title: Determining eligibility for lung transplantation: A nationwide assessment of the cutoff glomerular filtration rate.
abstract: BACKGROUND
  Historical concerns about lung transplantation in patients with a glomerular filtration rate (GFR) ≤ 50 ml/min/1.73 m(2) have not been validated. We hypothesize that a pre-transplant GFR ≤ 50 ml/min/1.73 m(2) represents a high mortality risk, especially in the setting of acute GFR decline. In addition, we explore the potential for improved risk stratification using a statistically derivable alternative cutoff.
  
  
  METHODS
  Adult, primary, lung recipients in the United Network for Organ Sharing database were analyzed (October 1987 to December 2011). Recursive partitioning identified the GFR value that provides maximal separation in 1-year mortality. Survival over/under the cutoffs was compared using stratified log-rank, Cox, and Kaplan-Meier methods, before and after 1:2 propensity score matching.
  
  
  RESULTS
  Median GFR at time of transplant for 19,425 study patients was 94.2 ml/min/1.73 m(2) (quartile 1-quartile, 2 76.9-105.9 ml/min/1.73 m(2)). Recursive partitioning identified a GFR of 40.2 ml/min/1.73 m(2) as the ideal inflection point for predicting 1-year survival. Cutoffs demonstrated statistically significant effects on survival after 840 patients with a GFR ≤ 50 ml/min/1.73 m(2) (hazard ratio, 1.28; 95% confidence interval, 1.15-1.43) and 401 patients with a GFR ≤ 40.2 ml/min/1.73 m(2) (hazard ratio, 1.57; 95% confidence interval, 1.36-1.83) were matched with high GFR controls (p < 0.001). In 13,509 patients with available GFR at the time of listing and transplant, a pre-transplant GFR decline of ≥ 50% from baseline was associated with worse survival (p < 0.001).
  
  
  CONCLUSIONS
  A pre-transplant GFR ≤ 50 ml/min/1.73 m(2) is associated with decreased survival. However, patients with GFR between 40 and 50 ml/min/1.73 m(2) do not suffer excessive post-transplant mortality and should not be automatically excluded from listing. Notably, outcomes are worse in patients with poor renal function and concomitant pre-transplant GFR decline. Strategies should be devised to detect and manage interval renal deterioration before lung transplantation.
authors.affiliation: School of Medicine; and the Departments of. Electronic address: asishana.osho@gmail.com.
authors.forename: Asishana A
authors.initials: AA
authors.lastname: Osho
authors.affiliation: Surgery.
authors.forename: Anthony W
authors.initials: AW
authors.lastname: Castleberry
authors.affiliation: Medicine.
authors.forename: Laurie D
authors.initials: LD
authors.lastname: Snyder
authors.affiliation: Surgery.
authors.forename: Asvin M
authors.initials: AM
authors.lastname: Ganapathi
authors.affiliation: Surgery.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Speicher
authors.affiliation: School of Medicine; and the Departments of.
authors.forename: Sameer A
authors.initials: SA
authors.lastname: Hirji
authors.affiliation: Anesthesiology, Duke University Medical Center, Durham, North Carolina.
authors.forename: Mark
authors.initials: M
authors.lastname: Stafford-Smith
authors.affiliation: Surgery.
authors.forename: Mani A
authors.initials: MA
authors.lastname: Daneshmand
authors.affiliation: Surgery.
authors.forename: R
authors.initials: R
authors.lastname: Duane Davis
authors.affiliation: Surgery.
authors.forename: Matthew G
authors.initials: MG
authors.lastname: Hartwig
mesh_terms: D000328:Adult; D015331:Cohort Studies; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D016040:Lung Transplantation / Q000401:mortality; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D012189:Retrospective Studies; D018570:Risk Assessment; D015996:Survival Rate; D014481:United States; D055815:Young Adult
keywords: GFR cutoff; GFR threshold; Lung transplantation; renal function