Lung transplantation

Author : Steven Hays Associate Medical Director, Lung Transplantation University of California, San Francisco

2008-07-21

Lung Transplantion : Indications, Evaluation, Surgical and Medical Care

Lung transplantation is a relatively new therapy for persons with advanced lung disease. The most common diseases considered for lung transplantation include chronic obstructive pulmonary disease, cystic fibrosis, pulmonary fibrosis, and pulmonary hypertension. This procedure is usually considered the ultimate treatment after medical therapies for the underlying lung disease have been exhausted and the disease is having a significant impact on survival and quality of life. This article outlines the indications for, the surgical and medical aspects of, as well as the outcomes and potential complications of lung transplantation.

Introduction

Lung transplantation is a relatively new therapy for persons with advanced lung disease. The most common diseases considered for lung transplantation include chronic obstructive pulmonary disease, cystic fibrosis, pulmonary fibrosis, and pulmonary hypertension. This procedure is usually considered the ultimate treatment after medical therapies for the underlying lung disease have been exhausted and the disease is having a significant impact on survival and quality of life.

Although the first lung transplant was attempted in 1963, it was not until 1981 that the procedure was performed with long term success (1). In 1981, a heart and lung transplantation was performed as treatment for pulmonary hypertension (2). This was followed in 1983 by single lung transplantation for pulmonary fibrosis (3), and in 1986 by double lung transplantation for obstructive lung disease (4). These successes have led to enormous growth in lung transplantation and currently there are over 2000 lung and heart-lung transplants performed annually worldwide (5) (see table).

Who is a candidate for lung transplantation?

The diseases for which lung transplantation is an option span the spectrum of lung pathology. The most common diagnoses are:

• Chronic obstructive pulmonary disease
• Idiopathic pulmonary fibrosis
• Cystic fibrosis
• Idiopathic pulmonary arterial hypertension
• Eisenmenger syndrome
• Emphysema due to alpha-1 antitrypsin deficiency(5-8)

Other less common indications have included:

• Bronchiectasis
• Sarcoidosis
• Lymphangioleiomyomatosis (LAM)
• Pulmonary Langerhans cell histiocytosis

Persons with advanced lung disease may be considered for lung transplantation if they meet the following guidelines (8):

• Untreatable advanced lung disease of any origin
• Absence of other significant medical diseases
• Substantial limitation of daily activities
• Limited life expectancy, usually less than two years
• A patient who is able to walk and has rehabilitation potential
• Acceptable nutritional status
• Satisfactory psychosocial profile and emotional support system

The reason that lung transplantation is not an option for all persons with advanced lung disease is that it remains a complex surgical and medical therapy. The following lists are recommendations made by the International Society for Heart and Lung Transplantation to consider when evaluating a patient’s candidacy for lung transplantation.

Unacceptable Risks (8)

• Malignancy in the last two years, with the exception of cutaneous squamous and basal cell tumors (skin cancer)
• Untreatable advanced dysfunction of another major organ system (e.g., heart, liver, or kidney)
• Non-curable chronic extrapulmonary infection (infection outside the lungs) including chronic active viral hepatitis B, hepatitis C, and human immunodeficiency virus (HIV)
• Significant chest wall/spinal deformity
• Documented nonadherence or inability to follow through with medical therapy or office follow-up, or both
• Untreatable psychiatric or psychologic condition associated with the inability to cooperate or comply with medical therapy
• Absence of a consistent or reliable social support system
• Substance addiction (e.g., alcohol, tobacco, or narcotics) that is either active or was active within the last six months

Increased Risks (8)

• Age older than 65 years
• Critical or unstable clinical condition
• Severely limited functional status with poor rehabilitation potential.
• Colonization with highly resistant or highly virulent bacteria, fungi, or mycobacteria
• Severe obesity defined as a body mass index (BMI) exceeding 30 kg/m2
• Severe or symptomatic osteoporosis
• Mechanical ventilation

When should one be referred and listed for lung transplantation?

In general, a person should be referred for a lung transplantation evaluation based on functional status and life expectancy. A person who has persistent New York Heart Association (NYHA) class III or IV function, in other words becomes short of breath with minor amounts of exertion or who has an only an estimated 50% chance of surviving another two to three years should be referred for a transplant assessment (8) if there are no obvious unacceptable risks. Because the natural history of each lung disease differs, the multi-disciplinary transplant team determines the appropriate timing for placing a person on a waiting list based on the evaluation data and the following guidelines.

Chronic Obstructive Pulmonary Disease (COPD)

Referral of persons with COPD for transplantation evaluation should be considered for those who continue to deteriorate despite optimal medical therapy and smoking cessation. The timing of referral for this group is particularly complicated because while patients may be quite symptomatic, they may not have a poor estimated survival. Therefore the question of whether to offer lung transplantation primarily for a benefit in quality of life frequently arises. Fortunately more accurate predictors of survival have emerged to assist with the timing. The BODE index combines multiple factors that have been shown to predict a poor outcome for persons with COPD. The BODE index includes the body mass index (BMI), the degree of airflow obstruction (assessed by percent predicted FEV1, which is a measurement of lung function), the degree of dyspnea (shortness of breath) (assessed by the modified Medical Research Council [MMRC] dyspnea scale), and the exercise capacity (assessed by a six-minute walk distance). The index increases as BMI, FEV1, and distance walked decrease and as the MMRC dyspnea scale increases (9).

Figure 1. Representative CT scan image from a person with advanced COPD showing emphysematous changes and subpleural blebs. Photo courtesy of Brett Elicker, MD, UCSF.

In addition, the National Emphysema Treatment Trial study identified a high-risk group of patients with a median survival of about three years with medical therapy. These are patients with an FEV1 of less than 20% and either a DLCO (Diffusing capacity of the Lungs for Carbon Dioxide, which measures the extent to which oxygen passes from the air sacs of the lungs into the blood) of less than 20% or diffusely distributed emphysema (10).

Guidelines for Referral (8)

• BODE index exceeding 5

Guidelines for Transplantation Listing (8)

• Patients with a BODE index of 7 to 10 or at least 1 of the following:
• History of hospitalization for exacerbation associated with acute hypercapnia (a condition where there is too much carbon dioxide in the blood, a Pco2 exceeding 50 mm Hg)
• Pulmonary hypertension (high blood pressure in the arteries that supply the lungs) or cor pulmonale (a change in the right ventricle of the heart as a result of a breathing disorder), or both, despite oxygen therapy
• FEV1 of less than 20% and either DLCO of less than 20% or homogenous distribution of emphysema

Interstitial lung diseases

The natural history of the different interstitial lung diseases (diseases in the lung tissue) is variable. Nevertheless, because idiopathic pulmonary fibrosis (IPF) is the most common and carries the poorest prognosis, with a median survival of two and a half to three and a half years, guidelines have been established based primarily on studying predictors of survival for IPF. Persons with idiopathic pulmonary fibrosis have the highest mortality on the transplant waiting list (5), making early referral for this group imperative.
Serial measurement of pulmonary function provides important prognostic information for this group. Several studies have demonstrated that a fall in FVC (a measurement of lung function), or oxygen saturation/p (A–a) O2 is associated with a higher mortality (11, 12). These data suggest that a 10% or greater decrease in FVC during six months of follow-up identifies patients at significantly increased risk of mortality (11). In addition, measurement of exercise capacity is of value to estimate survival in these patients. Specifically, an oxygen saturation of less than 88% during a six-minute walk test indicates a high risk of mortality (13).

Figure 2. Representative CT scan image from a person with idiopathic pulmonary fibrosis. Photo courtesy of Brett Elicker, MD, UCSF.

Guideline for Referral (8)

• Histologic (thin slices of tissue studied under a microscope) or radiographic (x-ray) evidence of usual interstitial pneumonia (lung disease) irrespective of vital capacity
• Histologic evidence of fibrotic nonspecific interstitial pneumonia

Guideline for Transplantation Listing (8)

• Histologic or radiographic evidence of usual interstitial pneumonia and any of the following:
• A DLCO of less than 39% predicted
• A 10% or greater decrease in FVC during six months of follow-up
• A decrease in pulse oximetry below 88% during a six-minute walk test
• Honeycombing on high-resolution computed tomography (HRCT), (fibrosis score of greater than two)
• Histologic evidence of nonspecific interstitial pneumonia and any of the following:
• A DLCO of less than 35% predicted
• A 10% or greater decrease in FVC or 15% decrease in DLCO during six months of follow-up

 

Cystic Fibrosis and Bronchiectasis

We group these diseases together because the physiology is similar. However the recommendations have been derived from studies of patients with cystic fibrosis (an inherited, chronic disease of the lungs and digestive system) and extrapolated to those with bronchiectasis (an abnormal stretching and enlarging of the breathing passages caused by mucus blockage) because of their small numbers. Determining the appropriate timing for lung transplantation referral and listing for patients with cystic fibrosis has been difficult. The original recommendations were based on a study which showed that an FEV1 of less than 30% was a useful predictor of survival (14). However subsequent analyses have failed to identify a single reliable predictor. Defining predictors of mortality and their thresholds has been difficult because the course of the disease is highly variable between individuals with cystic fibrosis.

Figure 3. Representative CT scan image from a person with cystic fibrosis showing extensive bilateral cystic bronchiectasis. Photo courtesy of Brett Elicker, MD, UCSF.

In practice, referral to a transplant center should be considered when FEV1 decreases to about 30% of predicted, or when there is a rapid decline in FEV1 (15). Early referral is recommended for female patients younger than 20 years who deteriorate rapidly, and for those with severe pulmonary exacerbations requiring treatment in the intensive care unit (ICU) because of their poor prognosis (15, 16). The decision to list for transplantation will entail a comprehensive evaluation that takes into account several indicators of disease severity.
Guidelines for Referral (8)

• FEV1 below 30% or predicted or a rapid decline in FEV1 — in particular in young female patients
• Exacerbation of pulmonary disease requiring ICU stay
• Increasing frequency of exacerbations requiring antibiotic therapy
• Refractory and/or recurrent pneumothorax (collapsed lung)
• Recurrent coughing up of blood not controlled by non-surgical, minimally invasive procedures

Guideline for Transplantation (8)

• Oxygen-dependent respiratory failure
• Hypercapnia
• Pulmonary hypertension

Pulmonary hypertension

The predictors of poor survival for patients with pulmonary hypertension include measures of functional status, hemodynamics (blood flow), and response to therapy. New York Heart Association (NYHA) functional class III or IV and a decreased six-minute walk distance (of less than 1000 feet) are associated with a worse prognosis (17, 18). In addition, elevated mean right atrial pressure (greater than 12 mmHg), elevated mean pulmonary arterial pressure (greater than 85 mmHg) and decreased cardiac index (less than 2 liters/min/m2) also portend a worse prognosis(19). Finally, treatment with vasodilator (treatment that expands the blood vessels) therapy is associated with improved survival (20). The following guidelines take into account these findings.

Figure 4. Representative CT scan image of a person with pulmonary hypertension showing marked enlargement of the pulmonary artery. Photo courtesy of Brett Elicker, MD, UCSF.

Guideline for Referral (8)

• NYHA functional class III or IV, irrespective of ongoing therapy
• Rapidly progressive disease

Guideline for Transplantation (8)

• Persistent NYHA class III or IV on maximal medical therapy
• Low (less than 350 meter) or declining six-minute walk test
• Failing therapy with intravenous epoprostenol, or equivalent
• Cardiac index of less than 2 liters/min/m2
• Right atrial pressure exceeding 15 mm Hg

How does the evaluation and listing process work?

When a person meets the general guidelines discussed above he/she can be referred to a designated lung transplant center. In the United States there are approximately 70 centers that have United Network for Organ Sharing (UNOS) approval for lung or heart-lung transplantation. Qualifications for the hospital, transplant physicians, and surgeons are specified by the UNOS. For more information about active centers and data about each center one can check the website: www.optn.org.

Each center has its own system for evaluation. The comprehensive transplant evaluation seeks to determine the ability of the patient to benefit from transplantation and to enjoy a successful outcome with long-term health. While outside information can be screened for basic eligibility, the evaluation will require a visit to the lung transplant center. The evaluation is conducted in stages and is customized to efficiently address key issues that might preclude transplantation in a particular patient.

Objectives of Evaluation Procedures

• To assess the patient's clinical, social and psychological suitability as a transplant recipient
• To impart information to the patient and his/her family concerning all aspects of transplantation
• To meet hospital staff and transplant patients
• To provide an opportunity for the patient, and his or her family, to begin to come to terms with the prospect of transplantation, and to be informed about the procedure and its aftermath

Investigations Conducted

The decision to place a patient on the waiting list is a multidisciplinary one. Following completion of the testing, the patient is presented at the Lung Transplant Listing Meeting, held weekly. The patient and relatives will be informed of the outcome and given the opportunity to discuss it with a representative of the transplant team.

The multidisciplinary transplant meeting is made up of a wide selection of healthcare professionals. These include:

• Cardiothoracic Surgeons                                     • Dieticians
• Pulmonologists                                                        • Pharmacists
• Cardiologist                                                               • Financial Counselors
• Transplant Coordinators                                     • Social Workers
• Transplant Nurses
If one decides to go forward with transplantation, he or she is then registered with UNOS and placed on the waiting list. If the patient is not deemed suitable and/or declines the option of transplantation the clinician explains to the patient and their family the options available to them. The General Practitioner and referring clinicians are informed of the outcome of the assessment.

Lung Allocation Score (LAS)

All patients listed for lung transplantation are assigned a Lung Allocation Score (LAS). The LAS system of lung allocation was implemented in May of 2005 by Organ Procurement and Transplantation Network (OPTN)/UNOS. Patients who are listed for lung transplantation are ranked on the waiting list in order of their score; the higher the score, the greater the likelihood of being offered donor lungs.

The LAS is based on multiple clinical variables from each individual patient and is designed to reflect both the seriousness of the patient's medical condition before transplant and the likelihood of success after a transplant. The variables used include: diagnosis, age, body mass index (kg/m2), diabetes, New York Heart Association functional class, forced vital capacity (% predicted), six-minute walk distance, pulmonary arterial systolic pressure, oxygen requirements at rest, use of continuous mechanical ventilation, and creatinine.

For more information about the lung allocation score:
http://www.unos.org/

What is involved in the surgery?

Four types of procedures are available, but only lung transplantation from deceased donors is discussed here(21):

• Single lung transplantation
• Double lung transplantation
• Heart-lung transplantation
• Transplantation of lung lobes from living related donors

The type of transplant that is offered depends in part on the underlying disease. Single lung transplantation is an option for chronic obstructive pulmonary disease and idiopathic pulmonary fibrosis. Double lung transplantation is required for cystic fibrosis and often for pulmonary hypertension, but may be also be an option for COPD and pulmonary fibrosis. Finally heart-lung transplants are only indicated for patients with congenital heart disease and Eisenmenger’s syndrome, pulmonary hypertension with right ventricular failure and the rare case of advanced lung disease and left ventricular failure. Lobar transplantation from living related donors is performed at a few centers primarily for pediatric recipients and will not be described in detail here. (living related lobar transplant) The transplant operation typically requires four to eight hours for a single lung transplant and six to 12 hours for a double lung transplant.

Single Lung Transplantation  

The standard posterolateral thoracotomy incision (see photo) is made on the side that has the most severely affected lung. With the assistance of a mechanical ventilator, the remaining diseased lung can provide enough oxygen and eliminate enough carbon dioxide while the lung to be replaced is deflated and removed. Occasionally, cardiopulmonary bypass is required to provide oxygen and blood pressure support and this more often occurs in patients with interstitial lung disease (22) and significant pulmonary hypertension. Once the lung is removed, and the donor lung is implanted, the three connections are made between the donor lung and the recipient: bronchus to bronchus, pulmonary artery to pulmonary artery, and pulmonary veins to left atrium of the heart.

Double Lung Transplantation  

The most common method for double lung transplantation is the bilateral sequential technique, pioneered in 1989(23). This operation is performed through a transverse thoracosternotomy, or “clamshell” incision (see photo), and the lungs are implanted separately and sequentially.

Figure 5. Image of a lung transplant recipient showing typical clamshell incision.

The advantages to this approach are that it avoids some complications associated with connecting the new lungs at the trachea as well as avoids cardiopulmonary bypass in most cases. The operation is conducted like separate right and left single lung transplants. The first transplanted lung supports the patient while the second lung is implanted. In recipients with pulmonary hypertension, cardiopulmonary bypass is often necessary, but in patients with other diagnoses, the need for cardiopulmonary bypass during double lung transplant is difficult to predict(22).

Surgical Recovery

Following implantation, the upper and lower portions of the sternum (breastbone) are secured with wires, the incision is closed, and the recipient is transferred to an intensive care unit (ICU). Most patients remain on mechanical ventilation upon arrival to the ICU. It is imperative to get the patient moving as soon as possible, therefore as soon as the lung(s) are functioning well, sedation is lightened and the endotracheal tube is removed. This typically happens within the first 24 hours following transplant. Most patients spend from two to four days in the ICU before transferring to the surgical ward. As the patient recuperates, the emphasis shifts toward regulating the medication regimen, establishing the routine for transplant monitoring, and continuing rehabilitation and education. The average stay in a hospital varies between transplant programs but is generally one to three weeks. Following discharge, most patients stay in close vicinity of the hospital for eight to 12 weeks because of the need for frequent clinic visits, lab studies and bronchoscopies (inspections of the airway through a small viewing instrument), and to ensure the ability for rapid assessment of surgical complications.

What kinds of medications are used?

One of the major hurdles to successful lung transplantation is the prevention of rejection by the immune system. Because it is not feasible to provide a perfect match, the strategy that has accounted for the most success has been to suppress the body’s immune system using drugs. While they work well to prevent an immune response against the transplanted organ, the drugs are nonspecific immune suppressants and predispose the patient to the side effects of infection and certain neoplasms (abnormal tissue masses that can be either benign or malignant).

Immunosuppression includes both an induction phase and a maintenance phase. The induction phase that takes place during the first week involves high doses of prednisone, and frequently a medication to dramatically decrease lymphocyte (a type of white blood cell) function: IL-2 receptor blocking agent or anti-lymphocyte antibodies. Not all centers use induction therapy. For maintenance immunosuppression, almost all centers employ a three-drug regimen that includes a calcineurin inhibitor (cyclosporine or tacrolimus), an anti-proliferative agent (Imuran or CellCept) and corticosteroid (see figure). We will briefly describe the mechanism and common side effects of these drugs.
Glucocorticoids
Methylprednisolone, prednisone
Side effects - Hyperglycemia, hypertension, cushingoid features (a range of symptoms associated with excess cortisol hormone), avascular necrosis (bone death) of the hip, hyperlipidemia (an elevation of lipids in the bloodstream), peptic ulcer disease, altered mental status, osteoporosis
Calcineurin inhibitors
Cyclosporine (Sandimmune®, Neoral®, Gengraf®), tacrolimus (FK506, Prograf®)
Side effects – Nephrotoxicity (poisonous effect on the kidney), neurotoxicity (poisonous effect on the nervous system), hypertension (high blood pressure), hepatotoxicity (poisonous effect on the liver), hyperlipidemia, hyperglycemia (high blood sugar), increased risk of malignancy. Cyclosporine also causes gingival hyperplasia (overgrowth of the gum tissue) and hirsutism (increased hair growth in women).
Drug interaction - These agents are metabolized though the liver’s cytochrome P-450 system. Other medications metabolized through cytochrome P-450 will compete and delay metabolism causing an increased serum level of the calcineurin inhibitor (e.g., diltiazem, nicardipine, verapamil, ketoconazole, fluconazole, and erythromycin). Medications that induce the activity of the cytochrome P-450 system cause a decrease in serum levels (e.g., rifampin, phenytoin, phenobarbital, and carbamazepine) An increase in the level of these drugs may increase the severity of side effects. A decrease in the level of the drugs may make organ rejection more likely.
Cell-cycle inhibitors
Mycophenolate mofetil (CellCept®), azathioprine (Imuran®)
Side effects - Nausea, diarrhea, anorexia, upper gastrointestinal bleeding, and myelosuppression (decrease in bone marrow activity). Azathioprine may additionally cause cholestatic jaundice, hepatotoxicity, and hair loss
Antilymphocyte antibodies
Muromonab-CD3 (OKT3®), daclizumab (Zenapax®), basiliximab (Simulect®)
Side effects - Mostly seen with OKT3 and include nausea, vomiting, diarrhea, encephalopathy (a brain disorder), noncardiogenic pulmonary edema (swelling or fluid in the lungs), fevers, chills, and increased risk of lymphoproliferative disorder (problems with the white blood cells known as lymphocytes).

What are some of the common complications of lung transplantation?

A variety of complications have been described following lung transplantation, including rejection, infection, neoplasms, phrenic nerve (a nerve that helps control the diaphragm) and diaphragm dysfunction, pneumothorax (collapsed lung), and pulmonary embolism (blockage of the pulmonary artery).

Rejection

Regardless of the therapy used, more than 40% of patients experience at least one episode of acute rejection during the first year, most commonly in the first several months after transplantation(5). Acute rejection is the host's immune response to recognizing the graft as foreign. Essentially, acute rejection results in the immune system creating inflammation in the transplanted organ. Acute rejection is diagnosed by bronchoscopy with transbronchial biopsies and is classified into five grades based on the severity and extent of the inflammation(24). Fortunately most episodes of acute rejection are amenable to treatment with augmented immunosuppression. The mainstay of therapy for acute rejection is pulse intravenous methylprednisolone, followed by higher oral prednisone doses.

Figure 6. This transbronchial biopsy shows a dense inflammatory infiltrate composed of lymphocytes and eosinophils surrounding a small blood vessel and extending into the surrounding interstitium (Moderate acute rejection - Grade A3). Photo courtesy of Kirk Jones, MD, UCSF.

Bronchiolitis obliterans

Bronchiolitis obliterans is the most important complication to limit long term survival following lung transplantation. The pathophysiology is not clear, but it is commonly referred to as chronic rejection. Obliterative bronchiolitis results in scarring of the bronchial tubes. This can eventually lead to difficulty in moving air into and out of the bronchial tubes.

Figure 7. This explant lung section shows a bronchiole with fibrous occlusion of the lumen resulting in a narrowing of the airway. These changes are those of obliterative bronchiolitis (Chronic airway rejection - Grade C). Photo courtesy of Kirk Jones, MD, UCSF.

Because it is not easily diagnosed by biopsy, a scoring system based on the degree of airway obstruction has been instituted to diagnose bronchiolitis obliterans syndrome. Four stages are described, based on severity, from grade 0 to grade III, as follows:

Stage 0 – FEV1 greater than 80% of baseline
Stage I – FEV1 66-80% of baseline
Stage II – FEV1 51-65% of baseline
Stage III – FEV1 50% or less of baseline

Infection

Infection is the leading cause of death in lung transplant recipients(5). In addition to the immunosuppression, the lung is particularly susceptible to infection because of reduced mucociliary clearance, decreased cough reflex resulting from denervation, and interruption of lymphatic drainage. What follows are the most common infections.

Bacterial pneumonia
Bacterial pneumonias are the most common infection following lung transplantation and occur in more than 35% of patients during the first year after the transplant (highest incidence is during the first month posttransplant). Bacterial pneumonias remain a major infectious complication throughout the patient's life. The donor lung is affected more commonly. Gram-negative organisms are most common, especially Enterobacter and Pseudomonas. Bronchitis due to Pseudomonas or staphylococcus aureus infection also is observed.

Cytomegalovirus (CMV) Infection
Prior to the advent of effective prophylactic (preventive) therapy, CMV was a common cause of pneumonia in patients who have received lung transplants, and the most common opportunistic infection. CMV is the most significant viral infection, and it usually occurs one to four months after the transplant.

Aspergillus infection
Locally invasive or disseminated Aspergillus infection accounts for 2-33% of posttransplant infections and 4-7% of deaths in patients who undergo lung transplants. Aspergillus infection commonly occurs in the bronchial tube where the transplanted lung is attached as this area lacks sufficient blood supply initially. This typically occurs within the first four months of transplantation.

Pneumocystis carinii pneumonia
Patients who have undergone lung transplant procedures have an increased susceptibility to P carinii infection, but prophylaxis with trimethoprim-sulfamethoxazole is effective in preventing the infection.

Malignancy

Organ transplant recipients have an increased risk for developing malignancy. The cumulative incidence of cancer following lung transplantation is nearly 20 percent at seven years for those surviving(5). The most common malignancy is skin, followed by malignancy of the lymph system. Post transplant lymphoproliferative disorder represents the diverse diseases of the lymph system that can occur after transplantation. It is closely associated with Epstein-Barr virus (EBV) infection.

Other Complications

Because of the complicated medical regimen and the host of side-effects the drugs impart, lung transplant recipients may have a variety of other medical and surgical problems such as:

Osteoporosis
Chronic kidney failure related in part to tacrolimus or cyclosporine
Systemic hypertension (high blood pressure)
Diabetes mellitus
Anemia
Gastroesophageal reflux disease (GERD)
Gastroparesis (when the stomach takes too long to empty)
Hypercholesterolemia and hypertriglyceridemia (generally known as high cholesterol)
Muscle weakness

What are the expected outcomes of lung transplantation?

The outcome of lung transplantation can be assessed by survival and quality of life.

Survival

Based on data from the International Society for Heart & Lung Transplantation (ISHLT) database, for all transplant recipients, survival is approximately 80% at one year, 65% at three years and 50% at 5 years(5) (see graph). Survival is better for younger cohorts (less than 50 years of age) compared to the older cohorts and recipients with cystic fibrosis have improved survival compared to other indications. While these survival statistics may at first glance appear daunting, the patient is reminded that patients are not listed for transplantation until the expected survival with their lung disease is less than two years.

Quality of life

Several studies have documented a significant improvement in both overall and health-related quality of life after lung transplantation. Almost 90 percent of surviving transplant recipients have expressed satisfaction with their decision to have a transplant and would encourage a friend with a similar problem to seek transplantation(25). More than 80% of recipients have no limitations at five years and 40% of these recipients are working (5).

Where can I get more information?

United Network for Organ Sharing — UNOS is a private, not-for-profit corporation that operates the national Organ Procurement and Transplantation Network (OPTN) and maintains the Scientific Registry for Organ Transplantation under a government contract. UNOS develops policies that regulate the transplant system, and all organ procurement organizations and transplant programs must be members of UNOS.
Further information is available at www.unos.org

Organ procurement organizations (OPOs) — The OPOs are nongovernmental organizations that recover organs in their service area and allocate them according to UNOS guidelines. There are 60 OPOs.
www.optn.org

The American College of Chest Physicians has information posted on their website.
http://www.chestnet.org/downloads/patients/guides/LungTransplantation.pdf
www.chestnet.org/about/links/lungTransplant.php

The International Society for Heart and Lung Transplantation - The ISHLT is a multinational, multidisciplinary organization of heart and lung transplant care providers dedicated to the advancement of the science and treatment of end-stage heart and lung diseases. More information is available: http://ishlt.org/

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