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Waiting List Survival Trends in Pediatric Lung Transplantation: A National Cohort Study
Elijah Roberts1, Maya Sela1, Chase Robinson1
1Office of Student Affairs, Baylor College of Medicine, Houston, Texas, USA.
Insights
Pediatric lung transplant waitlist survival has improved since 2014, showing significant progress in recent years. Key factors influencing outcomes include functional status and ethnicity, highlighting the need for continued research.
Area of Science:
- Pediatric transplantation research
- Organ allocation policy impact
- Survival outcome analysis
Background:
- Pediatric lung transplantation has seen survival improvements due to advancements in support devices and allocation scores (LAS, CAS).
- Recent policy changes, such as the 2017 removal of the Donation Service Area, aimed to further enhance outcomes, but their effects require updated evaluation.
- Understanding current trends in pediatric lung transplant waitlist survival and associated risk factors is crucial.
Purpose of the Study:
- To examine recent trends in pediatric lung transplant waitlist survival.
- To identify key factors influencing waitlist mortality in pediatric lung transplant candidates.
- To assess the impact of policy changes on pediatric lung transplant outcomes.
Main Methods:
- Analysis of 535 pediatric lung transplant candidates from the OPTN Database, categorized into four listing eras (2014-2017, 2017-2020, 2020-2023, 2023+).
- Primary outcome: waitlist mortality. Multivariable logistic regression and Kaplan-Meier curves were used to identify predictors and evaluate survival.
- Competing risks analysis using the Fine and Gray method to account for transplantation and clinical improvement removals.
Main Results:
- Poor functional status, mechanical ventilation at listing, African American ethnicity, and listing in region 1 were linked to higher waitlist mortality.
- One-year survival rates improved significantly from the 2014-2017 era to the 2020-2023 era (p < 0.05).
- Competing risks analysis revealed a consistent decline in waitlist mortality incidence across successive eras.
Conclusions:
- Pediatric lung transplant waitlist survival has demonstrably improved since 2014, with marked advancements observed in the 2020-2023 period.
- The observed improvements are likely multifactorial, necessitating further investigation to fully elucidate the contributing elements.
- Continued research is essential to understand and optimize outcomes for pediatric lung transplant candidates.
Background:
Advancements in pediatric lung transplantation, including support devices, the Lung Allocation Score (LAS), and the subsequent Composite Allocation Score (CAS), have led to significant improvements in survival on the waiting list. Policy changes, like the removal of the Donation Service Area in 2017, aimed to further improve outcomes, but their impact in more recent years remains unclear. Our study examines recent waiting list survival trends and key factors affecting outcomes for pediatric lung transplant candidates.
Methods:
Pediatric patients (n = 535) listed for lung transplantation in the OPTN Database were categorized into four eras based on year of listing: 2014-2017 (n = 182), 2017-2020 (n = 174), 2020-March 2023 (n = 134), and March 2023 onward (n = 45). Our primary outcome was death on the waiting list. Predictors of waitlist mortality were identified with multivariable logistic regression. Kaplan-Meier curves with a log-rank test were used to evaluate outcomes across eras. The Fine and Gray method was used to account for competing outcomes, including transplantation and removal from the waitlist due to clinical improvement.
Results:
Poor functional status, ventilation at time of listing, African American ethnicity, and listing in region 1 were associated with increased waitlist mortality. One-year survival increased from 2014-2017 to 2020-2023 (p < 0.05). When accounting for competing risks, Fine and Gray showed a declining incidence of waitlist mortality with each successive era.
Conclusion:
Waiting list survival for pediatric lung transplant candidates has improved since 2014, with notable progress in the 2020-2023 era. The reasons for these improvements are likely multifactorial, and further studies are needed to evaluate their impact.
