Choosing the Right Candidates For Lung Transplantation

SALT LAKE CITY—Choosing viable candidates for lung transplantation is a rigorous process, and the criteria for making such a selection change frequently. To help pulmonologists better understand which patients with pulmonary disease are good candidates and when referral is warranted, experts presented updated lung transplantation data and recommendations at CHEST 2006.¹ The presentation was based on new guidelines for lung transplantation referral, which were recently published in the Journal of Heart and Lung Transplantation.²

Lianne G. Singer, MD, Medical Director of the Lung Transplant Program at Toronto General Hospital, said that there are two reasons to refer eligible COPD patients for lung transplantation: to increase survival and to improve quality of life. However, the guidelines focus on survival benefit, because there are no data available to help predict the quality-of-life benefit of transplantation, Dr. Singer explained.

Results of clinical studies have suggested that lung transplantation is appropriate for COPD patients with a history of hospitalization for exacerbation with acute hypercapnia, pulmonary hypertension and/or cor pulmonale despite oxygen therapy, or an FEV1 of less than 20% and either Dlco of less than 20% or homogenous distribution of emphysema. The available data indicate posttransplantation survival rates of about 80% at one year, 50% at five years, and 35% at 10 years in this subgroup of COPD patients. Their most common long-term posttransplantation complication is bronchiolitis obliterans.

It may be possible to use the BODE index to identify lung transplantation candidates among COPD patients.³ The BODE index is a scoring system that combines four COPD mortality predictors—BMI, airflow obstruction, dyspnea, and exercise capacity, Dr. Singer reminded conference attendees. Since Celli and colleagues found that the BODE index predicted all-cause mortality and death from respiratory causes better than did FEV1, one might expect the greatest lung transplantation survival benefit among COPD patients in the highest BODE index quartile, suggested Dr. Singer.

A Viable Final Option in Cystic Fibrosis

Lung transplantation provides hope for patients with advanced cystic fibrosis (CF), acknowledged Selim M. Arcasoy, MD, Medical Director of the Lung Transplant Program at Columbia University Medical Center in New York City. “For these patients, lung transplantation is a viable but final therapeutic option limited by high death rates on the waiting list as well as high posttransplantation mortality,” he explained.

Dr. Arcasoy emphasized the heterogeneous prognosis and limited utility of prognostic predictors in patients awaiting transplantation. He pointed out the importance of dynamic and comprehensive assessment of lung function and multiple other clinical factors in determining the optimal timing of lung transplantation. He also suggested the consideration of recipient and local factors that affect waiting time.

Using the available data, specialists have been able to develop reasonably useful guidelines for referral to lung transplantation in CF, Dr. Arcasoy related. The current guidelines recommend referral for transplantation evaluation for CF patients with an FEV1 of less than 30% or an FEV1 that has declined rapidly—particularly if the patient is young or female.

Referral for transplantation is also appropriate for CF patients whose exacerbation frequency has increased and those who need ICU admission or experience recurrent pneumothorax or hemoptysis, said Dr. Arcasoy. He described these recommendations as more qualitative than quantitative and designed to steer pulmonologists toward earlier referral of CF patients for lung transplantation. He recommended proceeding with lung transplantation in patients with progressive disease and oxygen dependence, hypercapnia, or pulmon­ary hypertension.

Expedited Referral for IPF Patients

Patients with interstitial lung disease, such as idiopathic pulmonary fibrosis (IPF), should meet a number of criteria for lung transplantation, stated Robert M. Kotloff, MD, Chief of the Section of Advanced Lung Disease and Lung Transplantation at the Penn Lung Center in Elkins Park, Pennsylvania. Among those criteria are Dlco of less than 39%, oxygen saturation of less than 88%, and a fibrotic score indicating a predominance of honeycombing.

The process of referral for lung transplantation is much faster for patients with IPF than for patients with other pulmonary diseases, Dr. Kotloff pointed out. Since patients with IPF usually need a new lung right away, he explained, they typically undergo transplantation about 30 days after being placed on the list. The expedited referral process results in significantly reduced posttransplantation morbidity, Dr. Kotloff said.

It is important to inform IPF patients about the limitations of lung transplantation, he emphasized. These patients must be told, “No, you are not going to have a normal life after the lung transplant,” he said. Furthermore, pulmonary embolism appears to be relatively common in IPF patients who have undergone lung transplantation.⁴

Dr. Kotloff maintained that there is no downside to the early referral of IPF patients, because it optimizes the process of weaning these patients from steroids, educating them about likely outcomes, and completing the transplantation evaluation. In fact, he concluded, the time of diagnosis is an ideal time to refer IPF patients to a transplantation center.

—Timothy Begany

Reference
1. Orens JB, Singer LG, Arcasoy SM, et al. Selecting lung transplant candidates: guidelines update for the general pulmonologist. Presented at: annual meeting of the American College of Chest Physicians; October 24, 2006; Salt Lake City, Utah.
2. Orens JB, Estenne M, Arcasoy S, et al. International guidelines for the selection of lung transplant candidates: 2006 update—a consensus report from the Pulmonary Scientific Council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2006;25:745-755.
3. Celli BR, Cote CG, Marin JM, et al. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med. 2004;350:1005-1012.
4. Nathan SD, Barnett SD, Urban BA, et al. Pulmonary embolism in idiopathic pulmonary fibrosis transplant recipients. Chest. 2003;123:1758-1763.

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