title: Too high for transplantation? Single-center analysis of the lung allocation score.
abstract: BACKGROUND
  Recent studies using United Network for Organ Sharing data suggest that lung transplantation in patients with high lung allocation scores (LAS) may lead to organ and resource wastage. Therefore, to determine whether a LAS cutoff value should be considered, we evaluated the relation of LAS to waitlist and posttransplant mortality in our center to determine if it could identify patients for whom listing for transplantation may be futile.
  
  
  METHODS
  From May 1, 2005 to July 1, 2010, 537 adults were listed and 426 underwent primary lung transplantation at our institution. Endpoints were mortality before and after lung transplantation. The relationships of LAS at listing to waitlist mortality and of pretransplant LAS to posttransplant mortality were both analyzed by multiphase hazard function methodology.
  
  
  RESULTS
  Higher LAS was strongly associated with waitlist mortality (p<0.0001), with the highest quartile (LAS ranging from 47 to 95) experiencing 75% mortality within a year of listing. Although early (p=0.05), but not late (p=0.4), posttransplant survival was associated with higher LAS at transplantation, once other clinical characteristics predictive of early mortality were accounted for, neither waitlist nor pretransplant LAS was independently related to posttransplant mortality (p=0.12).
  
  
  CONCLUSIONS
  Higher LAS strongly predicts higher mortality on the lung transplantation waitlist, underscoring the value of LAS in prioritizing patients with the highest scores for transplantation. Early posttransplant mortality is modestly higher with higher pretransplant LAS, but the data of our center do not suggest a value above which transplantation should be denied as futile. This suggests that donor organs and resources are not being wasted.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Heart and Vascular Institute, Cleveland, Ohio.
authors.forename: Alexis E
authors.initials: AE
authors.lastname: Shafii
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Heart and Vascular Institute, Cleveland, Ohio. Electronic address: david.mason@baylorhealth.edu.
authors.forename: David P
authors.initials: DP
authors.lastname: Mason
authors.affiliation: Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Chase R
authors.initials: CR
authors.lastname: Brown
authors.affiliation: Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Lucy
authors.initials: L
authors.lastname: Thuita
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Heart and Vascular Institute, Cleveland, Ohio.
authors.forename: Sudish C
authors.initials: SC
authors.lastname: Murthy
authors.affiliation: Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Marie M
authors.initials: MM
authors.lastname: Budev
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Heart and Vascular Institute, Cleveland, Ohio.
authors.forename: Gösta B
authors.initials: GB
authors.lastname: Pettersson
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Heart and Vascular Institute, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Eugene H
authors.initials: EH
authors.lastname: Blackstone
mesh_terms: D000328:Adult; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008171:Lung Diseases / Q000401:mortality / Q000601:surgery*; D016040:Lung Transplantation / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D009820:Ohio / Q000453:epidemiology; D011379:Prognosis; D016016:Proportional Hazards Models; D040841:Resource Allocation / Q000379:methods*; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D009927:Tissue and Organ Procurement / Q000458:organization & administration*