We thank Dr. Egan for his interest in our publication (1) and for his endorsement of the German experience with the Lung Allocation Score (LAS). He pioneered the important concept of transplant benefit in donor lung allocation within the US, balancing the patient mortality risk after transplantation against that of remaining on the wait list. Translating this into clinical practice required great courage in 2005, given the fundamental shift needed to prioritize outcome benefit rather than current clinical need. The results remain unequivocal, demonstrating improved wait list mortality and transplant outcomes subsequently in the US (2).

Germany adopted the LAS in 2011, with the Netherlands following in 2014, primarily for national allocation in contrast to the primarily local allocation in the US. From the outset both countries have introduced special business rules, adapted to the needs specific to the European population. One of the reasons was that the LAS does not factor in the need for extracorporeal life support (ECLS). In the 5 years that the LAS has been in operation in Germany, more than a dozen special rules have been designed and introduced to provide clarity to physicians and allow parity among candidates.

On February 19th, 2015 the US adopted a modified LAS, entailing adjustments in of some existing coefficients, alongside introducing new parameters such as cardiac index, bilirubin and creatinine. The European countries await with anticipation the upcoming publications outlining experience and the impact of these amendments.

We agree wholeheartedly with Dr. Egan that the European model needs to be kept current by analyzing waitlist outcomes and survival after transplantation in Europe as well as additional parameters continuously. We firmly believe that data quality is of extreme importance to avoid “garbage in, garbage out” in statistical modeling (3). Eurotransplant has introduced practical business rules for oxygen titration to minimize this problem and national audits in Germany have improved data quality since their introduction in 2014.

DOI: 10.3238/arztebl.2017.0543b

On behalf of the authors

Prof. Dr. med. Jens Gottlieb

Medizinische Hochschule Hannover, Biomedical Research in Endstage
and Obstructive Lung Disease Hannover (BREATH), Mitglied des Deutschen Forschungszentrums für Lungenforschung
Gottlieb.Jens@mh-hannover.de

Jacqueline Smits, MD, PhD

Eurotransplant International Foundation, Leiden, Niederlande

Conflict of interest statement
The authors of both contributions declare that no conflict of interest exists.

1.
Gottlieb J, Smits J, Schramm R, et al.: Lung transplantation in Germany since the introduction of the Lung Allocation Score—
a retrospective analysis. Dtsch Arztebl Int 2017; 114: 179–85 VOLLTEXT
2.
Egan TM, Edwards LB: Effect of the lung allocation score on lung transplantation in the United States. J Heart Lung Transplant. 2016; 35: 433–9 CrossRef MEDLINE
3.
N.N.: Work with new electronic ‘brains’ opens field for army math experts. The Hammond Times 1957; 65 (retrieved on 20 March 2016 via Newspapers.com).
1.Gottlieb J, Smits J, Schramm R, et al.: Lung transplantation in Germany since the introduction of the Lung Allocation Score—
a retrospective analysis. Dtsch Arztebl Int 2017; 114: 179–85 VOLLTEXT
2. Egan TM, Edwards LB: Effect of the lung allocation score on lung transplantation in the United States. J Heart Lung Transplant. 2016; 35: 433–9 CrossRef MEDLINE
3. N.N.: Work with new electronic ‘brains’ opens field for army math experts. The Hammond Times 1957; 65 (retrieved on 20 March 2016 via Newspapers.com).

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