Cardiothoracic transplantation
Who is the high-risk recipient? Predicting mortality after lung transplantation using pretransplant risk factors

https://doi.org/10.1016/j.jtcvs.2009.07.036Get rights and content
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Objectives

The purpose of this study was to create a preoperative risk stratification score (RSS) based on pretransplant recipient characteristics that could be used to predict mortality following lung transplantation.

Methods

United Network for Organ Sharing provided deidentified patient-level data. The study population included 8780 adult recipients (age > 12 years) having lung transplantation from January 1, 1999, to December 31, 2006. Multivariate logistic regression (backward, P > .10) was performed. Using the odds ratio for each identified variable, an RSS was devised. The RSS included only pretransplant recipient variables and excluded donor variables.

Results

The strongest negative predictors of 1-year survival included extracorporeal membrane oxygenation, decreased estimated glomerular filtration rate, total bilirubin >2.0 mg/dL, recipient age, hospitalization at time of transplant, O2 dependence, cardiac index <2, steroid dependence, donor:recipient weight ratio <0.7, all non–cystic fibrosis/chronic obstructive pulmonary disease etiologies, and female donor–to–male recipient. Threshold analysis identified 4 discrete groups: low risk, moderate, elevated risk, and high risk. The 1-year actuarial survival was 80.4% for the entire group, compared with 56.8% in the high-risk group (RSS > 7.2, n = 490; 6%).

Conclusion

Pretransplant recipient variables significantly influence both early and late survival following lung transplantation. Some patients face a higher than average risk of mortality during their first year posttransplant, which challenges the goals of equitable organ allocation. RSS may improve organ allocation strategies by avoiding the potential negative impact of performing transplantation in extremely high-risk candidates.

CTSNet classification

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Abbreviations and Acronyms

ALT
alternate list transplant
BMI
body mass index
ECMO
extracorporeal membrane oxygenation
LAS
lung allocation score
OR
odds ratio
ROC
receiver operating characteristic
RSS
risk stratification score
SSLR
stratum-specific likelihood ratio
UNOS
United Network for Organ Sharing

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Disclosures: Supported in part by Health Resources and Services Administration contract 231-00-0115. The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government.

Presented at the 34th Annual Meeting of the Western Thoracic Surgical Association, Kona, Hawaii, June 24 to 28, 2008.