Dr. Jasleen Kukreja is a thoracic surgeon and program director of the UCSF Medical Center Lung Transplant Program. In 2014, the Scientific Registry of Transplant Recipients (SRTR) identified UCSF as the only program in the nation with higher than expected patient and graft survival rates. In terms of overall patient survival, UCSFs Lung Transplant Program is one of the most successful in the country. A part of the program since 2007, Kukreja shares her insights on why UCSF is among the top in the nation for patient survival.
UCSF's Lung Transplant Program is the nation's best in terms of patient survival and graft survival (survival of the transplanted lungs). What makes UCSF stand out?
Lung transplant is all about teamwork and we have a truly spectacular team. Every person in the program — pulmonologists, nursing staff, pre-op and post-operative coordinators, respiratory therapist, physical therapist, pharmacy staff and surgeons — is top-notch.
We also work very closely with patients to prepare them for transplant. That includes educating them about what to expect before, during, and, after surgery. By preparing our patients for what's to come, we can alleviate a lot of their anxiety.
Lung transplants are among the riskiest of transplant procedures. Why is that?
Few people realize that the surface area of the lungs is larger than the surface area of the skin. With every breath the lungs are exposed to potential airborne pathogens or toxins. That constant exposure makes it harder to care for a lung transplant patient than, say, someone with a kidney or even a heart transplant. That's one reason why long-term survival rates for lung transplant patients aren't as high as those with other solid organ transplants.
What's key to remember when looking at long-term survival rates is that by the time a patient comes through our door he or she is very sick. Without a transplant, death is almost certain. So we are very happy that 96 percent of our patients survive one year after lung transplant. With that high of a number I can tell my patients that, unless something dramatically unexpected happens, we will get them through the first year.
But chronic rejection is still a huge problem. No one knows why but most people's bodies eventually reject the new lungs. The good news is that we are better equipped to handle rejection than ever before. Today more than 50 percent of our patients make it to the 5-year mark. But we are dedicated to getting that number even higher.
How long does the typical lung transplant operation take?
On average, a bilateral lung transplant takes about eight hours but I've stayed in the operating room for as long as 16 or 17 hours at a time. A single lung transplant takes about half that amount of time. At UCSF we do mostly bilateral, whereas some other major centers do more single lung transplants.
UCSF has a reputation for accepting patients who are too sick to qualify for transplant at other centers. What's the key to success even with a high-risk patient population?
We don't shy away from high-risk patients and, it's true, we have been very fortunate to still have the best outcomes. I've had people who we were doing CPR on and then successfully transplanted and are now several years out. The majority of transplant programs would not take those patients, but I've had good success with them. Our success boils down to our aggressive perioperative management as well as long-term comprehensive monitoring. Again, it's all about teamwork.
How does it feel to save patients others deem too sick for transplant?
Restoring a person's ability to breathe is one of the most satisfying parts of my job. When I meet them, they are hanging on for dear life. After transplant, they send me photos, postcards from vacations where they are skiing, rock climbing, surfing, jogging, and biking. Lung transplant patients are keenly aware that they've been given a second chance at life, and they don't want to waste a single second.
Is it true that most donated lungs are too damaged to use?
It is. Unfortunately, only 20 percent of donated lungs are acceptable for transplant. The majority of donated lungs come from brain-dead donors who have been on ventilators, which are notorious for damaging the lungs. Being on a ventilator also increases the odds of a lung infection. In cases, where the donor suffered a fatal, traumatic injury, the lungs are often too bruised to transplant. The lungs are very delicate.
How does the transplant list work? Is it first come, first served?
Lung transplants used to be performed on a first-come, first-served basis but we realized that the people who needed transplants most urgently (the sickest) were the least likely to survive the wait. Now the system is designed so that the sickest patients go to the front of the line because they stand to benefit the most. Since making that change, the number of patients who die while waiting for a transplant has declined.
What can be done to increase the number of lungs available for transplant?
As it turns out, if given time, even infected or slightly bruised lungs can regain normal function. Currently, we are taking part in two international trials looking at improving the function of donated lungs prior to transplant. The lungs are put on a type of heart-lung machine that pumps them full of blood and antibiotics to ward off infection as well as to supply them oxygen. The early results are very encouraging. If all goes well, this new approach could significantly increase the donor pool, which will reduce waiting time on the list and save lives. In fact, these so-called "breathing lungs" may even prove to work better than lungs that are treated in the "normal" way, meaning they are put on ice without oxygen or blood before transplant. So this research has the potential to set a new precedent for the standard of care.
As a transplant surgeon, what other factors come into play?
Donated organs are a very precious resource. Our team puts a lot of thought into every lung transplant. We need to balance the needs of the patient with the needs of the donor's family during what is usually a very painful time. The family wants their loved one's gift to be put to the best possible use. It's up to the transplant team to help discern who will benefit the most from this organ. We weigh each case from a scientific and ethical point of view. It's never an easy decision, but the complexity of each case is one of the things that makes organ transplant surgery so rewarding.
Why did you become a thoracic surgeon?
When I was training as a general surgeon, I operated on everything but the chest. The mystique of the thoracic cavity was a big draw. I was curious. I wanted to get my hands in there. It was a challenge. I knew there weren't a lot of women who went into cardiothoracic surgery, which made it that much more appealing. And I am very glad I made the choice to become chest surgeon.
What do you like most about your job?
My job gives me an enormous amount of pleasure. I am humbled and exhilarated by my patients and by seeing what the human body is capable of overcoming. Not that many people can say that about their job. I also enjoy working with a team of people who are unbelievably brilliant and dedicated, while, at the same time, funny and easygoing. I am truly grateful for the experience.
Interviewed by freelance writer Catherine Guthrie
Photo by Tom Seawell
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