Development of the New Lung Allocation System in the United States

Abstract

This article reviews the development of the new U.S. lung allocation system that took effect in spring 2005. In 1998, the Health Resources and Services Administration of the U.S. Department of Health and Human Services published the Organ Procurement and Transplantation Network (OPTN) Final Rule. Under the rule, which became effective in 2000, the OPTN had to demonstrate that existing allocation policies met certain conditions or change the policies to meet a range of criteria, including broader geographic sharing of organs, reducing the use of waiting time as an allocation criterion and creating equitable organ allocation systems using objective medical criteria and medical urgency to allocate donor organs for transplant. This mandate resulted in reviews of all organ allocation policies, and led to the creation of the Lung Allocation Subcommittee of the OPTN Thoracic Organ Transplantation Committee. This paper reviews the deliberations of the Subcommittee in identifying priorities for a new lung allocation system, the analyses under-

Mitral Regurgitation After Orthotopic Lung Transplantation: Natural History and Impact on Outcomes

“…The LAS estimates the lung transplant candidate's medical urgency and probability of survival following a lung transplant and is used to determine lung allocation when a potential donor becomes available. 5 …”

Democratic Deliberation and the Ethical Review of Human Subjects Research

“…Research on the allocation rules for transplantable organs (Egan 2006), and on HIV epidemiology in at-risk communities (Merion 2005), has also been exempted. Most strikingly, research on the prevalence of preterm birth and infant death among participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) was held exempt.…”

Lung Transplantation for Cystic Fibrosis

“…Although the conclusions and implications of the Liou study have been challenged (4), taken together, the two studies suggest that in a system where patients are offered transplant in order of subjective urgency (as in the UK system) (7), the likelihood of survival benefit is higher than in a system with multiple centers, limited objective listing and transplant criteria, and allocation based on waiting time (as in the US) (2). The possibility that variability in transplant criteria between centers can account for some of the observations in the Liou study is reinforced by the observation that the introduction of an allocation system in the United States, based on estimates of transplant benefit and waiting list mortality (20), suggests a survival benefit for the majority: nearly 70% of adolescents with CF who were transplanted in the 2 years following the initiation of the new system were predicted to have a survival benefit at 3 years (Leah Edwards, UNOS, personal communication). If this prediction can be confirmed, it would strengthen the argument that transplant can provide survival benefit to children with CF.…”

“…The national system for lung allocation was revised in 2005 (20). Some disagreement remains whether the new allocation system responds in the best way to serve the needs of those with CF.…”

“…We also note that the situation in the United States has changed dramatically since Liou and colleagues' analysis. In 2002, the United Network on Organ Sharing introduced the lung allocation score (LAS) for allocation of lung organs to all patients aged 12 years or older (20). This score aims to allocate scarce organs to those patients who have the potential for greatest survival benefit (i.e., those who have the poorest predicted survival without transplant and the best predicted post-transplant survival).…”