Higher HDL-C Levels Before Lung Transplant Linked to Better Outcomes in Women: Study
USA: A recent study presented at the 44th Annual Meeting of the International Society for Heart and Lung Transplantation (ISHLT) and published in Respiratory Medicine revealed that higher pre-transplant high-density lipoprotein cholesterol (HDL-C) levels were associated with better outcomes after lung transplantation in women, but not in men.
Female recipients with elevated HDL-C experienced lower rates of primary graft dysfunction, shorter hospital stays, and improved survival, suggesting that HDL-C may serve as a sex-specific biomarker for risk assessment before lung transplantation.
The study was led by Haytham Elgharably from the Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Research, Cleveland, Ohio, USA, and colleagues. HDL-C, commonly known as "good cholesterol," has recently attracted interest in lung transplantation because of its anti-inflammatory and tissue-protective properties. However, whether its impact differs between male and female transplant recipients has remained unclear.
To investigate this question, the researchers conducted a retrospective cohort study involving 1,063 adults who underwent single or double lung transplantation at a tertiary care center between 2009 and 2019. The study included 349 women and 714 men, with median ages of 59 years and 62 years, respectively. The primary outcome was the development of primary graft dysfunction (PGD) within 72 hours after transplantation. Additional outcomes included chronic lung allograft dysfunction (CLAD), length of hospital stay, and overall survival. Multivariable regression analyses were performed to determine whether HDL-C independently predicted post-transplant outcomes.
The following were the key findings:
- Recipients with baseline HDL-C levels above 69 mg/dL had significantly better overall survival than those with lower HDL-C levels (HR 0.73).
- Female recipients with higher HDL-C levels experienced significantly better survival, lower grades of primary graft dysfunction, and shorter hospital stays after lung transplantation.
- Although male recipients showed similar trends, the associations were not statistically significant.
- Higher baseline HDL-C was an independent predictor of better post-transplant outcomes.
- Elevated HDL-C was associated with a 54% lower risk of mortality (HR 0.46).
- Higher HDL-C was linked to a 39% lower risk of primary graft dysfunction (OR 0.61).
- Elevated HDL-C was also associated with a lower risk of chronic lung allograft dysfunction (OR 0.91).
The authors acknowledged that the retrospective single-center design limits causal inference. They also noted the absence of data on other lipid markers, lipid-lowering therapy, inflammatory biomarkers, menopausal status, hormone replacement therapy, and longitudinal HDL-C measurements. In addition, baseline differences between male and female recipients may have influenced the results despite statistical adjustment.
The researchers concluded that higher pre-transplant HDL-C levels are associated with better early and long-term outcomes after lung transplantation, particularly in women. They suggested that sex-specific HDL-C thresholds may improve pre-transplant risk stratification and called for larger prospective multicenter studies to validate these findings.
Reference:
Elgharably, H., Awad, A. K., Lehr, C. J., Budev, M., McCurry, K. R., Smith, J. D., & Ayyat, K. S. (2026). High-density lipoprotein cholesterol influences the outcomes of lung transplantation in females, but not males. Respiratory Medicine, 261, 108944. https://doi.org/10.1016/j.rmed.2026.108944
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