When can a patient with COPD be considered for lung transplantation?
COPD, or chronic obstructive pulmonary disease, refers to a group of diseases that include chronic bronchitis, emphysema, and asthmatic bronchitis. The characteristic common to these diseases is obstruction to airflow out of the lungs. One of the major and most debilitating symptoms of COPD is shortness of breath. Participating in pulmonary rehabilitation programs and taking medications can usually keep this in check, allowing a patient with COPD to maintain a good quality of life. However, sometimes the disease worsens to the point where it is difficult for someone who suffers from COPD to take a shower or even reach down to tie his shoes. If a person with COPD reaches this level of discomfort, he or she may be a lung transplant candidate, although there are many other criteria that must also be fulfilled.
Who is likely to be a good lung transplant candidate?
Each year, at least 110 thousand people die in the United States from COPD, and yet less than fifteen hundred lung transplants are performed in the whole world. Clearly, only a tiny, carefully selected group of patients are chosen as candidates for lung transplantation.
The medical factors
To be considered, you should be in good health aside from your lung problem. It may be okay to have diseases like high blood pressure, diabetes, or ulcers, as long as these problems are controlled by medication, and you have not suffered any damage to your internal organs as a result of the disease. Other conditions-like osteoporosis, extreme obesity or heart disease (most often coronary artery disease)-are bigger problems because they can worsen after the transplant or cause complications during the operation that can reduce chances of survival. You may need special tests and/or treatment if you have these conditions before the transplant team can decide whether or not you are a transplant candidate. Also keep in mind that, in general, to be selected for lung transplant you should not be older than 65.
Other Factors
Medical factors are only one part of the selection process for lung transplant recipients. It is just as important to know whether you and your family can cope with the extensive medication regimen and follow up visits that are required following the transplant. You must be able and willing to comply with detailed instructions and should not be using alcohol, tobacco or narcotics for at least six months before applying.
Any significant psychiatric illness, such anxiety or depression, should be treated prior to the application process. Family members need to understand the transplant process and be willing to offer emotional support to the transplant recipient. In addition, transplant often places a severe financial burden on families. Even though insurance plans usually cover the transplant process, many do not include adequate medication coverage for the lifetime of the transplant recipient. For example, it is not uncommon for medication after transplant to cost as much as $2,000 per month. These issues should be carefully investigated with your insurance company before considering the possibility of transplant.
Are there specific test results that would indicate that I am sick enough for transplant?
Specialists have come up with a set of numbers that generally suggest when patients with COPD are ill enough to be considered for transplant. The most important tools used to determine the level of a candidate's illness are breathing tests. In general, if your forced expiratory volume in one second (FEV1) is less than 25 per cent of that predicted for your age, sex and height, you are ill enough to be considered. If you have done breathing tests, your doctor can give you this information. It is important to know that there is a "transplant window" and that if you become too ill-for example, if you can no longer walk around-you may not be eligible for transplant because you may not be strong enough to survive the operation.
What type of transplant would I receive?
You would most likely receive a single (or unilateral) lung transplant, as this is the most common transplant procedure for COPD patients. In single lung transplant surgeries, one of the COPD lungs is removed and replaced by a normal donor lung. The other, "native lung", is left in place. A person can function quite well on one lung, and receiving only one lung allows the donor's organs to be beneficial to two patients.
What happens if I am selected as a transplant candidate?
If you are selected as a transplant candidate, you are placed on a national waiting list administered by the United Network for Organ Sharing (UNOS)-which works with all donor organizations in the country-until a donor organ is available. Because of the extreme shortage of donor organs, especially of lungs, you would likely wait for anywhere from several months to more than two years. During the waiting period, it is very important that you keep yourself in the best possible condition so that you continue to be in the "transplant window" and give yourself the best chance of survival. You should continue to exercise on a regular basis (preferably in a pulmonary rehabilitation program), have supplemental oxygen requirements checked every three to six months, follow good nutrition, get adequate sleep, and practice preventive care.
What happens after the transplant?
Many people have an unrealistic expectation of life after transplant. In some ways, having a lung transplant is just trading one set of chronic health problems for a much more complex set of problems.
Medications
After the operation, you have to take a number of drugs to keep your body from rejecting the new lung. These immunosuppressive drugs are so potent they can have bad effects on some of the other organs in your body-which is one reason we are so careful to make sure you do not have damage to these organs before you are transplanted. Despite this risk, most people tolerate the immunosuppressive drugs fairly well for a number of years. All lung transplant recipients will have to take either cyclosporine (usually the brand Neoral) or tacrolimus (brand name Prograf) and one or two other immunosuppressive drugs. Other drugs in this group include azathioprine (Imuran), mycophenolate mofetil (Cellcept) and prednisone. A new drug being used by some transplant centers is called sirolimus (brand name Rapamune).
Occasionally, antibody drugs are used early after transplant to initiate the immunosuppression. These short-term drugs are known as antilymphocyte (cytolytic) antibody drugs which destroy lymphocytes or drugs which block the IL-2 receptor and do not allow the lymphocytes to become active against the grafted lung.
How long does it take to recover?
It usually takes a few months for a transplant patient to really feel back to normal. Your body takes some time to get used to the immunosuppressive drugs. In addition to that course of medication, you will probably also be taking one or more drugs to reduce your susceptibility to infection-a problem often caused by the immunosuppressive drugs. These can be hard on your stomach and may cause high blood pressure, so you might also be taking medications for those problems as well.
What do I need to be watching for after the operation?
The two biggest problems that occur early after transplant are acute rejection of the lung and infection. Because of the immunosuppression, you can develop unusual infections, so you must be tuned into even the smallest changes in your condition. Slight fevers or a little malaise or shortness of breath can mean a serious infection, and should trigger a visit to the doctor. In addition, for the first few months after transplant your transplant doctors will see you frequently, measuring your lung function, checking your blood, and probably performing one or two bronchoscopies-a procedure in which a flexible tube is passed either via your mouth or nose through the vocal cords and into the airways of the lung. In this way we are able to see the new lung "connections" and to take samples of the new lung for study, to make sure there is no rejection or infection.
What will I be able to do after transplant?
If everything goes well, you will be able to live a pretty normal life. You can do the things most people do, but you will not be able to participate in strenuous sports. Transplant recipients, however, are often very active, returning to work and living a full life. You should be careful to avoid children with respiratory viral infections or others with similar infections, and avoid known contagious diseases, as your immune system is no longer as able to ward off these diseases.
How long do people live after lung transplants?
Some patients are still alive ten years after a lung transplant; statistically however, the hard truth is that about half the patients will die within five years after transplant. People die from infections and from chronic rejection primarily, but they also die from the toxic effects of the immunosuppressive medicines. Chronic rejection resulting in bronchiolitis obliterans accounts for about half of the late deaths. Because of these problems, some transplanted patients die even sooner than if they had not been transplanted.
What is bronchiolitis obliterans?
Bronchiolitis obliterans is the scarring down of the small airways in the lung so that it becomes impossible for air to move through them. In its early stages, transplant recipients are often not even aware they are developing it. The main symptoms are malaise with mild shortness of breath, but sometimes there are no symptoms at all. It can often be picked up early on lung function studies even before symptoms occur. Unfortunately, by the time it is detected, bronchiolitis obliterans is very difficult or impossible to treat. Changes in immunosuppression can slow the progression of the disease, but the damage that is already present is rarely reversed. Thus, it is extremely important to have frequent lung function tests to watch for this problem. Usually, it does not occur until at least six months after the transplant, but can occur at any time after that.
What about complications of the immunosuppressive drugs?
The most common complications are tremor, which is usually mild and goes away by itself, and hair growth, which can result from the immunosuppressive drug cyclosporine. Some reduction in kidney function probably occurs in all patients, but in only 5-10 percent does it become serious enough to result in kidney failure-and usually that occurs several years after the operation. Another common complication of immunosuppressive drugs is nausea, often due to delayed emptying of the stomach.
Other problems include:
- high blood pressure
- seizures
- headaches
- osteoporosis
- chronic anemia
- blood clots
The blood clots are often related to intravenous catheters that are used for IV antibiotics and other drugs rather than the medications themselves.
Post transplant patients are also more prone to cancers. The most common cancer early after transplant is called posttransplant lymphoproliferative disorder (PTLD) and it is related to infection with the Epstein-Barr virus, the same virus that causes mononucleosis. It usually occurs within a year after transplant.
What about my usual preventive health care?
One of the biggest mistakes you can make is to forget your routine care after a lung transplant. The immunosuppressive drugs make it easier for your body to develop other types of cancers, as well as the PTLD noted above. Women should have yearly pap smears and mammograms and men should have their PSA's checked. Both men and women should have annual sigmoidoscopy or colonoscopy, especially if there is any history of cancer in the family. Up to 10 percent of late survivors of transplants die of medical complications unrelated to the transplant itself.
