A Patient's Guide to Lung Transplantation

Candidates for lung transplants have end-stage lung disease with a poor prognosis and have failed to respond to conventional medical therapy. There are recommended age limitations: single lung transplantation is recommended for individuals who are under 75 years of age, double lung transplantation for those under 65 and heart-lung transplantation for those under 60.

Patients must be ambulatory and free of cancer, HIV or active infectious disease, and they must have normal function of other vital organs, such as the heart, liver and kidneys. Patients must not be active smokers or substance abusers. They also need a strong social and family support system to help in the early post-transplant recovery phase.

Once an individual is deemed to be a good lung transplant candidate, he or she is listed with the United Network for Organ Sharing (UNOS). This organization is contracted by the federal government to procure and allocate donor organs fairly. People waiting for a transplant are assigned an organ on the basis of a lung allocation score. This score is calculated using objective criteria that predict how serious their disease is and the probability of their getting benefit from a lung transplant. The amount of time a person has been on the waiting list is no longer a factor in the allocation of available organs for transplant.

Most patients wait an average of 3 to 6 months for a donor lung, although there are some factors that may prolong the time until a donor lung becomes available. The long waiting times are attributed to the large number of patients listed and the limited number of donor organs suitable for transplant. Every lung transplant program in the country depends on the generosity of potential organ donors and their families.

Transplantation surgery is performed with general anesthesia, using an incision on the side of the chest for single lung transplantation or across the sternum or breastbone for double and heart-lung transplantation.

The native diseased lung or lungs are removed from the recipient while the donor lung is being recovered. The donor lung (or allograft) is placed in the chest in the normal anatomic position. The new lung is then attached to the recipient by way of three anastomosis or connections, one for the bronchus, one for the pulmonary artery and one for the pulmonary veins. In the case of a double lung transplant, the procedure is repeated for the second lung in the other side of the chest. In some cases patients require cardiopulmonary bypass during surgery. The incisions are then closed and two more chest tubes are placed around the new lung to help it re-expand with air.

After the surgery, the patient is transferred from the operating room into the intensive care unit, where close monitoring can be provided. Typically, patients are taken off the ventilator within 24 hours of the surgery's completion. Most patients have an epidural cath inserted for pain control.

Treatment with immunosuppressive medication is begun to prevent rejection of the transplanted lung by the patient's immune system. Once stable and breathing on their own, patients are transferred to the surgical ward, where they can begin to get out of bed and walk. Most patients still need oxygen for a few days or weeks after the transplant, but eventually they can come off oxygen completely and walk without any shortness of breath or coughing.

Patients are closely monitored for any potential complications after surgery. In particular, physicians look for evidence of rejection, which now occurs infrequently, and any infection that can occur as a result of immunosuppression. Frequent blood tests, chest X-rays, and spirometry are required initially. Bronchoscopy may be required to make a diagnosis of rejection or infection.

Patients are discharged from the Medical Center on average 14 to 21 days after surgery. The success of every transplant then depends on continued compliance with prescribed medication and close monitoring by the transplant physicians over the ensuing months and years.

As part of the Comprehensive Transplant Center, the Women's Guild Lung Institute provides a continuum of comprehensive treatments related to lung transplantation, individually tailored to each patient's specific needs. Available treatments include:

• Monitoring of patients awaiting a lung transplant
• Medical and surgical therapies, including Flolan therapy, lung volume reduction surgery (LVRS), lung transplantation and heart-lung transplantation
• Follow-up care including spirometry, bronchoscopy, transbronchial biopsies and management of immunosuppressive therapy

Cedars-Sinai's own Transplant Immunology Laboratory and HLA and Immunogenetics Laboratory provide pre-transplant analysis of genetic matching and antibodies that could cause rejection of a transplanted lung. The laboratories also offer a state-of-the-art monitoring system for detecting rejection and viral infections in an early phase, before a condition becomes life threatening. The rapid test results provided by the laboratories help improve patient and allograft survival, leading to better outcomes.