Indications for lung transplant referral: physician attitudes

[Indications and contraindications to lung transplant: patient selection]

Lung transplant (LT) is a valid treatment for patients with end-stage lung disease such as cystic fibrosis, emphysema, pulmonary fibrosis and pulmonary arterial hypertension (85% of indications) and for selected candidates. The "good recipient" was introduced early to a specialised center, has had complete pre-LT assessment and complete information. At the end of this assessment, the absolute contraindications were eliminated (cardiovascular pathologies, recent neoplasia, active viral diseases, severe psychiatric disorders), advanced age risks were discussed, co-morbidities to treat were listed and an individualised therapeutic pre-LT program has been decided (based on exercise and muscle rehabilitation, nutritional support, anti-infectious treatments, active management of co-morbidities such as diabetes, hypertension, gastro-esophageal reflux…) with a psychological follow-up if necessary. Timely inscription on waiting list must be decided, early enough to avoid extreme handicap or risk pre-LT death, but not too early to have a survival benefit linked to LT. Death without LT prognosis criteria are still studied, and even if they do not fully define the risk of death of an individualised patient, they are taken into account by the recommendations of the societies; since 2006, LT indications are based on severity criteria of the selected patient, defined for each recipient diagnosis. LT aims to improve survival and quality of life of the patient, and this is especially true when the patient is referred, prepared and monitored early enough by the transplant team; the aim is to limit the risk of death before LT (before listing and on waiting list) and early post-LT morbimortality.

Cardiac procedures in lung transplant recipients do not increase mortality in selected patients

BACKGROUND

Associated comorbidities in potential lung transplant recipients may significantly impact operative morbidity and mortality. We undertook this review to specifically study whether patients who underwent associated cardiac procedures either before (as a prerequisite) or during their lung transplantation had different outcomes when compared with the overall cohort of lung transplant recipients.

METHODS

A retrospective chart review was performed of all patients who underwent lung transplantation at the University of Texas Health Science Center at San Antonio from January 1994 to June 2004. The records of these patients were analyzed for patient-days on the ventilator, hospital length of stay, operative morbidity and mortality, and long-term survival. The patients were then divided into two groups and compared: patients who had a cardiac intervention either prerequisite to or concurrent with their transplant (group C, n = 13) and patients who did not (group NC [no cardiac intervention], n = 120).

RESULTS

Although the median length of stay was longer in group C when compared with group NC, the number of patient-days on the ventilator and the operative morbidity and mortality were similar for both groups. Likewise, overall long-term survival was not significantly different (Kaplan-Meier method, p = 0.70).

CONCLUSIONS

Patients who are otherwise deemed to be good candidates for lung transplantation but are found to have an associated cardiac condition that could adversely affect their candidacy may still be considered for transplantation in selected cases if the cardiac abnormality can be addressed either before or during transplantation.

Lung Transplantation

The timing of the referral and listing of patients for lung transplantation remains a difficult decision. Life expectancy and quality of life with and without transplantation are the pivotal issues that need to be considered by physicians and presented to prospective transplant candidates. The recognition of recent advances in the understanding of the various primary diseases, other potential therapies, and the latest posttransplant statistics are essential for a balanced discussion or decision about lung transplantation. This article provides a review of these and other pertinent issues for patients with various forms of advanced lung disease.