What are the criteria for lung transplantation?

Criteria for Lung Transplantation

Lung transplantation should be considered for patients with end-stage lung disease who have exhausted all other treatment options and meet specific physiological, functional, and disease-specific criteria that indicate poor survival without transplantation.

General Criteria for Lung Transplantation Referral

Disease-Specific Indications

• COPD/Emphysema:

  • BODE index of 5-6 1
  • FEV1 <25% predicted 1
  • PaCO2 >50 mmHg (6.6 kPa) and/or PaO2 <60 mmHg (8 kPa) 1
  • Not a candidate for endoscopic or surgical lung volume reduction 1
  • Progressive disease despite optimal medical management 1

• Pulmonary Fibrosis:

  • FEV1 <20% predicted with either DLCO <20% or homogenous emphysema 1
  • Oxygen dependency 1
  • Deteriorating course despite optimal medical management 1

• Pulmonary Alveolar Proteinosis (PAP):

  • Progressive disease despite whole lung lavage and/or pharmacological treatment 1
  • Must fulfill ISHLT criteria for patients with interstitial lung disease 1

Criteria for Listing (More Urgent)

• COPD/Emphysema - at least one of the following:

  • BODE index >7 1
  • FEV1 <15-20% predicted 1
  • Three or more severe exacerbations during the preceding year 1
  • One severe exacerbation with acute hypercapnic respiratory failure 1
  • Moderate to severe pulmonary hypertension 1

• Other Conditions:

  • Evidence of secondary pulmonary hypertension/cor pulmonale despite adequate oxygenation 1
  • History of hospitalization with acute hypercapnic respiratory failure 1

Contraindications

Absolute Contraindications

• Unstable or inadequate psychosocial profile/stability 1
• Significant extrapulmonary disorders that may negatively influence survival:
  • Severe liver dysfunction
  • Renal dysfunction
  • Cardiac dysfunction 1

Relative Contraindications

• Age restrictions (many centers limit candidates to <60-65 years) 1
• Poor functional status that cannot be rehabilitated
• Active infection with highly resistant organisms (requires careful evaluation)

Transplant Type Considerations

• Bilateral vs. Single Lung Transplantation:
  • Bilateral transplantation may offer better long-term outcomes, especially for patients <60 years 1
  • Single lung transplantation may be appropriate for older patients or those with specific conditions 1
  • 5-year survival rates: 57.3% for bilateral vs. 47.4% for unilateral transplantation 2

Pre-Transplant Evaluation Process

1. Comprehensive Assessment:

   • Pulmonary function testing (FEV1, DLCO)
   • Arterial blood gas analysis
   • Exercise capacity testing
   • Cardiac evaluation
   • Nutritional assessment
   • Psychosocial evaluation

2. Timing Considerations:

   • Early listing is important due to limited donor availability 1
   • Waiting time may exceed 2 years 1
   • Patients with rapidly progressive disease may die while awaiting transplantation

Post-Transplant Outcomes

• Current survival rates: 1-year (82.9%) and 5-year (59.6%) 2
• 90-day mortality: approximately 10% 2
• Common complications:
  • Acute (3.4%) and chronic (29.0%) rejection
  • Infections (38.0%)
  • Transplant failure (24.7%)
  • Airway complications (15.0%)
  • Malignancies (15.0%)
  • Cardiovascular events (10.9%) 2

Important Considerations

• Lung transplantation should be considered early in the disease course for appropriate planning
• Patients with giant bullae may benefit from bullectomy rather than transplantation if they have relatively normal surrounding parenchyma 3
• For patients with progressive lung disease despite optimal medical therapy, early referral to a transplant center is critical to maximize opportunity and optimize outcomes
• Post-transplant care requires close coordination with the transplant center for optimal outcomes 2

Lung transplantation represents a viable treatment option for carefully selected patients with end-stage lung disease, offering improvements in both quality of life and survival when other therapeutic options have been exhausted.