By Ramsey Hachem, M.D.
Washington University School of Medicine Barnes-Jewish Hospital
Division of Pulmonary and Critical Care
June, 2006
Over the past 25 years, lung trans-plantation has become a feasible treatment option for patients with end-stage lung disease. The first lung transplant procedure in man was performed in 1963 in Mississippi. The recipient suffered from lung cancer and chronic kidney disease and received a single lung transplant from a recipient who died of congestive heart failure. The procedure was successful and the recipient survived eighteen days, ultimately succumbing to malnutrition and kidney failure. Despite the outcome, this demonstrated that lung transplantation was technically feasible and that rejection could be prevented with the available immunosuppressants, at least for a short time. Over the next 15 years, few lung transplant procedures were performed, and the majority of recipients died early after surgery because of airway complications. However, in 1981, the first successful heart-lung transplantation was performed for pulmonary hypertension in California. This was followed in 1983 by the first successful single lung transplant for pulmonary fibrosis and in 1986 by the first double lung transplant for emphysema. These successes were attributed to improved surgical techniques and the advent of cyclosporine. Over the following several years, activity rapidly grew worldwide, and the operation became an accepted treatment for end-stage lung disease.
In recent years, approximately 1700 lung transplantations have been performed annually and the total number of procedures approaches 20,000 worldwide. But despite this vast experience, outcomes after lung transplantation have remained somewhat disappointing compared to other solid organ transplants. Several different measures can be used to assess outcome. Survival is perhaps the most straightforward gauge and the International Society for Heart and Lung Transplantation (ISHLT) has maintained a registry of lung transplant recipients from over a hundred centers worldwide. The Registry offers very robust information on actuarial survival for large numbers of recipients and can be accessed online at www.ishlt.org. According to the most recent Registry report, the median survival for all adult recipients is approximately five years. This means that one half of all recipients are living five years after transplantation. Ten years after transplantation only 25% of all recipients are living. The impact of recipient demographics, such as age, gender, and underlying diagnosis, on survival has been extensively evaluated. Obviously, the underlying diagnosis is usually linked to age since diseases such as cystic fibrosis and pulmonary hypertension often afflict younger patients than emphysema and pulmonary fibrosis. Not surprisingly, younger patients generally have a longer life expectancy. Indeed, recipients younger than 50 years of age have a 30% survival ten years after transplantation compared to a 12% survival among those over the age of 60.
However, the interaction between recipient age and diagnosis is complex. In addition, certain diagnoses carry higher risks of operative and post- operative complications that impact survival. In fact, those with pulmonary fibrosis and those with pulmonary hypertension are at increased risk of early graft dysfunction and usually require a longer recovery period in the intensive care unit and in the hospital. In addition, they generally have lower survival one and three months after transplantation compared to those with emphysema and those with cystic fibrosis. In general, recipients with emphysema and those with cystic fibrosis have the best one year survival, but those with emphysema have a significantly lower ten year survival compared to those with cystic fibrosis. In contrast, recipients with pulmonary hypertension have the lowest one year survival, but their ten year survival is similar to those with cystic fibrosis. Lastly, those with pulmonary fibrosis have lower one and ten year survival compared to those with emphysema and those with cystic fibrosis. But regardless of diagnosis or age, women generally have a better expected survival than men.
Nevertheless despite these survival results, the improvement in quality of life is perhaps the most striking reason that patients pursue lung transplantation. The majority has no exercise limitations and no longer needs supplemental oxygen within a few weeks of surgery. In fact, over 80% of five-year survivors have no activity limitations and many return to work or school. Multiple studies have demonstrated an improvement in health related quality of life after lung transplantation. Unfortunately however, this improvement in quality of life is limited by the development of chronic rejection which often reduces functional capacity as rejection progresses. Nonetheless, almost 90% of living recipients are satisfied with their decision to have a transplant and would encourage a friend to seek transplantation as a treatment for end-stage lung disease.