Multiple Listing in Lung Transplant Candidates

A Cohort Study

Joshua J. Mooney; Lingyao Yang; Haley Hedlin; Paul Mohabir; Gundeep S. Dhillon


American Journal of Transplantation. 2019;19(4):1098-1108. 

In This Article

Abstract and Introduction


Lung transplant candidates can be waitlisted at more than one transplant center, a practice known as multiple listing. The factors associated with multiple listing and whether multiple listing modifies waitlist mortality or likelihood of lung transplant is unknown. US lung transplant waitlist candidates were identified as either single or multiple listed using data from the Scientific Registry of Transplant Recipients. Characteristics of single and multiple listed candidates were compared and multivariable logistic regression was used to estimate associations with multiple listing. Multiple listed candidates were matched to single listed candidates using a combination of exact and propensity score matching methods. Cox proportional hazard models were used to estimate the relationship of multiple listing on waitlist mortality and receiving a transplant. Multiple listing occurred in 2.3% of lung transplant waitlist candidates. Younger age, female gender, white race, short stature, high antibody sensitization, college or postcollege education, lower lung allocation score, and a cystic fibrosis diagnosis were independently associated with multiple listing. Multiple listing was associated with an increased likelihood of lung transplant (adjusted hazard ratio [aHR] 2.74, 95% CI 2.37 to 3.16) but was not associated with waitlist mortality (aHR 0.99, 95% CI 0.68 to 1.44).


Within the United States, lung transplant candidates receive priority for donor lungs according to their transplant center's location relative to the donor and by their lung allocation score (LAS), which reflects their medical urgency and expected transplant benefit.[1–3] The geographic location of a transplant center can influence a candidate's waitlist outcome as candidates listed at transplant centers in donor service areas with low local lung availability have higher waitlist mortality and lower transplant access.[4] Although recent changes to lung allocation policy have slightly broadened donor lung allocation priority from beyond the local donor service area, the geographic location of a candidate's transplant center relative to a lung donor remains a central component of prioritizing donor lung allocation.[3,5]

Transplant candidates within the United States are allowed by the Organ Procurement and Transplantation Network (OPTN) to register for transplantation at more than one transplant center, a practice known as multiple listing. Multiple listing at lung transplant centers in differing geographic locations can theoretically allow a candidate LAS-based prioritization to a greater number of donor lungs and thereby potentially modify waitlist mortality or likelihood of lung transplant. The factors associated with multiple listing and the effect of multiple listing on candidate waitlist outcomes have been assessed in other solid organ transplants.[6–10] White race, higher education level, and the presence of private insurance are associated with an increased likelihood of multiple listing within liver, kidney, and heart transplant candidates.[6,11] Moreover, these multiple listed kidney, liver, and heart transplant candidates have an increased likelihood of transplant compared to similar single center listed candidates, and multiple listed kidney and heart transplant candidates also have lower waitlist mortality.[6,11]

As multiple listing contributes to inequalities in the likelihood of transplant and waitlist mortality in other solid organ transplant candidates, we hypothesize that similar findings may be present within lung transplant candidates. In this study we sought to understand the lung transplant candidate factors associated with multiple listing and the relationship of multiple listing on lung transplant waitlist outcomes including waitlist mortality and likelihood of receiving a transplant. Better understanding of the impact of multiple listing within lung transplant can help inform policies that improve allocation equity for all lung transplant candidates.