Affiliations: University of North Carolina Chapel Hill, NC,
Walter Reed Army Medical Center Washington, DC,
Inova Fairfax Hospital Fairfax, VA
Correspondence to: Thomas M. Egan, MD, MSc, Division of Cardiothoracic Surgery, Department of Surgery, 108 Burnett-Womack Building, CB No. 7065, University of North Carolina, Chapel Hill, NC, 27599-7065.
To the Editor: The study by Shorr and colleagues (July 2002)1was a thought-provoking analysis of patients awaiting orthotopic lung transplantation (OLT) for sarcoidosis in the United States. The authors noted that patients with sarcoidosis appeared to be less likely to undergo OLT than patients with idiopathic pulmonary fibrosis. The fact that listed patients with sarcoidosis were more likely to be black and female raises concerns about race or gender bias in organ allocation, but there is another more plausible explanation for their observation. Lung donors are more likely to be men,2and thus there is potentially a “size bias,” which also adversely affects patients with cystic fibrosis awaiting OLT. We routinely down-size donor lungs into CF recipients of small stature to increase their opportunity for undergoing transplantation.3
The recommendation of Shorr et al that patients with sarcoidosis be awarded a “waiting time credit,” as is done for patients with idiopathic pulmonary fibrosis, fails to address the fundamental issue of who should be offered a lung: the patient who is able to wait the longest or the patient who is most at risk of death on the list? In this respect, the current United Network for Organ Sharing lung distribution algorithm is fundamentally flawed.
The Lung Allocation Subcommittee of the United Network for Organ Sharing Thoracic Organ Committee is developing a distribution algorithm that considers the risk of dying on the waiting list coupled with the chance of posttransplant survival rather than using waiting time as the principal determinant of lung allocation.4–5 Patients with sarcoidosis and other less common lung diseases have posed some challenges in our analyses because of the relatively small numbers compared to patients with other diagnoses. Nevertheless, we found that sarcoidosis patients with pulmonary hypertension had a higher risk of death on the wait list than those with normal pulmonary artery pressures. Sarcoidosis patients with normal pulmonary artery pressures have an unpredictable natural history, which is a vexing problem for lung transplant surgeons trying to decide whether to perform a transplant in someone who is stable or to use the organ for someone who is more ill.
The opinions expressed herein are not to be construed as official or as reflecting the policies of either the Department of the Army or the Department of Defense.
To the Editor:
We appreciate the comments of Dr. Egan regarding our study1 of outcomes for patients with sarcoidosis awaiting lung transplantation. He raises two issues with our analysis.
First, he suggests that size bias might explain some of the differences we noted in waiting times. Because more lung donors are male but most sarcoidosis patients listed for lung transplant are female, there may be too few organs that would be appropriate for smaller, female patients. This certainly is a possibility. Thus, we have subsequently conducted a multivariate analysis to control for this potential source of confounding. In so doing, we find that gender does not correlate with probability of undergoing lung transplantation in patients with either sarcoidosis or idiopathic pulmonary fibrosis. Nonetheless, race remains a significant predictor of transplantation. These results underscore our concerns about the potential for racial bias in the allocation of lungs for transplantation and make size bias a less likely explanation for our observations.
Second, we only meant our data to suggest that perhaps the waiting time credit for patients with idiopathic pulmonary fibrosis be re-evaluated. The issue of the most appropriate allocation system for scarce organs is a complicated, multifaceted question, with significant social and ethical implications. Rather, we intended for our findings to spur discussion over this topic in the transplant community. Any algorithm for the distribution of lungs for transplantation cannot be based purely on numerical probabilities of benefit—such models cannot capture many factors, particularly when the disease studied is rare. Similarly, scoring systems that include severity of illness to the exclusion of prior waiting time may be open to gaming and abuse, as noted with the older allocation system for liver transplants.
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