Crawford Todd C, Grimm Joshua C, Magruder J Trent, Ha Jinny, Sciortino Christopher M, Kim Bo S, Bush Errol L, Conte John V, Higgins Robert S, Shah Ashish S, Merlo Christian A
Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Ann Thorac Surg. 2017 May;103(5):1607-1613. doi: 10.1016/j.athoracsur.2016.11.057. Epub 2017 Feb 21.
Since the introduction of the Lung Allocation Score (LAS), the mean LAS has risen. Still, it remains uncertain whether mortality has improved in the most severely ill lung transplant recipients over this time period.
Using the United Network for Organ Sharing database, we identified 3,548 adult lung transplant recipients from May 4, 2005, to March 31, 2014, with a match-time LAS in the upper quartile (>75th%ile). We divided this population across three eras: 1 = May 4, 2005, to December 31, 2008 (n = 1,280); 2 = January 1, 2009, to December 31, 2011 (n = 1,266); and 3 = January 1, 2012, to March 31, 2014 (n = 1,002). Cox proportional hazards models were constructed for the primary outcomes of 30-day and 1-year mortality to assess the independent impact of the era of transplantation.
The mean LAS at time of transplant for patients in the upper quartile in eras 1, 2, and 3 was 63, 73, and 79, respectively (p < 0.001). Later eras of transplantation benefited from a significant improvement in survival at 1 year (log-rank p = 0.001) but not at 30 days (log-rank p = 0.152). After risk adjustment, lung transplantation in more recent eras was associated with improved mortality at both 30 days (era 3 hazard ratio [HR] = 0.50, 95% confidence interval [CI] 0.32% to 0.78%, p = 0.002) and 1 year (era 2 HR = 0.77, 95% CI 0.64% to 0.94%, p = 0.008; era 3 HR = 0.54, 95% CI 0.43% to 0.68%, p < 0.001).
Despite a progressively rising LAS, survival is improving among recipients with the highest LAS at the time of lung transplantation. This calls into question the notion of a maximum LAS beyond which lung transplantation becomes futile, a so-called LAS ceiling.
自肺分配评分（LAS）引入以来，平均LAS有所上升。然而，在此期间，病情最严重的肺移植受者的死亡率是否有所改善仍不确定。
利用器官共享联合网络数据库，我们确定了2005年5月4日至2014年3月31日期间3548例成年肺移植受者，其匹配时LAS处于上四分位数（>第75百分位数）。我们将这一人群分为三个时代：1 = 2005年5月4日至2008年12月31日（n = 1280）；2 = 2009年1月1日至2011年12月31日（n = 1266）；3 = 2012年1月1日至2014年3月31日（n = 1002）。构建Cox比例风险模型，以30天和1年死亡率作为主要结局，评估移植时代的独立影响。
第1、2和3时代上四分位数患者移植时的平均LAS分别为63、73和79（p < 0.001）。后期移植时代在1年生存率方面有显著改善（对数秩检验p = 0.001），但在30天生存率方面没有改善（对数秩检验p = 0.152）。经过风险调整后，近期移植时代的肺移植在30天（第3时代风险比[HR] = 0.50，95%置信区间[CI] 0.32%至0.78%，p = 0.002）和1年（第2时代HR = 0.77，95% CI 0.64%至0.94%，p = 0.008；第3时代HR = 0.54，95% CI 0.43%至0.68%，p < 0.001）死亡率均有所改善。
尽管LAS逐渐上升，但肺移植时LAS最高的受者生存率正在提高。这对超过该值肺移植将变得徒劳的所谓LAS上限这一概念提出了质疑。
