Lung transplantation: a review of the optimal strategies for referral and patient selection

Abstract

One of the great challenges of lung transplantation is to bridge the dichotomy between supply and demand of donor organs so that the maximum number of potential recipients achieve a meaningful benefit in improvements in survival and quality of life. To achieve this laudable goal is predicated on choosing candidates who are sufficiently unwell, in fact possessing a terminal respiratory illness, but otherwise fit and able to undergo major surgery and a prolonged recuperation and rehabilitation stage combined with ongoing adherence to complex medical therapies. The choice of potential candidate and the timing of that referral is at times perhaps more art than science, but there are a number of solid guidelines for specific illnesses to assist the interested clinician. In this regard, the relationship between the referring clinician and the lung transplant unit is a critical one. It is an ongoing and dynamic process of education and two way communication, which is a marker of the professionalism of a highly performing unit. Lung transplantation is ultimately a team effort where the recipient is the key player. That principle has been enshrined in the three consensus position statements regarding selection criteria for lung and heart-lung transplantation promulgated by the International Society for Heart and Lung Transplantation over the last two decades. During this period, the number of indications for lung transplantation have broadened and the number of contraindications reduced. Risk management is paramount in the pre- and perioperative period to effect early successful outcomes. While it is not the province of this review to reiterate the detailed listing of those factors, an overview position will be developed that describes the rationale and evidence for selected criteria where that exists. Importantly, the authors will attempt to provide an historical and experiential basis for making these important and life-determining decisions. The reviews of this paper are available via the supplementary material section.

Waiting time and mortality rate on lung transplant candidates in Japan: a single-center retrospective cohort study

“…Advance in lung transplantation (LTX) has continued to evolve over the last decades and LTX has become a valuable option for selected patients with end-stage pulmonary disease. Delayed referral to a transplant center limits the opportunity for LTX; however, timely referral is difficult for most pulmonary diseases given the limited studies on listed individuals and limited evidence regarding proper consultation for LTX in each pulmonary disease [ 1 , 2 ]. This issue is more apparent in low-volume transplant centers or countries with severe donor shortages.…”

“…Following approval for transplant candidacy, the patients are registered to the Japan Organ Transplant Network (JOTN) and listed at each LTX center. The present system at JOTN allocates cadaveric donor lungs to candidates according to [ 1 ] donor age (under age of 18 preferentially to candidates under age of 18), [ 2 ] matched lung volume (with the ratio of 0.7–1.3 in the predicted vital capacity), [ 3 ] compatible ABO blood type (preferentially identical), and [ 4 ] waiting time (preferentially longer candidates on the wait list). Based on the current system that urgency is not considered, the waiting time is crucially considered in recipient selection.…”

The Anesthetic Management of the First Lung Transplant for a Patient with COVID-19 Respiratory Failure

“…The current evidence supports that younger recipients with single-system disorders will have better outcomes. 14 The protective measures for healthcare providers in the perioperative setting is another important aspect in managing COVID-19 patients. [15][16][17][18] During the 2003 SARS outbreak in Ontario, Canada, 51% of cases were healthcare workers.…”

Bilateral sequential lung transplantation: technical aspects

“…Advancements in LTx care has allowed us to mitigate these issues; however, BS-LTx is still the preferred approach today for obstructive lung disease. In cases of bullous emphysema, BS-LTx is the optimal approach, especially with a diagnosis of alpha-1 antitrypsin deficiency (18). Technically, incision at the 5 th intercostal space, as opposed to the 4 th for fibrotic lung disease, is recommended by some centers when using clamshell approach (19).…”