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High Composite Allocation Score Predicts Worse Early Outcomes Following Lung Transplantation
Abstract   Peer reviewed

High Composite Allocation Score Predicts Worse Early Outcomes Following Lung Transplantation

P.D. Cho, J. Song, J. White, H. Zappacosta, S. McKay, A. Abramov, M. Daniel, M. Husain and A. Ardehali
The Journal of heart and lung transplantation, v 45(5), pp 154-154
Apr 2026
DOI: https://doi.org/10.1016/j.healun.2026.02.325

Abstract

Purpose: The Composite Allocation Score (CAS) was introduced in March 2023 to enhance efficiency in lung allocation. The purpose of this study was to assess whether higher CAS is associated with post-transplant outcomes. Methods: We performed a retrospective cohort study using the United Network for Organ Sharing database from March 2023 to December 2024. Isolated lung transplant recipients (age ≥ 12 years) were included. Patients were stratified as high CAS (≥40) and low CAS (<40) at the time of match. Outcomes of interest included extracorporeal membrane oxygenation (ECMO) support at 72 hours, in-hospital mortality, length of hospital stay, and 1-year survival. Kaplan Meier and multivariable Cox regression analyses were used to evaluate 1-year survival following transplantation. Results: A total of 5,795 lung transplant recipients were identified, with 18.1% (n=1,049) having high CAS. Those with high CAS were younger (median 60 vs 63 years, p<0.001), more likely to have restrictive lung disease (88.7% (n=930) vs 69.7% (n=3,308), p<0.001), and more often bridged with ECMO (37.8% (n=397) vs 0.8% (n=38), p<0.001). Donors to high CAS recipients were younger (median 33 vs 38 years, p<0.001), and procurement travel distance was greater (median 547 vs 392 miles, p<0.001). High CAS recipients had higher ECMO at 72 hours (20.8% (n=218) vs 8.7% (n=413), p<0.001), higher in-hospital mortality (8.4% (n=98) vs 4.4% (n=231), p<0.001), and longer hospital stay (median 26 vs 19 days, p<0.001). High CAS recipients experienced lower 1-year survival than those with low CAS (90.5% vs 94.8%, p<0.001)(Figure). Increasing CAS was independently associated with higher 1-year mortality (adjusted hazard ratio: 1.11 per 5-point rise, 95% confidence interval: 1.02-1.23, p=0.02). Conclusion: High CAS at the time of match is linked with inferior early outcomes post-transplant. These findings support targeted optimization of modifiable donor-recipient factors and perioperative management for high-CAS recipients.

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