Lung Transplant Mortality Is Improving in Recipients With a Lung Allocation Score in the Upper Quartile

Todd C. Crawford, Joshua C. Grimm, J. Trent Magruder, Jinny Ha, Christopher M. Sciortino, Bo S. Kim, Errol L. Bush, John V. Conte, Robert S. Higgins, Ashish S. Shah, Christian A. Merlo

Research output: Contribution to journalArticle

12 Citations (Scopus)

Abstract

Background Since the introduction of the Lung Allocation Score (LAS), the mean LAS has risen. Still, it remains uncertain whether mortality has improved in the most severely ill lung transplant recipients over this time period. Methods Using the United Network for Organ Sharing database, we identified 3,548 adult lung transplant recipients from May 4, 2005, to March 31, 2014, with a match-time LAS in the upper quartile (>75th%ile). We divided this population across three eras: 1 = May 4, 2005, to December 31, 2008 (n = 1,280); 2 = January 1, 2009, to December 31, 2011 (n = 1,266); and 3 = January 1, 2012, to March 31, 2014 (n = 1,002). Cox proportional hazards models were constructed for the primary outcomes of 30-day and 1-year mortality to assess the independent impact of the era of transplantation. Results The mean LAS at time of transplant for patients in the upper quartile in eras 1, 2, and 3 was 63, 73, and 79, respectively (p < 0.001). Later eras of transplantation benefited from a significant improvement in survival at 1 year (log-rank p = 0.001) but not at 30 days (log-rank p = 0.152). After risk adjustment, lung transplantation in more recent eras was associated with improved mortality at both 30 days (era 3 hazard ratio [HR] = 0.50, 95% confidence interval [CI] 0.32% to 0.78%, p = 0.002) and 1 year (era 2 HR = 0.77, 95% CI 0.64% to 0.94%, p = 0.008; era 3 HR = 0.54, 95% CI 0.43% to 0.68%, p < 0.001). Conclusions Despite a progressively rising LAS, survival is improving among recipients with the highest LAS at the time of lung transplantation. This calls into question the notion of a maximum LAS beyond which lung transplantation becomes futile, a so-called LAS ceiling.

Original languageEnglish (US)
Pages (from-to)1607-1613
Number of pages7
JournalAnnals of Thoracic Surgery
Volume103
Issue number5
DOIs
StatePublished - May 2017

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Transplants
Lung
Mortality
Lung Transplantation
Confidence Intervals
Transplantation
Risk Adjustment
Survival
Proportional Hazards Models
Databases
Population

All Science Journal Classification (ASJC) codes

  • Surgery
  • Pulmonary and Respiratory Medicine
  • Cardiology and Cardiovascular Medicine

Cite this

Crawford, T. C., Grimm, J. C., Magruder, J. T., Ha, J., Sciortino, C. M., Kim, B. S., ... Merlo, C. A. (2017). Lung Transplant Mortality Is Improving in Recipients With a Lung Allocation Score in the Upper Quartile. Annals of Thoracic Surgery, 103(5), 1607-1613. https://doi.org/10.1016/j.athoracsur.2016.11.057
Crawford, Todd C. ; Grimm, Joshua C. ; Magruder, J. Trent ; Ha, Jinny ; Sciortino, Christopher M. ; Kim, Bo S. ; Bush, Errol L. ; Conte, John V. ; Higgins, Robert S. ; Shah, Ashish S. ; Merlo, Christian A. / Lung Transplant Mortality Is Improving in Recipients With a Lung Allocation Score in the Upper Quartile. In: Annals of Thoracic Surgery. 2017 ; Vol. 103, No. 5. pp. 1607-1613.
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abstract = "Background Since the introduction of the Lung Allocation Score (LAS), the mean LAS has risen. Still, it remains uncertain whether mortality has improved in the most severely ill lung transplant recipients over this time period. Methods Using the United Network for Organ Sharing database, we identified 3,548 adult lung transplant recipients from May 4, 2005, to March 31, 2014, with a match-time LAS in the upper quartile (>75th{\%}ile). We divided this population across three eras: 1 = May 4, 2005, to December 31, 2008 (n = 1,280); 2 = January 1, 2009, to December 31, 2011 (n = 1,266); and 3 = January 1, 2012, to March 31, 2014 (n = 1,002). Cox proportional hazards models were constructed for the primary outcomes of 30-day and 1-year mortality to assess the independent impact of the era of transplantation. Results The mean LAS at time of transplant for patients in the upper quartile in eras 1, 2, and 3 was 63, 73, and 79, respectively (p < 0.001). Later eras of transplantation benefited from a significant improvement in survival at 1 year (log-rank p = 0.001) but not at 30 days (log-rank p = 0.152). After risk adjustment, lung transplantation in more recent eras was associated with improved mortality at both 30 days (era 3 hazard ratio [HR] = 0.50, 95{\%} confidence interval [CI] 0.32{\%} to 0.78{\%}, p = 0.002) and 1 year (era 2 HR = 0.77, 95{\%} CI 0.64{\%} to 0.94{\%}, p = 0.008; era 3 HR = 0.54, 95{\%} CI 0.43{\%} to 0.68{\%}, p < 0.001). Conclusions Despite a progressively rising LAS, survival is improving among recipients with the highest LAS at the time of lung transplantation. This calls into question the notion of a maximum LAS beyond which lung transplantation becomes futile, a so-called LAS ceiling.",
author = "Crawford, {Todd C.} and Grimm, {Joshua C.} and Magruder, {J. Trent} and Jinny Ha and Sciortino, {Christopher M.} and Kim, {Bo S.} and Bush, {Errol L.} and Conte, {John V.} and Higgins, {Robert S.} and Shah, {Ashish S.} and Merlo, {Christian A.}",
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Crawford, TC, Grimm, JC, Magruder, JT, Ha, J, Sciortino, CM, Kim, BS, Bush, EL, Conte, JV, Higgins, RS, Shah, AS & Merlo, CA 2017, 'Lung Transplant Mortality Is Improving in Recipients With a Lung Allocation Score in the Upper Quartile', Annals of Thoracic Surgery, vol. 103, no. 5, pp. 1607-1613. https://doi.org/10.1016/j.athoracsur.2016.11.057

Lung Transplant Mortality Is Improving in Recipients With a Lung Allocation Score in the Upper Quartile. / Crawford, Todd C.; Grimm, Joshua C.; Magruder, J. Trent; Ha, Jinny; Sciortino, Christopher M.; Kim, Bo S.; Bush, Errol L.; Conte, John V.; Higgins, Robert S.; Shah, Ashish S.; Merlo, Christian A.

In: Annals of Thoracic Surgery, Vol. 103, No. 5, 05.2017, p. 1607-1613.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Lung Transplant Mortality Is Improving in Recipients With a Lung Allocation Score in the Upper Quartile

AU - Crawford, Todd C.

AU - Grimm, Joshua C.

AU - Magruder, J. Trent

AU - Ha, Jinny

AU - Sciortino, Christopher M.

AU - Kim, Bo S.

AU - Bush, Errol L.

AU - Conte, John V.

AU - Higgins, Robert S.

AU - Shah, Ashish S.

AU - Merlo, Christian A.

PY - 2017/5

Y1 - 2017/5

N2 - Background Since the introduction of the Lung Allocation Score (LAS), the mean LAS has risen. Still, it remains uncertain whether mortality has improved in the most severely ill lung transplant recipients over this time period. Methods Using the United Network for Organ Sharing database, we identified 3,548 adult lung transplant recipients from May 4, 2005, to March 31, 2014, with a match-time LAS in the upper quartile (>75th%ile). We divided this population across three eras: 1 = May 4, 2005, to December 31, 2008 (n = 1,280); 2 = January 1, 2009, to December 31, 2011 (n = 1,266); and 3 = January 1, 2012, to March 31, 2014 (n = 1,002). Cox proportional hazards models were constructed for the primary outcomes of 30-day and 1-year mortality to assess the independent impact of the era of transplantation. Results The mean LAS at time of transplant for patients in the upper quartile in eras 1, 2, and 3 was 63, 73, and 79, respectively (p < 0.001). Later eras of transplantation benefited from a significant improvement in survival at 1 year (log-rank p = 0.001) but not at 30 days (log-rank p = 0.152). After risk adjustment, lung transplantation in more recent eras was associated with improved mortality at both 30 days (era 3 hazard ratio [HR] = 0.50, 95% confidence interval [CI] 0.32% to 0.78%, p = 0.002) and 1 year (era 2 HR = 0.77, 95% CI 0.64% to 0.94%, p = 0.008; era 3 HR = 0.54, 95% CI 0.43% to 0.68%, p < 0.001). Conclusions Despite a progressively rising LAS, survival is improving among recipients with the highest LAS at the time of lung transplantation. This calls into question the notion of a maximum LAS beyond which lung transplantation becomes futile, a so-called LAS ceiling.

AB - Background Since the introduction of the Lung Allocation Score (LAS), the mean LAS has risen. Still, it remains uncertain whether mortality has improved in the most severely ill lung transplant recipients over this time period. Methods Using the United Network for Organ Sharing database, we identified 3,548 adult lung transplant recipients from May 4, 2005, to March 31, 2014, with a match-time LAS in the upper quartile (>75th%ile). We divided this population across three eras: 1 = May 4, 2005, to December 31, 2008 (n = 1,280); 2 = January 1, 2009, to December 31, 2011 (n = 1,266); and 3 = January 1, 2012, to March 31, 2014 (n = 1,002). Cox proportional hazards models were constructed for the primary outcomes of 30-day and 1-year mortality to assess the independent impact of the era of transplantation. Results The mean LAS at time of transplant for patients in the upper quartile in eras 1, 2, and 3 was 63, 73, and 79, respectively (p < 0.001). Later eras of transplantation benefited from a significant improvement in survival at 1 year (log-rank p = 0.001) but not at 30 days (log-rank p = 0.152). After risk adjustment, lung transplantation in more recent eras was associated with improved mortality at both 30 days (era 3 hazard ratio [HR] = 0.50, 95% confidence interval [CI] 0.32% to 0.78%, p = 0.002) and 1 year (era 2 HR = 0.77, 95% CI 0.64% to 0.94%, p = 0.008; era 3 HR = 0.54, 95% CI 0.43% to 0.68%, p < 0.001). Conclusions Despite a progressively rising LAS, survival is improving among recipients with the highest LAS at the time of lung transplantation. This calls into question the notion of a maximum LAS beyond which lung transplantation becomes futile, a so-called LAS ceiling.

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