Risk Stratification of Lung Transplant Candidates: Implications for Organ Allocation

Kotloff RM. — Tue, 07 May 2013 00:00:00 GMT

In this issue, Tsuang and colleagues identify a new variable that independently predicts survival after lung transplantation: an increase in the lung allocation score 30 days before transplantation. The editorialist discusses the study and its findings, and concludes that the study should prompt a discussion about whether the current allocation system should be modified to limit access for candidates with unacceptably low predicted posttransplantation survival.

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

Tsuang* WM, Vock* DM, Finlen Copeland C, et al. — Tue, 07 May 2013 00:00:00 GMT

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.

Annals of Internal Medicine: Hematology/Oncology Topic Collection

Risk Stratification of Lung Transplant Candidates: Implications for Organ Allocation

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