Discrepancy between severity of lung impairment and seniority on the lung transplantation list
Temple University, Filadelfia, Pennsylvania, United States Transplantation Proceedings
(Impact Factor: 0.98).
01/2005; 36(10):3156-60. DOI: 10.1016/j.transproceed.2004.11.009
Organ allocation for lung transplantation, based mainly on accrued time on a waiting list, may not be an equitable system of organ allocation. To provide an objective view of the current practice concerning lung allocation, and timing for transplantation, we examined illness severity and list seniority in patients on a lung transplantation waiting list.
Adult patients awaiting lung transplantation underwent testing for mean pulmonary artery pressure (mPpa), maximum oxygen consumption (VO2 max), 6-minute walk distance (6MWD), forced expiratory volume in 1 second, mean partial pressure of carbon dioxide, partial pressure of oxygen/fractional concentration of inspired oxygen, and diffusing capacity of the lung for carbon monoxide. Relationships between physiological variables and waiting list rankings were then determined.
Thirty-four patients were tested and there was no correlation between time spent waiting on the list and mPpa (r=0.01; P=.94), VO2 max percentage predicted (r=0.07; P=.71), or 6MWD (r=0.15; P=.42). Many patients with functional impairments as indicated by low maximum VO2 or by short 6MWD are scheduled to receive their transplant after patients with levels that indicate a lower degree of risk. When compared with a hypothetical reranking based on mean Ppa, 24 of the 34 patients (71%) on our current waiting list were found to be 5 positions higher or lower than this new risk-based ranking. Sixteen patients (47%) were 10 or more positions away from their hypothetical severity-based ranking, and 9 (26%) were at least 15 positions out of place. Sixteen of the 34 patients were ranked lower than they would be based on a severity of illness using the pulmonary artery pressure alone, 17 were ranked higher than "should be" based on pulmonary artery mean, and only 1 patient (ranked in position 15) was appropriately positioned based on seniority and severity of disease based on PA mean.
Rank order for lung transplantation has no relationship with illness severity, and the discrepancy between disease severity and seniority on the lung waiting list may compromise overall outcomes in the lung transplantation population.
Available from: Pierre-Olivier Bridevaux
Available from: Ronald Freudenberger
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ABSTRACT: This article reviews trends in thoracic organ transplantation based on OPTN/SRTR data from 1995 to 2004. The number of active waiting list patients for heart transplants continues to decline, primarily because there are fewer patients with coronary artery disease listed for transplantation. Waiting times for heart transplantation have decreased, and waiting list deaths also have declined, from 259 per 1000 patient-years at risk in 1995 to 156 in 2004. Fewer heart transplants were performed in 2004 than in 1995, but adjusted patient survival increased to 88% at 1 year and 73% at 5 years. Emphysema, idiopathic pulmonary fibrosis and cystic fibrosis were the most common indications among lung transplant recipients in 2004. Waiting time for lung transplantation decreased between 1999 and 2004. Waiting list mortality decreased to 134 per 1000 patient-years at risk in 2004. One-year survival following transplantation has improved significantly in the past decade. The number of combined heart-lung transplants performed in the United States remains low, with only 39 performed in 2004. Overall unadjusted survival, at 58% at 1 year and 40% at 5 years, is lower among heart-lung recipients than among either heart or lung recipients alone.
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ABSTRACT: Since the first successful single-lung transplant in 1983 and double-lung transplant in 1986, thousands of patients have benefited from the procedures. Until 1995, allocation of donor lungs was based purely on time on the waiting list. In 1995, a 90-day credit was given to patients with idiopathic pulmonary fibrosis, while still maintaining allocation based on waiting list time. In 2005, the lung allocation score (LAS) was implemented, dramatically changing the way lungs are allocated. This article will explore the reasons for the creation of the LAS, the design of the score, early experience with transplant results under the new system, and further changes that may be made to the system of lung allocation. As surgical techniques and medical management evolve, so to will the management of potential donors and the allocation of their organs, with the aim of benefiting patients needing lung transplantation in the United States.
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