Rationing Lung Transplants - Procedural Fairness in Allocation and Appeals

From the Department of Occupational Therapy and the Lab for Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, MA (K.L.)
New England Journal of Medicine (Impact Factor: 55.87). 07/2013; 369(7). DOI: 10.1056/NEJMp1307792
Source: PubMed


Organ transplantation requires explicit rationing and relies on public trust and altruism to sustain the organ supply. The well-publicized cases of two pediatric candidates for lung transplants have shaken the transplant community with emergency legal injunctions arguing that current lung-allocation policy is "arbitrary and capricious." Although the resulting transplantation seemingly provided an uplifting conclusion to an emotional public debate, this precedent may open the floodgates to litigation from patients seeking to improve their chances of obtaining organs. These cases questioned the potential disadvantaging of children and the procedural fairness in lung allocation. But legal appeals exacerbate inequities and undercut public . . .

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    ABSTRACT: RATIONALE: Bronchiolitis obliterans syndrome (BOS) is the primary limiting factor for long-term survival following lung transplantation, and has previously been associated with microbial infections. OBJECTIVE: To cross-sectionally and longitudinally characterize microbial communities in allografts from transplant recipients with and without BOS using a culture-independent method based on high-throughput sequencing. METHODS: Allografts were sampled by bronchoalveolar lavage (BAL), and microbial communities were profiled using 16S rRNA gene amplicon pyrosequencing. Community profiles were compared using the weighted Unifrac metric and the relationship between microbial populations, BOS, and other covariates was explored using PERMANOVA and logistic regression. MEASUREMENTS AND MAIN RESULTS: Microbial communities in transplant patients fell into two main groups, those dominated by Pseudomonas or those dominated by Streptococcus and Veillonella which appear to be mutually exclusive lung microbiomes. Aspergillus culture was also negatively correlated with the Pseudomonas-dominated group. The re-establishment of dominant populations present in patients pre-transplant, notably Pseudomonas in CF individuals, was negatively correlated with BOS. CONCLUSIONS: Re-colonization of the allograft by Pseudomonas in CF individuals is not associated with BOS. In general, re-establishment of pre-transplant lung populations in the allograft appears to have a protective effect against BOS, whereas de novo acquisition of microbial populations often belonging to the same genera may increase the risk of BOS.
    American Journal of Respiratory and Critical Care Medicine 01/2013; 187(6). DOI:10.1164/rccm.201209-1680OC · 13.00 Impact Factor
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    ABSTRACT: Rationale: After lung transplantation, insults to the allograft generally result in one of four histopathologic patterns of injury: acute rejection, lymphocytic bronchiolitis, organizing pneumonia, and diffuse alveolar damage (DAD). We hypothesized that DAD, the most severe form of acute lung injury, would lead to the highest risk of chronic lung allograft dysfunction (CLAD) and that a Type I immune response would mediate this process. Objectives: Determine whether DAD is associated with CLAD and explore the potential role of CXCR3/ligand biology. Methods: Transbronchial biopsies from all lung transplant recipients were reviewed. The association between the four injury patterns and subsequent outcomes were evaluated using proportional hazards models with time-dependent covariates. Bronchoalveolar lavage (BAL) concentrations of the CXCR3 ligands (CXCL9/MIG, CXCL10/IP10, and CXCL11/ITAC) were compared between allograft injury patterns and "healthy" biopsies using linear mixed-effects models. The effect of these chemokine alterations on CLAD risk was assessed using Cox models with serial BAL measurements as time-dependent covariates. Results: There were 1,585 biopsies from 441 recipients with 62 episodes of DAD. An episode of DAD was associated with increased risk of CLAD (HR 3.0 95% CI 1.9-4.7) and death (HR 2.3 95% CI 1.7-3.0). There were marked elevations in BAL CXCR3 ligand concentrations during DAD. Furthermore, prolonged elevation of these chemokines in serial BALF measurements predicted the development of CLAD. Conclusions: DAD is associated with marked increases in the risk of CLAD and death after lung transplantation. This association may be mediated in part by an aberrant Type I immune response involving CXCR3/ligands.
    American Journal of Respiratory and Critical Care Medicine 09/2013; 188(9). DOI:10.1164/rccm.201305-0861OC · 13.00 Impact Factor
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    ABSTRACT: To the Editor: In their Perspective article, Ladin and Hanto (Aug. 15 issue)(1) misrepresent the lung-allocation policy of the Organ Procurement and Transplantation Network (OPTN) by stating that candidates younger than 12 years of age are restricted to receiving lungs from donors younger than 12 years of age. In fact, within each organ procurement organization (OPO), lungs from donors younger than 18 years of age must be made available to all pediatric patients before being made available to adults. Children younger than 12 years of age may receive lungs from adult donors if the lungs are declined by adolescents and . . .
    New England Journal of Medicine 11/2013; 369(21):2064-2066. DOI:10.1056/NEJMc1311946#SA1 · 55.87 Impact Factor
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