Impact of the Lung Allocation Score on Survival Beyond 1 Year

[Clark]

http://onlinelibrary.wiley.com/doi/10.1111/ajt.12903/abstract

Impact of the Lung Allocation Score on Survival Beyond 1 Year
B. G. Maxwell1,†, J. E. Levitt2,†, B. A. Goldstein3, J. J. Mooney2, M. R. Nicolls2, M. Zamora4, V. Valentine5, D. Weill2 andG. S. Dhillon2,*
DOI: 10.1111/ajt.12903
American Journal of Transplantation
Early View (Online Version of Record published before inclusion in an issue)

Abstract

Implementation of the lung allocation score (LAS) in 2005 led to transplantation of older and sicker patients without altering 1-year survival. However, long-term survival has not been assessed and emphasizing the 1-year survival metric may actually sustain 1-year survival while not reflecting worsening longer-term survival. Therefore, we assessed overall and conditional 1-year survival; and the effect of crossing the 1-year threshold on hazard of death in three temporal cohorts: historical (1995–2000), pre-LAS (2001–2005) and post-LAS (2005–2010). One-year survival post-LAS remained similar to pre-LAS (83.1% vs. 82.1%) and better than historical controls (75%). Overall survival in the pre- and post-LAS cohorts was also similar. However, long-term survival among patients surviving beyond 1 year was worse than pre-LAS and similar to historical controls. Also, the hazard of death increased significantly in months 13 (1.44, 95% CI 1.10–1.87) and 14 (1.43, 95% CI 1.09–1.87) post-LAS but not in the other cohorts. While implementation of the LAS has not reduced overall survival, decreased survival among patients surviving beyond 1 year in the post-LAS cohort and the increased mortality occurring immediately after 1 year suggest a potential negative long-term effect of the LAS and an unintended consequence of increased emphasis on the 1-year survival metric.

[Clark]

Note that the implementation of LAS in 2005 nearly eliminated living lung donation in the US. Note also that the long term follow up discussions I've attended rarely include preexisting donors until I bring the topic up, including the many lung donors from before 2005.