Which shall I choose? Lung transplantation listing preference for individuals with interstitial lung disease and chronic obstructive pulmonary disease

Single or double lung transplantation is a therapeutic option for individuals with end-stage chronic obstructive pulmonary disease (COPD) or interstitial lung disease (ILD). Since the new lung allocation system was implemented in the United States in 2005, the number of lung transplants has increased almost every year. However, there are still more individuals on the waitlist for lung transplantation than there are lung donors available. As a result, death without a transplant is an unfortunate outcome for some patients on the waitlist. The likelihood of dying on the waitlist (or waitlist removal for clinical deterioration) is approximately 15% per year for individuals with ILD. As nearly 75% of transplants are bilateral (two lungs to one recipient), one potential strategy to increase the number of lung transplant recipients is to promote single lung transplantation (two recipients receiving a single lung from a single donor pair) when clinically feasible.

There is an important distinction between listing preference and the surgical procedure that a patient undergoes (Figure 1). Providers may, and often do, list their patients with a preference for bilateral lung transplantation only (restricted) versus any other procedure preference (unrestricted). The procedure options available to a particular patient will depend to a large extent on the patient’s underlying diagnosis, presence of anatomical abnormalities in the chest, degree of pulmonary hypertension, disease severity, and other patient-related factors (e.g., age). Local and regional circumstances may also dictate a transplant center’s approach to listing because of the dynamics of interacting with the Organ Procurement Organizations. Donor characteristics, including donor size, suitability of one or both lungs for transplant, and “marginal” viability of the available lung or lungs, will also affect the procedure a matched recipient will undergo. However, a reflexive approach to “restricted” listing by some centers can limit the opportunities for eventual (and timely) transplantation. Individuals with an “unrestricted” listing preference have more opportunities to receive transplant offers. Accordingly, an investigation of the net effect of listing practices is both interesting and important at the individual and societal levels.

National Heart, Lung, and Blood Institute
Cystic Fibrosis Foundation
Cystic Fibrosis Foundation Lung Transplant Consortium