Clinical lung and heart/lung transplantation
Listing for lung transplantation: life expectancy and transplant effect, stratified by type of end-stage lung disease, the Eurotransplant experience

https://doi.org/10.1016/S1053-2498(01)00241-8Get rights and content

Abstract

Background: Increased referral for lung transplantation, persistent shortage of donor lungs, and moderate transplant outcome call not only for adequate listing criteria, but also for an optimal allocation scheme. We used global cohort survival after listing and survival benefit from transplantation to study the effect of a lung allocation scheme, primarily driven by waiting time, on the different types of end-stage lung disease.

Methods

We followed all adult patients consecutively listed for first, lung-only transplantation between 1990 and 1996 (n = 1,208) for at least 2 years, with an additional 2-year follow-up after transplantation (n = 744). We used the competing risk method, the Kaplan-Meier method, and a time-dependent non-proportional hazards model to analyze waiting-list outcome and global mortality after listing, post-transplant survival, and transplant effect, respectively. Each analysis was stratified for type of end-stage lung disease.

Results

At 2 years, 57% of the total cohort had received lung transplants, whereas 25% had died on the waiting list. The 2-year survival post-transplant was 55%. The global mortality of the cohort, since listing, amounted to 46% at 2 years. Compared with continued waiting, patients experienced benefit from transplantation by Day 100, which lasted until the end of the 2-year analysis period. We noticed the highest global mortality rates for patients with pulmonary fibrosis and pulmonary hypertension (54% and 52%); emphysema patients had the lowest (38%). Patients with pulmonary fibrosis and cystic fibrosis had much earlier benefit from transplantation, 55 and 90 days, respectively. Transplantation also benefited emphysema patients by Day 260.

Conclusions

Lung transplantation conferred transplant benefit in a Western European cohort of adults, in particular for patients with pulmonary fibrosis and cystic fibrosis, but also for patients with emphysema. The global survival rate, reflecting the real life expectancy for a newly listed transplant candidate, is poor for patients with pulmonary fibrosis and pulmonary hypertension. Allocation algorithms that lessen the impact of waiting time and take into account the type of end-stage lung disease should be developed.

Section snippets

Methods

This study included all 1,208 adult patients (age ≥ 16 years) consecutively registered for first, lung-only transplantation on the Eurotransplant waiting list between January 1, 1990, and December 31, 1996. The treating transplant physician decided between single and double lung transplantation. The end-stage lung diseases were grouped into 6 types: cystic fibrosis, pulmonary fibrosis, emphysema, pulmonary hypertension, congenital heart disease, and other (Table I). All patients were considered

Results

The 2 most frequent types of end-stage lung disease in the cohort were emphysema (33%) and pulmonary fibrosis (27%) (Table I).

Discussion

Prolonging life for patients placed on the lung transplant waiting list requires their surviving until transplantation and surviving after transplantation (as long as possible). Our data from the Eurotransplant registry confirm that transplantation is the best treatment option for patients with end-stage lung disease, as we observed survival benefit of transplantation for all patients in our study—with the exception of the patients with congenital heart disease. The combined efforts of

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