Lung transplant waitlist mortality: Height as a predictor of poor outcomes

Abstract

The LAS was designed to minimize pretransplant mortality while maximizing post-transplant outcome. Recipients <12 are not allocated lungs based on LAS. Waitlist mortality has decreased for those >12, but not <12, suggesting this population may be disadvantaged. To identify predictors of waitlist mortality, a retrospective analysis of the UNOS database was performed since implementation of the LAS. There were 16,973 patients listed for lung transplant in the United States; 12,070 (71.1%) were transplanted, and 2498 (14.7%) patients died or were removed from the wait list. Significantly more pediatric patients died or were removed compared with adults (22.0% vs. 14.4%, p < 0.01). In multivariate analysis, in addition to higher LAS at time of listing (adj. HR1.058, 1.055-1.060), shorter height (1.008, 1.006-1.010), male gender (1.210, 1.110-1.319), and requiring ECMO (1.613, 1.202-2.163) were associated with pretransplant mortality. Post-transplant survival was not affected by height. The current age cutoff may impose limitations within the current lung allocation system in the United States. Height is an independent predictor of waitlist mortality and may be a valuable factor for the development of a comprehensive lung allocation system.

The Future of Lung Transplantation

“…11 Most potential lung grafts are turned down at the time of evaluation because of concerns about the health of the lungs related to donor history, chest trauma, pneumonia, aspiration, or various ICU complications. 4,[11][12][13] The problem of donor shortage appears to be worse in certain populations, specifically women (primarily thought to be because of shorter stature and a greater incidence of pretransplant allosensitization, making it more difficult to identify suitable donors), 10,[14][15][16] patients with cystic fibrosis (primarily thought to be because of shorter stature and a difference in allocation systems in patients < 12 years of age), 15,17 and patients with idiopathic pulmonary hypertension (primarily because of severity of disease not being captured by pulmonary function testing). 18,19 Four ways in which we think the problem of donor shortage may be improved are: (1) use of more donors after circulatory death to increase the total number of donors, (2) use of extended criteria for donor selection, (3) use of the relatively new technology of ex vivo lung perfusion (EVLP) to increase utilization rate, and (4) utilization of bioengineered lungs.…”

Bioengineering of Pulmonary Epithelium With Preservation of the Vascular Niche

“…However, the need for lung transplant continues to exceed the availability of donor organs. Each year approximately 25% of listed patients either die or are too sick to undergo transplant and are removed from the waiting list (Keeshan et al, 2015;Valapour et al, 2020). Unfortunately the graft shortage persists and it is becoming clear that empirical criteria for donor selection are too stringent.…”

Pursuing distributive justice in pediatric lung transplantation

“…In the article in this issue of the Journal by Keeshan et al. , the authors take a creatively different approach to the problem of distribution of lungs to young donors. In lieu of age, the authors use height as a discriminator.…”