Cystic fibrosis (CF) and pulmonary hypertension (PH) were once common categories for referral to lung transplant. However, advances in medical therapies have allowed many patients with these diseases to avoid transplant. Today, at most transplant centers throughout the world, lung transplants are being performed on increasingly older patients, primarily with interstitial lung disease (ILD) followed by chronic obstructive pulmonary disease (COPD). Unlike CF and PH, few treatments with the ability to extend survival currently exist for ILD, specifically idiopathic pulmonary fibrosis (IPF), and COPD. When these patients continue to decline despite maximized medical therapy, surgical options may be indicated.
“We largely follow the International Society of Heart Lung Transplant guidelines, but there are nuances with every patient and some variation from center to center,” says Katherine Vandervest, MD, a transplant pulmonologist on the medical staff at Baylor University Medical Center, part of Baylor Scott & White Health. “In general, patients have to progress to a more severe level of disease. And there are some common criteria for referral and listing based on the type of underlying lung disease. COPD patients tend to have a slower progressive course after smoking cessation, and, thus, one factor for referral consideration is an FEV1 < 25 percent. Unlike COPD, idiopathic pulmonary fibrosis can be a more unpredictable disease with higher mortality within two years of diagnosis. So it is important to consider a referral to a lung transplant center early, especially if the patient is requiring any oxygen support.”
At Baylor Dallas, lung transplants may be performed on adult patients from 18 up to age 75. Above age 70, the patient must be an otherwise exceptional candidate. If approved for listing, patients in the advanced age category will generally be offered a single lung transplant only.
While data suggest a slight survival advantage for double-lung transplant over single-lung transplant in the long term, both procedures can extend life expectancy in end-stage lung diseases. To provide the opportunity to as many people as possible who are candidates, Baylor Dallas offers single-lung transplant only in older patients with ILD or COPD.
In addition to age > 75, other contraindications to being put on the wait list include weight (not too overweight or underweight), smoking or use of any nicotine-containing product within the last six months, use of illicit substances of any kind, narcotic dependence and poor exercise tolerance.
“General requirements are for a patient to show compliance with medical therapy, have strong caregiver support and good rehab potential,” says Dr. Vandervest. “We understand that as the disease progresses, it will be harder for a patient to maintain exercise tolerance and conditioning. But we highly encourage patients to enroll in pulmonary rehab even before we see them for potential evaluation. Pulmonary rehab is an evidence-based therapy for physical improvement in patients with advanced lung diseases. Patients who are in better shape and are less frail tend to have better recoveries.”
