Elsevier

The Lancet

Volume 351, Issue 9095, 3 January 1998, Pages 24-27
The Lancet

Articles
Effect of diagnosis on survival benefit of lung transplantation for end-stage lung disease

https://doi.org/10.1016/S0140-6736(97)06405-2Get rights and content

Summary

Background

Although certain forms of end-stage lung disease are debilitating, whether the associated mortality rate exceeds that of transplantation is unclear. We undertook analysis to clarify the survival benefit of lung transplantation for various types of end-stage lung disease.

Methods

We analysed data for all patients listed for transplantation in the USA for emphysema, cystic fibrosis, or interstitial pulmonary fibrosis in the years 1992–94. The numbers of patients entered on the waiting list, post-transplantation, died waiting, and currently waiting were: emphysema group 1274, 843, 143, and 165; cystic fibrosis group 664, 318, 193, and 59; interstitial pulmonary fibrosis group 481, 230, 160, and 48. A time-dependent non-proportional hazard analysis was used to assess the risk of mortality after transplantation relative to that for patients on the waiting list.

Findings

The clearest survival benefit from lung transplantation occurred in the cystic fibrosis group. The relative risks of transplantation compared with waiting were 0·87, 0·61, and 0·61 at 1 month, 6 months, and 1 year (p=0·008), respectively. For interstitial pulmonary fibrosis, the corresponding relative risks were 2·09, 0·71, and 0·67 (p=0·09). No survival benefit was apparent in the emphysema group. The risks of transplantation relative to waiting were 2·76, 1·12, and 1·10 at 1 month, 6 months, and 1 year, respectively, and the relative risk did not decrease to below 1·0 during 2 years of follow-up.

Interpretation

These findings suggest that lung transplantation does not confer a survival benefit in patients with end-stage emphysema by 2 years of follow-up. Other benefits not accounted for in this analysis such as improved quality of life, however, may justify lung transplantation for these patients.

Introduction

Although lung transplantation has become an invaluable approach for the treatment of end-stage respiratory disease, rates of successful outcomes are not yet as good as those for other transplanted organs. Based on data from the Joint United Network for Organ Sharing (UNOS)/International Society for Heart and Lung Transplantation (ISHLT) Thoracic Registry, 1-year mortality is more than 25% and 5-year mortality is greater than 50%.1 In addition, obliterative bronchiolitis affects more than 50% of patients late after transplantation2 and accounts for 57% of the deaths after 1 year.1

The most common indication for lung transplantation is emphysema.1 Although emphysema is debilitating, mortality from this disorder may not be as high as that from other forms of end-stage lung disease, especially in patients younger than 60 years.3, 4, 5, 6 Moreover, for some patients with emphysema, volume-reduction surgery7, 8, 9 may be an alternative. To clarify the actual survival benefit of lung transplantation for the more common causes of end-stage lung disease, including emphysema, we undertook an analysis of data from the Joint UNOS/ISHLT Thoracic Registry.

Section snippets

Methods

The cohort for this study included all patients listed for transplantation with UNOS (listed for transplantation in the USA) between Jan 1, 1992, and Dec 31, 1994. The cohort included patients with the three most common indications—emphysema, cystic fibrosis, and interstitial pulmonary fibrosis.

The UNOS lung allocation scheme does not take into account disease severity; organs are allocated solely on the basis of waiting time, blood type, and body size. We included only patients undergoing

Results

Characteristics of the patients and their outcomes at the time of analysis are given in table 1. As expected, the group with cystic fibrosis was younger on average. Table 1 also gives the mean duration of follow-up in each of the clinical stages for each diagnosis. For the entire cohort, mean follow-up exceeds 18 months, with adequate follow-up for the data to be analysed over a 2-year period.

Survival while awaiting transplantation was significantly greater for patients with emphysema than for

Discussion

The data reported here support a survival benefit of lung transplantation for patients with cystic fibrosis and interstitial pulmonary fibrosis. Although there was a high mortality risk immediately after transplantation, by 1 year later survival was better than that for patients on the waiting list for both diagnoses. By contrast, for patients with emphysema, the mortality rate while they were on the waiting list was low, so post-transplantation survival did not exceed waiting-list survival

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