Lung Transplantation

Lung transplantation involves a major operative procedure and is considered treatment for end-stage lung diseases unresponsive to other therapies. Because of advancements in surgical technology and control of rejection, the one-year survival rate following lung transplantation is 82 percent and the three-year survival rate has increased from 55.7 percent (1988–1994) to 63.3 percent (2000–2003). The primary diseases for which lung transplantation is considered include chronic obstructive pulmonary disease (COPD), a term referring to both emphysema (including those cases due to inherited deficiency [Page 1037]of alpha-1 antitrypsin) and chronic bronchitis; idiopathic pulmonary fibrosis; cystic fibrosis, an inherited disease typically manifesting itself in childhood which involves primarily the lung and gastrointestinal tract; end-stage sarcoidosis. Because of a shortage of donor organs, the total number of patients who underwent lung transplantation in 2003 numbered less than 1,800 and it has been estimated that upward of 20 percent of transplantation candidates die while waiting for donor lung(s).

Prior to being placed on a transplantation list, patients are referred to a transplant center for evaluation. In addition to physiologic testing, extensive psychosocial evaluation and counseling is performed. Pre- and posttransplant psychological functioning has been found to be an important predictor of quality of life and adherence to life-sustaining medical treatment following transplantation. Contraindications to lung transplantation vary among centers but may include age over 65 years, current tobacco smoking, current alcohol or substance abuse, human immunodeficiency virus (HIV) infection, intractable infections, unstable mental illness, and generalized debility.

Once placed on a lung transplantation list, patients undergo extensive tissue typing (done so that compatible organs can be sought) and categorized as to the urgency of their need for transplantation. Patients are thereafter “on call” for transplantation and must guarantee their ability to arrive at the transplantation center within a very short, fixed period of time following notification of the availability of suitable organs for transplantation. In addition, patients must maintain compliance with a complicated medication regimen and actively participate in a pulmonary rehabilitation program. Failure to do so typically results in removal from the transplantation list.

Prior to undergoing lung transplantation, patients are placed on an aggressive immunosuppressive regimen for the purpose of preventing rejection of the transplanted organ(s), the primary cause of death following transplantation. Other complications of lung transplantation include primary graft dysfunction (typically due to reduced blood supply before/during transplantation or poor blood circulation in the organ following transplantation); kidney failure which may require dialysis (dialysis is most typically required in patients who had preoperative idiopathic pulmonary fibrosis with pulmonary hypertension); malignancy (∼10 percent); and bacterial, fungal and viral infections.

Lung transplantation involves a major operative procedure and may consist of transplantation of a single lung lobe (more commonly utilized in children), or single- or double-lung transplantation, performed with or without heart transplantation. The underlying condition of the patient, along with his or her indication for transplantation, will determine which surgical transplant procedure is undertaken.

Extensive medical monitoring posttransplantation is necessarily performed for the life of the patient. This monitoring includes repeated measurement of lung function, surveillance procedures for rejection, infection, and blood testing. Research is ongoing to determine better methods for soliciting organ donation among diverse population of the United States, prediction of risk for/recognition of and treatment of rejection, and best methods for long-term immunosuppression.

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