Lung transplantation is a therapeutic consideration for many patients with nonmalignant end-stage lung disease, and it prolongs survival and improves quality of life in appropriately selected recipients. Since 1985 more than 51,000 adult lung transplants have been recorded worldwide, and annual volume has reached ~4000 transplants per year.
The indications for lung transplantation span the gamut of lung diseases, and the distribution reflects both the prevalence and prognosis of the diseases and the applicable organ allocation policies. According to international registry data, the most common indications in recent years have been idiopathic pulmonary fibrosis (IPF), ~30%; chronic obstructive pulmonary disease (COPD), ~27%; cystic fibrosis (CF), ~15%; α1-antitrypsin deficiency emphysema, ~3%; and idiopathic pulmonary arterial hypertension (IPAH), ~2.5%. Other lung diseases have comprised the balance of primary indications, and retransplantation has accounted for ~3% of procedures. Since 2001, IPF has increased from ~15 to ~30%, and COPD has decreased from ~40 to ~27% among the indications.
REFERRAL AND RECIPIENT SELECTION
Transplantation should be considered when other therapeutic options have been exhausted and when the patient’s prognosis is expected to improve as a result of the procedure. Survival rates after transplantation can be compared with predictive indices for the patient’s disease, but each patient’s individual clinical circumstances must be incorporated into the assessment. Moreover, quality of life is a primary motive for transplantation for many patients, and the prospect of improved quality-adjusted survival is often attractive even if the survival advantage itself is questionable.
Disease-specific consensus guidelines for referring patients for evaluation and for listing them for transplantation are summarized in Table 292-1. Candidates for lung transplantation are also thoroughly screened for comorbidities that might affect the outcome adversely. Conditions such as systemic hypertension, diabetes mellitus, gastroesophageal reflux, and osteoporosis are not unusual, but if uncomplicated and adequately managed, they do not disqualify patients from transplantation. The upper age limit is ~70–75 years at most centers, and the proportion of older recipients has been increasing. In 2014, 29% of adult recipients in the United States were ≥65 years old.
TABLE 292-1Disease-Specific Guidelines for Referral and Transplantation |Favorite Table|Download (.pdf) TABLE 292-1 Disease-Specific Guidelines for Referral and Transplantation
Chronic Obstructive Pulmonary Disease
Referral for Evaluation
Progressive despite medications, oxygen, and pulmonary rehabilitation
PaO2 <60 mmHg or Paco2 >50 mmHg
BODE index 5–6
Listing for Transplantation
BODE index ≥7
Moderate to severe pulmonary hypertension
Three or more severe exacerbations in preceding year
One severe exacerbation with acute hypercapnic respiratory failure
Referral for Evaluation
FEV1 <30% or rapidly declining despite optimal therapy
Pulmonary hypertension (in absence of hypoxemic exacerbation)
6-min walk distance <400 m
Clinical deterioration with increasing frequency of exacerbations, with
– An episode of acute respiratory failure requiring ventilatory support