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October 2008

Early Evaluation for Lung Transplants Important for Emphysema Patients

Jeffrey Golden, M.D.
Medical Director
UCSF Lung Transplant Program

Patients with emphysema, which affects more than 3 million people in the United States, have some of the best rates of survival following lung transplantation. A recent analysis by the Scientific Registry of Transplant Recipients reported that the one-year survival rate for lung transplant patients at UCSF Medical Center is 90 percent while the five-year survival rate is 50 percent. These rates exceed the national average, which is 78 percent for one-year and 45 percent for five-year survival.

Despite these promising outcomes, many doctors are reluctant to refer or evaluate emphysema patients for lung transplant. This may be due in part to a 2005 change in national guidelines that no longer call for a first-come, first-serve lung wait list but mandate that patients with progressive lung disease other than emphysema receive a higher priority due to the likelihood of successful transplantation and higher risk of death while waiting for a transplant.

Emphysema patients are less likely than patients with advanced cystic fibrosis or idiopathic pulmonary fibrosis to die while waiting for an organ. However, a lung transplant, which is the only cure for the disease, should be considered for patients with severe or end-stage emphysema who experience progressive deterioration in quality of life and exercise tolerance.

Transplant Evaluation

Emphysema patients may be candidates for single or double lung transplants, depending on individual characteristics and organ availability. Both options have similar risks and complications. However, patients who have undergone double lung transplantation, rather than single, have a slightly higher long-term survival rate.

Despite the 2005 guidelines, it is important that emphysema patients be evaluated early for transplant. Comorbidities recorded during evaluation may give patients higher points for transplant. In addition, an evaluation often helps patients prepare psychologically and medically for the procedure.

For instance, it could encourage overweight patients to lose weight since being overweight is a transplant risk or motivate them to stop smoking since patients being considered for transplant at UCSF Medical Center must have stopped smoking at least six months prior to transplant. Smoking cessation is crucial for all emphysema patients, regardless of their transplant candidacy.

Transplant candidates and pre-transplant patients often decrease their exercise activity once they sense they are short of breath, causing them to become increasingly deconditioned, jeopardizing their health and their transplant. Physical rehabilitation is an integral part of inpatient and outpatient care for lung transplant recipients at UCSF. The Physical Therapy and Wellness Clinic at UCSF Mission Bay offers consultations and classes in rehabilitation conditioning for emphysema patients who are not surgery candidates.

Earlier Approach to Medical Treatment

Emphysema patients also may benefit from being prescribed certain medications in the early stages of disease, rather than later when the condition has progressed and symptoms are severe. These include the frequent use of beta-adrenergic or anticholinergic drugs, inhaled steroids and oxygen therapy.

Patients receiving oxygen should be monitored not only when resting, but also when they walk. Keeping oxygen saturation high — to at least 88 percent — is clearly associated with reduced mortality.

Research

Since its inception in 1991, the UCSF Lung Transplant Program ranks among the top 10 percent worldwide in transplant procedures completed each year. The program performed 35 lung transplants in 2007 and nine of those patients had emphysema.

Experts are studying ways to predict and prevent obliterative bronciolitis (OB) — the foremost obstacle to prolonged survival in lung transplant recipients. OB is a manifestation of chronic allograft rejection following lung transplantation from an unrelated donor. It develops in nearly 50 percent of all patients who receive organs from an unrelated donor. UCSF is investigating the use of ultra-fast, high-resolution CT scanning to predict impending OB, a novel endobronchial airway biopsy technique to assess early pathogenetic events leading to airway rejection and the detection of increased fibroblast proliferative activity in serial lavage fluid.

Researchers also have begun a proteomic study in serial bronchoscopic-derived material to detect epithelial markers of injury which could be predictive of OB.

Other new therapies to prevent rejection, including a new anti-fibrotic immunosuppressant called Rapamyacin and inhaled cyclosporine are being investigated.

For more information, contact the Physician Referral Service at UCSF Medical Center:

Phone (888) 689-UCSF or (888) 689-8273
Email referral.center@ucsfmedctr.org

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