A positive smoking history among donors has been
associated with worse outcomes among lung transplant recipients. Smoking has several adverse effects on the lung,
like permeability changes, airflow obstruction, loss of lung tissue and
increased cancer risk, all of which can be reversed, to a certain extent, by
quitting smoking. But, if donors with a
positive history are excluded, that could mean compromising on the survival of
patients who are awaiting a transplant.
Previously, lung transplantation was carried out
only in a few selected patients with
end-stage lung disease and the donor selection criteria were strict. Only young
donors with near-perfect gas exchange who did not have other risk factors such
as a history of cigarette smoking were accepted. Later, as transplantation
became more common, donor selection criteria became less strict to balance
supply and demand and reduce the mortality of patients on the waiting list.
Researchers studied the risks associated with transplantation of lungs from donors
with positive smoking histories and
compared them with the effect of non-acceptance of such organs and waiting for
a potential transplant from a donor with a negative smoking history.
They found that out of the 1295 lung transplantations that they studied,
the 510 (39%) recipients who received lungs from donors with a positive smoking
history had worse 3-year post transplantation survival than those who had
received lungs from donors with negative smoking histories. Recipients of lungs from smoking donors spent more
time in intensive-care units and hospitals and could derive less functional
benefit from transplantation than recipients of lungs from donors with negative
smoking histories. In bilateral lung-transplant recipients, the highest FEV1 (Forced Expiratory Volume) reported in the first 2
years after transplantation was lower in recipients of lungs from smoking
donors than in recipients of lungs from non-smoking donors. The outcomes were
worst when the donor's estimated cigarette consumption exceeded one pack per
the other hand, out of the 2181 patients who were registered on the waiting
list, 802 (37%) died or were removed from the list without receiving a
it was found that positive donor smoking history adversely affects recipient
survival, the individual probability of survival is greater if they are
accepted than if such patients are declined a transplant and the patient
chooses to wait for a potential transplant from a donor with a negative smoking
a non-smoking donor selection strategy were adopted, the donor pool would fall
by roughly 40% which would increase overall mortality by compromising patient
survival from waiting-list entry. The total number of life-years lost by use of
lungs from donors with positive smoking histories was significantly less than
the number of life-years lost if these lungs were not used at all.
gathered by the UK Transplant Registry shows that patients with septic lung
disease have a 40% greater survival chance and those with fibrosis a 61%
greater chance with an allocation strategy that includes lungs from donors with
positive smoking histories than with strategies that exclude such donors. In
chronic obstructive pulmonary disease (COPD), bilateral lung transplantation is
better than monolateral lung transplantation. In pulmonary fibrosis, survival
advantage is gained from waiting-list registration by acceptance of an
available single lung transplant even though post-transplantation outcomes
could be better by bilateral lung transplantation.
reports have suggested that the effect of smoking history is relevant only to
the early postoperative course. The death rate from malignant disease showed no
difference between recipients of lungs from donors with positive smoking
histories and non-smoking donors. However, the patients were less in number to
draw strong inferences.
from donors with positive smoking histories have lower functional reserve
before donation or greater vulnerability to immunological and infectious
injuries after transplantation than lungs from non-smoking donors.
the researchers concluded that
lungs from donors with positive smoking history improves overall survival of
patients registered for lung transplantation and should be continued. However,
such recipients should be better informed that the use of such lungs could
reduce their lifetime.
Effect of donor smoking on survival after lung transplantation: a cohort study
of a prospective registry; Robert Bonser et al; The Lancet Online Publication