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Original Research |

An Acute Change in Lung Allocation Score and Survival After Lung Transplantation: A Cohort Study

Wayne M. Tsuang*, MD; David M. Vock*, PhD; C. Ashley Finlen Copeland, MSW; David J. Lederer, MD, MS; and Scott M. Palmer, MD, MHS
[+] Article and Author Information

* Drs. Tsuang and Vock contributed equally to this manuscript.


From Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina; North Carolina State University, Raleigh, North Carolina; and College of Physicians and Surgeons and Mailman School of Public Health, Columbia University, New York, New York.

Disclaimer: Data use was in accordance with the United Network for Organ Sharing (UNOS) data-use agreement. The data reported here have been supplied by UNOS as the contractor for the Organ Procurement and Transplantation Network (OPTN). The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy of or interpretation by the OPTN or the U.S. government.

Grant Support: Drs. Tsuang and Palmer were partly supported by the National Heart, Lung, and Blood Institute (awards T32-HL007538 and 5K24-HL091140-05, respectively).

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-1781.

Reproducible Research Statement: Study protocol and statistical code: Available from Dr. Vock (e-mail, vock@umn.edu). Data set: Please go to www.unos.org.

Requests for Single Reprints: Scott M. Palmer, MD, MHS, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, 106 Research Drive, DUMC Box 103002, Durham, NC 27710; e-mail, palme002@mc.duke.edu.

Current Author Addresses: Dr. Tsuang, Ms. Finlen Copeland, and Dr. Palmer: Duke University Medical Center, 106 Research Drive, DUMC Box 103002, Durham, NC 27710.

Dr. Vock: University of Minnesota School of Public Health, A460 Mayo Building, MMC 303, 420 Delaware Street SE, Minneapolis, MN 55455.

Dr. Lederer: Columbia University Medical Center, 622 West 168th Street, PH-14, Room 104, New York, NY 10032.

Author Contributions: Conception and design: W.M. Tsuang, D.M. Vock, D.J. Lederer, S.M. Palmer.

Analysis and interpretation of the data: W.M. Tsuang, D.M. Vock, D.J. Lederer, S.M. Palmer.

Drafting of the article: W.M. Tsuang, D.M. Vock, C.A. Finlen Copeland, S.M. Palmer.

Critical revision of the article for important intellectual content: W.M. Tsuang, D.M. Vock, C.A. Finlen Copeland, D.J. Lederer, S.M. Palmer.

Final approval of the article: W.M. Tsuang, D.M. Vock, C.A. Finlen Copeland, D.J. Lederer, S.M. Palmer.

Statistical expertise: W.M. Tsuang, D.M. Vock, S.M. Palmer.

Administrative, technical, or logistic support: W.M. Tsuang, S.M. Palmer.

Collection and assembly of data: W.M. Tsuang, C.A. Finlen Copeland, S.M. Palmer.


Ann Intern Med. 2013;158(9):650-657. doi:10.7326/0003-4819-158-9-201305070-00004
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Chinese translation

Background: Lung transplantation is an effective treatment for patients with advanced lung disease. In the United States, lungs are allocated on the basis of the lung allocation score (LAS), a composite measure of transplantation urgency and utility. Clinical deteriorations result in increases to the LAS; however, whether the trajectory of the LAS has prognostic significance is uncertain.

Objective: To determine whether an acute increase in the LAS before lung transplantation is associated with reduced posttransplant survival.

Design: Retrospective cohort study of adult lung transplant recipients listed for at least 30 days between 4 May 2005 (LAS implementation) and 31 December 2010 in the United Network for Organ Sharing registry. An acute increase in the LAS was defined as an LAS change (LASΔ) greater than 5 units between the 30 days before and the time of transplantation. Multivariable Cox proportional hazard models were used to examine the relationship between an LASΔ >5 and posttransplant graft survival.

Setting: All U.S. lung transplantation centers.

Patients: 5749 lung transplant recipients.

Measurements: Survival time after lung transplantation.

Results: 702 (12.2%) patients experienced an LASΔ >5. These patients had significantly worse posttransplant survival (hazard ratio, 1.31 [95% CI, 1.11 to 1.54]; P = 0.001]) after adjustment for the LAS at transplantation (LAS-T) and other clinical covariates. The effect of an LASΔ >5 was independent of the LAS-T, underlying diagnosis, center volume, or donor characteristics.

Limitation: Analysis was based on center-reported data.

Conclusion: An acute increase in LAS before transplantation is associated with posttransplant survival after adjustment for LAS-T. Further emphasis on serial assessment of the LAS could improve the ability to offer accurate prediction of survival after transplantation.

Primary Funding Source: National Institutes of Health.

Figures

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Figure 1.

Study flow diagram.

LAS = lung allocation score; UNOS = United Network for Organ Sharing.

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Figure 2.

Survival between LASΔ >5 and LASΔ ≤5 cohorts, by LAS-T strata.

LAS = lung allocation score; LAS-T = LAS at transplantation.

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Appendix Figure 1.

Adjusted survival between LASΔ >5 and LASΔ ≤5 for patients with obstructive disease and median value of all other regression coefficients, by LAS-T strata.

Similar results were obtained for other native diseases. LAS = lung allocation score; LAS-T = LAS at transplantation.

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Appendix Figure 2.

Estimate log(hazard ratio) for a change in LAS relative to a change of 0 when the change in LAS was considered as a continuous covariate with a restricted cubic spline transformation to allow for a nonlinear relationship.

LAS = lung allocation score.

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Appendix Figure 3.

Proportion of transplant recipients included in the study cohort with an acute change in LAS, by transplantation center.

The centers are ordered by the mean number of transplantations performed in adults annually by center during the study period (May 2005 to December 2010), with the volume increasing from left to right. The horizontal line delineates the overall proportion of patients in the study cohort with an acute change in LAS before transplantation. LAS = lung allocation score.

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Appendix Figure 4.

Log(hazard ratio) for the effect of an acute change by transplantation center, with 90% CIs when the effect of acute change was allowed to vary by center in a multivariable mixed-effect Cox model.

The total volume of transplantations performed by center during the study period increases from left to right (only 64 centers had patients with acute change). Allowing the effect of acute change to vary by center was not significant (P = 0.34). The horizontal line delineates the overall proportion of patients in the study cohort with an acute change in LAS before transplantation. LAS = lung allocation score.

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Appendix Figure 5.

Development of the wait-list study cohort.

LAS = lung allocation score.

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