How Should Lungs Be Allocated for Transplant?

Egan, Thomas M.

doi:10.1055/s-0037-1620265

Cited by 28 publications

(18 citation statements)

References 55 publications

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“…3 As ever, the balance is the risk versus the benefit, and the LAS appears to be a powerful and informative tool to assist in achieving that goal by computing the likelihood of life days gained for an individual recipient, but the process begins with the referring clinician who takes primary responsibility for timely referral of a potential candidate. 54 A close working relationship between the LTx unit and the referring source will help optimize outcomes.…”

Section: Resultsmentioning

confidence: 99%

Lung transplantation: a review of the optimal strategies for referral and patient selection

Mitchell

Glanville

2019

Ther Adv Respir Dis

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One of the great challenges of lung transplantation is to bridge the dichotomy between supply and demand of donor organs so that the maximum number of potential recipients achieve a meaningful benefit in improvements in survival and quality of life. To achieve this laudable goal is predicated on choosing candidates who are sufficiently unwell, in fact possessing a terminal respiratory illness, but otherwise fit and able to undergo major surgery and a prolonged recuperation and rehabilitation stage combined with ongoing adherence to complex medical therapies. The choice of potential candidate and the timing of that referral is at times perhaps more art than science, but there are a number of solid guidelines for specific illnesses to assist the interested clinician. In this regard, the relationship between the referring clinician and the lung transplant unit is a critical one. It is an ongoing and dynamic process of education and two way communication, which is a marker of the professionalism of a highly performing unit. Lung transplantation is ultimately a team effort where the recipient is the key player. That principle has been enshrined in the three consensus position statements regarding selection criteria for lung and heart-lung transplantation promulgated by the International Society for Heart and Lung Transplantation over the last two decades. During this period, the number of indications for lung transplantation have broadened and the number of contraindications reduced. Risk management is paramount in the pre- and perioperative period to effect early successful outcomes. While it is not the province of this review to reiterate the detailed listing of those factors, an overview position will be developed that describes the rationale and evidence for selected criteria where that exists. Importantly, the authors will attempt to provide an historical and experiential basis for making these important and life-determining decisions. The reviews of this paper are available via the supplementary material section.

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Section: Resultsmentioning

confidence: 99%

Lung transplantation: a review of the optimal strategies for referral and patient selection

Mitchell

Glanville

2019

Ther Adv Respir Dis

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“…We conclude that a sequence number in isolation is not a suitable proxy for lung allograft quality, given the small effect size and weak evidence for an association between the sequence number at the time of acceptance and recipient outcomes after transplantation. In light of recent changes to the U.S. lung allocation policy (2,21,22), ongoing monitoring of organ acceptance practices is warranted. n Note: HR reference category is sequence number 1.…”

Section: Original Researchmentioning

confidence: 99%

“…Donor lung allocation in the United States is performed through an algorithm that considers medical and biological compatibility, geography, and medical urgency (1,2). This process, known as the "match-run," generates a list of prioritized candidates, each with a sequence number that defines where on that list each potential recipient resides.…”

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confidence: 99%

Donor Lung Sequence Number and Survival after Lung Transplantation in the United States

et al. 2018

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Rationale: In the United States, an algorithm known as the "match-run" creates an ordered ranking of potential recipients for available lung allografts. A potential recipient's match-run position, or "sequence number," is available to the transplant center when contacted with a lung offer. Lung offers with higher sequence numbers may be interpreted as a crowd-sourced evaluation of poor organ quality, though the association between the sequence number at which a lung is accepted and its recipient's post-transplant outcomes is unclear. Objectives: We sought to evaluate the primary reasons provided when a lung offer was refused by a transplant center, transplant center and donor/organ factors associated with a higher sequence number at acceptance, and the association of the sequence number at acceptance with post-transplant mortality and graft failure. Methods: Match-run outcomes for lung offers that occurred in the United States from May 2007 through June 2014 were merged with recipient follow-up data through December 2017. Associations between the sequence number at the time of acceptance and selected transplant center and donor characteristics were estimated using multivariable logistic and multinomial regression models. The associations between the final sequence number and recipient survival and graft survival were estimated using multivariable time-to-event models. Results: Of 10,981 lung offer acceptances, nearly 70% were accepted by one of the top 10 ranked candidates. Higher median annual center volume and potential indicators of organ quality (e.g., abnormal chest radiograph or bronchoscopy) were associated with a higher sequence number at acceptance. There was weak evidence for a small positive relationship between the sequence number at acceptance and both mortality and graft failure. For example, the unadjusted and adjusted hazard ratios for death associated with the log-sequence number at acceptance were 1.019 (95% confidence interval, 1.001-1.038) and 1.011 (95% confidence interval, 0.989-1.033), respectively. On the absolute scale, using the multivariable model, a 10-fold increase in the sequence number translated into a 0.8% absolute decline in the predicted 5-year survival. Conclusions: Acceptance of a donor lung offer at a later point in the match-run was associated with measurable indicators of organ quality, but not with clinically meaningful differences in posttransplant mortality or graft failure.

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“…4,5 Additionally, lung donor offers would often be turned down by patients who remained "too well" for transplant but were on the waiting list to ensure they would be eligible for transplant should they become exceedingly ill. 5 The policy remained unchanged until 1995 when 90 days of wait time were added for patients with pulmonary fibrosis based on a study by Hosenpud et al demonstrating that patients with pulmonary fibrosis had a higher likelihood of dying on the wait list than patients with emphysema. 1,6 By the late 1990s, over 5,000 solid organ transplants including over 800 lung transplants were being performed annually in the United States under this system. 3 In 1998, HHS issued the Final Rule on organ transplantation that established a regulatory framework for the structure and operations of the OPTN.…”

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confidence: 99%

“…One-year survival was chosen as it was felt that pretransplant factors to determine posttransplant survival beyond 1 year were difficult to reliably calculate. 1 The probability of survival per day over the course of a year is calculated, and the PTAUC is determined based on the AUC that gives the number of days in a year that a candidate is expected to live after a transplant. 2 The greater the number, the greater the likelihood of survival.…”

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confidence: 99%

The Lung Allocation Score and Its Relevance

Lyu

Goff²,

Chan

2021

Semin Respir Crit Care Med

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Lung transplantation in the United States, under oversight by the Organ Procurement Transplantation Network (OPTN) in the 1990s, operated under a system of allocation based on location within geographic donor service areas, wait time of potential recipients, and ABO compatibility. On May 4, 2005, the lung allocation score (LAS) was implemented by the OPTN Thoracic Organ Transplantation Committee to prioritize patients on the wait list based on a balance of wait list mortality and posttransplant survival, thus eliminating time on the wait list as a factor of prioritization. Patients were categorized into four main disease categories labeled group A (obstructive lung disease), B (pulmonary hypertension), C (cystic fibrosis), and D (restrictive lung disease/interstitial lung disease) with variables within each group impacting the calculation of the LAS. Implementation of the LAS led to a decrease in the number of wait list deaths without an increase in 1-year posttransplant survival. LAS adjustments through the addition, modification or elimination of covariates to improve the estimates of patient severity of illness, have since been made in addition to establishing criteria for LAS value exceptions for pulmonary hypertension patients. Despite the success of the LAS, concerns about the prioritization, and transplantation of older, sicker individuals have made some aspects of the LAS controversial. Future changes in US lung allocation are anticipated with the current development of a continuous distribution model that incorporates the LAS, geographic distribution, and unaccounted aspects of organ allocation into an integrated score.

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How Should Lungs Be Allocated for Transplant?

Cited by 28 publications

References 55 publications

Lung transplantation: a review of the optimal strategies for referral and patient selection

Lung transplantation: a review of the optimal strategies for referral and patient selection

Donor Lung Sequence Number and Survival after Lung Transplantation in the United States

The Lung Allocation Score and Its Relevance

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