Yet, due in part to 2005 changes in the national guidelines used to determine priority on waiting lists for lungs, many physicians may be reluctant to evaluate emphysema patients for transplant. In the past, length of time on the national waiting list determined priority, but the 2005 changes mandated that patients with progressive lung diseases other than emphysema receive a higher priority due to the likelihood of successful transplantation and higher risk of death. Emphysema patients are less likely than patients with advanced cystic fibrosis or idiopathic pulmonary fibrosis to die while waiting for an organ.
"At UCSF, a majority of our transplant patients have lung fibrosis, rather than emphysema. Lung fibrosis has an improved outcome with transplantation—there is no alternative therapy. But carefully selected patients with emphysema also will benefit from transplantation. Some are likely to have both a better quality-of-life and survival benefit," says Golden. "I don't think many doctors realize we will even consider lung transplantation in patients age 65 and older."
Golden, who also conducts research on genes, medications and viruses that can influence the likelihood of transplant rejection and postsurgical complications, initiated the UCSF Lung Transplant Program in 1991. The program ranks among the top 10 percent worldwide in transplant procedures completed each year. A recent analysis by the Scientific Registry of Transplant Recipients indicates that the one-year survival rate for patients receiving lung transplants at UCSF significantly exceeds the national average. About 50 percent of all US lung transplant recipients survive five years or more.
Because the waiting list for lungs no longer operates on a first-come, first-served basis, patients at earlier stages of emphysema may not need to be listed for transplantation, Golden says. But he stresses that patients ought to be evaluated to determine whether they might later become transplant candidates.
An evaluation often helps a patient to begin to prepare psychologically. It also is a good time to stress the benefits of losing weight, since being overweight is a transplant risk as well as a general health risk, Golden says. The evaluation should be timed so that the patient is still able to benefit from active rehabilitation.
Emphysema patients also may benefit from more frequent use of common beta-adrenergic or anticholinergic drugs at an earlier stage of disease, Golden believes. In addition, he says, "I see no reason why an inhaled steroid should not be added early on, rather than waiting until the patient has more severe disease."
Patients on oxygen should be monitored not only when they are resting, but also when they walk. Keeping oxygen saturation up—to at least 88 percent—is clearly associated with reduced mortality, Golden says.
All patients should be told to stop smoking. Patients being considered for lung transplantation at UCSF must have stopped smoking at least six months prior to surgery.
Active rehabilitation is crucial for emphysema patients who are not candidates for surgery, as well as for surgical patients before and after transplantation, according to Golden. "One of the biggest problems, pretransplant, is simply that patients are not part of an active rehabilitation program. Patients decrease their exercise activity once they sense they are short of breath. They then become more deconditioned, which causes them to become yet more burdened by exercise."
Physical rehabilitation is offered at UCSF for lung transplant patients before and after surgery, as well as for those with advanced lung disease. In addition, the Physical Therapy and Wellness Clinic at UCSF Mission Bay offers consultations and classes for emphysema patients who are not surgery candidates.
To contact Jeffrey Golden, M.D., call (415) 353- 2961.
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