Kaposi sarcoma in lung transplant recipients with public health service increased-risk donors: A retrospective cohort study and review of the literature.

Purpose: To investigate the relationship between Public Health Service (PHS) increased-risk donors and post-lung transplant (LT) Kaposi sarcoma (KS). Methods: This retrospective cohort study included LT recipients (April 1, 2019-April 1, 2024) who had PHS increased-risk donors at our institution. Data were abstracted from UNOS and electronic medical records. Published post-LT KS cases were also reviewed. Descriptive statistics and Kaplan-Meier estimates were used. Results: Of 467 LT recipients, 90 (23.9%) had PHS increased-risk donors, including 13 [14.4%] men who have sex with men (MSM). Four of these 13 (30.8%) recipients developed KS (median time to diagnosis, 365 days [IQR 276-502]). Basiliximab was the most common induction agent; all 4 patients were on standard 3-drug immunosuppression. All 4 recipients had pulmonary KS without extrapulmonary involvement and positive human herpes virus 8 (HHV-8) immunohistochemistry results. Pulmonary nodules were incidentally noted on chest CT in 3 asymptomatic patients; 1 patient presented with dyspnea and central airway obstruction. Immunosuppression was reduced and mTOR inhibitors were initiated for all 4 patients; 1 patient underwent stenting of the left main bronchus and radiation, and 1 was treated with liposomal doxorubicin. Three recipients improved, and 1 is awaiting follow-up imaging (median follow-up, 276 days [IQR 177-433]). In our data pooled with 15 published cases, mean survival time was lower in patients with disseminated KS (182 vs. 563 days, p=0.011). Conclusion: LT recipients with MSM donors may be at an increased risk for post-LT KS from donor-derived HHV-8. Larger, more definitive, multicenter studies are needed.