Lung transplantation in advanced COPD: is it worth it?

Abstract

Chronic obstructive pulmonary disease (COPD) is a condition of progressive airflow obstruction occurring primarily as a result of tobacco use that accounts for substantial worldwide morbidity and mortality. Medical therapy, with the exception of oxygen and smoking cessation, does not appreciably alter the natural progression of the disease. In contrast, when performed in carefully selected candidates, lung transplantation can provide substantial benefits in physiology, function, quality of life, and survival. Strict selection criteria limit transplant to highly compliant candidates with advanced disease but preserved functional status who are capable of successfully undergoing the operation. Although either single or bilateral lung transplant may be offered in COPD, recent evidence suggests that bilateral transplant is the preferred operation due to superior long-term outcomes. Regardless of the type of transplant operation, however, all lung transplant recipients are susceptible to numerous complications, including posttransplant infection and rejection. Despite these and other potential complications, advances in medical and surgical management now make lung transplantation a worthwhile therapeutic option in appropriately selected patients. In fact, lung transplant represents the only intervention that can substantially improve long-term outcomes in COPD patients with very advanced disease. Further work to refine recipient selection, improve lung allocation algorithms, and develop better treatments of chronic allograft dysfunction will lead to an even greater benefit to lung transplantation in this ill patient population.

Figure 1. Indications for adult lung transplants by year

(Reprinted with permission from Christie JD, Edwards LB, Aurora P, et al. Registry of the International Society for Heart and Lung Transplantation: twenty-fifth official adult lung and heart/lung transplantation report – 2008. J Heart Lung Transplant 2008;27:957-969) CF = Cystic fibrosis, IPF = Idiopathic pulmonary fibrosis, COPD = Chronic obstructive pulmonary disease, AT Def = alpha 1-antitrypsin deficiency, IPAH = Idiopathic pulmonary hypertension

Figure 2. Kaplan-Meier survival after lung transplantation for recipients with COPD for transplants performed between January 1990 and June 2006, stratified by procedure type and age

(Reprinted with permission from Christie JD, Edwards LB, Aurora P, et al. Registry of the International Society for Heart and Lung Transplantation: twenty-fifth official adult lung and heart/lung transplantation report – 2008. J Heart Lung Transplant 2008;27:957-969)