Better is the Enemy of Good: Are Too Many Acceptable Offers Turned Down for Lung Transplant Candidates?
Jason W. Greenberg, David L. Morales, David G. Lehenbauer, Kyle W. Riggs, Don Hayes, Md Monir Hossain, Farhan Zafar
The Heart Institute; Division of Congenital Cardiovascular Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
Objective: Waitlist mortality for lung transplant (LTx) increases proportionally to the number of offers refused. Nevertheless, a growing body of literature suggests that post-transplant survival and graft function are equivalent irrespective of the number of times a particular graft is rejected. We sought to characterize national trends in offer acceptance, waitlist (WL) mortality, and post-transplant patient and graft survival depending upon Lung Allocation Score (LAS).
Methods: United Network for Organ Sharing (UNOS) was used to identify 34,531 LTx candidates >12 years old listed from 2005-2019 (truncated due to data availability) and their 26,983 corresponding donors. Patients were categorized by listing LAS: <40 (n=21,778; 63%), 40-60 (n=9,056; 26%), 61-80 (n=1,621; 5%), and >80 (n=2,076; 6%). â€śAcceptable organ offersâ€? were defined as those from donors whose grafts were ultimately accepted for transplant.
Results: The first 8 offers â€“ including 3 acceptable organ offers â€“ were rejected for the most ill patients (LAS >80), with the first 14 total and 6 acceptable offers, respectively, for LAS 61-80 (both p<0.001 vs. other LAS; Table. For patients with LAS 61-80 and >80, the first acceptable organ offer occurred on the 2nd and 1st WL days on average, respectively, but a median of 13 and 6 respective days were spent on the WL prior to offer acceptance (both p<0.001 vs. other LAS). During these timeframes, 9% of patients in both LAS 61-80 and LAS >80 either died or were removed from the WL due to clinical decompensation (both p<0.001 vs. other LAS). 30-day WL mortality for these groups was 22 and 44%, respectively (both p<0.001 vs. other LAS; Table). The characteristics of transplanted organs were similar between all LAS groups with respect to PaO2:FiO2 ratio and the proportion of abnormal chest x-ray or bronchoscopic findings (p>0.3 for all; Table). Post-transplant survival was equivalent between the candidates for whom the first or second offer was accepted (with the second offer, on average, being an â€śacceptable organ offerâ€? for each group) compared to those who accepted offers later (p>0.4 for all LAS groups).
Conclusions: Waitlist mortality is exceedingly high for patients with LAS >60, yet the first several offers, including organs that are ultimately accepted by other patients who do well, are rejected. Post-transplant survival for each LAS group is equivalent whether the first offers or later offers are accepted, suggesting that more aggressive offer acceptance could avert significant WL mortality for the most ill LTx candidates.
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