For Referring Physicians

When to Refer Patients for Lung Transplantation

If you are a physician with a patient who has lung disease, the following guidelines may help you determine whether the patient should be evaluated for transplantation.

When a patient is referred to the Cedars-Sinai Lung Transplant Center, an initial phone call will be needed to gather medical and insurance information. Following that, a visit will be scheduled for the patient to meet with a pulmonologist, transplant surgeon, transplant coordinator and a finance coordinator for an initial evaluation.

The following are intended to serve as guidelines. Each patient's situations different, the transplant team at Cedars-Sinai Medical Center is always available for consultation. Specific criteria are available for:

The following criteria outline who may be considered for lung transplantation—and who is excluded from consideration.

Inclusion Criteria for Lung Transplantation

Patients may be considered for lung or heart/lung transplantation if they present with end-stage lung disease including the following conditions:

  • No response to conventional treatment
  • Limited life expectancy (less than two years)
  • Severely impaired lifestyle and exercise tolerance, NYHA Class III–IV symptoms
  • Oxygen dependence
  • Less than 75 years of age for single lung transplants
  • Less than 70 years of age for double lung transplants
  • Less than 60 years of age for heart/lung transplants
Exclusion Criteria for Lung Transplantation

Patients may not be considered for lung or heart/lung transplantation if they exhibit any of the following:

  • Active or recent malignancy within two years of curative treatment without evidence of recurrence (within five years for breast cancer and melanoma)
  • Irreversible left-sided heat failure with an ejection fraction of less than 45% may only be a candidate for heart/lung transplantation.
  • High dose steroid therapy (more than 40 mg daily) that cannot be tapered or discontinued
  • Untreated or uncontrolled psychiatric disorders such as depression and psychosis
  • Extrapulmonary end-stage organ disease (multiple-organ transplant may be considered, when appropriate)
  • Known active infection or infection with highly resistant pathogens
  • History of noncompliance
  • Absence of strong social support system
  • Poor rehab potential
Relative Exclusion Criteria

The selection committee may use its discretion for the following relative exclusion criteria:

  • Ventilator dependency
  • Recent smoking history or substance abuse (within six months)
  • Severe cachexia and malnourishment (BMI less than 19)
  • Morbid obesity (BMI greater than 30)
  • Severe extrapulmonary or systemic disorders (i.e. active autoimmune disease, poorly controlled IDDM, coronary artery disease)
  • History of pleurodesis or pleural effusion
  • Presence of significant esophageal dysfunction

Some of the conditions for which single lung transplant can be considered are:

Some of the conditions for which a double lung transplant can be considered are:

  • Bilateral pulmonary sepsis
  • Bronchiectasis
  • Cystic fibrosis
  • Eisenmenger's syndrome (with correctable cardiac defects)
  • Limited bronchoalveolar cell carcinoma
  • Lymphangioleiomyomatosis (lam)
  • Primary and secondary pulmonary hypertension
  • Select cases of emphysema in patients younger than 60 years old
  • Select cases for which a single lung transplant would be considered

If the patient has the following conditions, he or she may be a candidate for a heart and lung transplantation:

  • Eisenmenger's with uncorrectable cardiac defects
  • Pulmonary hypertension with severe left ventricular dysfunction
  • Combined severe end stage heart and lung disease that is not directly related to each other

If the patient has previously had a lung transplant, he or she may be a candidate for another lung transplant, if he or she has:

  • Advanced chronic rejection
  • Severe primary graft failure
  • Airway anastomotic dehisence

Some factors make the possibility of a successful lung or heart and lung transplant unlikely. Other factors are less clear cut. These relative factors tend to make lung transplant less viable.

Absolute Contraindications for Lung Transplantation

A patient is not a candidate for lung transplantation if the following conditions apply:

  • Active smoking or substance abuse
  • Co-existing failure of organs other than the lungs. (Such a patient may, however, be a candidate for multiple organ transplantation.)
  • Current diagnosis of malignancy, including lung cancer; some types of skin cancer may not exclude a patient for consideration
  • HIV disease or infection
  • Irreversible left heart failure
  • Lack of medical insurance
  • Inability to walk with a poor potential for improvement through rehabilitation
  • Severe connective tissue disease with extensive extrathoracic manifestations
  • Severe, untreated psychiatric disorders or a history of medical non-compliance
  • Uncorrectable coronary artery disease
Relative Contraindications for Lung Transplantation

The following factors tend to make lung transplantation a less viable option:

  • Age greater than 60 for heart-lung transplantation
  • Age greater than 70 for bilateral lung
  • Age greater than 75 for single lung transplantation
  • Bilateral pulmonary sepsis (single lung only)
  • Dependence on a ventilator
  • Dependence on high doses of steroids (e.g. prednisone at a dose of 20 mg a day or more)
  • Active Hepatitis B or C infection with evidence of end-organ liver damage
  • Infection with treatment-resistant organisms
  • Lack of personal support system
  • Malnutrition or obesity. This is gauged as being 20% more or 20% less than an ideal body weight for the patient's height and build.
  • Prior thoracic surgery/pleurodesis
  • Recent history of malignancy. This means within two years of definitive treatment or within five years of treatment for breast cancer or melanoma.
  • Severe osteoporosis
  • Presence of significant esophageal dysfunction
  • The availability of effective alternative treatment plan

Consultations

For physician-to-physician consultations:

Lung Transplantation Center
Women's Guild Lung Institute
Cedars-Sinai Medical Center 

Fax: 310-423-0129