Lung Transplantation:Lung Transplantation:What? Who? When?What? Who? When?

Marshall I. Hertz, MD

University of Minnesota Medical School and Fairview-University Medical Center

Medical Director, Lung Transplantation

Director, Center for Advanced Lung Disease

Topics for DiscussionTopics for Discussion

Organ transplantation in the USOrgan transplantation in the US

Overview of lung transplantationOverview of lung transplantation

Inadequate supply of lungs for Inadequate supply of lungs for

transplantationtransplantation

University of Minnesota

Major Biomedical Advances Major Biomedical Advances 1954-20041954-2004

VaccinesVaccines AntibioticsAntibiotics Life support technologiesLife support technologies Open heart surgeryOpen heart surgery Molecular geneticsMolecular genetics Organ transplantationOrgan transplantation

University of Minnesota

Organ Transplantation in the United StatesOrgan Transplantation in the United States1 Jan 1988 – 31 Jan 20051 Jan 1988 – 31 Jan 2005

OrganOrgan NumberNumber

KidneyKidney 201,846201,846

LiverLiver 69,05769,057

Pancreas*Pancreas* 16,67416,674

IntestineIntestine 977977

HeartHeart 36,76436,764

Lung*Lung* 13,32213,322

TotalTotal 338,640338,640

www.unos.orgUniversity of Minnesota

1963: First kidney transplant in Minnesota1963: First kidney transplant in Minnesota 1966: First pancreas transplant in the world1966: First pancreas transplant in the world 1966: First intestinal transplant in the world1966: First intestinal transplant in the world 1968: First successful human bone marrow transplant1968: First successful human bone marrow transplant 1978: First heart transplant in Minnesota1978: First heart transplant in Minnesota 1978: First living-donor pancreas transplant in the world1978: First living-donor pancreas transplant in the world 1981: First pediatric heart transplant in Minnesota1981: First pediatric heart transplant in Minnesota 1986: First heart-lung transplant in Minnesota1986: First heart-lung transplant in Minnesota 1988: First lung transplant in Minnesota1988: First lung transplant in Minnesota 1991: First living-related lung transplant in Minnesota1991: First living-related lung transplant in Minnesota 1996: First living donor liver transplant in Minnesota1996: First living donor liver transplant in Minnesota

U of M Firsts in TransplantationU of M Firsts in Transplantation

Organization of Transplant Services Organization of Transplant Services in the United Statesin the United States

Department of Health and Human ServicesDepartment of Health and Human Services– United Network for Organ SharingUnited Network for Organ Sharing

– Scientific Registry of Transplant RecipientsScientific Registry of Transplant Recipients

Organ Procurement Organizations (LifeSource)Organ Procurement Organizations (LifeSource) Transplant CentersTransplant Centers

– Physicians and surgeonsPhysicians and surgeons

– Nurse coordinatorsNurse coordinators

– Social workersSocial workers

– Administrators, financial representativesAdministrators, financial representatives

University of Minnesota

Types of Organ DonorsTypes of Organ Donors

Non-livingNon-living– Brain deathBrain death– Cardiac deathCardiac death

LivingLiving– Biologically relatedBiologically related– ““Emotionally” relatedEmotionally” related– Non-directed (“Good Samaritan”)Non-directed (“Good Samaritan”)

University of Minnesota

Living Donor TransplantationLiving Donor TransplantationU.S. Donors by Organ Type (2004)U.S. Donors by Organ Type (2004)

0

10002000

30004000

50006000

70008000

900010000

Kidney Liver Pancreas Intestine Lung

Non-living donation Living donation

UNOS

Types of Lung TransplantsTypes of Lung Transplants

Non-living donorNon-living donor– Single lungSingle lung– Bilateral (double)Bilateral (double)– Heart and lungHeart and lung

Living donorLiving donor– Bilateral (double) lobarBilateral (double) lobar

University of Minnesota

NUMBER OF LUNG TRANSPLANTS REPORTED BY YEAR AND PROCEDURE TYPE

0

200

400

600

800

1000

1200

1400

1600

1800

Num

ber

of T

rans

plan

ts

Bilateral/Double LungSingle Lung

13 15 46 83189

418

708

922

1089

1229

13681377

14641457

14771564

1602 17671703

ISHLT 2005

Types of Lung RecipientsTypes of Lung Recipients

Pulmonary fibrosisPulmonary fibrosis Emphysema/Alpha-1 Emphysema/Alpha-1

antitrypsin deficiencyantitrypsin deficiency Pulmonary hypertensionPulmonary hypertension– PrimaryPrimary– Congenital heart diseaseCongenital heart disease

Cystic fibrosisCystic fibrosis

University of Minnesota

ADULT LUNG TRANSPLANTATIONIndications By Year (Number)

0

250

500

750

1000

1250

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Transplant Year

Nu

mb

er o

f T

ran

spla

nts

Cystic Fibrosis IPF Emphysema A1A PPH

ISHLT 2005

Characteristics of Lung Transplant Characteristics of Lung Transplant Recipients with Pulmonary FibrosisRecipients with Pulmonary Fibrosis

•Severe disease

•Breathing tests (PFT)

•Exercise limitation (6-min. walk)

•Pulmonary hypertension (Echo)

•Age <65 years (55 for bilateral, 45 for heart-lung)

•Capable of following complicated medication schedule

•No severe disease in other organs (kidney, heart)

•Non-smoking, non-drinking

University of Minnesota

Problems after Organ TransplantationProblems after Organ Transplantation Immune system reacts against Immune system reacts against

transplanted organ (rejection)transplanted organ (rejection)– AcuteAcute– ChronicChronic

Medication side effectsMedication side effects

University of Minnesota

Outcomes after Lung TransplantationOutcomes after Lung Transplantation

FunctionFunction Quality of lifeQuality of life SurvivalSurvival

University of Minnesota

1995 1996 1997 1998 1999 2000 2001 2002 20030

10,00020,00030,00040,00050,00060,00070,00080,00090,000

Donors Transplants Wait List

““The Growing Need”The Growing Need”Organ Donors vs. Wait Listed PatientsOrgan Donors vs. Wait Listed Patients

Based on OPTN data as of January 26, 2004. www.life-source.org

The Donor Shortage:The Donor Shortage:Possible ApproachesPossible Approaches•Use more non-living donors

•Increased public awareness

•Presumed consent laws

•“Breakthrough collaborative”

•Use more living donors

•Xenotransplants, bioartificial lungs, stem cells

•Make better use of existing non-living donors

University of Minnesota

Current Lung Allocation System (1990)Current Lung Allocation System (1990)

Who?Who?– Based on active waiting time onlyBased on active waiting time only– 90 days of “extra” waiting time assigned to 90 days of “extra” waiting time assigned to

idiopathic pulmonary fibrosis patients (1995)idiopathic pulmonary fibrosis patients (1995) Where?Where?– Lungs offered first to recipients within the Lungs offered first to recipients within the

donor OPOdonor OPO– Then to recipients within concentric 500 mile Then to recipients within concentric 500 mile

circlescircles

University of Minnesota

Goals of the new lung allocation planGoals of the new lung allocation plan

Reduce waiting list deathsReduce waiting list deaths Improve overall survivalImprove overall survival

University of Minnesota

New lung allocation planNew lung allocation plan(May 4, 2005)(May 4, 2005)

• Based on disease type, disease severity, and expected survival after transplant

•Scores range from 1 to 100

•Patient information has to be updated every 6 months

•Blood group, size, and geography still matter

•Time on wait list does not count

University of Minnesota

Questions, answers?Questions, answers?