eMedicine Specialties > Transplantation > Surgery

Lung Transplantation: Follow-up

Author: Susan D Moffatt-Bruce, MD, PhD, FRCS(C), FACS, Assistant Professor, Division of Cardiothoracic Surgery, Department of Surgery, Assistant Professor, Department of Molecular Virology, Immunology and Medical Genetics, Surgical Director of Lung Transplantation, Deputy Director of Comprehensive Transplant Center, Ohio State University
Contributor Information and Disclosures

Updated: May 13, 2009

Outcome and Prognosis

The International Society for Heart and Lung Transplantation Registry reports a 1-year survival rate of 78% and 5-year survival rate of 51% following lung transplantation.1 Mortality is highest in the first year, and attrition was consistent across the subsequent time periods. In the first 30 days, graft failure, noncytomegalovirus (CMV) infections, cardiovascular complications, and technical problems account for most of the mortality. After the first year, bronchiolitis obliterans syndrome (BOS) and nonCMV infections were the predominant causes of death. By 5 years, malignancies and cardiovascular causes account for almost 17% of reported causes of death.

Overall survival according to pre-transplant diagnosis shows that after 1 year, patients with chronic obstructive pulmonary disease (COPD) and idiopathic pulmonary fibrosis (IPF) had the worst long-term survival.1 In general, bilateral procedures have better survival in each diagnosis category, especially in patients with COPD. Survival according to pretransplant CMV serologic status was most influenced by the CMV status of the donor. Survival during the first 5 years after transplantation was significantly better among recipients of a transplant from a donor who was CMV-seronegative.

Whether lung transplantation truly increases survival over the natural history of the underlying disease remains difficult to ascertain in the absence of randomized trials. A survival advantage has been reported for patients with cystic fibrosis and pulmonary fibrosis who have received transplants, but this advantage has not been demonstrated for patients with emphysema.

Patients are referred for transplantation at a point in the course of their disease at which death is considered likely within 2-3 years. Therefore, transplantation would be expected to confer a survival advantage. Severe dyspnea and poor quality of life can be additional considerations for lung transplantation.

Future and Controversies

Cost of lung transplantation

Highly sophisticated and extraordinary therapies, such as lung transplantation, are performed at a great cost to society. Presently, active research is being conducted on enhancing the patient's quality of life following lung transplantation. Several studies have reported a significant improvement in different quality-of-life domains, tested pretransplant and posttransplant. Other studies comparing candidates and lung transplant recipients have demonstrated significant improvements in energy levels, physical functioning, mobility, and symptoms such as dyspnea and anxiety. The recipients have expressed greater satisfaction with their lives and their health following lung transplantation.

Attempts to compute the costs of lung transplantation to general society and to determine the cost effectiveness of this therapy have been made. Cost evaluations should take into account both the actual cost and the improved quality of life provided by this therapy compared to standard care. The cost is expressed in units of QUALY (quality-adjusted life-year), which reflects the real or anticipated survival time and health-related quality of life. The University of Washington Medical Center estimated that lung transplantation costs $176,817 per QUALY compared to traditional therapy. Canadian centers have reported a lower cost effectiveness of lung transplantation ($62,860 per life-year gained, Canadian dollars, 1993).

Living donor transplantation

For patients who are considered too ill to await cadaveric transplantation, living lobar lung transplantation may be an option.34 Despite fairly extensive experience, no donor mortality has been reported, and morbidity has been relatively low. Compared to bilateral cadaveric lung transplants, long-term studies have shown that the relatively smaller-sized lobes can provide similar pulmonary function and exercise capacity. Living lobar lung transplantation should be considered in a patient with a clinically deteriorating condition. Although no deaths have been reported in the donor cohort, a risk of death between 0.5% and 1% should be quoted, pending further data. A case series of 128 living lobar lung transplantations performed in 123 patients between 1993 and 2003 was published.35 The actuarial survival among the living lobar recipients was 70%, 54%, and 45%, at 1, 3, and 5 years, respectively.35

 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Helmut Unruh, MD, and Sat Sharma, MD, FRCPC, to the development and writing of this article.



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References
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Further Reading

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Keywords

lung transplantation, lung transplant, lung transplant pictures, lung pictures, advanced stage pulmonary disease, chronic obstructive pulmonary disease, interstitial lung disease, cystic fibrosis (CF), immunosuppression, lung disease, lung disease treatment, lung pictures, lung transplant pictures, lung disease pictures, tacrolimus, FK-506, cyclosporine A, cyclosporin, rejection, organ rejection, lung transplant rejection, bronchiolitis obliterans syndrome, OKT3, ATG, antithrombocyte globulin, forced vital capacity, FVC, FEV1, forced expiratory volume, expiratory volume, pulmonary arterial hypertension, single-lung transplantation, SLT, bilateral sequential lung transplantation, double-lung transplantation, single-lung transplant, double-lung transplant, heart-lung transplant, PEEP, peak end expiratory pressure, DLT, lung surgery

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Contributor Information and Disclosures

Author

Susan D Moffatt-Bruce, MD, PhD, FRCS(C), FACS, Assistant Professor, Division of Cardiothoracic Surgery, Department of Surgery, Assistant Professor, Department of Molecular Virology, Immunology and Medical Genetics, Surgical Director of Lung Transplantation, Deputy Director of Comprehensive Transplant Center, Ohio State University
Susan D Moffatt-Bruce, MD, PhD, FRCS(C), FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society of Transplant Surgeons, American Society of Transplantation, American Thoracic Society, Central Surgical Association, International Society for Heart and Lung Transplantation, Ohio State Medical Association, Royal College of Physicians and Surgeons of Canada, Society of Thoracic Surgeons, Transplantation Society, and Western Thoracic Surgical Association
Disclosure: Nothing to disclose.

Medical Editor

Jeffrey C Milliken, MD, Chief, Division of Cardiothoracic Surgery, University of California at Irvine Medical Center; Clinical Professor, Department of Surgery, University of California at Irvine School of Medicine
Jeffrey C Milliken, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, American Heart Association, American Society for Artificial Internal Organs, California Medical Association, International Society for Heart and Lung Transplantation, Phi Beta Kappa, Society of Thoracic Surgeons, Southwest Oncology Group, and Western Surgical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Shreekanth V Karwande, MBBS, Chair, Professor, Department of Surgery, Division of Cardiothoracic Surgery, University of Utah School of Medicine and Medical Center
Shreekanth V Karwande, MBBS is a member of the following medical societies: American Association for Thoracic Surgery, American College of Chest Physicians, American College of Surgeons, American Heart Association, Society of Critical Care Medicine, Society of Thoracic Surgeons, and Western Thoracic Surgical Association
Disclosure: Nothing to disclose.

Chief Editor

Mary C Mancini, MD, PhD, Professor and Chief, Cardiothoracic Surgery, Department of Surgery, Louisiana State University Health Sciences Center-Shreveport
Mary C Mancini, MD, PhD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Phi Beta Kappa, Society of Thoracic Surgeons, and Southern Surgical Association
Disclosure: Nothing to disclose.

 
 
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