Normothermic ex-vivo preservation with the portable Organ Care System Lung device for bilateral lung transplantation (INSPIRE): a randomised, open-label, non-inferiority, phase 3 study

Background: Severe primary graft dysfunction (PGD) of grade 3 (PGD3) is a common serious complication following lung transplantation. We aimed to assess physiological donor lung preservation using the Organ Care System (OCS) Lung device compared with cold static storage. Methods: In this non-inferiority, randomised, controlled, open-label, phase 3 trial (INSPIRE) recipients were aged 18 years or older and were registered as standard criteria primary double lung transplant candidates. Eligible donors were younger than 65 years old with a ratio of partial pressure of oxygen in arterial blood to the fraction of inspired oxygen of more than 300 mm Hg. Transplant recipients were randomly assigned (1:1) with permuted blocks, stratified by centre, to receive standard criteria donor lungs preserved in the OCS Lung device (OCS arm) or cold storage at 4\ub0C (control arm). The composite primary effectiveness endpoint was absence of PGD3 within the first 72 h after transplant and 30-day survival in the per-protocol population, with a stringent 4% non-inferiority margin. Superiority was tested upon meeting non-inferiority. The primary safety endpoint was the mean number of lung graft-related serious adverse events within 30 days of transplant. We did analyses in the per-protocol and intention-to-treat populations. This trial is registered with ClinicalTrials.gov, number NCT01630434. Findings: Between Nov 17, 2011, and Nov 24, 2014, we randomly assigned 370 patients, and 320 (86%) underwent transplantation (n=151 OCS and n=169 control); follow-up was completed in Nov 24, 2016. The primary endpoint was met in 112 (79\ub74%) of 141 patients (95% CI 71\ub78 to 85\ub78) in the OCS group compared with 116 (70\ub73%) of 165 patients (62\ub77 to 77\ub72) in the control group (non-inferiority point estimate 129\ub71%; 95% CI 12 1e to 121\ub70; p=0\ub70038; and superiority test p=0\ub7068). Patient survival at day 30 post-transplant was 135 (95\ub77%) of 141 patients (95% CI 91\ub70\u201398\ub74) in the OCS group and 165 patients (100%; 97\ub78\u2013100\ub70) in the control group (p=0\ub70090) and at 12 months was 126 (89\ub74%) of 141 patients (83\ub71\u201393\ub79) for the OCS group compared with 146 (88\ub71%) of 165 patients (81\ub78\u201392\ub78) for the control group. Incidence of PGD3 within 72 h was reported in 25 (17\ub77%) of 141 patients in the OCS group (95% CI 11\ub78 to 25\ub71) and 49 (29\ub77%) of 165 patients in the control group (22\ub78 to 37\ub73; superiority test p=0\ub7015). The primary safety endpoint was met (0\ub723 lung graft-related serious adverse events in the OCS group compared with 0\ub728 events in the control group [point estimate 120\ub7045%; 95% CI 12 1e to 0\ub7047; non-inferiority test p=0\ub7020]). In the intention-to-treat population, causes of death at 30 days and in hospital were lung graft failure or lung infection (n=2 for OCS vs n=7 for control), cardiac causes (n=4 vs n=1), vascular or stroke (n=3 vs n=0), metabolic coma (n=0 vs n=2), and generalised sepsis (n=0 vs n=1). Interpretation: The INSPIRE trial met its primary effectiveness and safety endpoints. Although no short-term survival benefit was reported, further research is needed to see whether the reduced incidence of PGD3 within 72 h of a transplant might translate into earlier recovery and improved long-term outcomes after lung transplantation. Funding: TransMedics Inc