Waiting List Survival Trends in Pediatric Lung Transplantation: A National Cohort Study

BACKGROUND: Advancements in pediatric lung transplantation, including support devices, the Lung Allocation Score (LAS), and the subsequent Composite Allocation Score (CAS), have led to significant improvements in survival on the waiting list. Policy changes, like the removal of the Donation Service Area in 2017, aimed to further improve outcomes, but their impact in more recent years remains unclear. Our study examines recent waiting list survival trends and key factors affecting outcomes for pediatric lung transplant candidates. METHODS: Pediatric patients (n = 535) listed for lung transplantation in the OPTN Database were categorized into four eras based on year of listing: 2014-2017 (n = 182), 2017-2020 (n = 174), 2020-March 2023 (n = 134), and March 2023 onward (n = 45). Our primary outcome was death on the waiting list. Predictors of waitlist mortality were identified with multivariable logistic regression. Kaplan-Meier curves with a log-rank test were used to evaluate outcomes across eras. The Fine and Gray method was used to account for competing outcomes, including transplantation and removal from the waitlist due to clinical improvement. RESULTS: Poor functional status, ventilation at time of listing, African American ethnicity, and listing in region 1 were associated with increased waitlist mortality. One-year survival increased from 2014-2017 to 2020-2023 (p < 0.05). When accounting for competing risks, Fine and Gray showed a declining incidence of waitlist mortality with each successive era. CONCLUSION: Waiting list survival for pediatric lung transplant candidates has improved since 2014, with notable progress in the 2020-2023 era. The reasons for these improvements are likely multifactorial, and further studies are needed to evaluate their impact.