O9.3 Lung Transplantation

Lung transplantation is a complex therapy for selected patients with severe COPD and it is indicated to improve quality-of-life and most likely improve survival. International guidelines (Weill 2015) and national consensus guidelines from the Australian Organ and Tissue Donation and Transplantation Authority http://www.tsanz.com.au/organallocationprotocols and NHRMC Ethical Guidelines for Organ Donation from Deceased Donors https://www.nhmrc.gov.au/guidelines-publications/e76 recommend COPD patients be referred to one of Australia’s four lung transplant centres for consideration of lung transplantation where the majority of the following are present:

  • Progressive symptoms, despite maximal treatment including medication, pulmonary rehabilitation, and oxygen therapy
  • Patient is not a candidate for endoscopic or surgical lung volume reduction surgery (LVRS). Simultaneous referral of COPD patients for both lung transplant and LVRS evaluation is appropriate
  • BODE index of 5-6
  • PaCO2 > 50 and/or PaO2 < 60 mmHg
  • FEV1 < 25% predicted

The absolute contraindications include recent malignancy, untreatable advanced dysfunction of another major organ system, psychological/psychiatric conditions associated with poor compliance, substance abuse or dependence (including ANY tobacco/marijuana) in the prior six months, absence of social support and poor rehabilitation potential. According to Weill, the Australian Organ and Tissue Donation and Transplantation Authority and the NHMRC, relative contraindications include age older than 65 years, obesity, malnutrition, severe symptomatic osteoporosis and colonisation with resistant/virulent organisms/viruses.

If successful transplantation is possible, a detailed multi-disciplinary medical assessment and eventual wait-listing for transplant may follow. Not all potential patients will be suitable or appropriate. Based on specific patient and donor variables, waiting times vary from one month to years. The 2014 Australian and New Zealand Cardiothoracic Organ Transplant Registry Report http://www.anzcotr.org.au/ states that the expected one, five and ten year survival rates post-transplant are 90%, 65% and 45%. Complex medications, regular investigations (eg: blood work, spirometry etc) and Transplant Centre follow-up are required indefinitely post-operatively.