Donor Lung Sequence Number and Survival after Lung Transplantation in the United States

Abstract

Rationale: In the United States, an algorithm known as the "match-run" creates an ordered ranking of potential recipients for available lung allografts. A potential recipient's match-run position, or "sequence number," is available to the transplant center when contacted with a lung offer. Lung offers with higher sequence numbers may be interpreted as a crowd-sourced evaluation of poor organ quality, though the association between the sequence number at which a lung is accepted and its recipient's post-transplant outcomes is unclear. Objectives: We sought to evaluate the primary reasons provided when a lung offer was refused by a transplant center, transplant center and donor/organ factors associated with a higher sequence number at acceptance, and the association of the sequence number at acceptance with post-transplant mortality and graft failure. Methods: Match-run outcomes for lung offers that occurred in the United States from May 2007 through June 2014 were merged with recipient follow-up data through December 2017. Associations between the sequence number at the time of acceptance and selected transplant center and donor characteristics were estimated using multivariable logistic and multinomial regression models. The associations between the final sequence number and recipient survival and graft survival were estimated using multivariable time-to-event models. Results: Of 10,981 lung offer acceptances, nearly 70% were accepted by one of the top 10 ranked candidates. Higher median annual center volume and potential indicators of organ quality (e.g., abnormal chest radiograph or bronchoscopy) were associated with a higher sequence number at acceptance. There was weak evidence for a small positive relationship between the sequence number at acceptance and both mortality and graft failure. For example, the unadjusted and adjusted hazard ratios for death associated with the log-sequence number at acceptance were 1.019 (95% confidence interval, 1.001-1.038) and 1.011 (95% confidence interval, 0.989-1.033), respectively. On the absolute scale, using the multivariable model, a 10-fold increase in the sequence number translated into a 0.8% absolute decline in the predicted 5-year survival. Conclusions: Acceptance of a donor lung offer at a later point in the match-run was associated with measurable indicators of organ quality, but not with clinically meaningful differences in posttransplant mortality or graft failure.

Lung Donation and Transplant Recipient Outcomes at Independent vs Hospital-Based Donor Care Units

“…We adjusted for clinically relevant donor and recipient factors associated with primary graft dysfunction and short-and long-term recipient survival (see the eFigure in Supplement 1 for a proposed causal diagram). 12,[17][18][19][21][22][23] From the Cox model, we also estimated the average adjusted…”

“…We adjusted for clinically relevant donor and recipient factors associated with primary graft dysfunction and short- and long-term recipient survival (see the eFigure in Supplement 1 for a proposed causal diagram). 12 , 17 , 18 , 19 , 21 , 22 , 23 From the Cox model, we also estimated the average adjusted 1-year graft survival in each group. We tested the proportionality assumption in the adjusted model as described in the eMethods in Supplement 1 .…”

Worth a Double Take? An In-Depth Review of Lung Retransplantation

“…An important limitation associated with this approach is the restricted capability to comprehensively analyze the influence of individual transplant center practices on LRT outcomes, as these databases typically lack granular information on center-specific selection criteria and approaches to surgical and medical management following LRT. Therefore, in addition to the complexity of this intervention-both in terms of perioperative approach and in long-term care, the center where the patients undergo evaluation might influence their listing, have an impact on lung allograft acceptance as well as the outcomes of both initial LT and LRT [7,15,26,27].…”

Critical care and ventilatory management of deceased organ donors impact lung use and recipient graft survival

“…Given the recognition that remaining on the lung transplant waitlist carries its own mortality risk, current practice has shifted from the identification of ideal donors to the identification of acceptable donors using less stringent selection criteria 10 . However, there is no consensus on donor lung selection criteria and variations in selection criteria are influenced by transplant program and surgeon risk tolerance 11 …”

“…10 However, there is no consensus on donor lung selection criteria and variations in selection criteria are influenced by transplant program and surgeon risk tolerance. 11 The identification of relationships between donor characteristics and lung graft outcomes would provide evidence to guide increased donor lung use without adversely affecting lung transplant outcomes.…”