Semin Respir Crit Care Med 2018; 39(02): 126-137
DOI: 10.1055/s-0037-1620265
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

How Should Lungs Be Allocated for Transplant?

Thomas M. Egan
1   Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
2   Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
› Author Affiliations
Further Information

Publication History

Publication Date:
26 March 2018 (online)

Abstract

As lung transplantation became established therapy for end-stage lung disease, there were not nearly enough suitable lungs from brain-dead organ donors to meet the need, leading to a focus on how lungs are allocated for transplant. Originally lungs were allocated by the United Network for Organ Sharing (UNOS) like hearts—by waiting time, first to listed recipients in the organ procurement organization of the donor, then to potential recipients in concentric 500 nautical mile circles. This resulted in long waiting times and increasing waitlist deaths. In 1999, the Health Resources and Services Administration published a Final Rule, requesting UNOS to review organ allocation algorithms to ensure that they complied with the desire to allocate organs based on urgency, avoiding futile transplants, and minimizing the role of waiting time in organ allocation. This led to development of the lung allocation score (LAS), which allocates lungs based on urgency and transplant benefit, introduced in 2005. The U.S. LAS system was adopted by Eurotransplant to allocate unused lungs between donor countries, and by both Germany and the Netherlands for lung allocation in their countries. This article will review the history of lung allocation, discuss the impact of LAS and its shortcomings, suggest recommendations to increase the number of lungs for transplant, and improve allocation of donated lungs. Ultimately, the goal of organ transplant research is to have so many organs to transplant that allocation systems are unnecessary.

 
  • References

  • 1 Smits JM, Vanhaecke J, Haverich A. , et al. Waiting for a thoracic transplant in Eurotransplant. Transpl Int 2006; 19 (01) 54-66
  • 2 Metras H. Note preliminaire sur la greffe totale du poumon chez le chien. C R Acad Sci (Paris) 1950; 231: 1176-1178
  • 3 Metras D, Kreitmann B, Riberi A. , et al. Bilateral single-lung transplantation in children. Ann Thorac Surg 1995; 60 (6, Suppl): S578-S581
  • 4 Métras D, Kreitmann B, Shennib H, Noirclerc M. Lung transplantation in children. J Heart Lung Transplant 1992; 11 (4 Pt 2): S282-S285
  • 5 Hardy JD, Eraslan S, Dalton Jr ML. Autotransplantation and homotransplantation of the lung: further studies. J Thorac Cardiovasc Surg 1963; 46: 606-615
  • 6 Hardy JD, Webb WR, Dalton Jr ML, Walker Jr GR. Lung homotransplantation in man. JAMA 1963; 186: 1065-1074
  • 7 Egan TM, Kaiser LR, Cooper JD. Lung transplantation. Curr Probl Surg 1989; 26 (10) 673-751
  • 8 Reitz BA, Wallwork JL, Hunt SA. , et al. Heart-lung transplantation: successful therapy for patients with pulmonary vascular disease. N Engl J Med 1982; 306 (10) 557-564
  • 9 Toronto Lung Transplant Group. Unilateral lung transplantation for pulmonary fibrosis. N Engl J Med 1986; 314 (18) 1140-1145
  • 10 Dark JH, Patterson GA, Al-Jilaihawi AN, Hsu H, Egan T, Cooper JD. Experimental en bloc double-lung transplantation. Ann Thorac Surg 1986; 42 (04) 394-398
  • 11 Patterson GA, Cooper JD, Dark JH, Jones MT. ; Toronto Lung Transplant Group. Experimental and clinical double lung transplantation. J Thorac Cardiovasc Surg 1988; 95 (01) 70-74
  • 12 Stiller CR, Keown PA. Cyclosporine therapy in perspective. In: Morris PJ, Tilney NL. , eds. Progress in Transplantation. Edinburgh: Churchill Livingstone; 1984: 11-45
  • 13 Lima O, Cooper JD, Peters WJ. , et al. Effects of methylprednisolone and azathioprine on bronchial healing following lung autotransplantation. J Thorac Cardiovasc Surg 1981; 82 (02) 211-215
  • 14 A definition of irreversible coma. Report of the Ad Hoc Committee of the Harvard Medical School to examine the definition of brain death. JAMA 1968; 205 (06) 337-340
  • 15 Guidelines for the determination of death. Report of the medical consultants on the diagnosis of death to the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. JAMA 1981; 246 (19) 2184-2186
  • 16 President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Defining death: a report on the medical, legal and ethical issues in the determination of death. Washington, DC: U.S. Government Printing Office; 1981 . Available at: http://tinyurl.com/zq6p5to
  • 17 History of UNOS. 2017. Available at: https://unos.org/about/history-of-unos/ . Accessed on October 15, 2017
  • 18 History of Transplant. 2017. Available at: https://unos.org/transplantation/history/ . Accessed on October 15, 2017
  • 19 UNOS Policies. 2017. Available at: https://optn.transplant.hrsa.gov/governance/policies/ . Accessed on October 15, 2017
  • 20 Board of Directors. 2017. Available at: https://optn.transplant.hrsa.gov/members/board-of-directors/ . Accessed on October 15, 2017
  • 21 OPTN Data. 2017. Available at: https://optn.transplant.hrsa.gov/data/ . Accessed on October 15, 2017
  • 22 Organ Procurement and Transplantation Network (OPTN). OPTN deceased donor potential study (DDPS), DHHS Contract 234–2005–37011C/0023, March 2015. Available at: http://optn.transplant.hrsa.gov/media/1161/ddps_03-2015.pdf . Accessed on October 22, 2015
  • 23 Raju S, Coltharp WH, Gerken MV, Warren ET, Griffith J, Hardy JD. Successful single lung transplantation. South Med J 1988; 81 (07) 931-933
  • 24 Hosenpud JD, Bennett LE, Keck BM, Edwards EB, Novick RJ. Effect of diagnosis on survival benefit of lung transplantation for end-stage lung disease. Lancet 1998; 351 (9095): 24-27
  • 25 Department of Health and Human Services. Organ Procurement and Transplantation Network; Final Rule. 42 CFR - Part 121. Fed Regist 1999; 64: 56649-56661
  • 26 Institute of Medicine. Committee on Non-Heart-Beating Transplantation II. Non-Heart-Beating Organ Transplantation: Practice and Protocols. Washington, D.C.: National Academy Press; 2000
  • 27 Egan TM, Murray S, Bustami RT. , et al. Development of the new lung allocation system in the United States. Am J Transplant 2006; 6 (5 Pt 2): 1212-1227
  • 28 Egan TM. Lung donor allocation systems. In: Vigneswaran W, Garrity E. , eds. Lung Transplantation. Essex, UK: Informa Healthcare; 2010: 105-114
  • 29 Egan TM, Edwards LB, Coke MA, Murray S, Bustami R, Shearon TH. Lung allocation in the United States. In: Lynch III JP, Ross D. , eds. Lung and Heart-Lung Transplantation (Lung Biology in Health and Disease Series. Vol. 217. New York, NY: Marcel Dekker Inc. (Taylor & Francis/CRC Press); 2006: 285-300
  • 30 Preparing your patients for changes to the lung allocation system 2015. Available at: https://optn.transplant.hrsa.gov/news/changes-to-the-lung-allocation-system/ . Accessed on October 15, 2017
  • 31 Lung Allocation Score calculation UNOS 2017. Available at: https://www.unos.org/wp-content/uploads/unos/lung_allocation_score.pdf . Accessed on October 15, 2017
  • 32 Policy modification to lung distribution sequence 2017. Available at: https://transplantpro.org/news/thoracic/policy-modification-to-lung-distribution-sequence/ . Accessed on November 25, 2017
  • 33 Egan TM, Edwards LB. Effect of the lung allocation score on lung transplantation in the United States. J Heart Lung Transplant 2016; 35 (04) 433-439
  • 34 McCurry KR, Shearon TH, Edwards LB. , et al. Lung transplantation in the United States, 1998-2007. Am J Transplant 2009; 9 (4 Pt 2): 942-958
  • 35 Arnaoutakis GJ, Allen JG, Merlo CA. , et al. Impact of the lung allocation score on resource utilization after lung transplantation in the United States. J Heart Lung Transplant 2011; 30 (01) 14-21
  • 36 Merlo CA, Weiss ES, Orens JB. , et al. Impact of U.S. lung allocation score on survival after lung transplantation. J Heart Lung Transplant 2009; 28 (08) 769-775
  • 37 Russo MJ, Iribarne A, Hong KN. , et al. High lung allocation score is associated with increased morbidity and mortality following transplantation. Chest 2010; 137 (03) 651-657
  • 38 Crawford TC, Grimm JC, Magruder JT. , et al. Lung transplant mortality is improving in recipients with a lung allocation score in the upper quartile. Ann Thorac Surg 2017; 103 (05) 1607-1613
  • 39 Maxwell BG, Mooney JJ, Lee PH. , et al. Increased resource use in lung transplant admissions in the lung allocation score era. Am J Respir Crit Care Med 2015; 191 (03) 302-308
  • 40 Halpern SD. Beyond “the LAS is broken”. Ways to improve lung allocation. Am J Respir Crit Care Med 2015; 191 (03) 245-246
  • 41 Maxwell BG, Levitt JE, Goldstein BA. , et al. Impact of the lung allocation score on survival beyond 1 year. Am J Transplant 2014; 14 (10) 2288-2294
  • 42 Smits JM, Nossent GD, de Vries E. , et al. Evaluation of the lung allocation score in highly urgent and urgent lung transplant candidates in Eurotransplant. J Heart Lung Transplant 2011; 30 (01) 22-28
  • 43 Gottlieb J, Greer M, Sommerwerck U. , et al. Introduction of the lung allocation score in Germany. Am J Transplant 2014; 14 (06) 1318-1327
  • 44 Gottlieb J, Smits J, Schramm R. , et al. Lung transplantation in Germany since the introduction of the lung allocation score. Dtsch Arztebl Int 2017; 114 (11) 179-185
  • 45 Egan TM. Imitation is the sincerest form of flattery. Dtsch Arztebl Int 2017; 114 (31-32): 543
  • 46 Gottlieb J. Lung allocation. J Thorac Dis 2017; 9 (08) 2670-2674
  • 47 Trulock EP, Christie JD, Edwards LB. , et al. Registry of the International Society for Heart and Lung Transplantation: twenty-fourth official adult lung and heart-lung transplantation report-2007. J Heart Lung Transplant 2007; 26 (08) 782-795
  • 48 Childress JF. The gift of life. Ethical problems and policies in obtaining and distributing organs for transplantation. Crit Care Clin 1986; 2 (01) 133-148
  • 49 Egan TM. Ethical issues in thoracic organ distribution for transplant. Am J Transplant 2003; 3 (04) 366-372
  • 50 Peters DA. A unified approach to organ donor recruitment, organ procurement, and distribution. J Law Health 1988- 1989; 3 (02) 157-187
  • 51 Albertsen A. Drinking in the last chance saloon: luck egalitarianism, alcohol consumption, and the organ transplant waiting list. Med Health Care Philos 2016; 19 (02) 325-338
  • 52 Abecassis M, Bridges ND, Clancy CJ. , et al. Solid-organ transplantation in older adults: current status and future research. Am J Transplant 2012; 12 (10) 2608-2622
  • 53 Verheijde JL, Rady MY, McGregor JL. The United States Revised Uniform Anatomical Gift Act (2006): new challenges to balancing patient rights and physician responsibilities. Philos Ethics Humanit Med 2007; 2: 19
  • 54 Kurtz SF, Strong CW, Gerasimow D. The 2006 Revised Uniform Anatomical Gift Act - A Law to Save Lives. Health Lawyers News. 2007;44–49
  • 55 National donor designation report card. 2017. Available at: https://www.donatelife.net/mission-vision/
  • 56 Organ donor recruitment. Council on Scientific affairs. JAMA 1981; 246 (19) 2157-2158
  • 57 Hsieh AH, Bishop MJ, Kubilis PS, Newell DW, Pierson DJ. Pneumonia following closed head injury. Am Rev Respir Dis 1992; 146 (02) 290-294
  • 58 Rogers FB, Shackford SR, Trevisani GT, Davis JW, Mackersie RC, Hoyt DB. Neurogenic pulmonary edema in fatal and nonfatal head injuries. J Trauma 1995; 39 (05) 860-866 , discussion 866–868
  • 59 Avlonitis VS, Fisher AJ, Kirby JA, Dark JH. Pulmonary transplantation: the role of brain death in donor lung injury. Transplantation 2003; 75 (12) 1928-1933
  • 60 Weill D, Benden C, Corris PA. , et al. A consensus document for the selection of lung transplant candidates: 2014–an update from the Pulmonary Transplantation Council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2015; 34 (01) 1-15
  • 61 Ingemansson R, Eyjolfsson A, Mared L. , et al. Clinical transplantation of initially rejected donor lungs after reconditioning ex vivo. Ann Thorac Surg 2009; 87 (01) 255-260
  • 62 Aigner C, Slama A, Hötzenecker K. , et al. Clinical ex vivo lung perfusion–pushing the limits. Am J Transplant 2012; 12 (07) 1839-1847
  • 63 Cypel M, Yeung JC, Liu M. , et al. Normothermic ex vivo lung perfusion in clinical lung transplantation. N Engl J Med 2011; 364 (15) 1431-1440
  • 64 Cypel M, Liu M, Rubacha M. , et al. Functional repair of human donor lungs by IL-10 gene therapy. Sci Transl Med 2009; 1 (04) 4ra9
  • 65 Steen S, Sjöberg T, Pierre L, Liao Q, Eriksson L, Algotsson L. Transplantation of lungs from a non-heart-beating donor. Lancet 2001; 357 (9259): 825-829
  • 66 Gámez P, Córdoba M, Ussetti P. , et al; Lung Transplant Group of the Puerta de Hierro Hospital. Lung transplantation from out-of-hospital non-heart-beating lung donors. one-year experience and results. J Heart Lung Transplant 2005; 24 (08) 1098-1102
  • 67 Gomez-de-Antonio D, Campo-Cañaveral JL, Crowley S. , et al. Clinical lung transplantation from uncontrolled non-heart-beating donors revisited. J Heart Lung Transplant 2012; 31 (04) 349-353
  • 68 Egan T, Blackwell J, Birchard K. , et al. Assessment of lungs for transplant recovered from uncontrolled donation after circulatory determination of death donors. Ann Am Thorac Soc 2017; 14 (Supplement_3): S251
  • 69 Egan TM, Requard III JJ. Uncontrolled donation after circulatory determination of death donors (uDCDDs) as a source of lungs for transplant. Am J Transplant 2015; 15 (08) 2031-2036
  • 70 Egan TM, Requard JJ, Gazda S, Casey N. Health of potential uncontrolled Donation after circulatory determination of death (uDCDD) lung donors: impact on the size of the uDCDD donor pool. J Heart Lung Transplant 2015; 34 (4S): S281
  • 71 Egan TM, Requard III J, Edwards T. Can lungs be recovered quickly from first person authorized (FPA) uncontrolled donation after circulatory determination of death donors (uDCDDs)? The law vs knowledge and attitudes among FPA adults. J Heart Lung Transplant 2017; 36 (4S): S284
  • 72 Valenza F, Citerio G, Palleschi A. , et al. Successful transplantation of lungs from an uncontrolled donor after circulatory death preserved in situ by alveolar recruitment maneuvers and assessed by ex-vivo lung perfusion. Am J Transplant 2016; 16 (04) 1312-1318
  • 73 Egan TM. Lung transplant from an uncontrolled donation after circulatory determination of death donor: moving to other countries. Am J Transplant 2016; 16 (04) 1051-1052
  • 74 Vega JD. The change in heart allocation policy in the United States: is it working as designed?. J Heart Lung Transplant 2010; 29 (03) 255-256
  • 75 Iribarne A, Meltzer DO, Chauhan D. , et al. Distribution of donor lungs in the United States: a case for broader geographic sharing. Clin Transplant 2016; 30 (06) 688-693