From the Guidelines
Lung transplantation is indicated for patients with end-stage lung disease, including chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis (IPF), cystic fibrosis, pulmonary arterial hypertension, and bronchiectasis, who have exhausted all other medical and surgical treatment options and have a life expectancy of less than 2-3 years without transplantation. The primary considerations for lung transplantation include the severity of disease, life expectancy, and potential for improvement in quality of life and survival.
Key Indications
- COPD: FEV1 less than 20% predicted, plus either a DLCO less than 20% or homogenous emphysema on imaging 1
- IPF: forced vital capacity or diffusing capacity less than 40% predicted, or evidence of progressive disease 1
- Pulmonary arterial hypertension: mean pulmonary artery pressure exceeding 50 mmHg
- Other indications: cystic fibrosis, bronchiectasis, and other end-stage lung diseases
Contraindications
- Active malignancy
- Severe dysfunction of other organs
- Active infection
- Significant coronary artery disease
- Substance abuse
- Poor adherence to medical regimens
Patient Selection
Patients must demonstrate adequate nutritional status (BMI 17-30), reasonable functional status, and strong social support. The decision for transplantation balances the severity of disease against the risks of surgery and lifelong immunosuppression, which typically includes tacrolimus, mycophenolate mofetil, and prednisone 1.
Transplantation Type
Bilateral lung transplantation may be a better option than single lung transplantation, as it is associated with better long-term outcomes, at least among patients younger than 60 years 1. However, the advantages of bilateral lung transplantation over single lung transplantation are less clear if the risk of death while still on the waiting list is considered.
Outcome
Lung transplantation offers improved quality of life and survival for appropriately selected patients with end-stage lung disease, with five-year survival rates estimated at 50 to 56% in IPF patients 1.
From the Research
Indications for Lung Transplant
The indications for lung transplant include:
- Advanced stages of lung diseases that have failed to respond to all other therapeutic interventions 2
- End-stage lung disease, such as emphysema, cystic fibrosis, pulmonary fibrosis, and pulmonary arterial hypertension 3
- Near-end stage disease with limited life expectancy due to lung disease and significant loss in quality of life 2
- Patients with advanced lung disease who are likely to benefit from lung transplantation, as determined by a comprehensive, multidisciplinary evaluation 4
Selection Criteria
The selection criteria for lung transplant candidates include:
- Age 5, 3
- Degree of mobility 3
- Nutritional and muscular condition 3
- Concurrent extrapulmonary disease 3
- Underlying lung disease prognosis, along with the likelihood of posttransplant success 4
- Risk factors for poor posttransplant outcomes, such as comorbidities and secondary pulmonary hypertension 5, 2
Timing and Evaluation
- Determining optimal timing for lung transplantation can be challenging, and most programs favor initiating the process early and proactively 4
- A comprehensive, multidisciplinary evaluation is used to elucidate disease prognosis and identify risk factors for poor posttransplant outcomes 4
- Candidacy criteria vary significantly by center, and close communication between referring and transplant providers is necessary to improve access to transplant and outcomes 4