Lung Transplantation in Patients With Chronic Obstructive Pulmonary Disease in a National Cohort Is Without Obvious Survival Benefit Knut Stavem, MD, PhD, a,b Øystein Bjørtuft, MD, PhD, c Ørnulf Borgan, PhD, d Odd Geiran, MD, PhD, e and Jacob Boe, MD, PhD, c Background: The objective in lung transplantation is to prolong life, but the survival effect in patients with chronic obstructive pulmonary disease (COPD) or 1-anti-trypsin deficiency emphysema is still unresolved. This study assesses the impact of diagnosis, single-lung transplantation (SLT) vs bilateral lung transplantation (BLT) and timing of transplantation on survival in a national cohort. Methods: In 219 consecutive patients accepted onto the lung transplantation waiting list in Norway, 1990 to 2003, we assessed predictors of death: (1) on the waiting list; (2) 90 days after transplantation; and (3) 90 days after transplantation. For each period we used Cox regression, including age, gender, diagnosis, baseline pulmonary function tests, cardiac catheterization data, exercise capacity and transplant type, as potential predictors. Survival benefit was assessed graphically by combining adjusted survival curves after transplantation with the curve for those waiting, modeling transplan- tation after 6, 12 or 24 months. Results: Mean patient age was 49 years (SD 10), with 55% women. High forced expiratory volume in 1 second (FEV 1 ) percentage predicted death on the waiting list. Diagnoses other than COPD/ emphysema and receiving SLT were associated with death 90 days after transplantation. Only low forced vital capacity (FVC) percentage predicted death 90 days after transplantation. In COPD/ emphysema, there was no clear survival benefit from BLT or SLT. For patients in the “Other” group, the data suggest a survival benefit from BLT. Conclusions: In COPD/emphysema, there was no obvious survival benefit from lung transplantation, which questions prolongation of life as the primary motivation for the procedure. J Heart Lung Transplant 2006; 25:75– 84. Copyright © 2006 by the International Society for Heart and Lung Transplantation. Lung transplantation is established as a therapeutic intervention in end-stage pulmonary disease. More than 17,000 lung transplantations have been performed worldwide. 1 One-year survival is between 70% and 80% both for single-lung transplantation (SLT) and bilateral lung transplantation (BLT), 1 and between 40% and 50% after 4 years. 1,2 Patients undergoing lung transplanta- tion have been shown to have improved lung func- tion 3,4 and a better health-related quality of life. 5–8 The rationale behind existing recommendations for timing of referral for lung transplantation is based on the objective of attaining a survival benefit from the procedure; that is, post-transplant survival should ex- ceed the expected survival without the procedure. 9 Some studies have reported survival benefit from the procedure, 10 particularly in patients with cystic fibrosis, idiopathic pulmonary fibrosis and primary pulmonary hypertension (PPH). 11–16 In cystic fibrosis, a survival benefit has been reported for both children 17 and adults. 11,13 In addition, a survival benefit of transplan- tation for emphysema has been shown in some stud- ies. 14,16 In contrast, other studies have failed to detect a survival benefit of the procedure in general, 18 in patients with cystic fibrosis, 12 and in end-stage emphy- sema. 11 The significance of these results is limited by uncer- tainties regarding the methodology 10 and the validity of several assumptions used in the analyses. 9 The different study populations had variations in composition and From the a Department of Medicine, Akershus University Hospital, Lørenskog, Norway; b Norwegian Health Services Research Centre, Lørenskog, Norway; c Department of Thoracic Medicine, Rikshospi- talet University Hospital, Oslo, Norway; d Department of Mathematics, University of Oslo, Oslo, Norway; and e Department of Cardiotho- racic Surgery, Rikshospitalet University Hospital, Oslo, Norway. Submitted December 9, 2004; revised June 21, 2005; accepted June 24, 2005. Reprint requests: Knut Stavem, MD, Department of Medicine, Akershus University Hospital, NO-1478 Lørenskog, Norway. Tele- phone: +47-67929453. Fax: +47-67902125. E-mail: knut.stavem@ klinmed.uio.no Copyright © 2006 by the International Society for Heart and Lung Transplantation. 1053-2498/06/$–see front matter. doi:10.1016/ j.healun.2005.06.025 75