Incorporating Effects of Time Accrued on the Waiting List into Lung Transplantation Survival Models
Jarrod E. Dalton, Paul R. Gunsalus, Carli J. Lehr, Johnie Rose, Belinda Udeh, Maryam Valapour
Abstract
Abstract Rationale U.S. lung transplant mortality risk models do not account for patients’ disease progression as time accrues between mandated clinical parameter updates. Objectives To investigate the effects of accrued waitlist (WL) time on mortality in lung transplant candidates and recipients beyond those expressed by worsening clinical status and to present a new framework for conceptualizing mortality risk in end-stage lung disease. Methods Using Scientific Registry of Transplant Recipients data (2015–2020, N = 12,616), we modeled transitions among multiple clinical states over time: WL, posttransplant, and death. Using cause-specific and ordinary Cox regression to estimate trajectories of composite 1-year mortality risk as a function of time from waitlisting to transplantation, we quantified the predictive accuracy of these estimates. We compared multistate model-derived candidate rankings against composite allocation score (CAS) rankings. Measurements and Main Results There were 11.5% of candidates whose predicted 1-year mortality risk increased by >10% by day 30 on the WL. The multistate model ascribed lower numerical rankings (i.e., higher priority) than CAS for those who died while on the WL (multistate mean; median [interquartile range] ranking at death, 227; 154 [57–334]; CAS median [interquartile range] ranking at death, 329; 162 [11–668]). Patients with interstitial lung disease were more likely to have increasing risk trajectories as a function of time accrued on the WL compared with other lung diagnoses. Conclusions Incorporating the effects of time accrued on the WL for lung transplant candidates and recipients in donor lung allocation systems may improve the survival of patients with end-stage lung diseases on the individual and population levels.