When to Refer for Lung Transplant

UH Harrington Heart & Vascular Institute Update | September/October 2023

By Silpa Kilaru, MD, Medical Director, Lung Transplant

For patients with end-stage lung disease such as chronic obstructive pulmonary disease (COPD) and idiopathic pulmonary fibrosis/interstitial lung disease (IPF/ILD), lung transplant can be a viable option for motivated and robust patients. The majority of patients who are referred for transplant have one of these conditions (COPD 26 percent and IPF 29 percent) based on the 2022 International Society for Heart and Lung Transplant registry. Other indications for transplant include pulmonary arterial hypertension (PAH), sarcoidosis, coal workers pneumoconiosis, alpha 1 anti-trypsin deficiency, cystic fibrosis, bronchiectasis, scleroderma and COVID fibrosis.

Silpa Kilaru, MD

COPD

Transplant for COPD is an option for patients with progressive disease despite maximal treatment including medication, pulmonary rehabilitation and supplemental oxygen. Lung transplant for COPD is primarily for better quality of life. Often patients can live for many years with COPD with supplemental oxygen; thus transplant is a conscious decision for lifestyle improvement.

• Their BODE score(Body mass index, airflow Obstruction, Dyspnea and Exercise capacity – a predictor of number and severity of acute COPD exacerbations) should be 7-10, with evidence of hypercapnia.
• Forced expiratory volume (FEV) 1 < 15% and three or more exacerbations a year. If they have moderate to severe PAH, they should also be considered for lung transplant sooner.

Idiopathic Pulmonary Fibrosis/interstitial Lung Disease (IPF/ILD)

In contrast, transplant for IPF/ILD is for survival benefit. Unfortunately, there are no proven therapies that ultimately prevent disease progression in this patient population and transplant is the only option. Early referral is the key and patients should be referred for transplant as soon as there is histopathologic or radiographic evidence of usual interstitial pneumonia regardless of lung function. Even if patients are not on supplemental oxygen at rest or with exertion, they should be referred for early evaluation. Other parameters to consider include:

• decline in forced vital capacity (FVC) over 10 percent during past six months
• decline in diffusing capacity of the lungs for carbon monoxide (DLCO) over 15 percent during the past six months
• evidence of pulmonary arterial hypertension, which should also prompt an early referral.

A Thorough Process with a Full Team

The evaluation for lung transplant is complex, requiring one to two weeks of rigorous testing, including lab work, radiographic studies, a right and left heart catheterization and colonoscopy. Patients need to complete health maintenance including DEXA scan, dental clearance and immunizations. They also need to meet the various members of the team including a transplant pulmonologist, surgeon, social worker, financial support, psychiatry and nutrition.

Lung transplant is a rigorous endeavor and patients and their families need to understand that this is a significant lifestyle change requiring frequent follow-up for the rest of their lives post-transplant to ensure optimal care. Lung transplant is journey that may have many complications along the way, however, for a select patient population it does offer a second chance that is truly rewarding.

We are happy to evaluate any referrals for lung transplant. Please call 216-844-2407 or email Silpa.Kilaru@UHhospitals.org for further information.