[The management of lung transplantation candidates. A case series]

[Selection of lung transplant candidates in France in 2019]

INTRODUCTION

In 2015, the International Society for Heart and Lung Transplantation (ISHLT) published a consensus document for the selection of lung transplant candidates. In the absence of recent French recommendations, this guideline is useful in order to send lung transplant candidates to the transplantation centers and to list them for lung transplantation at the right time.

BACKGROUND

The main indications for lung transplantation in adults are COPD and emphysema, idiopathic pulmonary fibrosis and interstitial diseases, cystic fibrosis and pulmonary arterial hypertension (PAH). The specific indications for each underlying disease as well as the general contraindications have been reviewed in 2015 by the ISHLT. For cystic fibrosis, the main factors are forced expiratory volume in one second, 6-MWD, PAH and clinical deterioration characterized by increased frequency of exacerbations; for emphysema progressive disease, the BODE score, hypercapnia and FEV1; for PAH progressive disease or the need of specific intravenous therapy and NYHA classification. Finally, the diagnosis of fibrosing interstitial lung disease is usually a sufficient indication for lung transplantation assessment.

OUTLOOK AND CONCLUSION

These new recommendations, close to French practices, help clinicians to find the right time for referral of patients to transplantation centers. This is crucial for the prognosis of lung transplantation.

[Evolution and progress of lung transplantation: An analysis of a cohort of 600 lung transplant patients at the Hospital Foch]

Lung transplantation is deemed to be the only effective therapy that improves survival for patients with end stage lung disease. The aim of our study was to examine the progress achieved over the last two decades and to demonstrate the effectiveness and safety of this treatment.

METHODS

A retrospective analysis of a cohort of 600 consecutive lung transplant patients treated at the hospital Foch (Suresnes, France) between 1988 and 2014. They were split into three groups of 200 patients each: 1988-2004, 2004-2011, 2011-2014.

RESULTS

Time and mortality on waiting list, perioperative mortality, the incidence of acute rejection in the first year and chronic lung allograft dysfunction (CLAD) at 5 years posttransplantation, have all decreased. Global survival at 1 and 5 years for the 600 patients increased from 78% and 57% to 86% and 75% respectively for the 200 last patients. Patients with cystic fibrosis have a better 5 year survival than those with emphysema or pulmonary fibrosis (68% vs. 54 % for emphysema and 37% for fibrosis). For the last 200 patients, 5 year survival is 81% for CF patients, 78 % for emphysema and 47% for fibrosis. Emergency transplantation had a 60% 5 years survival. Proliferative complications, arterial hypertension and renal function impairment are being monitored long term.

CONCLUSION

The twenty-five years experience shows a consistent improvement in the results of lung transplantation which is now accepted as the only effective curative treatment for end stage lung disease.

The effects of inspiratory muscle training on exercise capacity, dyspnea and respiratory functions in lung transplantation candidates: a randomized controlled trial

OBJECTIVE

To investigate whether inspiratory muscle training would contribute to the improvement of exercise capacity, dyspnea perception and respiratory functions in lung transplantation candidates.

DESIGN

Prospective randomized controlled trial.

SETTING

Pulmonary Rehabilitation center.

SUBJECTS

A total of 34 patients with severe lung disease requiring lung transplantation were randomly allocated to either pulmonary rehabilitation plus inspiratory muscle training group (PR + IMT group, n = 17) or pulmonary rehabilitation group (PR group, n = 17) before any lung transplantation operation.

METHODS

All patients underwent supervised pulmonary rehabilitation program on two days per week for three months. The PR + IMT group received inspiratory muscle training in addition to the standard pulmonary rehabilitation program. The 6-minute walk test, maximal inspiratory pressure, modified Medical Research Concile dyspnea scores and spirometric parameters were measured for each patient.

RESULTS

The PR + IMT group had statistically significantly increased in walking distance (100 m, P = 0.03), maximum inspiratory pressure (26 cmH₂O, P = 0.001) and alveolar volume ratio of carbonmonoxide diffusion capacity (9%, P = 0.02) than PR group. Although both groups demonstrated a statistically significant decrease in the dyspnea score, no significant differences were found between the groups ( P = 0.075). There was no change in spirometric variables in both groups.

CONCLUSION

A greater increase in exercise capacity was observed in the PR + IMT group. Our study showed that inspiratory muscle training improved exercise capacity even further and increased the benefits provided by pulmonary rehabilitation.

Effects of pulmonary rehabilitation in lung transplant candidates: a systematic review

OBJECTIVES

The aim of this systematic review of randomised controlled trials (RCTs), and quasi-experimental and retrospective studies is to investigate the effects of pulmonary rehabilitation (PR) in patients with advanced chronic disease on the waiting list for lung transplantation.

SETTING

PR performed for inpatient or outpatient lung transplant candidates.

INTERVENTION

PR programme including aerobic exercise training and/or resistance exercise training.

PRIMARY AND SECONDARY OUTCOMES

Quality of life and exercise capacity (primary outcomes). Survival rate after transplant surgery; pulmonary function; respiratory muscle strength; psychological aspects; upper and lower extremity muscle strength and adverse effects (secondary outcomes). Two review authors independently selected the studies, assessed study quality and extracted data. Studies in any language were included.

RESULTS

This was a systematic review and studies were searched on the Cochrane Library, MEDLINE, EMBASE, CINAHL and PEDro. Experimental and retrospective studies evaluating the effects of PR in candidates for lung transplantation (>18 years old) with any lung diseases were included. 2 RCTs, and two quasi-experimental and two retrospectives studies, involving 1305 participants were included in the review. 5 studies included an enhancement reported in quality of life using the Short Form 36 questionnaire and showed improvements in some domains. All studies included exercise capacity evaluated through 6 min walk test and in five of them, there were improvements in this outcome after PR. Owing to the different characteristics of the studies, it was not possible to perform a meta-analysis.

CONCLUSIONS

Studies included in this review showed that PR is an effective treatment option for patients on the waiting list for lung transplantation and can improve quality of life and exercise capacity in those patients. Although individual studies reported positive effects of PR, this review shows that there is a need for more studies of a high methodological quality addressing PR effects in lung transplant candidates.

TRIAL REGISTRATION NUMBER

PROSPERO CDR42015025110.

[Contraindications to lung transplantation: evolving limits?]

In France, the higher frequency of pulmonary sample in organ donors and the enhancement of surgical and perioperative life support techniques, have increased the number procedures and the short term prognosis of lung transplantation (LT). In this setting, the classical contraindications of LT need to be reconsidered. In this article, some of the classical contraindication of LT are confronted to the experience acquired in other solid organ transplantations or from some LT centers. Specific situations such as LT in patients with previous cancer, HIV infection, viral hepatitis, nutritional disorders, acutely ill LT candidates and aging candidates are addressed. Surgical contraindications are not reviewed.