Beyond the Survival Gap: Equity in High-Emergency Lung Transplantation

The ethical and clinical landscape of lung transplantation (LT) is defined by continuous efforts to balance “urgency” (saving the sickest patients) and “utility” (ensuring the best long-term outcomes). Historically, rapid-access allocation for patients at immediate risk of death was seen as a “rescue” procedure that involved a necessary survival penalty; early reports indicated significantly worse outcomes compared with standard allocation LT.1 However, the recent study by Mal et al2 reinforces a pivotal shift in this narrative, suggesting that the survival gap for high-emergency LT (HELT) patients has effectively closed. This nationwide retrospective analysis of 1085 LT patients highlights that the HELT cohort represents the most physiologically challenging patients in the transplant community. 96.6% of HELT recipients were hospitalized or in the intensive care unit at the time of transplant, compared with just 20.5% of standard allocation patients. Furthermore, the reliance on mechanical support was stark: 38.3% of HELT patients required extracorporeal membrane oxygenation as a bridge to transplantation, and 18.5% required invasive mechanical ventilation. The median wait time after HELT status was granted was only 4 d. This rapid access is a notable success of the French system, as it nearly eliminates the risk of waitlist mortality. Interestingly, the proportion of HELT procedures has stabilized at approximately 19% in France, suggesting that the strict selection criteria have prevented overutilization of this emergency status. When comparing HELT to standard allocation LT, Mal et al reported a higher 1-y mortality risk in HELT patients (hazard ratio, 1.35) on univariate analysis; however, this association disappeared in their multivariable model (hazard ratio, 1.23; P = 0.17) after adjustment for factors such as donor age and graft ischemic time.2 Although this survival parity is a triumph, it does not imply that HELT is low risk. The authors also highlight a substantial burden of postoperative morbidity, with HELT patients spending more time in the intensive care unit (27 versus 21.1 d) and requiring more postoperative extracorporeal support (48.6% versus 32.4%). These findings are not unique to France; they mirror a broader global evolution toward urgency-based allocation. In the United States, the Lung Allocation Score (LAS) was used for nearly 2 decades before being replaced by the current Composite Allocation Score (CAS) in 2023. During the LAS era, the sickest LT candidates were prioritized on the basis of waitlist urgency and predicted posttransplant survival, rather than just time listed for transplant as in the previous wait time-based system. Despite transplanting sicker patients, 1-y survival remained similar between the sickest and standard LT patients in early studies and increased over time.3 Waitlist mortality decreased, allowing an increase in transplant volume nationally, although this was accompanied by a higher risk of postoperative complications and increased resource utilization.4,5 Several European countries, including Spain, the United Kingdom, and Italy, have seen similar trends after the implementation of high-acuity allocation systems.6 The shift to the CAS system in the United States and similar urgency-based systems in France and other countries worldwide marks an important step toward improving equity in organ allocation. However, although continual improvement in allocation is a laudable goal, it is impossible to fully define the perfect allocation system. Moving beyond survival metrics to address core disparities in access is an essential next step, which requires a nuanced understanding of the broader transplantation landscape. Although analyses of proposed determinants of LT access—such as insurance and socioeconomic status, distance to transplant centers, and listing location—have not consistently demonstrated strong associations with transplant rates or outcomes, ultimately the relationship between these variables and LT access will vary depending on the system in which patients are waitlisted.7,8 In contrast, recent legal and regulatory mandates, including the transition from LAS to CAS in the United States and the formalization of HELT criteria in France, have directly reshaped how waitlist urgency, geographic boundaries, and expected posttransplant outcomes are prioritized in allocation decisions.9 These policy shifts underscore systemic complexities—regional practice variation and legal challenges to allocation rules—that patient-level registry data alone cannot fully capture. Therefore, navigating these political, legal, and social frameworks becomes a multidisciplinary challenge. To truly improve the future of LT, we must go beyond a solely surgical perspective and involve a broader coalition of public health, legal, and clinical experts to tackle the multifaceted barriers to care. The analysis presented by Mal et al confirms that the “emergency” label no longer mandates a poor outcome. By leveraging awake extracorporeal membrane oxygenation and improved patient selection, the French transplant community has reinforced that it is possible to honor the principle of urgency without sacrificing long-term utility. As we move forward, in France and globally, the focus must shift from merely achieving survival to reducing the high postoperative morbidity that still characterizes the high-acuity recipient’s journey and addressing the ongoing equity challenge in access to LT. Just as issues with the LAS system prompted the adoption of the CAS system in the United States, we predict that the HELT system in France will inevitably reveal programmatic and systemic problems that require addressing. The only way to address these issues is to collect and analyze data, as Mal et al have done so eloquently. As a transplant community, we look forward to seeing the French LT system evolve.