Survival Benefit of Lung Transplantation in the Modern Era of Lung Allocation

Abstract

ORCID IDs: 0000-0002-5459-9579 (D.M.V.); 0000-0002-4186-5698 (M.T.D.). AbstractRationale: Lung transplantation is an accepted and increasingly employed treatment for advanced lung diseases, but the anticipated survival benefit of lung transplantation is poorly understood.Objectives: To determine whether and for which patients lung transplantation confers a survival benefit in the modern era of U.S. lung allocation.Methods: Data on 13,040 adults listed for lung transplantation between May 2005 and September 2011 were obtained from the United Network for Organ Sharing. A structural nested accelerated failure time model was used to model the survival benefit of lung transplantation over time. The effects of patient, donor, and transplant center characteristics on the relative survival benefit of transplantation were examined.Measurements and Main Results: Overall, 73.8% of transplant recipients were predicted to achieve a 2-year survival benefit with lung transplantation. The survival benefit of transplantation varied by native disease group (P = 0.062), with 2-year expected benefit in 39.2 and 98.9% of transplants occurring in those with obstructive lung disease and cystic fibrosis, respectively, and by lung allocation score at the time of transplantation (P , 0.001), with net 2-year benefit in only 6.8% of transplants occurring for lung allocation score less than 32.5 and in 99.9% of transplants for lung allocation score exceeding 40.Conclusions: A majority of adults undergoing transplantation experience a survival benefit, with the greatest potential benefit in those with higher lung allocation scores or restrictive native lung disease or cystic fibrosis. These results provide novel information to assess the expected benefit of lung transplantation at an individual level and to enhance lung allocation policy.

Heart and lung organ offer acceptance practices of transplant programs are associated with waitlist mortality and organ yield

“…The most important is the ability of programs to screen offers out of match runs from donors with certain characterprograms with high offer acceptance may be transplanting organs from high-risk donors that may not confer significant survival benefit 20. The most important is the ability of programs to screen offers out of match runs from donors with certain characterprograms with high offer acceptance may be transplanting organs from high-risk donors that may not confer significant survival benefit 20.…”

Contemporary Issues in Lung Transplant Allocation Practices

“…The LAS is assigned to each waitlisted patient at the time of listing, and estimates both waitlist and posttransplant survival in an attempt to avoid futile transplants [5]. Recent work using the U.S. transplant registry which leverages a structural nested accelerated failure time model shows that patients with a higher LAS at the time of transplant do indeed experience a survival benefit [34]. Thus, the LAS discerns priority and benefit among waitlisted patients.…”

A novel patient-centered “intention-to-treat” metric of U.S. lung transplant center performance

“…Just as the focus on post-transplant survival has altered clinical practice by incentivizing transplantation of those expected to have better outcomes, the ITTS metric could further incentivize centers to avoid listing sick patients, particularly during critical illness or when LAS scores are high, settings in which transplantation may still be beneficial. 1 In addition, since not all participants in our study underwent transplantation, our prediction model for expected ITTS included only candidate factors, leaving us unable to control for donor factors or recipient characteristics at the time of transplantation. These factors, however, did not appear to vary meaningfully across centers with low, moderate, and high ITTS values.…”

“…1,2 U.S. lung transplant centers are regulated by the Department of Health and Human Services, with their accreditation status dependent on center performance. 3 The Scientific Registry of Transplant Recipients (SRTR) monitors center performance and issues publicly-available program-specific reports (PSRs) on center performance, which are scrutinized by the Department of Health and Human Services, third party payers, transplant center personnel, and potential transplant candidates, their caregivers, and their physicians.…”