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Impact of Composite Allocation Score on Outcomes of Lung Transplantation for Candidates with Pulmonary Arterial Hypertension
Abstract   Peer reviewed

Impact of Composite Allocation Score on Outcomes of Lung Transplantation for Candidates with Pulmonary Arterial Hypertension

P.D. Cho, S. McKay, J. White, H. Zappacosta, J. Song, A. Abramov, M. Daniel, M. Husain and A. Ardehali
The Journal of heart and lung transplantation, v 45(5), pp 501-501
Apr 2026
DOI: https://doi.org/10.1016/j.healun.2026.02.1082

Abstract

Purpose: In March 2023, the lung allocation policy was revised to improve organ access for all lung transplant candidates. We sought to evaluate whether the Composite Allocation Score (CAS) system impacted candidates with Pulmonary Arterial Hypertension (PAH). Methods: We included all adult, isolated lung transplant candidates listed from May 2021 to December 2024. Patients were divided into the four diagnostic groups (A: chronic obstructive pulmonary disease; B: PAH; C: cystic fibrosis; D: interstitial lung disease). Waitlist mortality and transplant rates (Tx) within 6 months of listing were compared among the groups before and after implementation of CAS using multivariable competing risk regression. Post-transplant outcomes were assessed. Results: A total of 12,531 candidates were listed for lung transplantation during the study period, with 6.14% (n=769) being in Group B. Groups A, C, and D had lower waitlist mortality and higher Tx rates following CAS implementation (p<0.05). while group B had no significant change in waitlist mortality (adjusted sub-hazard ratio (aSHR): 1.07, 95% confidence interval (CI): 0.62-1.86, p=0.81) and Tx rate (aSHR: 1.17, 95% CI: 0.96-1.42, p=0.13). Under the LAS system, group B had higher waitlist mortality compared to A (A vs B aSHR: 0.31, 95% CI: 0.16-0.62, p<0.001), but not significantly different compared to groups C and D (p>0.05). However, following CAS policy implementation, candidates of group B had the highest waitlist mortality compared to groups A, C, and D (p<0.05)(Figure A). Further, group B had the least likelihood of transplantation (p<0.001)(Figure B). Following transplantation, recipients of group B in the CAS period experienced the highest in-hospital mortality (A: 3.2% B: 8.4% C: 5.0% D: 5.3%, p<0.001). Conclusion: Lung transplant candidates with PAH under CAS system had worse waitlist outcomes and higher short-term mortality post-transplant. Further revisions to the CAS policy may be needed to address this disparity.

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