Decision Analytics Journal 3 (2022) 100058

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Decision Analytics Journal

journal homepage: www.elsevier.com/locate/dajour

An explanatory analytics model for identifying factors indicative of long-

versus short-term survival after lung transplantation
Mostafa Amini a , Ali Bagheri a , Dursun Delen a,b ,∗
a Department of Management Science and Information Systems, Spears School of Business, Oklahoma State University, Stillwater, OK, USA
b
Faculty of Engineering and Natural Sciences, Istinye University, Istanbul, Turkey

ARTICLE INFO ABSTRACT

Keywords: Due to the shortage of available organs compared to the number of patients on waitlists, the organ allocation
Lung transplantation process has always been challenging and calls for an equitable and optimized allocation system. This system
Long-term survival demands minimizing the waitlist mortality and improving transplantation benefits (e.g., survival time and
Organ allocation
quality of life). According to prior research, lung recipients’ long-term survival time is lower than other solid
Machine learning
organs recipients. This paper proposes and implements an explanatory analytics framework to study the most
Random forest
Shapley additive explanations
prominent factors contributing to long-term survival after lung transplantation. We collect data from the United
Network for Organ Sharing registry database. It contains more than 44 thousand unique patients undergoing
lung transplantation in the US since 1987. In our proposed framework, we first employ several machine
learning (ML) algorithms for classification and choose the best-performing one for further analysis of factors.
Then, we utilize a state-of-the-art explainable artificial intelligence method with the chosen ML algorithm for
the model explanation and interpretation. The proposed framework lists the most critical factors influencing
long-term survival after lung transplantation and their corresponding importance measures. For instance, our
results suggest that Hepatitis B surface antibody (HBV_SURF) and forced expiratory volume in one second
(FEV1) are among the important factors but have not been well examined by lung transplant researchers. Our
framework is also able to provide the main contributing factors for each patient individually. Medical scholars
and practitioners can use our findings for further analysis and improvement of the lung allocation system.

1. Introduction Procurement and Transplantation Network (OPTN), in May 2005, lung

Lung transplantation (LTx) is a life-saving therapeutic option for
patients suffering from end-stage pulmonary disease unresponsive to
other medical or surgical treatments. More than seventy thousand LTx
procedures have been reported to the International Society for Heart
and Lung Transplantation (ISHLT), since its inception, through 260
lung transplant centers and 184 centers that perform both heart and
lung transplants worldwide [1]. The biggest managerial challenge with
LTx is handling the imbalance between the demand for lungs and the
number of available ones. In the US, according to Health Resources &
Services Administration (HRSA) [2], in 2020, 3521 candidates were on
the waiting list while 2539 organs were available for LTx.
The widening gap between the number of people waiting for LTx
and the number of available organs calls for an equitable and optimized
organ allocation to decrease the waiting list mortality while improving
LTx benefits (e.g., survival time and quality of life). In the US, prior
to the implementation of lung allocation score (LAS) by the Organ
allocation was based on the accumulated waitlist time, regardless of the
severity of patients’ condition, leading to higher waitlist mortalities and
lower survival benefits (wasting the scarce donor organs). Currently,
lungs are allocated to adult US patients (12 years or older) based on
age, geographical location, blood type compatibility, LAS score, and
waiting time (if necessary). LAS score is an adjusted estimate, scaled
from 0 to 100, representing each candidate’s survival on the waiting
list (transplant urgency) and his or her 1-year survival if a transplant
is performed (transplant benefit) [3].
Due to the growing worldwide experience of LTx and recent im-
provements in lung allocation policies, operative techniques, and post-
operative care of organ recipients, the survival rate of patients under-
going LTx has been improving during the past three decades with a
median survival of 4.2 years in the 1990–1998 period compared to
6.1 years in the 1999–2008 period [4]. However, the long-term survival
of lung recipients remains relatively low in comparison with other solid
organ transplants, such as kidney, liver, heart, and pancreas [5], with

∗ Corresponding author.
E-mail addresses: moamini@okstate.edu (M. Amini), ali.bagheri@okstate.edu (A. Bagheri), dursun.delen@okstate.edu, dursun.delen@istinye.edu.tr
(D. Delen).
URL: http://spears.okstate.edu/delen (D. Delen).

https://doi.org/10.1016/j.dajour.2022.100058
Received 5 April 2022; Received in revised form 21 April 2022; Accepted 25 April 2022
Available online 3 May 2022
2772-6622/© 2022 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
M. Amini, A. Bagheri and D. Delen Decision Analytics Journal 3 (2022) 100058

a median survival of 5.8 years and 5- and 10-year survival rates of

54% and 32% [6]. In the US, although LAS implementation has led to
irrefutable advancements in lung allocation and LTx outcomes, critics
argue that the 1-year survival factor in the LAS calculation is not a
reliable marker for lung-term transplant benefits. Accordingly, OPTN
considers continuous refinement of the LAS calculation method as more
LTx procedures are performed, and more outcome data is gathered [7].
To this end, studying a specific group of patients with prolonged
survival will increase the understanding of the most important factors
that influence the long-term LTx benefits. With this objective in mind,
in this research, we use a feature-rich dataset containing factors related
to both the recipient and the donor as well as the transplant procedure
to identify the most important factors contributing to long-term LTx
survival.

2. Background and literature review

Due to the primary focus of OPTN on 1-year survival in calculating

LAS, the majority of prior research on post LTx survival concentrated
on investigating risk factors affecting short-term survival (<= 1 year)
and, hence, variables associated with long-term survival (>= 10 years)
are not well explored. The previous studies of long-term LTx survival
analysis have mostly utilized descriptive analytics [8] and traditional
statistical methods of survival analysis, such as Kaplan–Meier [9] and
Cox proportional hazards models [10], to estimate long-term survival
rates and to explain the significance of variables in improving survival.
These studies have been limited to a specific cohort of deceased pa-
tients [11], transplant centers [12], post LTx health condition [13],
or transplant type [14]. Few studies employed other techniques as
well as more comprehensive and inclusive datasets. Weiss et al. [15]
utilized Logistic Regression (LR) to identify factors differentiating long-
term versus intermediate-term LTx survival (defined as greater than
10 years and 1 to 5 years, respectively). Jawitz et al. [16] used LR
model and sensitivity analysis to compare factors associated with LTx
survival greater than 10 years. However, common shortcomings of
the above-mentioned research are: (1) the number of variables under
study is limited, (2) variables are selected based on the experiences
and intuitions of the analysts, and (3) traditional statistical approaches
make specific assumptions on the distribution of the variables as well
as the linearity of models, which affect their prediction power and
interpretability [17].
As successful alternatives, machine learning (ML) techniques have
attracted more and more attention from scholars in the healthcare
analytics field during the past decade [18]. These techniques, without
any prior knowledge or assumption on data, can handle much larger
sets of variables and provide even more accurate predictions compared
to classical methods. Despite a growing trend in ML applications in
organ transplant survival analysis [19,20], these studies are rare for
LTx survival [21]. Oztekin et al. [22] studied patients who survived
9 years after combined lung–heart transplantation. They proposed an
integrated data mining methodology including ML and Cox hazard
models to investigate factors contributing to the long-term survival
rate. In another study, Delen et al. [23] used ML models and sensitivity
analysis for variable selection and then developed a Cox model for
lung–heart transplant survival. Additionally, using a k-mean clustering
algorithm, they identified three risk groups of patients for further in-
depth analysis. However, to the best of our knowledge, there is no
applied ML study investigating solely long-term survivability after LTx.
Besides, [22,23] lack utilizing state-of-the-art methods for model expla-
nation and interpretation. Explainable artificial intelligence (XAI), as a
rapidly developing field of research, has recently shown considerable
advances in understanding and interpreting black-box ML models [24]
and has increasingly been used in the healthcare analytics field [25,26],
but rarely in organ transplantation research [27,28].
Considering the mentioned gap in the literature, in this paper, we
propose an exploratory analytics framework including ML methods
Fig. 1. Proposed analytic framework.
to investigate the most important variables influencing the long-term
survival of patients undergoing LTx. Due to the recent critiques about
the black-box nature of ML methods and their lack of interpretability,
we take advantage of a novel XAI method to explain the importance of
risk factors. The rest of this paper is organized as follows. In Section 3,
we describe the data and methodology. In Section 4, the results are
represented and discussed. Finally, we conclude this paper in Section 5.
3. Materials and methods
In this paper, we adopted a hybrid analytic approach consisting of
a predictive phase and an explanation phase to discover significant
factors participating in patients’ survival after LTx. We employed the
prediction power of ML models for classification in the first phase.
Then, we leveraged the most advanced explainable AI technique, the
SHapley Additive exPlanations (SHAP) algorithm, to explain the best
predictions from the first phase. Fig. 1 represents the framework we
adopted for this paper.
3.1. Data acquisition and preparation
Following the formal data requisition procedures, we accessed the
data from United Network for Organ Sharing (UNOS), a ‘‘mission-
driven non-profit serving as the nation’s transplant system under con-
tract with the federal government’’ [29]. The datasets included in-
formation on all waiting list registrations and transplants, listed or
performed in the US from 1987 until July 2021 (our request date)
from deceased and living donor transplants. The lung-related data
included 44,931 records of unique patients that had gone through
a lung transplant, each with 512 variables. These variables included
clinical and demographic factors related to donors, recipients, and the
transplant procedure. The patients and hospitals had been de-identified
for research purposes and to address privacy and security issues. Fig. 2
represents the demographic information of the dataset we obtained.

2
M. Amini, A. Bagheri and D. Delen
Fig. 2. Demographic information of the data (age, ethnicity, gender).
The primary objective of this study was to leverage predictive
models and explainable AI techniques to discover the impactful factors
for a patient’s lung transplant’s prolonged survival. We recognized two
post-operative variables that could be used towards finding candidate
outcomes. These variables are pstatus, a binary variable that represents
whether the patient has survived at the last follow-up time (0 if living),
and ptime, a continuous variable, that denotes the time frame from
transplant until last follow-up or death. See Fig. 2 for ptime distribution
in the dataset for lung transplants when the patient is dead (pstatus =
1).
We excluded organ transplantations of non-adult patients (less than
18 years of age) and the patients whose death was not related to the
lung (using the variable COD, defined as the cause of death). Following
UNOS recommendations, to avoid overestimating patients with short
survival time, we also cut off the records with transplant dates within
14 months of the data acquisition. Next, we removed patients with
missing ptime because we could not determine their survival time.
Abiding by the cleaning steps in [30], we then omitted the intra-
and postoperative factors since our research was to address the factors
before the operation. Next, we cleaned all invalid and duplicated
records. We eliminated variables that would not have any predictive
power (e.g., IDs and codes) and variables with little change in the entire
dataset (e.g., constants for more than 95% of the data). To address
missing values, we first distinguished various missing patterns in the
dataset using the variable definitions and handled them accordingly
via removal, imputation, or recoding. We ended up having 37,580
patient records and 171 variables in the dataset. Unlike previous stud-
ies [22,31,32] we removed only variables with many missing (more
than 70%), thereby providing a more comprehensive approach while
using state-of-the-art ML and explainable AI techniques.
From Fig. 3, 27% of patients survive one year or less, whereas 14%
survive ten years or more. The data is derived based on the reported
deaths. However, the number of patients that outlive ten years needs
to be adjusted, whereas living patients should also be considered in
this category. This approach has been previously used in [25]. This
way, we carried about a quarter of the data in the long survival
category (i.e., >= 10 years). Fig. 4 shows the frequency and cumulative
percentage of the adjusted long survival category compared with other
categories. For identifying factors indicative of long- versus short-term
survival after LTx, we finally chose two categories of short term (<=
1 year) and long term (>= 10 years) for our classification. These time
thresholds were commonly suggested by LTx scholars for short- and
long-term survival [15,16]. These categories involved 13,080 patients
(9,864 records after cleaning).
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Decision Analytics Journal 3 (2022) 100058
3.2. Prediction models
In the first phase of our analysis, we were to build the most accurate
model for classifying patients with respect to their survival time after
the transplant. The model would then be used as an input for the
explanation phase.
To select the predictive models, we speculated that tree-based mod-
els, such as gradient boosted trees (GBT) and Random Forests (RF),
would outperform others because most of the variables were either
categorical or binary. However, former studies proved the strength
of number-based models such as logistic regression (LR), K nearest
neighbors (KNN), support vector machines (SVM), and artificial neural
networks (ANN). As a result, we tried models from both groups. We
also included a decision tree (DT) to evaluate and foolproof the results
of tree-based models. We found no fallible split in trees or any sign of
cheating variables.
To enhance the predictive performance measures, we fine-tuned
the hyperparameters of the models. For example, in the case of RF
(our winning model), we tried numerous split criteria (information
gain, information gain ratio, and Gini index) for the decision trees. We
increased the number of trees gradually to achieve the best performing
configuration.
In addition, to use the data efficiently and prevent our models
from overfitting the training dataset or choosing a specific test set, we
conducted k-fold cross-validation (with 𝑘 = 10) for all the predictive
models. This way, we improved the generalization capabilities of the
models.
3.3. Explanation models
In general, the need for model explanation is two-fold. First, we
need to comprehend what variables are used for classification judgment
in the black box of advanced algorithms to certify their legitimacy. A
machine may solely learn the characteristics of the dataset and produce
accurate predictions that have nothing to do with desired patterns
in the data. In this case, the explanation phase tells us whether the
variables used are both meaningful and relevant. Second, to be effective
for practitioners and end-users, we need an explanation model to return
the most prominent variables and their importance, especially when
working with a feature-rich dataset [33]. So, in the second phase of
our study, we were required to explain the predictions drawn from the
previous step.
Recently, many scholars in data analytics research have dedicated
their research to the explanation aspect. Consequently, a variety of
approaches, such as LIME [33], DeepLIFT [34], Layer-Wise Relevance
M. Amini, A. Bagheri and D. Delen
Fig. 3. Yearly ptime distribution after LTx (pstatus = 1).
Fig. 4. Yearly ptime distribution after LTx with adjusted >= 10 category.
Propagation [35], Shapley regression values [36], Shapley sampling
values [37], and Quantitative Input Influence [38] have been developed
(for detailed discussion and review on explanation methods see [24,
39]).
In this vein, Lundberg and Lee [40] proposed a unified framework
for interpreting black-box predictions by assigning each feature an
importance value, called the ‘SHapley Additive exPlanations’ (SHAP)
value. SHAP values are defined as the sequential impact of each fea-
ture’s value on the model’s output, averaged over all possible orders by
which features are added to the model. Due to the complexity of the
problem, SHAP values can only be approximated. However, Lundberg
et al. [41] suggested computing precise values for a prediction when
working with tree-based machine learning algorithms for instance.
Given an instance x and the feature set 𝐹 , SHAP algorithm computes
the marginal contribution of the feature 𝑖 in the performance of the
provided prediction model compared to all subsets of 𝐹 conditioning
on (with or without) feature 𝑖 (Eq. (1)).
∑ 𝑃𝑆 (𝑥) − 𝑃𝑆−𝑖 (𝑥)
𝑆𝐻𝐴𝑃𝑖 (𝑥) = ( ) ,
𝑆⊆𝐹 ,𝑖∈𝑆 |𝐹 |
|𝑆|
|𝑆|
where, 𝑆 is any subset of features, 𝑃𝑆 (𝑥) denotes predicted outcome by
a model trained with subset 𝑆 for instance 𝑥, and | ⋅ | indicates the size
of a set.
The strength of these SHAP values is that they are locally accurate,
that is, for each instance, prediction is an aggregation of an additive set
of marginal contributions. In our study, the short versus long survival
of each patient with a LTx is collectively determined by a set of
values for each feature that helps us understand that instance prediction
accurately.
Decision Analytics Journal 3 (2022) 100058
In this phase of our study, we employed SHAP to shed light on the
black box of our best performing predictive model and interpret which
factors play a critical role in prediction.
4. Results
Our analysis included two phases to understand the critical fac-
tors of short- versus long-term survival in LTx, i.e., predictive models
and model explanation. We explain the results of these phases in the
following sections.
4.1. Predictive models
The objective of this phase was to discover a model with the
most robust predictions. As we mentioned before, due to the superior
capability of tree-based models in handling categorical variables, we
surmised that such models would be a better fit. However, the literature
brought a few number-based methods to our consideration. We tuned
(1) the hyperparameters and tested models in both categories to keep
an open mind and approach. Table 1 represents the performance of
these algorithms. Although LR, among the number-based algorithms,
has comparable performance to tree-based models, we still can see the
superiority of tree-based models, most significantly RF.
We compared four evaluation metrics of performance to conclude
our best model. These metrics are accuracy, sensitivity, specificity, and
area under ROC curve (AUC). A model must excel in all these metrics in
classification problems, where only one decent metric (e.g., specificity
of SVM) cannot be a determining criterion. It is evident from the results
that RF is the best model where it outperforms all others in almost all
metrics.
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M. Amini, A. Bagheri and D. Delen
Table 1
Predictive models’ performance.
Fig. 5. Top twenty features ranking and importance.
4.2. Model explanation
We utilized the SHAP algorithm [41] to achieve the explanation
phase objectives in the final step. First, to ensure that the predictive
models relied on meaningful and relevant patterns and features; next,
to investigate the most relevant factors among the selected features and
their criticality level for long-term survival. Given the promising result
of RF from the previous phase (between 75%–80% for all the evaluation
metrics), we applied RF as the base model in the SHAP algorithm. We
calculated SHAP values in each fold in a 10-fold cross-validation setting
with RF. Then, we took the average of SHAP values for each variable.
Fig. 5 presents the ranking of the top twenty features and their
averaged importance. Table 2 shows the top selected variables by SHAP
and their definitions. We do not see any irrelevant data or judgment by
the predictive models from this table. Next, we explain the variables in
Table 2.
Some of the variables in Table 2 have already been studied in-
dividually or with a few other factors using traditional methods in
prior research and shown to be significant predictors for long-term LTx
survival. Mabilangan et al. [42] and Kurihara et al. [43] evaluated the
impact of Cytomegalovirus (CMV_IGG) infection status of lung donors
and recipients on long-term survival after LTx and found it a significant
risk factor. Lehr et al. [44] showed that the extremes of age (AGE)
decrease the long-term survival in adults after LTx. Kanask et al. [45]
indicated that organ recipients who were obese (WGT_KG_CALC) had a
shorter survival time after LTx. Banga et al. [46] found serum albumin
(TOT_SERUM_ALBUM) as a predictor for prolonged hospital length
of stay after LTx, which is shown to be associated with long-term
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Decision Analytics Journal 3 (2022) 100058
survival. Doricic et al. [47] used serum creatinine (END_CREAT) and
other clinical factors to predict the long-term mortality after LTx. Singer
et al. [48] investigated the impact of pretransplant ventilation support
(VENT_SUPPORT_AFTER_LIST) on short- and long-term survival after
LTx. Jawitz et al. [16] found donor age (AGE_DON) and total bilirubin
(TBILI) as differentiators between short- and long-term survival after
LTx. Yu et al. [14], by a metanalysis of prior research, studied the trans-
plant type (TX_TYPE) and concluded that bilateral LTx is associated
with longer survival time.
This existing literature, among others, demonstrates the effective-
ness of our holistic and advanced study of the donor, recipient, and
LTx procedure characteristics. Our findings can shed light on other im-
portant predictors that have not been investigated by medical scholars
for long-term LTx survival. For instance, Dhillon et al. [49] studied the
impact of Hepatitis B surface antibody (HBV_SURF_TOTAL) on one-year
thoracic transplant survival. Doershuk et al. [50] evaluated the rela-
tionship between forced expiratory volume in one second (FEV1_TRR)
and LTx timing and short-term survival.
Notice here that we omitted the LAS score from our variable’s list
so that it does not affect the variable importance measures. According
to the LAS calculation method [29], some variables used in LAS calcu-
lation are in our top 20 variable list. The presence of variables such as
AGE, WGT_KG_CALC, TBILI, FUNC_STAT_TRR, END_CREAT, BMI_CALC
in our ranking list is an additional demonstration of the effectiveness
of our exploratory analysis. Therefore, our findings can be utilized as a
preliminary study for advanced medical research to improve LAS score
calculation and organ allocation continuously.
M. Amini, A. Bagheri and D. Delen Decision Analytics Journal 3 (2022) 100058

Table 2 transplant, and other characteristics. With the advantage of the SHAP
List of top 20 features and their definitions.
algorithm, our proposed approach can picture how these features can
Variable Definition impact the longevity of this patient. Fig. 6 illustrates contributing
CMV_IGG Recipient CMV by IDD test result at transplant features that push the model output from the base value (the average
HBV_SURF_TOTAL Recipient HBV surface antibody total at transplant model output over the training dataset) to the ‘‘high’’ survival time
AGE Recipient age (year) or ‘‘low’’. Features driving the survival time prediction to ‘‘high’’ are
WGT_KG_CALC Calculated recipient weight (kg) shown in red; those pushing the prediction to ‘‘low’’ are blue.
MED_COND_TRR Recipient medical condition pre-transplant at In this example, for a specific patient, in addition to the model
transplant output (short or long survival), the generated SHAP values clarify
BUN_DON Deceased donor terminal blood urea nitrogen which factors are prominent and what their impact is on the model
TOT_SERUM_ALBUM Patient total serum Albumin at registration output, thereby increasing the trust in the model. Also, SHAP values
allow the physicians to reevaluate the situation for each patient. In the
FUNC_STAT_TRR Recipient functional status at transplant
case of short-time survivability (our example), the transplant should be
DAYSWAIT_CHRON Total days on waiting list
reconsidered, or the conditions should be compared to other patients on
VENT_SUPPORT_AFTER_LIST Events occurring between listing and transplant:
the waitlist. Although, in general, we suggest organ allocation to those
episode of ventilatory support
patients with high survivability, SHAP values for each patient can help
FEV1_TRR Pulmonary status: FEV1% predicted at transplant
compare patients even in the same class.
END_CREAT Serum Creatinine at
Another benefit of SHAP values for each individual is the ability
transplant/offer/removal/current time (HL, LU
only) to provide patients with recommendations. For example, if a patient’s
AGE_DON Donor age (year)
weight is striking his survivability, the doctor can give practical advice
or postpone the transplant. Finally, in the case of any discrepancies
BMI_CALC Calculated candidate BMI
or underlying conditions, the doctors can reject or adjust the model’s
BRONCHO_RT_DON DDR right lung bronchoscopy
output by looking at the individual SHAP values.
PROTEIN_URINE Deceased donor protein in urine
TX_TYPE Type of transplant 5. Summary and conclusion
WGT_KG_DON_CALC Calculated donor weight (kg)
TBILI Most recent serum total Bilirubin at transplant In this paper, we studied factors indicative of patients’ long- versus
TX_PROCEDUR_TY Recipient procedure type short-term survival after LTx by proposing an explanatory analytics
framework. We collected a comprehensive dataset of LTx operations
from the United Network for Organ Sharing (UNOS) registry database,
including recipient, donor, and LTx procedure characteristics. Based
on the survival time of lung recipients, we defined two categories of
patients representing short- and long-term survival after LTx. After
going through a comprehensive data cleaning and preprocessing in the
proposed framework, we trained and tested various ML algorithms to
find the best predictive one for our binary classification problem and
preprocessed data in hand. We found RF as the one with the best
predictive performance and chose it for further analysis. In the next
step, to interpret and explain the predictions, we employed a novel
explainable AI method accompanied by RF to understand the most
critical factors affecting the long-term survival after LTx. As a result,
our proposed framework provided a list of the top 20 important factors
and their corresponding importance measures. Policymakers can use
our findings in improving the lung allocation system. In addition, our
framework can predict and explain the individual long-term survival
of LTx candidates and can be utilized as a recommendation system for
organ matching and allocation.
One limitation of this study is that the data is limited to only US
Fig. 6. SHAP values for an individual patient. LTx patients. Although we believe that our data set is large enough to
obtain robust results, our framework and results could be validated by
scholars who have access to larger organ transplant registries’ data like
ISHLT.
We also did not have access to the patients’ medical history and
4.3. Individual explanation
underlying condition before the transplant. This variable and others
such as gender and race could be controlled for in future studies.
In healthcare analytics, it is crucial to investigate the process of
any decision support system for an individual patient. This way, the Moreover, each of the top variables in Table 2 calls for a more focused
performance of advanced algorithms can help physicians by providing investigation through statistical and causal models.
the main contributing factors for each patient. In addition, physicians Finally, from a broader perspective, LTx has brought patients hope
can enforce necessary adjustments based on the patient’s underlying for prolonged survival and enhanced health-related quality of life
conditions. SHAP algorithm is an appropriate tool in this regard. On (HRQoL). Although these hopes come true for many patients, some
the one hand, it provides a holistic picture of the major risk factors die earlier than they would have without LTx and a considerable
and their relative importance (Fig. 5). On the other hand, it delivers an proportion of lung recipients face comorbidities and adverse health
individual-level analysis of the features and their contribution to each events. Hence, survival analysis alone cannot provide an adequate
patient’s probability of an outcome. measure of the level of success or failure of LTx, and studying the
Consider a patient in his fifties with positive HBV and CMV, who HRQoL of lung recipients is an essential task. Previous studies on
is above the average weight, has poor functionality at the time of HRQoL after LTx often relied on survey data from living and well

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M. Amini, A. Bagheri and D. Delen
enough lung recipients. The major limitation of these studies is that the
data are not missing at random [51]. Thus, one interesting direction of
research is assessing the contributing factors to HRQoL after LTx using
transplant registries’ follow-up data and ML/AL methods.
Declaration of competing interest
The authors declare that they have no known competing finan-
cial interests or personal relationships that could have appeared to
influence the work reported in this paper.
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