Lung transplant

Lung transplant program in San Antonio

Lung transplant

Individuals with lung disease are likely to experience a variety of symptoms such as shortness of breath, chronic cough and exhaustion. If left untreated, lung disease can be deadly.

Patients with serious lung diseases who meet certain criteria may be a candidate to receive a lung transplant. Lung transplantation can be considered when a patient with advanced lung disease has failed other medical or surgical therapies.

Lung transplantation for patients with severe diseases of the lung — such as emphysema, cystic fibrosis, pulmonary fibrosis, sarcoidosis and pulmonary hypertension — is considered only after all other treatments have failed. In some cases, congenital heart disease may cause advanced lung disease, requiring repair of these heart defects at the time of lung transplantation.

Methodist Hospital Lung Transplant Program is designed to give each lung transplant patient a personalized treatment plan. Our multidisciplinary team collaborates with patients and their support systems from eligibility through recovery. We are here to navigate patients every step of the way.

To schedule a consultation, call (210) 575-9500 or submit a request.

Individuals eligible for a lung transplant typically suffer from any of several serious lung diseases, including:

• Alpha-1-antitrypsin deficiency
• Chronic obstructive pulmonary disease (COPD), including emphysema
• Cystic fibrosis
• Interstitial lung disease
• Lymphangioleiomyomatosis
• Pulmonary fibrosis
• Pulmonary arterial hypertension
• Sarcoidosis
• Severe bronchiectasis

Our multi-disciplinary selection committee reviews each candidate’s eligibility on an individual basis.

General candidate eligibility considerations:

• High (>50%) risk of death from lung disease within two years if lung transplantation is not performed
• High (>80%) likelihood of surviving at least 90 days after lung transplantation
• High (>80%) likelihood of 1–year post-transplant survival from a general medical perspective provided there is adequate graft function

Absolute contraindications:

• Recent history of malignancy. A 2-year disease-free interval combined with a low predicted risk of recurrence after lung transplantation may be considered. However, a 5-year disease-free interval should be demonstrated in most cases.
• Poorly controlled significant dysfunction of another major organ system unless combined organ transplantation can be performed.
• Uncorrected atherosclerotic disease with suspected or confirmed end-organ ischemia or dysfunction and/or coronary artery disease not amenable to revascularization.
• Acute medical instability, including, but not limited to, acute sepsis, myocardial infarction, and liver failure.
• Uncorrectable bleeding diathesis.
• Chronic infection with highly virulent and/or resistant microbes that are poorly controlled pre-transplant.
• Evidence of active Mycobacterium tuberculosis infection.
• Significant chest wall or spinal deformity expected to cause severe restriction after transplantation.
• Class II or III obesity (BMI ≥35).
• Current non-adherence to medical therapy or a history of repeated or prolonged episodes of non-adherence to medical therapy.
• Psychiatric or psychologic conditions associated with the inability to cooperate with the medical team and/or adhere to complex medical therapy.
• Absence of an adequate or reliable social support system.
• Severely limited functional status with poor rehabilitation potential.

Our transplant team will evaluate each patient to determine whether a lung transplant may be beneficial. A comprehensive evaluation will include lung function tests, blood tests, imaging scans and other indicated studies. Specialists will screen for other serious conditions, including chronic infections, cancer, and cardiovascular disease.

Meet the lung transplant team

The Methodist Hospital Lung Transplant Team is comprised of a diverse group of health care professions, including physicians, nurses, nurse practitioners, social workers, dietitians, and physical therapists.

Lung doctors (pulmonologists): These medical doctors are specially trained to care for patients with advanced lung disease and lung transplant recipients. The lung doctors will see you before transplant to determine if a lung transplant is the best option for you. They will also see you routinely after transplant to keep your new lungs healthy for as long as possible and will provide the majority of your post-transplant care.

Transplant Surgeons: These doctors will perform the transplant operation. You will meet the surgeons during your evaluation and explain the risks related to the surgery. After transplant, they will check your incision and take care of any surgical problems.

Transplant Nurse Practitioners: These registered nurses have advanced practice degrees and transplant training. They work with the doctors to help care for you in the hospital and during your clinic visits.

Transplant Coordinators: These nurses teach you and your caregivers about the transplant process. They will also coordinate your care before and after transplant. They are generally your first point of contact for issues that arise before or after lung transplant.

Transplant Social Worker: The transplant social worker focuses on the emotional and social parts of the transplant process. He or she will evaluate your ability to cope with the impact that lung transplantation will have on you and your family. The social worker will also provide information about local resources, support, and counseling.

Transplant Clinical Pharmacist: This specialized pharmacist will educate you about your transplant medications, including side effects and drug interactions. He or she will review your medications each time you are seen in clinic.

Dietician: The dietician (nutritionist) will talk to you about your diet and nutritional needs and maintaining a healthy weight.

Transplant Financial Coordinator: The financial coordinator will review your insurance benefits and provide information about the potential cost to you of a transplant.

Why you require a lung transplantation

There are a variety of diseases that affect the lungs such that they no longer function properly. In these cases, lung transplant can be considered.

These diseases include:

• Pulmonary fibrosis (scarring of the lung)
• Chronic obstructive pulmonary disease (COPD) or emphysema
• Cystic fibrosis
• Bronchiectasis
• Pulmonary arterial hypertension
• Sarcoidosis
• Lymphangioleiomyomatosis (LAM)
• Congenital heart disease with Eisenmenger syndrome
• Other rare diseases

You may be considered for a lung transplant if:

• You have severe and progressive lung disease that is no longer responding to the most complete and effective treatment.
• You have a disease or condition for which transplant is considered to be effective.
• You are willing to accept the risks of surgery and the subsequent lifelong medical treatment.
• You are physically and emotionally capable of undergoing surgery and subsequent medical treatment.
• You are not using tobacco or any form of nicotine and not abusing alcohol or drugs.
• You have a reliable social support system.

Types of transplants

Single- or Double-Lung Transplantation

Based on your lung disease, your overall health, and availability of donor lungs, the transplant team may decide to replace one or both of your lungs.

Heart-Lung Transplantation

Rarely, the lungs and the heart are replaced at the same time. This is considered when the lung disease affects both the heart and lungs and both are irreversibly damaged.

Benefits and risks of lung transplantation

Benefits

Lung transplantation has the potential to extend your life and improve the quality of your life. However, it is not possible to predict how long you will live after a lung transplant.

• Nationally, approximately 85 to 89 percent of patients survive to 1 year after transplant.
• The average survival of patients after a lung transplant is 6 to 7 years.
• More than 80 percent of patients are satisfied with their decision to have a transplant.
• About 80 percent of lung transplant recipients are able to perform daily activities without restriction.

Each lung transplant center has survival statistics for its transplant programs. For transplant programs in the United States, these statistics are collected by the Scientific Registry of Transplant Recipients and are publicly available.

Risks

Two of the most common complications after lung transplant are rejection and infection. Rejection occurs when the body recognizes that the transplanted lungs are not your own, leading your immune system to try to attack the new lungs. To prevent or delay rejection, medications known as immunosuppressants or anti-rejection medications are used to suppress the immune system. These include standard medications and stronger medications if needed. The dosages of these drugs may be adjusted frequently in response to drug levels in the blood, rejection, or side effects. Rejection may occur despite use of these medications.

Because of these anti-rejection medications, the immune system will be less able to fight infection from bacteria, viruses, and mold. You may get infected more easily and infections can be severe. You will need to take special precautions to avoid exposure to infections and report any symptoms of infection immediately to the transplant team.

Other complications may result from the stress of the surgery or medication side effects. This may include strain on other organs such as the liver, kidneys, heart, or bone marrow. You will also be at increased risk for developing some types of cancer, especially skin cancer. In addition, you may have long-term problems with the function of your transplanted lungs.

Lung transplant evaluation

Initial visit

You will first meet with a lung transplant pulmonologist at Methodist Hospital San Antonio. You will get some blood work, lung function testing (pulmonary function tests or PFTs), a walk test, and a CT scan if you haven’t had one performed recently. If you and the lung transplant team determine that you should move forward with the lung transplantation process, you will be scheduled to complete a lung transplant evaluation. If it’s too early to consider a transplant or if there are other concerns, the evaluation may be delayed or not recommended.

Evaluation

Even if you have a severe lung condition, the transplant team may decide that you are not a good candidate for a transplant if you have other problems that may affect the safety and success of a transplant. In order to determine if you are a good candidate as quickly as possible, you must undergo a transplant evaluation. The evaluation includes blood work, imaging studies (x-rays and CT scans), and consultations with different members of the transplant team. This evaluation will be done over several appointments and generally takes 1-2 weeks. The purpose of the evaluation is to identify problems or concerns, such as severe medical conditions other than your lung condition, that would make you unlikely to do well with a lung transplant.

You will be scheduled for some or all of the following tests:

• Blood, urine, and stool tests
• Pulmonary function test (breathing test to determine your lung capacity)
• Chest x-ray
• CT scan of the lung
• Electrocardiogram (EKG)
• Echocardiogram (ultrasound of the heart)
• Left heart catheterization (check for blockages to the blood vessels supplying the heart)
• Right heart catheterization (measure the pressures in the heart and lungs)
• Bone density scan
• Ventilation-perfusion (V/Q) scan of the lungs (determines the blood and air supply to each lung)
• Esophageal manometry (measures how the muscles in your esophagus work)

In addition, you will need to provide the results of the following screening tests or have them done:

• Females will need a current gynecologic evaluation with Pap smear and HPV testing.
• Females over age 40 will need a current mammogram.
• Males over age 40 need a current prostate specific antigen test (PSA).
• Patients over age 50 need a current colonoscopy (within the last 5 years).

After the evaluation is complete, all the information collected during the evaluation will be reviewed with the entire multidisciplinary transplant team, and a decision will be made. This decision may be:

• You will be added to the transplant waitlist after financial approval is obtained.
• You will be asked to do additional testing or see additional specialists to help decide if you are a good transplant candidate.
• You are declined for transplant because your evaluation shows that a lung transplantation is not the best option for you.

The waitlist

Once it is determined that you are a transplant candidate and insurance approval is received, you will be placed on the national waiting list for a lung transplant. The national transplant waitlist is managed by the United Network for Organ Sharing (UNOS). UNOS helps to ensure the best use of a limited supply of organs and to give all candidates a fair chance to receive the organ regardless of race, gender, religion, lifestyle, financial, or social status.

All patients on the waitlist are assigned a numerical value called the Lung Allocation Score (LAS), which is calculated by a computer based on physical and laboratory data. The LAS may change if your lung disease worsens. The duration of time you are on the waitlist will vary based on your blood type, your height, how bad your lung disease is, and your LAS. There is no way to know how long you will wait for a transplantation.

While you are on the waitlist:

• You will continue to be followed up in the transplant clinic on a regular basis.
• You should maintain the best health possible.
• You should inform the transplant team immediately of any change in health status or if you are admitted to the hospital.
• You need to be reachable by phone at all times.

While you are on the wait list, the lung transplant team will provide ongoing education to you and your family about what to expect before, during, and after your lung transplant.

It is possible that you may be temporarily inactivated or permanently removed from the waitlist for one of the following reasons:

• You develop health problems that would make transplantation unsafe.
• You engage in any smoking or substance abuse.
• You request to be removed from the waitlist.
• You refuse transplant when an organ becomes available.

Organ selection

Donor lungs are matched with recipients based on blood type, body size (height and weight), and the size of the lungs. When donor lungs become available, they are first offered to the patient with the highest LAS who also matches the donor’s size and blood type. When a set of lungs is offered, the lung transplant team will review the donor’s medical and social history and examine the quality of the lungs to determine if they are acceptable size and quality for your transplant.

The lung transplant procedure

When potential donor lungs become available, a transplant coordinator will call you and instruct you to stop eating and drinking and come to the hospital as soon as possible. When you receive the call, you should arrive within four hours. You will be under the care of the lung transplant team once you arrive at the hospital. The coordinator will let you know where in the hospital to go.

One you reach your hospital room, you will be prepared for lung transplant surgery. A chest x-ray, EKG, and blood tests will be done, and you will sign the consent for the surgery after it is reviewed with you. You may need to wait a significant amount of time for the transplant team to travel to the donor’s location and evaluate the donor lungs. There is a chance the transplant will be cancelled if the surgeon who examines the donor lungs determines that they are not good quality. If this happens, you will be sent home and prepare for the next opportunity.

After it is confirmed that the surgery will proceed, you will be taken to the operating room by the anesthesiologist. The length of time required for the actual operation varies, but generally takes 6 to 10 hours. You will have a breathing tube inserted to help you breathe. During the operation, an incision will be made across your chest for a double (bilateral) lung transplant or along the side of your chest for a single lung transplant. Your lung(s) will be removed, and new lung(s) will be placed in the chest.

Immediately after the surgery, you will be sent to the intensive care unit (ICU) to recover. You will be monitored very closely in the ICU. You will remain the ICU until you are ready to move to a regular hospital room. On average, the hospital stay for a lung transplant is about 2 to 4 weeks. You may require transfer to a rehabilitation facility before you go home.

A transplant coordinator will provide post-transplant education for you and your caregivers before you leave the hospital. You will also meet with the transplant pharmacist who will explain all your transplant medications. You will receive your medications before you are discharged.

Discharge

After discharge, you and your primary caregiver will be required to remain in San Antonio for a minimum of 3 months after your transplant. You will be seen in the lung transplant clinic on a regular basis, and be required to complete outpatient pulmonary rehabilitation. During clinic visits, you will undergo regular testing including x-rays and PFTs to monitor your condition as well as be seen by a transplant pulmonologist. The normal patient schedule to be seen is:

• Every week up to 3 months after transplant
• Every month from 3 months to 1 year after transplant
• Every 3 months after the first year after transplant.