Lung transplantation: a treatment option in end-stage lung disease

Abstract

Background: Lung transplantation is the final treatment option in the end stage of certain lung diseases, once all possible conservative treatments have been exhausted. Depending on the indication for which lung transplantation is performed, it can improve the patient's quality of life (e.g., in emphysema) and/ or prolong life expectancy (e.g., in cystic fibrosis, pulmonary fibrosis, and pulmonary arterial hypertension). The main selection criteria for transplant candidates, aside from the underlying pulmonary or cardiopulmonary disease, are age, degree of mobility, nutritional and muscular condition, and concurrent extrapulmonary disease. The pool of willing organ donors is shrinking, and every sixth candidate for lung transplantation now dies while on the waiting list.

Method: We reviewed pertinent articles (up to October 2013) retrieved by a selective search in Medline and other German and international databases, including those of the International Society for Heart and Lung Transplantation (ISHLT), Eurotransplant, the German Institute for Applied Quality Promotion and Research in Health-Care (Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen, AQUA-Institut), and the German Foundation for Organ Transplantation (Deutsche Stiftung Organtransplantation, DSO).

Results: The short- and long-term results have markedly improved in recent years: the 1-year survival rate has risen from 70.9% to 82.9%, and the 5-year survival rate from 46.9% to 59.6%. The 90-day mortality is 10.0%. The postoperative complications include acute (3.4%) and chronic (29.0%) transplant rejection, infections (38.0%), transplant failure (24.7%), airway complications (15.0%), malignant tumors (15.0%), cardiovascular events (10.9%), and other secondary extrapulmonary diseases (29.8%). Bilateral lung transplantation is superior to unilateral transplantation (5-year survival rate 57.3% versus 47.4%).

Conclusion: Seamless integration of the various components of treatment will be essential for further improvements in outcome. In particular, the follow-up care of transplant recipients should always be provided in close cooperation with the transplant center.

Figure 1

Patient survival a) According to age group (transplantation period January 1990 to June 2011 [6]) b) According to surgical procedure (transplantation period January 1994 to June 2011 [6]) DLuTx, double lung transplantation; SLuTx, single lung transplantation

eFigure

Interaction between components of treatment and current clinical practice in lung transplantation. Once the candidate for lung transplantation has attended a qualified transplantation center, the decision about whether to place the patient on the waiting list is made taking account of the patient’s individual disease-specific factors and any contraindications. To optimize long-term results, intensive pneumological support and aftercare in the transplantation centers and obligatory close collaboration with patients’ doctors and local hospitals are essential. If the various elements of therapy interact successfully together, a new lung can mean a new quality of life. (LAS, lung allocation score)