An International Case Study of Lung Transplantation

Selim M. Arcasoy, M.D.Professor of Medicine

Medical Director, Lung Transplantation Program

Director, Interstitial Lung Disease Program

New York-Presbyterian Hospital

Columbia University Medical Center

The Impact of Lung Disease

• Chronic, progressive and disabling symptoms– Breathlessness, cough, sputum production

• Decline in functional status and quality of life– Greater than 35 million Americans have lung disease

• Financial cost to society (>$150 billion per year)– Decreased work days and productivity, disability, costs

of medical care

• Premature mortality– Number 3 killer in the U.S. behind heart disease & cancer

– 400,000 Americans die of lung disease every year

– Responsible for one in six deaths

Four Major Lung Diseases Treatable with Lung Transplantation

• Chronic obstructive pulmonary disease (COPD)• Emphysema/chronic bronchitis due to tobacco

smoking or alpha1-antitrypsin deficiency (genetic)

• 12 million have COPD, 12 million are under-diagnosed

• Pulmonary fibrosis (scarring of the lungs)• End result of more than 200 diseases

• Affects >500,000 Americans

• Cystic fibrosis (CF): A genetic disease• ~30,000 Americans have CF with 1,000 new cases/yr

• Pulmonary hypertension

Cystic FibrosisPatient 1

• 9-year old girl – Diagnosed with CF at age 4 months

– Recurrent respiratory infections and low body weight

– Developed pulmonary MRSA infection 2 years prior

• Nine hospitalizations for intravenous antibiotics

• Lung function at 30% of predicted for her age and needs to use 3 LPM of supplemental oxygen

• Family makes contact with our Lung Txp Program– Required tests ordered and performed in Turkey

– Tests reviewed and family moves to U.S. for evaluation

Cystic FibrosisPatient 1

• First visit on April 6, 2007

• Further testing and consultations – Multidisciplinary team discussion

• Placed on the active lung transplant list

• Recurrent infections while awaiting transplant

• Lung transplantation on November 25, 2009

Cystic FibrosisPatient 2. A Case of Good Fortune

• Older sister of our first patient– Diagnosed at age 7 years

– Much healthier than her younger sister

• Attending school in the U.S. as her family moved for her sister’s transplant

• Becomes sicker in 2010– Lung function drops from 51% to 22%

– Hospitalized with fever and respiratory failure

– Urgent lung transplant evaluation and listing

• Lung transplantation performed on Sep 17, 2010

End-stage Lung

And, here they are….

Stages of Respiratory Disease and Failure

History of Lung Transplantation

JD Hardy, MD

June 11, 1963• 36 patients underwent lung transplantation between

1963 and 1975 with no long-term survivors

• Introduction of cyclosporine in 1978

• First successful heart-lung Tx performed in 1981, single lung Tx in 1983 and double lung Tx in 1986• 1954 - First successful kidney transplant• 1967 - First successful liver transplant• 1968 - First successful heart transplant

Number of Lung Transplants in the Last 3 Decades

JHLT. 2013 Oct; 32(10): 965-978

2013

YES

• Advanced lung disease with limited lifespan and severe functional limitation

• Lack of alternative therapies

• Demonstrated compliance with therapy and follow-up

• Strong family support

Who is a Candidate for Lung Transplant?General Guidelines

NO

• Active or recent cancer

• Advanced dysfunction of a major organ system

• Untreatable infection

• Substance addiction

• Documented noncompliance and lack of family support

A complex decision that requires extensive evaluation

and multidisciplinary team discussion

Patient characteristicsType of lung disease

Other medical illnessesPrognosis without transplant

Risks Mortality Morbidity Complexity

Benefits Survival Function Quality of Life

Lung Transplantation on a ScaleRisk-Benefit Balance

PatientExpectations

Steps From Initial Evaluation to Transplantation

• First visit to meet the transplant team• Focus on initial patient screening, assessment of

patient/family motivation, and education

• Extensive testing and consultations

• Multidisciplinary team meeting for a decision• Potential outcomes:

• Immediate active listing• Accepted as a potential future candidate, but needs to

meet certain goals or get sicker• Denial because of contraindications

Transplant Listing and The Call

• Patients are placed on the active national list

• All listed patients are assigned a Lung Allocation Score (LAS) based on their clinical characteristics• Age, disease, lung, heart and kidney function, labs

• Score ranging from 0 (less ill) to 100 (gravely ill)

• Waiting period with significant regional variation

• Donor and recipient matched by blood type and size

• Transplant has to occur within 6 to 8 hours after removal of lungs from the donor

Ex Vivo Lung Perfusion“Lung In A Box”

Extracorporeal Membrane Oxygenation

(ECMO)

Case 3

Before And After

25

14

20 18 1922

26

35

43

5155

46

57

51

59

67

0

10

20

30

40

50

60

70

80

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

NewYork-Presbyterian HospitalLung Transplant Volume Per Year

1996-2012

New Program

New York-Presbyterian HospitalLung Transplant Survival

7/01/2001 - 12/31/2012 (n = 559)

SurvivalNYPH vs UNOS1-year: 91% vs 84%5-year: 68% vs 53%10-year: 47% vs 28%

Functional Status Before and After Lung Transplantation

0%

20%

40%

60%

80%

100%

Pre-Tx 5 Years Post-Tx

Requires Total Assistance

Performs with SomeAssistance

No Activity Limitations

Employment Status Before and After Lung Transplantation

0%

20%

40%

60%

80%

100%

Pre-Tx 5 Years Post-Tx

Working Part Time

Working Full Time

Retired

Not Working