Waiting time, access rate, survival after transplant: the lung transplant journey is characterized by significant differences between men and women. Disadvantaged in the stages preceding the transplant, women have a better survival rate afterwards.
These observations are taken from a study carried out in France and published in European Respiratory Journal Open Research. The analysis focused on 1,710 participants – 802 women and 908 men – treated in one of 12 French transplant centers between 2009 and 2018 and followed for approximately six years after transplantation. The main underlying pathologies were chronic obstructive pulmonary disease (COPD), cystic fibrosis and diffuse interstitial lung disease.
Six more weeks on waiting list for women
The analysis shows that women spend on average six weeks longer on the waiting list for a lung transplant than men (115 days compared to 73 days). Two causes can explain this discrepancy. In women, anti-HLA antibodies, which can develop during pregnancy, are more common. The presence of these antibodies, known to be responsible for hyperacute rejections, limits the choice of donor. “We avoid choosing a donor to whom the antibodies will attack”specifies at Daily Dr Adrien Tissot, pulmonologist at Nantes University Hospital and first author of the study.
Another cause is a size gap between the sexes: women are on average 13 cm shorter than men. The latter, the majority (56%) among donors, have a larger lung volume and this difference counts in the matching of grafts. “The mismatch between the size of donors and that of recipients leads to a longer waiting time for seconds”, underlines Dr Tissot.
Lung recipients “oversized” however, do not have worse results after transplantation. “Making cuts in the lung, removing lobes or parts of a lobe, results in a longer operating time and an increased risk for patients, but the intervention does not translate into a difference in survival in women with a reduced graft compared to others »insists Dr Tissot.
The study also shows that women have less access to a lung transplant than men (91.6% versus 95.6%). Previous research had already shown that they were more likely to die on the waiting list. But on this aspect, the study was unable to determine the reasons for exclusion from the list (death, deterioration incompatible with a transplant, etc.).
A difference in 5-year survival, especially marked in COPD
Another lesson, after transplantation, 5-year survival was higher in women than in men (70% versus 61%). This gap in favor of women “is observed mainly for patients with COPD, the difference being less marked for other pathologiesnotes Dr Tissot. This point is interesting because COPD is a behavioral disease, linked to smoking”. While the causes of better survival in women remain to be determined, specific work is underway on the COPD patient population.
To remedy inequalities, several avenues are possible. Women who have anti-HLA antibodies and/or small lung volumes may be placed on waiting lists earlier. “This would prevent them from deteriorating and not being transplanted,” believes Dr Tissot. At the level of transplant centers, surgical teams could also be encouraged to make more systematic volume reductions. At the national level, a reflection on the modalities of allocation of grafts must be carried out, also recommends the pulmonologist.
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