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Clinical Decisionmaking

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No one clinical factor can identify which cystic fibrosis patients more urgently need lung transplants

Patients who are listed for lung transplants face a long wait, with the 1996 median waiting time to transplantation of 567 days. Donor lungs are distributed to patients (who match blood type and body size) solely according to who has been waiting longest on the United Network for Organ Sharing national waiting list. Recently, the Department of Health and Human Services advocated a revision of the organ allocation system that would also consider medical urgency. But for patients with cystic fibrosis, a common indication for lung transplantation, no single clinical factor reliably determines which patient among many is in most urgent need of a donor lung, according to a study supported in part by the Agency for Healthcare Research and Quality (National Research Service Award fellowship F32 HS00124).

Roger D. Yusen, M.D., of Washington University School of Medicine in St. Louis, MO, and his colleagues reviewed the records of 146 cystic fibrosis patients at one medical center who were listed for lung transplantation. They compared the characteristics of patients who died awaiting transplantation with those of patients who survived until transplantation or the end of the study.

Patients who either walked a shorter distance in 6 minutes, had higher systolic pulmonary artery pressure, or suffered from diabetes mellitus were significantly more likely to die while waiting for a lung transplant. For each 50 meter increase in the 6-minute walk distance, the risk of death decreased by 31 percent, and for each 5 mm Hg increase in the systolic pulmonary artery pressure, the chance of death increased by 41 percent. Finally, the presence of diabetes mellitus increased the risk of death before transplantation by 57 percent. However, these factors and other features overlapped considerably between the group of patients who died waiting and the group who lived until transplantation or the end of the study. These findings underscore the difficulties of trying to devise legitimate medical urgency criteria for allocating donor lungs.

See "Outcome of patients with cystic fibrosis awaiting lung transplantation," by Carmine Dario Vizza, Dr. Yusen, John P. Lynch, and others, in the September 2000 American Journal of Respiratory and Critical Care Medicine 162, pp. 819-824.

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