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Impact of the Lung Allocation Score on Lung Transplantation for Pulmonary Arterial Hypertension

¹ Division of Pulmonary and Critical Care Medicine, ² Department of Epidemiology and Biostatistics, ⁴ Division of Adult Cardiothoracic Surgery, and ⁵ Division of Cardiology, University of California, San Francisco, California; and ³ Division of Pulmonary and Critical Care Medicine, VA Palo Alto Health Care System, Palo Alto, and Stanford University, Stanford, California

Correspondence and requests for reprints should be addressed to Hubert Chen, M.D., M.P.H., 350 Parnassus Avenue, Suite 609; San Francisco, CA 94143-0924. E-mail: hubert.chen{at}ucsf.edu

Rationale: In 2005, lung allocation for transplantation in the United States changed from a system based on waiting time to a system based on the Lung Allocation Score (LAS).

Objectives: To study the effect of the LAS on lung transplantation for idiopathic pulmonary arterial hypertension (IPAH) compared with other major diagnoses.

Methods: We studied 7,952 adults listed for lung transplantation between 2002 and 2008. Analyses were restricted to patients with IPAH, idiopathic pulmonary fibrosis (IPF), chronic obstructive pulmonary disease (COPD), and cystic fibrosis (CF). Transplantation, waiting list mortality, and post-transplant mortality were compared between diagnoses for patients listed before and after implementation of the LAS.

Measurements and Main Results: The likelihood of transplantation from the waiting list increased for all diagnoses after implementation of the LAS. Waiting list mortality decreased for every diagnosis, except for IPAH, which remained unchanged. Implementation of the LAS was not associated with changes in post-transplant mortality for any diagnosis. Under the LAS system, patients with IPAH were less likely to be transplanted than patients with IPF (hazard ratio [HR], 0.53; P < 0.001) or CF (HR, 0.49; P < 0.001) and at greater risk of death on the waiting list than patients with COPD (HR, 3.09; P < 0.001) or CF (HR, 1.83; P = 0.025) after adjustment for demographics and transplant type. Post-transplant mortality for IPAH was not statistically different from that of other diagnoses.

Conclusions: Implementation of the LAS has improved the likelihood of lung transplantation for listed patients with IPAH, but mortality on the waiting list remains high compared with other major diagnoses.

Key Words: lung transplantation • pulmonary arterial hypertension • lung allocation score

AT A GLANCE COMMENTARY Scientific Knowledge on the Subject The Lung Allocation Score (LAS) was developed to prioritize patients most in need of transplant and most likely to benefit. The effect of the LAS on patients with pulmonary arterial hypertension has not been studied. What This Study Adds to the Field Implementation of the LAS system has improved the likelihood of transplantation for listed patients with pulmonary arterial hypertension, but mortality on the waiting list remains high.

 

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Idiopathic Pulmonary Arterial Hypertension and Equity of Donor Lung Allocation in the Era of the Lung Allocation Score: Are We There Yet?

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