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 almost 40,000 procedures have been recorded worldwide, and since 2009 more than 3000 transplants have been reported annually.
The indications span the gamut of lung diseases, but in some respects the distribution of indications differs among countries. According to aggregate international data, the most common indications in the last few years have been chronic obstructive pulmonary disease (COPD), ~29%; idiopathic pulmonary fibrosis (IPF), ~28%; cystic fibrosis (CF), ~16%; α1-antitrypsin deficiency emphysema, ~3.5%; and idiopathic pulmonary arterial hypertension (IPAH), ~3%. Other diseases have made up the balance of primary indications, and retransplantation has accounted for ~3% of procedures.
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 clinical course must be integrated into the assessment as well. 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 may be marginal.
Disease-specific consensus guidelines for referring patients for evaluation and for proceeding with transplantation are summarized in Table 320e-1 and are linked to clinical, physiologic, radiographic, and pathologic features that influence the prognosis of the respective diseases. 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; however, if uncomplicated and adequately managed, they do not disqualify patients from transplantation. The upper age limit is ~70 years at most centers, but the median age of recipients has been increasing steadily over the last decade. In the United States in 2009, 22% of recipients were ≥65 years old.
TABLE 320e-1Disease-Specific Guidelines for Referral and Transplantation |Favorite Table|Download (.pdf) TABLE 320e-1 Disease-Specific Guidelines for Referral and Transplantation
|Chronic Obstructive Pulmonary Disease |
BODE index >5
BODE index 7–10
Any of the following criteria:
Hospitalization for exacerbation, with PaCO2 >50 mmHg
Pulmonary hypertension or cor pulmonale, despite oxygen therapy
FEV1 <20% with either DLCO <20% or diffuse emphysema
|Cystic Fibrosis/Bronchiectasis |
FEV1 <30% or rapidly declining FEV1
Hospitalization in ICU for exacerbation
Increasing frequency of exacerbations
Refractory or recurrent pneumothorax
Recurrent hemoptysis not controlled by bronchial artery embolization
Oxygen-dependent respiratory failure
|Idiopathic Pulmonary Fibrosis |
Pathologic or radiographic evidence of UIP, regardless of vital capacity
Pathologic or radiographic evidence of UIP
Any of the following criteria:...