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Lung Transplantation in Germany Since the Introduction of the Lung Allocation Score
Jens Gottlieb1, Jacqueline Smits, Rene Schramm
1Hannover Medical School, Biomedical Research in End-stage and Obstructive Lung Disease Hannover (BREATH), member of the German Center for Lung Research; Eurotransplant International Foundation, Leiden, Niederlande; Department of Cardiac Surgery, Ludwig-Maximilians-Universität München; Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar; Department of Internal Medicine III (Hematology, Oncology, Pneumology), University Medical Center, Johannes Gutenberg University Mainz; Department of Pneumonology and Immunology, Charité-Universitätsmedizin Berlin; Richard DeVos Heart & Lung Transplant Program, Grand Rapids/Michigan, USA; Department of Cardiovascular Surgery, University Heart Center Hamburg.
Background:
The allocation of donor lungs for transplantation in Germany was changed on 10 December 2011 to a system based on the Lung Allocation Score (LAS). The aim of the present study is to determine whether this change has prolonged the survival of patients on the transplant waiting list and of those who have undergone lung transplantation (LTx).
Methods:
We retrospectively compared data from the three-year periods before and after the change to an LAS-based allocation system (2009-2011 vs. 2012-2014).
Results:
The number of patients on the active waiting list declined from 606 on 12/31/2011 to 432 on 12/31/2014, a 29% decrease. The number of patients who died while on the waiting list fell from 306 in 2009-2011 to 226 in 2012-2014 (-26%, p = 0.04). Waiting-list mortality declined across all disease groups. Meanwhile, the number of lung transplantation procedures per year increased by 21% over the period of observation, from 865 to 1045. During the period in which the LAS was used, the proportion of transplant recipients with restrictive lung disease (46% vs. 31%; p<0.001) surpassed the proportion of those with a diagnosis of obstructive lung disease (33% vs. 40%; p = 0.003). The percentage of transplantations in patients treated with mechanical ventilation or extracorporeal respiratory support before transplantation rose from 9% to 13%. The one-year survival rate after lung transplantation was 76% in 2009-2011 and 81% in 2012-2014.
Conclusion:
The introduction of the LAS in Germany was associated with a decrease in the number of patients on the waiting list, and also in the number of deaths among patients on the waiting list. The distribution of primary diagnoses among transplant recipients shifted away from obstructive and toward restrictive lung diseases. In the future, additional parameters of patients on the waiting list should be considered to enable further improvement of the allocation model.