cocaine use was associated with slightly lower 12-month
(Figure 9c, eSlide L(a) 18) and 5-year (Figure 10c, eSlide L
(a) 31) survival, although the absolute differences were
very small (85% vs 85.2% and 57.5% vs 59% at 1 and
5 years, respectively). Use of other drugs (non-intravenous
street drugs such as crack; marijuana; or prescription nar-
cotics, sedatives, hypnotics, or stimulants) was not associ-
ated with a difference in survival at 12 months (Figure 9d,

Figure 7 Kaplan−Meier survival for adult lung transplant recipients by donor cause of death (transplants: January 2000−June 2017 and
January 2000−June 2013, respectively). (a) 12 months. (b) 5 years conditional on survival to 1 year. CVA, cerebrovascular accident; NS,
not significant.
1022 The Journal of Heart and Lung Transplantation, Vol 39, No 10, October 2020

Figure 8 Kaplan−Meier survival for adult lung transplant recipients by donor PO2 (transplants: January 2005−June 2017 and January
2005−June 2013, respectively). (a) 12 months. (b) 5 years conditional on survival to 1 year. NS, not significant.

Figure 9 Kaplan−Meier survival within 12 months for adult lung transplant recipients by donor substance use (transplants from eras as
shown). (a) Smoking. (b) Alcohol. (c) Cocaine. (d) Other. NS, not significant.

eSlide L(a)18); however, an impact on longer-term survival
was apparent. Five-year survival, conditional on survival to
1 year, was significantly different between recipients who
received an organ from a donor with a history of such sub-
stance abuse compared with those without such history
(57.3% vs 59.7% respectively, p = 0.0002, Figure 10d,
eSlide L(a) 31), although again the absolute differences
were very small. This differential impact on short- vs lon-
ger-term survival may have several explanations. For exam-
ple, if there is a genuine detrimental impact on transplant
outcome where there is a history of this kind of substance
abuse in the donor, the impact on early outcomes may be
ameliorated by the younger age and lack of other medical
comorbidities of donors with this social history.
Donor diabetes and hypertension
Some of the most interesting findings were seen in recipi-
ents of organs from donors with a history of systemic
hypertension and diabetes. Although these donor factors are
known to impact cardiac transplant survival,12 an effect on
lung transplant survival is not well recognized and may not
be anticipated. Recipients of organs from a donor with a
history of diabetes had significantly lower 12-month and 5-
year conditional survival (Figure 11a and b, eSlides L(a) 19
and 32). The numerical differences (81.3% vs 85%, p <
0.0001 at 12-month and 63% vs 67%, p = 0.0014 at 5 years)
were as large as the differences noted for donors with a his-
tory of smoking and older donors at 12 months, mandating
Chambers et al. ISHLT 37th Adult Lung Transplantation Report 1023

Figure 10 Kaplan−Meier survival within 5 years conditional on survival to 1 year for adult lung transplant recipients by donor sub-
stance use (transplants from eras as shown). (a) Smoking. (b) Alcohol. (c) Cocaine. (d) Other.

Figure 11 Kaplan−Meier survival for adult lung transplant recipients by donor diabetes (transplants from eras as shown). (a) 12
months. (b) 5 years conditional on survival to 1 year.

further investigation. Although multivariable analyses were
not performed for this report, and further analyses of the
impact of donor diabetes were limited by the relatively
small number of procedures (eSlides L(a) 24 and 37), this
association has been previously noted in adjusted analyses
of post-transplant survival in adult lung transplant recipi-
ents.1,2 This suggests that the impact on post-transplant sur-
vival is independent of other factors recorded in the
Registry. The adverse effect of donor hypertension was also
significant at both 1 and 5 years; however, the differences
were not as large (Figure 12a and b, eSlides L(a) 19 and
32). Donor hypertension was also found to be indepen-
dently associated with post-transplant survival in the multi-
variable analyses included in previous reports.2 Together,
these data suggest that these 2 donor comorbidities, both
part of the metabolic syndrome, have a long-lasting impact
on survival in adult lung transplant recipients. The biologi-
cal mechanism(s) underlying what appears to be a robust
association are unclear, but the implications are intriguing.
Although diabetes and hypertension are very well estab-
lished risk factors for cardiac disease, their impact on lung
disease and by inference the cells (pulmonary epithelium,
stroma, and endothelium) that would be transferred endur-
ingly to the recipient during transplantation has not been
well studied. However, recent studies have identified an
association between diabetes and restrictive lung function
impairment14 as well as activation of profibrotic signaling
pathways.15 These findings reinforce the associations noted
1024 The Journal of Heart and Lung Transplantation, Vol 39, No 10, October 2020

Figure 12 Kaplan−Meier survival for adult lung transplant recipients by donor hypertension (transplants: January 2000−June 2017 and
January 2000−June 2013, respectively). (a) 12 months. (b) 5 years conditional on survival to 1 year.

in previous reports and highlight a rich area for further
investigation.
Ischemic time
The impact of ischemic time on adult lung transplant out-
comes was the focus of the 2017 Report and so is not
examined in depth in this Report. Nevertheless, the
equivalent, and possibly even superior, outcomes seen in
recipients of organs with longer ischemic times are again
apparent (eSlides L(a) 20 and L(a) 33) and are also noted
in the pediatric lung report.13 This association is one
with longevity, with differences in survival becoming
more apparent over time, such that 5-year post-transplant
survival is 70% in recipients where the ischemic time is
≥4 hours, compared with 65% in recipients of organs
with shorter ischemic times (p < 0.0001, eSlide L(a) 33).
Recipients with ischemic time ≥4 hours and donor age
≥50 years had lower 12-month survival than those with
donor age <35 years, but there was no impact on long-
term survival (eSlides L(a) 21 and 34). We next exam-
ined the effect of donor hypertension, in combination
with ischemic time, on recipient survival. Although not
all pairwise comparisons were significant, the highest
survival at both 1 and 5 years was seen in recipients of
donor organs where there was no history of hypertension
and the ischemic time was ≥4 hours (eSlide L(a) 22 and
Figure 13, eSlide L(a) 35).

Figure 13 Kaplan−Meier survival within 5 years conditional on survival to 1 year for adult lung transplant recipients by donor history
of hypertension and ischemic time (transplants: January 2005−June 2013).
Chambers et al. ISHLT 37th Adult Lung Transplantation Report
Figure 14 Kaplan−Meier freedom from BOS conditional on survival to discharge for adult lung transplant recipients by donor age
(transplants: January 2000−June 2017). BOS, bronchiolitis obliterans syndrome.
Freedom from BOS conditional on survival to
discharge
BOS is the leading cause of long-term graft dysfunction
and graft loss after lung transplantation.16 Unfortunately,
despite decades of research, management remains largely
empirical with few evidence-based treatment options.
Large epidemiological analyses, including previous Reg-
istry Reports3 incorporating donor and recipient factors,
have provided important insight into risk factors for the
subsequent development of BOS. These reports highlight
what may be the most pertinent pathogenic mechanisms
and thus provide a potential focus for future mechanistic
studies. We therefore next examined associations between
donor risk factors and BOS development in this focus
theme report.
We first explored freedom from BOS by donor age. As
seen in Figure 14 (eSlide L(a) 39), there was an association
between donor age and freedom from BOS, but this differ-
ence was small and only significant in the oldest vs youn-
gest donor age groups. The proportion of recipients free
from BOS at 10 years post-transplant was 24% for recipi-
ents of organs from donors <35 years, 21% for donors age
35 to 49 years, and 20.6% for donors aged ≥50 years
(Figure 14, eSlide L(a) 39). Older donors will have different
causes of death, more comorbidities, and potentially a more
extensive history of substance use and of environmental
exposures, so we next investigated the impact of these fac-
tors on freedom from BOS. We found no association
between donor cause of death or donor PO2 and freedom
from BOS (eSlide L(a) 40). There was a comparatively
1025
strong association between ischemic time and freedom
from BOS (eSlide L(a) 41), consistent with the findings of
the 2017 Report with longer ischemic times associated with
enduring freedom from BOS.3 At 10 years post-transplant,
18.9% of recipients where the ischemic time was <4 hours
are free from BOS, compared with 24.6% of those where
the ischemic time was ≥4 hours (eSlide L(a) 41), reinforc-
ing the paradoxical effect of ischemic time on one of the
most critically important outcomes in the field of adult lung
transplantation.
Although we did not observe an association between
donor smoking and freedom from BOS (Figure 15a,
eSlide L(a) 42), we did note an association between donor
alcohol use and freedom from BOS (Figure 15b, eSlide L
(a) 42). Recipients of organs from donors with a history
of consuming 2 or more alcoholic drinks per day experi-
enced lower freedom from BOS; however, the numerical
differences were small (Figure 15b, eSlide L(a) 42).
There was no association between donor cocaine or other
drug use and freedom from BOS (Figure 15c and d,
eSlide L(a) 43).
Finally, given the significant associations seen
between donor diabetes and hypertension and post-trans-
plant survival, we examined associations between these
donor comorbidities and freedom from BOS. There was
no association between either donor diabetes (Figure 16a,
eSlide L(a) 44) or donor hypertension (Figure 16b, eSlide
L(a) 44) and freedom from BOS, suggesting perhaps that
the lower survival seen in recipients of organs with these
donor characteristics may be related to complications
other than BOS.
1026 The Journal of Heart and Lung Transplantation, Vol 39, No 10, October 2020

Figure 15 Kaplan−Meier freedom from BOS conditional on survival to discharge for adult lung transplant recipients by donor sub-
stance use (transplants from eras as shown). (a) Smoking. (b) Alcohol. (c) Cocaine. (d) Other. BOS, bronchiolitis obliterans syndrome; NS,
not significant.

Figure 16 Kaplan−Meier freedom from BOS conditional on survival to discharge for adult lung transplant recipients by donor diabetes
and hypertension (transplants from January 2000 to June 2017). (a) Diabetes. (b) Hypertension. BOS, bronchiolitis obliterans syndrome;
NS, not significant.

Conclusions and anoxia. In univariate analyses, we identified significant

In this 2020 ISHLT adult lung transplant report, we focused
on deceased donor trends over time. We observed many
important changes over the past 30 years, reflecting chang-
ing practice and demographics worldwide. We noted a
gradual aging of the donor pool; a decline in smoking rates;
and an increase in metabolic syndrome comorbidities,
including diabetes and hypertension. The cause of death
leading to lung donation is also changing, with a decline in
traumatic deaths and increases in cerebrovascular accidents
associations between donor factors and recipient outcomes.
We confirmed the findings of previous reports where factors
that receive the most attention at the time of donor assess-
ment (PO2, age, ischemic time, and donor smoking) have
either no association with post-transplant outcomes, less of
an effect than may be anticipated, or a paradoxical effect.
We also found that factors that are often overlooked at the
time of an organ offer, in particular donor diabetes, may be
more important than previously recognized. We hope that
Chambers et al. ISHLT 37th Adult Lung Transplantation Report
this information will assist those who are making organ
acceptance decisions to select donor lungs based on the
best available evidence, with choices made by carefully
quantifying and balancing a suite of donor and recipient
factors against the risk of wait-list mortality. Furthermore,
we hope these analyses will stimulate further research
focused on refining donor selection algorithms and safely
expanding the donor pool, as well as more fundamental
research exploring ways to improve allograft and recipient
longevity.
Disclosure statement
Kiran Khush is supported by National Institutes of Health/
National Heart, Lung, and Blood Institute award
R01HL125303 to study evidence-based strategies for donor
heart evaluation and serves as scientific adviser and speaker
for CareDx, Inc. Luciano Potena serves as a speaker for
Thermo Fisher, Sandoz, Abbott, and Novartis. Josef Stehlik
is supported by American Heart Association grant
16SFRN31890003 to study patient health status in disease
transitions and serves as consultant for Medtronic and Abbott.
Daniel Chambers received research funding from Astellas
and Boeringher-Ingelheim. Andreas Zuckermann serves on
the speakers bureau of Paragonix, Mallinckrodt, and Franz
Kohler Chemie. Eileen Hsich is supported by National Insti-
tutes of Health/National Heart, Lung, and Blood Institute
award R01HL141892 to study disparities in survival among
heart transplant candidates and recipients. The remaining
authors have no conflicts of interest to disclose.
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