Lung Allocation Score Thresholds Prioritize Survival After Lung Transplantation

Abstract

The lung allocation score (LAS) prioritizes lung transplant (LTx) candidates with poor transplant-free survival and expected survival benefit from LTx. Although patients with the highest LAS have the shortest waiting time, mortality benefit is unclear in this group, raising criticism that the LAS inappropriately prioritizes critically ill candidates. We aim to identify a threshold above which increasing LAS values do not predict increasing survival benefit. The United Network for Organ Sharing Registry was queried for first-time adult LTx candidates with LAS≥ 30 between May 2005 and December 2016. Survival was tracked from the time of listing through the posttransplant period and compared with survival while remaining on the waitlist, using proportional hazards regression. The survival benefit of LTx was modeled as a piecewise-constant time-dependent covariate, moderated by candidate LAS. Of the overall cohort (N= 21,157), LTx was particularly protective for 365 patientswith an initial LAS of 70 to 79 (hazard ratio of death after undergoing LTx relative toremaining on the waitlist, 0.2; 95%CI, 0.1-0.3). However, the survival benefit of LTx did not meaningfully increase for 1,042 patients listed with even higher LAS. Among patients with cystic fibrosis, the survival benefit of LTx was constant above an LAS of approximately50. Consistent survival benefit of LTx was observed among patients with an initial LAS of 70 and greater. This result supports equalizing priority for donor lung allocation for patients with LAS≥ 70. A lower LAS threshold for maximum priority is indicated in patients with cystic fibrosis.