Original article
General thoracic
Lung Transplantation for Patients With High Lung Allocation Score: Single-Center Experience

Presented at the Forty-seventh Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2011.
https://doi.org/10.1016/j.athoracsur.2011.09.045Get rights and content

Background

The lung allocation score (LAS) assigns organ allocation priority based on medical urgency and the likelihood of posttransplant survival. This study is a review of a single institutional experience for lung transplantation in the era of LAS.

Methods

We performed a retrospective review of 527 consecutive patients, from May 2005 to February 2010, who underwent lung transplant at our institution, comprising a high LAS group (LAS ≥ 50, n = 108) and a low LAS group (LAS < 50, n = 419). Kaplan-Meier and univariate analyses were performed to assess postoperative mortality as a primary outcome, and length of ventilator support and intensive care unit stay as secondary outcomes. Risk factors, including demographics, pulmonary status, and surgical and donor variables, were compared. Predictors of mortality were determined using a Cox proportional hazard model.

Results

Survivals after 30 days, 90 days, 1 year, and 3 years were 92.6%, 87.8%, 71.5%, and 52.0%, respectively, in the high LAS group, and 96.9%, 93.5%, 83.2%, and 73.9% in the low LAS group (p < 0.001). The incidence of prolonged ventilator support and the need for tracheostomy were higher, and intensive care unit stay was longer in the high LAS group. In the high LAS group, ischemic time greater than 8 hours was an independent predictor for mortality (hazard ratio: 3.080; 95% confidence interval 1.101 to 8.161, p = 0.032).

Conclusions

Lung transplant in patients with high a LAS is associated with significantly decreased survival and increased complications compared with patients with a low LAS. Ischemic time greater than 8 hours is a significant predictor of death in patients with a high LAS.

Section snippets

Patients and Study Design

This study was a retrospective review of the cardiothoracic transplantation database that is prospectively maintained at the University of Pittsburgh Medical Center (Institutional Review Board approval number: 0000421). The University of Pittsburgh Medical Center Lung and Heart-Lung Transplant Evaluation and Recipient Research Registry is approved by the University of Pittsburgh Institutional Review Board for use in patient management, quality assurance reports, and clinical research. A consent

Baseline Characteristics

Patient characteristics are displayed in Table 1. The LAS distribution was skewed (Fig 1). Mean LAS was 37.7 ± 5.1 in the low LAS group and 70.1 ± 15.0 in the high LAS group. The indication for lung transplant was notably different between the 2 groups. Chronic obstructive pulmonary disease (COPD) was the most frequent diagnosis in the low LAS group and accounted for 43.7% of lung transplants in that group. In contrast, in the high LAS group, idiopathic pulmonary fibrosis (IPF) accounted for

Comment

Lung transplant has become an increasingly viable option for patients with a variety of end-stage lung diseases; however, access to transplant remains limited by the availability of suitable donated organs. The LAS was developed to distribute organs in a manner that balances waiting list urgency with the probability of posttransplant survival [4]. There are several large national cohort studies, all of them using the UNOS database, demonstrating that an elevated LAS is associated with decreased

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    Introduction of the LAS has re-distributed allografts such that waitlist mortality initially increased, and now varies significantly by age and diagnosis group.9–11 Furthermore, candidates with high LAS do not necessarily have the associated transplant benefit compared to candidates with a more moderate LAS, likely secondary to a stronger weighting of the LAS toward decreasing waitlist mortality over increasing post-transplant survival.8,12,17,34 Despite a built-in mechanism for the re-evaluation and addition of variables to the LAS over time, there have been few adjustments since 2005.8

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