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. 2020 Aug;110(2):414-423.
doi: 10.1016/j.athoracsur.2020.02.061. Epub 2020 Apr 3.

Increased Calculated Panel Reactive Antigen Is Associated With Increased Waitlist Time and Mortality in Lung Transplantation

Yaron D Barac  1 , Mike S Mulvihill  2 , Oliver Jawitz  2 , Jacob Klapper  2 , John Haney  2 , Mani Daneshmand  2 , Basil Nasir  2 , Dongfeng Chen  2 , Carmelo A Milano  2 , Matthew G Hartwig  2
Affiliations

Increased Calculated Panel Reactive Antigen Is Associated With Increased Waitlist Time and Mortality in Lung Transplantation

Yaron D Barac et al. Ann Thorac Surg. 2020 Aug.

Abstract

Background: Sensitized candidates with unacceptable antigens are a group that demands special attention in organ transplantation. Calculated panel reactive antigen (cPRA) is not used to modify allocation priorities in lung transplantation. The impact of cPRA on waiting list time and mortality is unknown.

Methods: We performed a retrospective review of candidates for lung transplantation listed from May 2005 to 2018. Data from the Organ Procurement and Transplantation Network/United Network for Organ Sharing STAR (Standard Analysis and Research) dataset was paired with additional unacceptable human leukocyte antigen (UA-HLA) data, which were used to calculate the listing cPRA. Candidates were stratified based on the lack of UA-HLAs or cPRA level for candidates with unacceptable antigens reported. Unadjusted competing risks and adjusted subdistribution hazard models were fit.

Results: A total of 29,085 candidates met inclusion criteria for analysis. Of these, 23,562 (81%) with no UA-HLAs, 3472 (11.9%) with a cPRA less than 50, and 2051 with a cPRA greater than or equal to 50 (7.1%). On adjusted analysis, a cPRA greater than or equal to 50 was independently associated with increased waitlist mortality at 1 year (hazard ratio, 1.71; 95% confidence interval, 1.55-1.88; P < .001) and decreased rate of transplantation (71.9% vs 69.5% vs 44.4%; P < .001). Furthermore, patients with a cPRA greater than or equal to 50 had a longer waitlist time compared with a cPRA less than 50 and no UA-HLA candidates (mean 293.69 days vs 162.38 days and 143.26 days, respectively; P < .001). However, once transplanted, posttransplant survival among the cohorts was similar.

Conclusions: Further evaluation of organ allocation with consideration of a candidate's cPRA may be warranted in order to optimize equity in access to transplants.

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Conflict of interest statement

A Disclosure/Conflict of Interest

The authors have nothing to disclose and have no conflict of interest.

Figures

Figure 1:
Figure 1:
Study cohort diagram showing inclusion and exclusion criteria.
Figure 2.
Figure 2.
Examination of the relationship between waitlist mortality and candidate calculated Panel Reactive Antigen (cPRA), treated as a restricted cubic spline. The blue line (and blue shaded region) reflects the adjusted hazard of waitlist mortality (and 95% CI) by cPRA, treated as a restricted cubic spline. The gray line reflects the unadjusted univariate model for hazard of waitlist mortality (and 95% CI). Solid gray volume demonstrates the distribution of cPRA for candidates that reported UA-HLA. The hazard of waitlist mortality is increasing with higher cPRA.
Figure 3.
Figure 3.
Cumulative incidence curves for candidates awaiting lung transplantation, demonstrating the following competing risks: transplantation, death or decompensation, or recovery. Cohort is partitioned by calculated Panel Reactive Antigen. cPRA ≥ 50 was independently associated with increased waitlist mortality, decreased rate of transplantation and a longer waitlist time compared with cPRA < 50 and no UA-HLA candidates.
Figure 4.
Figure 4.
Unadjusted cumulative hazard for transplantation for candidates listed for lung transplantation, stratified by candidate calculated Panel Reactive Antigen (cPRA). Patient with cPRA of 0 has a higher probability of being transplanted.
Figure 5.
Figure 5.
10-year unadjusted Kaplan-Meier estimate of survival of recipients following lung transplantation, stratified by calculated Panel Reactive Antigen (cPRA), no difference was found between the different cPRA groups.
Figure 6.
Figure 6.
Cox regression model for mortality post-transplant. High calculated Panel Reactive Antigen was not found to be a risk factor for reduced survival post-transplant.
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