title: The ripple effect of a complication in lung transplantation: Evidence for increased long-term survival risk.
abstract: OBJECTIVE
  Lung transplantation is a life-saving procedure for patients who have end-stage lung disease. The frequency and severity of complications have not been fully characterized. We hypothesized that early in-hospital, postoperative complications decrease long-term survival.
  
  
  METHODS
  We retrospectively identified in-hospital complications in lung transplant recipients, from the period January 2007 to October 2013. Complications were graded using the extended Accordion Severity Grading System (ASGS). Complications were categorized by event and organ system. Survival analysis was performed (P < .05) using a time-dependent model.
  
  
  RESULTS
  Among 748 eligible patients, 3381 independent in-hospital, postoperative complications occurred in 92.78% of patients. Median follow-up was 5.4 years. Complications associated with significant decrease in 5-year survival were: renal (hazard ratio [HR] 2.58, 95% confidence interval [CI] 1.40-4.48); hepatic (HR 4.08, 95% CI 2.86-5.82); cardiac (HR 1.95, 95% CI 1.56-2.45). The maximum ASGS of ≥5 (18.5% vs 73.8%), and the weighted ASGS sum >10 (2.5% vs 73.8%), were found to be significant predictors of long-term survival. Multivariate analysis identified a weighted ASGS sum of >10, and renal, cardiac, and vascular complications as predictors of decreased long-term survival.
  
  
  CONCLUSIONS
  Rigorous delineation of complications after lung transplantation showed that grade 5 ASGS in-hospital postoperative complications, and a weighted ASGS sum >10, were independent predictors of decreased long-term survival well beyond the initial perioperative period. These results may identify important targets for best practice guidelines and quality-of-care measures after lung transplantation.
authors.affiliation: Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Ernest G
authors.initials: EG
authors.lastname: Chan
authors.affiliation: Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Valentino
authors.initials: V
authors.lastname: Bianco
authors.affiliation: Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Thomas
authors.initials: T
authors.lastname: Richards
authors.affiliation: Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: J W Awori
authors.initials: JW
authors.lastname: Hayanga
authors.affiliation: Department of Pulmonary Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Matthew
authors.initials: M
authors.lastname: Morrell
authors.affiliation: Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Norihisa
authors.initials: N
authors.lastname: Shigemura
authors.affiliation: Department of Pulmonary Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Maria
authors.initials: M
authors.lastname: Crespo
authors.affiliation: Department of Pulmonary Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Joseph
authors.initials: J
authors.lastname: Pilewski
authors.affiliation: Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: James
authors.initials: J
authors.lastname: Luketich
authors.affiliation: Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa. Electronic address: dcunhaj@upmc.edu.
authors.forename: Jonathan
authors.initials: J
authors.lastname: D'Cunha
mesh_terms: D000368:Aged; D015897:Comorbidity; D005260:Female; D006801:Humans; D016040:Lung Transplantation / Q000009:adverse effects* / Q000401:mortality; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010414:Pennsylvania; D011183:Postoperative Complications / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome
keywords: accordion severity grading system; lung transplantation; outcomes; postoperative care; surgical complications; survival