Health-Related Quality of Life Following Single or Bilateral Lung Transplantation

Health-Related Quality of Life Long-Term Study in Lung Transplant Patients: A Single-Center Experience

INTRODUCTION

Health-related quality of life (HRQL) assessment plays a crucial role in the follow-up care of lung transplanted (LTx) patients. Previous reports have indicated that the HRQL achieved by these patients is often poorer compared to that of healthy individuals. However, the factors contributing to this lower HRQL remain unclear. This prospective study aimed to assess the effectiveness of using both a generic and a disease-specific HRQL instrument in evaluating the outcomes of patients who have undergone LTx.

METHODS

A total of 111 LTx patients were enrolled in the study, with 88 survivors completing the 5-year follow-up and 23 nonsurvivors identified within the first 3 y. Among the participants, 84 underwent double LTx, while 27 received a single LTx. Patients were interviewed before LTx, at 6 mo post-transplantation, and annually thereafter. Two validated instruments were utilized: the Euro quality of life five dimensions, a generic measure, and the St. George's Respiratory Questionnaire (SGRQ), a disease-specific questionnaire.

RESULTS

The study showed significant improvements in Euro Quality of Life five Dimensions scores from 6 mo after LTx. Specifically, the percentage of patients without Mobility problems increased from 23% before LTx to 71% at 5 y (P = <0.001), while the ability to self-care improved from 48% to 100% (P = <0.001). The ability to carry out usual activities improved from 13% to 86% (P = <0.001), and the proportion of patients without anxiety and depression increased from 50% to 86% (P > 0.004). However, there was no significant improvement observed in Pain, with only a slight reduction from 57% to 42.8% (P = 0.22). The SGRQ also showed improvements in all dimensions (symptoms, impact, activities) (P < 0.001). However, by the fifth year, the HRQL scores remained below normal reference values. Chronic graft dysfunction was associated with a decline in SGRQ scores. Bilateral LTx patients exhibited better SGRQ scores compared to unilateral LTx patients from the first year post-transplantation. Notably, there were no differences in scores between nonsurvivors and survivors.

CONCLUSIONS

The study highlights the long-term improvement in HRQL among LTx patients, with greater improvements observed in physical dimensions compared to psychological dimensions. Bilateral LTx was associated with better SGRQ scores than unilateral LTx, and chronic graft dysfunction primarily affected SGRQ scores. These findings underscore the importance of utilizing both generic and specific HRQL instruments in assessing LTx outcomes.

Single vs Bilateral Lung Transplant in the Management of Patients With Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Lung transplantation is recommended for select patients with end-stage chronic obstructive pulmonary disease (COPD). However, a consensus has not been reached regarding the optimal choice of lung transplantation: single lung transplants (SLTs) vs bilateral lung transplants (BLTs). This meta-analysis aimed to evaluate the safety and efficacy of SLT compared with BLT in managing end-stage COPD.

METHODS

Cochrane, Embase, PubMed, and Scopus were searched for articles by 2 independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis system. The review was registered prospectively with PROSPERO (CRD42022343408).

RESULTS

Seven studies of 311 screened met the eligibility criteria, with a total of 10,652 patients with end-stage COPD, SLT (n = 6233), or BLT (n = 4419). Overall survival rates of BLT group were more favorable than SLT group at 1 (odds ratio [OR] = 1.29, 95% CI: 1.16, 1.43, I2 = 0%), 5 (OR = 1.46, 95% CI: 1.35, 1.58, I2 = 23%), and 10 years (OR = 1.71, 95% CI: 1.57, 1.87, I2 = 12%) as well as the hazard ratio (HR = 0.73, 95% CI: 0.70, 0.76, I2 = 40%). Subgroup analysis on survival rates of alpha-1 antitrypsin deficiency also displayed a trend favoring BLT compared with SLT at 1 (OR = 1.60, 95% CI: 1.24, 2.08, I2 = 28%), 5 (OR = 1.84, 95% CI: 1.50, 2.26, I2 = 42%), and 10 years (OR = 1.98, 95% CI: 1.59, 2.48, I2 = 47%) as well as the HR (HR = 0.67, 95% CI: 0.35, 1.28, I2 = 82%).

CONCLUSION

Compared with SLT, BLT seems to demonstrate more favorable trends in survival rates for the management of end-stage COPD. Despite the promising results, the groups have significant heterogeneity in baseline characteristics. Further prospective studies with extended follow-up periods are needed to ascertain the efficacy of treatment.

Single Lung Transplant for Secondary Pulmonary Hypertension: The Right Option for the Right Patient

Introduction: The optimal treatment for Secondary Pulmonary Hypertension from End-Stage Lung Disease remains controversial. Double Lung Transplantation is widely regarded as the treatment of choice as it eliminates all diseased parenchyma and introduces a large volume of physiologically normal allograft. By comparison, the role of single lung transplantation for pulmonary hypertension (PAH) is less clear. The remaining diseased lung will limit clinical improvements and permit downstream sequelae; including residual cough, recurrent infection, and continued pulmonary hypertension. But not every patient can undergo DLT. Advanced age, frailty, co-morbid conditions, and limited availability of organs will all affect surgical candidacy and can offset the benefits of double lung procedures. Studies that compare SLT and DLT do not commonly explore the utility of single lung procedures even though multiple theoretical advantages exist; including reduced waiting times, less waitlist mortality, fewer surgical complications, and lower operative mortality. Worse, multiple forms of publication and selection bias may favor DLT in registry-based studies. In this review, we present the prevailing literature on single and double lung transplants in patients with secondary pulmonary hypertension and clarify the potential utility of these procedures. Materials and Methods: A PubMed search for English-language articles exploring single and double lung transplants in the setting of secondary pulmonary hypertension was conducted from 1990 to 2023. Key words included "single lung transplant", "double lung transplant", "pulmonary hypertension", "rejection", "complications", "extracorporeal membranous oxygenation", "death", and all appropriate Boolean operators. We prioritized research from retrospective studies that evaluated clinical outcomes from single centers. Conclusions: The question is not whether DLT is better at resolving lung disease; instead, we must ask if SLT is an acceptable form of therapy in a select group of high-risk patients. Further research should focus on how best to identify recipients that may benefit from each type of procedure, and the clinical utility of perioperative VA ECMO.

Lung Transplant Procedure of Choice: Bilateral Transplantation Versus Single Transplantation Complications, Quality of Life, and Survival

This article examines the existing literature regarding single (SLT) and bilateral lung transplantation (BLT) to help answer the question of which approach is preferable. Specifically, this review highlights the following subjects: disease-specific indications for SLT versus BLT; the impact of procedure type on posttransplantation functional status; the impact of procedure type on posttransplantation quality of life; chronic rejection after lung transplantation; ethical challenges facing the choice between single and bilateral transplants; and, novel strategies in this arena.

Health-Related Quality of Life Outcomes Following Single or Bilateral Lung Transplantation: A Systematic Review

BACKGROUND

Lung transplantation is the definitive treatment for end-stage lung disease. There has been uncertainty regarding whether single or bilateral lung transplantation confers patients' greater health-related quality of life. This systematic review was performed to evaluate the impact of single lung transplantation (SLTx) against bilateral lung transplantation on short- and long-term health-related quality of life.

METHODS

A literature search was conducted on PubMed for studies matching the eligibility criteria between January 2000 and January 2022. OVID (MEDLINE), Google Scholar, EBSCOhost (EMBASE), and bibliographies of included studies were reviewed. Inclusion of studies was based on predetermined eligibility criteria. Quality appraisal and data tabulation were performed using predetermined forms. Results were synthesized by narrative review. The structure of this systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This systematic review was prospectively registered in the PROSPERO register (CRD42022344389).

RESULTS

Ten studies (1916 patients) were included. Within 12 mo posttransplantation, there was no evidence of the improved health-related quality of life with respect to the type of lung transplantation procedure. Bilateral lung transplantation patients reported significantly greater scores in both the physical and mental health domains of health-related quality of life. Bilateral lung transplantation offered significantly better health-related quality of life outcomes at later follow-up periods. Bilateral lung transplantation showed a significantly slower reduction in health-related quality of life physical composite scores relative to SLTx.

CONCLUSION

Bilateral lung transplant (BLTx) recipients perceive the greater health-related quality of life beyond 1-y post-lung transplantation. BLTx recipients better retain their health-related quality of life long-term posttransplantation than those receiving SLTx.

Relationship of Exercise Capacity, Physical Function, and Frailty Measures With Clinical Outcomes and Healthcare Utilization in Lung Transplantation: A Scoping Review

Measures of exercise capacity, frailty, and physical function are commonly used in lung transplant candidates and recipients to evaluate their physical limitations and the effects of exercise training and to select candidates for transplantation. It is unclear how these measures are related to clinical outcomes and healthcare utilization before and after lung transplantation. The purpose of this scoping review was to describe how measures of exercise capacity, physical function, and frailty are related to pre- and posttransplant outcomes.

Lung transplantation for interstitial lung disease

Lung transplantation (LTx) can be a life-extending treatment option for patients with advanced and/or progressive fibrotic interstitial lung disease (ILD), especially idiopathic pulmonary fibrosis (IPF), fibrotic hypersensitivity pneumonitis, sarcoidosis and connective tissue disease-associated ILD. IPF is now the most common indication for LTx worldwide. Several unique features in patients with ILD can impact optimal timing of referral or listing for LTx, pre- or post-transplant risks, candidacy and post-transplant management. As the epidemiology of LTx and community practices have evolved, recent literature describes outcomes and approaches in higher-risk candidates. In this review, we discuss the unique and important clinical findings, course, monitoring and management of patients with IPF and other progressive fibrotic ILDs during pre-LTx evaluation and up to the day of transplantation; the need for co-management with clinical experts in ILD and LTx is emphasised. Some post-LTx complications are unique in these patient cohorts, which require prompt detection and appropriate management by experts in multiple disciplines familiar with telomere biology disorders and infectious, haematological, oncological and cardiac complications to enhance the likelihood of improved outcomes and survival of LTx recipients with IPF and other ILDs.

Near-normal aerobic capacity in long-term survivors after lung transplantation

The clinical course of lung transplantation (LT) is diverse: some patients present chronic lung allograft dysfunction (CLAD) and progressive decline in pulmonary function, but others maintain normal spirometric values and active lives.

This is a multicentre study reporting, for the first time, near-normal peak V′_O2 values during cardiopulmonary exercise testing and normal exercise capacity in long-term lung transplant recipients without CLADhttps://bit.ly/35ftce3

Utilization of Quantitative Computed Tomography Assessment to Identify Bronchiolitis Obliterans Syndrome After Single Lung Transplantation

OBJECTIVE

To evaluate quantitative chest computed tomography (CT) methods for the detection of air trapping (AT) and to assess its diagnostic performance for the diagnosis of bronchiolitis obliterans syndrome (BOS) in single lung transplant (SLT) patients.

METHODS

Adult patients who had a SLT at a single transplant center and underwent CT scan after transplantation were retrospectively included. CT findings of air trapping were measured by three different methods: expiratory air-trapping index (ATIexp), mean lung density on expiratory acquisition (MLDexp) and expiratory to inspiratory ratio of mean lung density (E/I-ratio(MLD). Sensitivity, specificity and diagnostic accuracy of the three methods for the detection of BOS status evaluated by serial routine measures of pulmonary function tests (gold standard) were assessed.

RESULTS

Forty-six SLT patients (52.2% females, mean age 58 ± 6 years) were included in the analysis, 12 (26%) patients with a diagnosis of BOS. Quantitative CT diagnosis of AT ranged from 26 to 35%. Sensitivity, specificity and accuracy of each method for the detection of BOS were 85.7%, 84.7% and 85.0% for ATIexp, 78.5%, 93.4% and 90.0% for MLD and 64.2%, 89.1% and 83.3% E/I-ratio(MLD), respectively.

CONCLUSION

Quantitative measures of AT obtained from standard CT are feasible and show high specificity and accuracy for the detection of BOS in SLT patients.

Lung transplantation for emphysema

Lung transplantation (LT) is proved to be effective in patients with end-stage lung disease who are failing optimal therapy. Chronic obstructive pulmonary disease (emphysema) is the most common indication for adult lung transplantation. As most patients with emphysema (EMP) can survive long term, it could be difficult to decide which patient should be listed for LT. LT is a complex surgery. Therefore, it is extremely important to choose a recipient in whom expected survival is at less equal or comparable to the survival without surgery. This paper reviews patient selection, bridging strategies until lung transplantation, surgical approach and choice of the procedure, and functional outcome in emphysema recipients.

Risk Factors for Acute Rejection in the First Year after Lung Transplant. A Multicenter Study

Rationale: Acute rejection, manifesting as lymphocytic inflammation in a perivascular (acute perivascular rejection [AR]) or peribronchiolar (lymphocytic bronchiolitis [LB]) distribution, is common in lung transplant recipients and increases the risk for chronic graft dysfunction.Objectives: To evaluate clinical factors associated with biopsy-proven acute rejection during the first post-transplant year in a present-day, five-center lung transplant cohort.Methods: We analyzed prospective diagnoses of AR and LB from over 2,000 lung biopsies in 400 newly transplanted adult lung recipients. Because LB without simultaneous AR was rare, our analyses focused on risk factors for AR. Multivariable Cox proportional hazards models were used to assess donor and recipient factors associated with the time to the first AR occurrence.Measurements and Main Results: During the first post-transplant year, 53.3% of patients experienced at least one AR episode. Multivariable proportional hazards analyses accounting for enrolling center effects identified four or more HLA mismatches (hazard ratio [HR], 2.06; P ≤ 0.01) as associated with increased AR hazards, whereas bilateral transplantation (HR, 0.57; P ≤ 0.01) was associated with protection from AR. In addition, Wilcoxon rank-sum analyses demonstrated bilateral (vs. single) lung recipients, and those with fewer than four (vs. more than four) HLA mismatches demonstrated reduced AR frequency and/or severity during the first post-transplant year.Conclusions: We found a high incidence of AR in a contemporary multicenter lung transplant cohort undergoing consistent biopsy sampling. Although not previously recognized, the finding of reduced AR in bilateral lung recipients is intriguing, warranting replication and mechanistic exploration.

Changes in Health-Related Quality of Life During the First Year in Lung Transplant Recipients

BACKGROUND

Health-related quality of life (HRQOL) has increasingly been accepted as a supplementary outcome measure for patients before and after lung transplantation (LT). This longitudinal study was conducted to recognize the tracks of HRQOL during the first year after transplantation and the main factors associated with HRQOL of LT recipients. The research was conducted in accordance with the 2000 Declaration of Helsinki and the Declaration of Istanbul 2008. The transplant organs were from volunteer donation, and next of kin provided written informed consents of their own free will. No prisoners were used, and donors were neither paid nor coerced.

METHODS

A total of 118 patients were investigated before and 3, 6, 9, and 12 months post-transplantation. The Medical Outcomes SF-36 (Chinese version) was used to measure the HRQOL. The recipients' demographic characteristics and clinical data were evaluated to determine the relative contributions to HRQOL outcomes.

RESULTS

Recipients reported a mean physical component summary of 39.62 ± 6.57, 57.90 ± 9.99, 59.15 ± 8.73, 58.79 ± 8.52, and 58.72 ± 8.99 before transplantation and at 3, 6, 9, and 12 months after LT (F = 64.960, P < .001). By 3 months after transplant, patients experienced significant improvement in physical component summary (MD = 18.27, SE = 1.52, P < .001); but between 3 and 12 months, no significant improvement was observed (MD = 0.82, SE = 1.77, P = .645). Patients reported a continuous rise with means of 44.63 ± 5.35, 51.13 ± 10.25, 51.92 ± 9.72, 53.23 ± 10.34, and 55.40 ± 8.83 for the mental component summary before LT and at 3, 6, 9, and 12 months after transplant (F = 13.059, P < .001). By 3 months after transplant, patients experienced significant improvement in mental component summary (MD = 6.50, SE = 1.50, P < .001). Between 3 and 12 months, a continuous significant improvement was observed (MD = 4.27, SE = 1.92, P = .030). The generalized estimated equation showed that age, marital status, residence, disease diagnosis, transplant type, sleep disorders, gastrointestinal complications, and BODE index (body mass index, obstruction, dyspnea, exercise) were all found to be related to HRQOL.

CONCLUSION

The HRQOL of LT patients improved significantly at 3 months after transplantation, but between 3 and 12 months after transplantation, the changes were not obvious. Health practitioners should pay more attention to elderly patients, unmarried patients, patients living in urban areas, patients diagnosed with pneumoconiosis, patients with left single-lung transplantation, patients with sleep disorders, patients with high BODE indexes, and patients with gastrointestinal complications.

Assessment of Quality of Life Among Patients After Lung Transplantation: A Single-Center Study

INTRODUCTION

Lung transplantation (LTx) is the only effective method of treatment to improve the health and quality of life (QoL) of patients with end-stage lung diseases. After LTx, medical examination accompanied by quality of life assessment should be performed on routine follow-up visits. The aim of the study was to assess the QoL of patients after LTx.

MATERIAL AND METHODS

The study group consisted of 60 patients (29 women and 31 men); 20 patients received single lung transplantation (SLT), and 40 received double lung transplantation (DLT). To determine the patient's QoL, the General Health Questionnaire (GHQ), the World Health Organization Quality of Life Test-BREF (WHOQOL-BREF), and the Saint George Respiratory Questionnaire (SGRQ) were used. Spirometry and the 6-minute walk test were analyzed to examine efficiency of transplanted organs.

RESULTS

In SGRQ there are differences between patients with cystic fibrosis and interstitial lung disease in symptom domain (20.28% vs 39.26%, P = .025) and total score (19.38% vs 32.47%, P = .028). As reported in the GHQ, men had worse overall results than women in sten scale (5.22 points vs 4.69 points). Patients after SLT achieved similar scores in every questionnaire.

CONCLUSION

Studies assessing QoL should be an important addition to lung function tests and an integral part of control during postoperative follow-up visits. This study is one of the important contributions to understanding of how essential QoL is after LTx. The authors of this study realize that their work does not cover the whole issue, and further studies in this area are warranted.

Single vs. bilateral lung transplantation: when and why

PURPOSE OF REVIEW

Lung transplantation is a life-saving treatment for several end stage lung diseases. Over the last two decades, the number of lung transplantation performed worldwide has steadily increased but several thousand people still die every year waiting for lung transplantation. However, the optimal procedure for lung transplantation in non-septic lung conditions remains debatable.

RECENT FINDINGS

In pulmonary fibrosis and COPD, many recent studies suggest superiority of bilateral lung transplantation over single lung transplantation when long-term survival is evaluated; consequently, bilateral lung transplantation has been favored by many lung transplantation centers. However, the quality of evidence to support the superiority of bilateral lung transplantation remains low in the absence of prospective studies, and other available studies do not show differences in outcomes between the two types of procedure.

SUMMARY

In the absence of good high quality evidence, it is difficult to make strong general recommendations for the type of lung transplant, and the decision often has to be individualized. However, the number of recipients on the wait list continues to surpass the amount of available organs and due consideration needs to be given to single lung transplantation as an option whenever possible.

Long-Term Physical HRQOL Decreases After Single Lung as Compared With Double Lung Transplantation

BACKGROUND

Single lung transplantation (SLT) and double lung transplantation (DLT) are associated with differences in morbidity and mortality, although the effects of transplant type on patient-reported outcomes are not widely reported and conclusions have differed. Previous studies compared mean health-related quality of life (HRQOL) scores but did not evaluate potentially different temporal trajectories in the context of longitudinal follow-up. To address this uncertainty, this study was designed to evaluate longitudinal HRQOL after SLT and DLT with the hypothesis that temporal trajectories differ between SLT and DLT.

METHODS

Patients transplanted at a single institution were eligible to be surveyed at 1 month, 3 months, 6 months, and then annually after transplant using the Short Form 36 Health Survey, with longitudinal physical component summary (PCS) and mental component summary (MCS) scores as the primary outcomes. Multivariable mixed-effects models were used to evaluate the effects of transplant type and time posttransplant on longitudinal PCS and MCS after adjusting age, diagnosis, rejection, Lung Allocation Score quartile, and intubation duration. Time by transplant type interaction effects were used to test whether the temporal trajectories of HRQOL differ between SLT and DLT recipients. HRQOL scores were referenced to general population norms (range, 40 to 60; mean, 50 ± 10) using accepted standards for a minimally important difference (½ SD, 5 points).

RESULTS

Postoperative surveys (n = 345) were analyzed for 136 patients (52% male, 23% SLT, age 52 ± 13 years, LAS 42 ± 12, follow-up 37 ± 29 months [range, 0.6 to 133]) who underwent lung transplantation between 2005 and 2016. After adjusting for model covariates, overall posttransplant PCS scores have a significant downward trajectory (p = 0.015) whereas MCS scores remain stable (p = 0.593), with both averaging within general population norms. The time by transplant type interaction effect (p = 0.002), however, indicate that posttransplant PCS scores of SLT recipients decline at a rate of 2.4 points per year over the total observation period compared to DLT. At approximately 60 months, the PCS scores of SLT recipients, but not DLT recipients, fall below general population norms.

CONCLUSIONS

The trajectory of physical HRQOL in patients receiving SLT declines over time compared with DLT, indicating that, in the longer term, SLT recipients are more likely to have physical HRQOL scores that fall substantively below general population norms. Physical HRQOL after 5 years may be a consideration for lung allocation and patient counseling regarding expectations when recommending SLT or DLT.

Transplant options for end stage chronic obstructive pulmonary disease in the context of multidisciplinary treatments

Lung transplantation (LTx) in advanced stage chronic obstructive pulmonary disease (COPD) patients is associated with significant improvement in lung function and exercise capacity. However, demonstration that the procedure also provides a survival benefit has been more elusive compared to other respiratory conditions. Identification of patients with increased risk of mortality is crucial: a low forced expiratory volume in 1 second (FEV₁) is perhaps the most common reason for referral to a lung transplant center, but in itself is insufficient to identify which COPD patients will benefit from LTx. Many variables have to be considered in the selection of candidates, time for listing, and choice of procedure: age, patient comorbidities, secondary pulmonary hypertension, the balance between individual and community benefit. This review will discuss patient selection, transplant listing, potential benefits and critical issues of bilateral (BLTx) and single lung (SLTx) procedure, donor-to-recipient organ size-matching; furthermore, it will describe LTx outcomes and its effects on recipient survival and quality of life.

Bilateral versus single lung transplantation: are two lungs better than one?

There is a long-standing debate over whether single or bilateral lung transplant provides better short and long-term clinical outcomes. We performed a detailed PubMed search on relevant clinical research publications on single (SLT) and bilateral lung transplantation (BLT). We included studies that were published before and after the implementation of the lung allocation score (LAS). We reviewed disease-specific short- and long-term outcomes associated with each transplantation technique. The majority of published studies are retrospective cohort studies that use institutional data or large patient registries. Outcomes associated with transplantation technique vary by disease specific indication, age, and patient severity. Over the past decade, the relative proportion of bilateral lung transplantation has increased. Increasing adoption of bilateral lung transplant likely reflects the general acceptance of several advantages associated with the technique. However, making a clear, evidence-based decision is difficult in light of the fact that there has never been and probably never will be a randomized trial. Our institutional preference is bilateral lung transplant. However, consideration for the technique should still be made on a case-by-case basis.

Five-Year Mortality Hazard Is Reduced In Chronic Obstructive Pulmonary Disease Patients Receiving Double- versus Single-Lung Transplants

BACKGROUND

Previous studies suggest double-lung transplant (DLT) may be associated with superior survival compared to single-lung transplantation (SLT) in chronic obstructive pulmonary disease (COPD) recipients. The purpose of this study was to compare survival in patients with COPD undergoing DLT versus SLT since the inception of the lung allocation score.

METHODS

We used the United Network for Organ Sharing database to retrospectively identify adult patients with COPD who underwent isolated lung transplantation from 5/4/2005-12/31/2014. We then separated patients into DLT versus SLT. Short-term (1 y) and long-term survival (5 y) were compared between DLT and SLT cohorts by the method of Kaplan-Meier, and Cox proportional hazards modeling was used to adjust for case mix.

RESULTS

Four thousand eight hundred thirty-two COPD patients were listed, and 3554 underwent lung transplantation over the study period, including 1358 SLTs (38%) and 2196 DLTs (62%). Survival 1 y after listing was 93% for those remaining wait listed (n = 1892) versus 91% for SLT (n = 1093) versus 89% for DLT (n = 1847) (log-rank P < 0.01). Survival at 1 y after transplant was 88% for both SLT and DLT groups (log-rank P = 0.93); however, 5-y survival was significantly lower after SLT (51% versus 59%, log-rank P < 0.01). After risk adjustment, hazard for 1-y mortality after DLT was not significantly reduced compared to SLT (hazard ratio 0.89 [0.69-1.14], P = 0.36) but was significantly reduced 5 y after DLT (hazard ratio 0.88 [0.78-0.99], P = 0.04).

CONCLUSIONS

In the largest survival analysis of COPD recipients since the inception of the lung allocation score, the hazard for 5-y mortality was significantly reduced in recipients who underwent DLT as compared to SLT.

Patient-reported health outcomes in long-term lung transplantation survivors: A prospective cohort study

During the last three decades lung transplantation (LTx) has become a proven modality for increasing both survival and health-related quality of life (HRQoL) in patients with various end-stage lung diseases. Most previous studies have reported improved HRQoL shortly after LTx. With regard to long-term effects on HRQoL, however, the evidence is less solid. This prospective cohort study was started with 828 patients who were on the waiting list for LTx. Then, in a longitudinal follow-up, 370 post-LTx patients were evaluated annually for up to 15 years. For all wait-listed and follow-up patients, the following four HRQoL instruments were administered: State-Trait Anxiety Inventory, Zung Self-rating Depression Scale, Nottingham Health Profile, and a visual analogue scale. Cross-sectional and generalized estimating equation (GEE) analysis for repeated measures were performed to assess changes in HRQoL during follow-up. After LTx, patients showed improvement in all HRQoL domains except pain, which remained steady throughout the long-term follow-up. The level of anxiety and depressive symptoms decreased significantly and remained constant. In conclusion, this study showed that HRQoL improves after LTx and tends to remain relatively constant for the entire life span.

Survival Benefit of Lung Transplantation in the Modern Era of Lung Allocation

RATIONALE

Lung transplantation is an accepted and increasingly employed treatment for advanced lung diseases, but the anticipated survival benefit of lung transplantation is poorly understood.

OBJECTIVES

To determine whether and for which patients lung transplantation confers a survival benefit in the modern era of U.S. lung allocation.

METHODS

Data on 13,040 adults listed for lung transplantation between May 2005 and September 2011 were obtained from the United Network for Organ Sharing. A structural nested accelerated failure time model was used to model the survival benefit of lung transplantation over time. The effects of patient, donor, and transplant center characteristics on the relative survival benefit of transplantation were examined.

MEASUREMENTS AND MAIN RESULTS

Overall, 73.8% of transplant recipients were predicted to achieve a 2-year survival benefit with lung transplantation. The survival benefit of transplantation varied by native disease group (P = 0.062), with 2-year expected benefit in 39.2 and 98.9% of transplants occurring in those with obstructive lung disease and cystic fibrosis, respectively, and by lung allocation score at the time of transplantation (P < 0.001), with net 2-year benefit in only 6.8% of transplants occurring for lung allocation score less than 32.5 and in 99.9% of transplants for lung allocation score exceeding 40.

CONCLUSIONS

A majority of adults undergoing transplantation experience a survival benefit, with the greatest potential benefit in those with higher lung allocation scores or restrictive native lung disease or cystic fibrosis. These results provide novel information to assess the expected benefit of lung transplantation at an individual level and to enhance lung allocation policy.

Outcomes after lung transplantation

With more than 50,000 procedures having been performed worldwide, lung transplantation (LT) has become the standard of care for patients with end-stage chronic respiratory failure. LT leads to dramatic improvements in both pulmonary function and health related quality of life. Survival after LTs has steadily improved, but still lags far behind that observed after other solid organ transplantations, as evidenced by a median survival rate that currently stands at 5.8 years. Because of these disappointing results, the ability of LT to expand survival has been questioned. However, the most recent studies, based on sophisticated statistical modeling suggest that LT confers a survival benefit to the vast majority of lung transplant recipients. Chronic lung allograft dysfunction (CLAD) that develops in about 50% of recipients 5 years after LT is a major impediment to lung transplant survival. A better understanding of the mechanisms underlying CLAD could allow for better post-transplant survival.

Quality of Life and Bronchiolitis Obliterans Syndrome in Patients after Lung Transplantation

Background

Lung transplantation has become an established and effective treatment for patients with end-stage pulmonary disease.

Objective

To investigate health-related quality of life in correlation with occurrence and degree of bronchiolitis obliterans syndrome after transplantation.

Methods

In a cross-sectional study design, 119 consecutive lung transplant recipients (63.9% bilateral and 36.1% single lung transplants) responded voluntarily to a set of standardized questionnaires (12-Item Short-Form Health Survey, Center for Epidemiologic Studies-Depression Scale, Coping With Everyday Life, Beck Anxiety Inventory, Zerssen list of complaints) that covered health-related quality of life and psychological well being. Also, we performed pulmonary function studies to clinically grade bronchiolitis obliterans syndrome in all patients.

Results

In this cohort, 41.2% of patients developed bronchiolitis obliterans syndrome at a mean interval of 5.6 years after lung transplantation. Actuarial freedom from bronchiolitis obliterans syndrome was 90.1%±2.3% at 1 year, 79.9%±3.7% at 3 years, and 59.5%±4.8% at 5 years after lung transplantation. Recipients with bronchiolitis obliterans syndrome reported significantly lower well being and quality of life than those without bronchiolitis obliterans syndrome, who scored similar to healthy volunteers. In a subanalysis, body functioning ( P<.001) and related areas of coping ( P<.001) were mostly affected by bronchiolitis obliterans syndrome.

Conclusions

Quality of life was negatively affected by the onset of bronchiolitis obliterans syndrome. However, even patients who develop bronchiolitis obliterans syndrome reported a temporary benefit from lung transplantation. In addition to optimal medical care and efforts in preventing bronchiolitis obliterans syndrome, psychological support of lung recipients seems to be essential, especially when bronchiolitis obliterans syndrome occurs.

A global perspective of lung transplantation: Part 1 - Recipient selection and choice of procedure

Lung transplantation has grown considerably in recent years and its availability has spread to an expanding number of countries worldwide. Importantly, survival has also steadily improved, making this an increasingly viable procedure for patients with end-stage lung disease and limited life expectancy. In this first of a series of articles, recipient selection and type of transplant operation are reviewed. Pulmonary fibrotic disorders are now the most indication in the U.S., followed by chronic obstructive pulmonary disease and cystic fibrosis. Transplant centers have liberalized criteria to include older and more critically ill candidates. A careful, systematic, multi-disciplinary selection process is critical in identifying potential barriers that may increase risk and optimize long-term outcomes.

Effects of Recipient Age and Diagnosis on Health-related Quality-of-Life Benefit of Lung Transplantation

RATIONALE

The average age of lung transplant recipients is increasing, and the mix of recipient indications for transplantation is changing.

OBJECTIVES

To determine whether the health-related quality-of-life (HRQL) benefit of lung transplantation differs by recipient age and diagnosis.

METHODS

In this prospective cohort study, we obtained serial HRQL measurements in adults with advanced lung disease who subsequently underwent lung transplantation (2004-2012). HRQL assessments included the St. George's Respiratory Questionnaire, 36-Item Short-Form Health Survey (SF-36), EQ-5D, Standard Gamble, and Visual Analog Scale for current health. We used linear mixed effects models for associations between age or diagnosis and changes in HRQL with transplantation. To address potential survivorship bias, we fitted Markov models to the distribution of discrete post-transplant health states (HRQL better than pretransplant, not better, or dead) and estimated quality-adjusted life-years post-transplant.

MEASUREMENTS AND MAIN RESULTS

A total of 430 subjects were listed, 387 were transplanted, and 326 provided both pretransplant and post-transplant data. Transplantation conferred large improvements in all HRQL measures: St. George's change of -47 units (95% confidence interval, -48 to -44), 36-Item Short-Form Health Survey physical component summary score of 17.7 (16.5-18.9), EQ-5D of 0.27 (0.24-0.30), Standard Gamble of 0.48 (0.44-0.51), and Visual Analog of 44 (42-47). Age was not associated with meaningful differences in the HRQL benefits of transplantation. There was less HRQL benefit in interstitial lung disease than in cystic fibrosis.

CONCLUSIONS

Lung transplantation confers large HRQL benefits, which vary by recipient diagnosis, but do not differ substantially in older recipients.

Interventional Options for COPD- LVRS, Bronchoscopic Therapies and the Future

This article serves as aCME available, enduring material summary of the following COPD9USA presentations: "Lung Volume Reduction Surgery" Presenter: William A. Bulman, MD "Bronchoscopic Approaches to Lung Volume Reduction" Presenter: Frank Sciurba, MD "Stem Cell Therapies for Advanced Emphysema" Presenter: Edward P. Ingenito, MD, PhD "Lung Transplantation for COPD" Presenter: Daniel Dilling, MD, FACP, FCCP.

A systematic review of health-related quality of life and psychological outcomes after lung transplantation

BACKGROUND

Lung transplantation (LTx) aims to reduce physical disability and mental distress, extend survival, and improve health-related quality of life (HRQoL). In this systematic review we aimed to: (1) augment evidence regarding measures to assess HRQoL and psychological outcomes after LTx; and (2) summarize HRQoL and psychological outcomes after LTx.

METHODS

Validated and standardized instruments with well-known psychometric properties used for assessing HRQoL and psychological outcomes after LTx were identified by means of comprehensive literature searches of PsychINFO and Medline/PubMed, up through March 2014, using the following search terms in various combinations: lung transplantation; physical functioning; symptom experience; mental health; anxiety; depression; distress; social functioning; life satisfaction; and health-related quality of life.

RESULTS

The search strategy identified 371 titles and abstracts. Of these, 279 were retrieved for further assessment and 63 articles selected for final review. Thirty-nine studies were found for HRQoL, 15 for physical functioning, 5 for mental health and 4 for social functioning. A total of 50 psychometric instruments were encountered.

CONCLUSIONS

Considerable heterogeneity exists in methodology, operational concepts and applied outcome measures in the existing literature on HRQoL and psychological outcomes after LTx. Nevertheless, the studies generally point to significant improvements in both mental health and HRQoL post-transplant. Further research is warranted utilizing consistent outcome measures, including LTx-specific measures and longitudinal study designs.

Continued Utility of Single-Lung Transplantation in Select Populations: Chronic Obstructive Pulmonary Disease

BACKGROUND

The use of single lung transplantation (SLTx) for chronic obstructive pulmonary disease is often viewed as inferior therapy compared with bilateral lung transplantation (BLTx). We hypothesized from our experience that subpopulations of recipients with emphysema exist in which SLTx represents therapy that is equivalent to BLTx, therefore allowing more patients access to transplantation.

METHODS

Consecutive patients undergoing LTx for emphysema between 1992 and 2012 at a single institution were identified and analyzed retrospectively. A similar cohort from the United Network of Organ Sharing (UNOS) national database was identified for comparison. Five-year survival in patients receiving SLTx and those receiving BLTx were compared using Kaplan-Meier survival curves and log-rank tests.

RESULTS

Two hundred thirty-six patients meeting criteria were identified from our institution. Two hundred six underwent SLTx, and 30 underwent BLTx. Five-year survival for single-center SLTx (53.2% ± 3.6%) and BLTx (56.7% ± 10.2%) was not significantly different (p = 0.753). The national database included 7,256 patients meeting selection criteria, with 4,408 undergoing SLTx and 2,848 undergoing BLTx. Five-year survival among the national cohorts was lower for SLTx (46.4% ± 0.8%) compared with BLTx (55.9% ± 1.1%) (p < 0.0001). However, 5-year survival for our single-center SLTx experience (53.2% ± 3.6%) was comparable to the national BLTx cohort (55.9% ± 1.1%) (p = 0.539).

CONCLUSIONS

Five-year survival after SLTx for emphysema was comparable to that for BLTx in cohorts from our institution and from the UNOS national database. Further study should focus on the mechanism behind these improved outcomes. Given the potential for a larger number of life-years saved, SLTx should continue to be considered a therapeutic option in appropriately selected patients with chronic obstructive pulmonary disease (COPD).

Impact of lung allocation score on survival in cystic fibrosis lung transplant recipients

BACKGROUND

The lung allocation score (LAS) has changed organ allocation for lung transplantation in the United States. Previous investigations of transplant recipients reported an association between high LAS and an increased risk of death after lung transplantation. We hypothesize that a high LAS predicts survival in lung transplant recipients with cystic fibrosis (CF) in the United Network for Organ Sharing Scientific Registry of Transplant Recipients database.

METHODS

A cohort study was conducted of 1,437 U.S. adult lung transplant recipients with CF from May 1, 2005, through December 31, 2012. The cohort was divided into a high-risk group and a low-risk group based on LAS. Survival data were examined using Kaplan-Meier estimates and Cox proportional hazard models to compare survival. The primary outcome was adjusted survival at 1 year after lung transplantation.

RESULTS

The high-risk group of 318 patients with a median LAS of 69.6 (interquartile range 56.3-87.2) was compared with a low-risk group of 1,119 patients with a median LAS of 38.8 (interquartile range 36.3-42.3). Patients in the high-risk group had a 41% increased relative risk of cumulative mortality at 1 year after transplantation compared with the low-risk group (16.1% vs 12.0%). After adjustment for known predictors of mortality, the risk of death at 1 year after transplantation remained elevated (hazard ratio = 1.41; 95% confidence interval = 1.00-2.01). The high-risk group had worse survival at 90 days and 2 years after lung transplantation.

CONCLUSIONS

High LAS are associated with worse survival in lung transplant recipients with CF.

Single versus bilateral lung transplantation: do guidelines exist?

An ongoing debate exists between proponents of single or double lung transplantation for end-stage pulmonary disease. Short-term and long-term outcomes, as well as individual and societal benefits are some of the key considerations. This article examines the evidence that directly compares these two approaches and informs the debate about the relative merits of single and bilateral transplantation.

A functional assessment of patients two years after lung transplantation in Poland

THE AIM OF THE STUDY

The aim of the study was to assess the long-term results of lung transplantation (LT) in Poland two years after the procedure.

MATERIAL AND METHODS

The study included patients who underwent LT between December 2004 and December 2009 in the Silesian Center for Heart Diseases in Zabrze. Various lung functions (forced vital capacity - FVC; forced expiratory volume in 1 second - FEV1), the quality of life (SF-36 questionnaire), the level of perceived dyspnea (Medical Research Council - MRC; basic dyspnea index - BDI), and the patient's mobility (the 6-minute walking test - 6MWT) were assessed before and approximately 24 months after LT. Among 35 patients who underwent LT, 20 patients were referred to our study (mean age: 46.6 ± 9.03 years).

RESULTS

After LT, a statistically significant increase was observed in the distance achieved in the 6MWT (323.8 vs. 505.8 m), FVC (1.64 vs. 2.88 L), and FEV1 (1.37 vs. 2.09 L). An improvement in perceived dyspnea in MRC and BDI questionnaires was observed in patients with chronic obstructive pulmonary disease (COPD) after LT. The assessment of the quality of life, excluding perceived pain, showed the most significant improvement in the physical cumulative score (PCS; 25 vs. 45 points), especially in patients with idiopathic pulmonary fibrosis.

CONCLUSIONS

Lung transplantation in Poland, in patients who live longer than 2 years after the procedure, significantly improves the mobility, lung function, perceived dyspnea, and the quality of life.

Impact of lung transplantation on recipient quality of life: a serial, prospective, multicenter analysis through the first posttransplant year

BACKGROUND

Quality of life (QOL) is an important but understudied outcome after lung transplantation. Previous cross-sectional, single-center studies suggest improved QOL, but few prior longitudinal multicenter data exist regarding the effect of transplantation on the patient’s QOL.

METHODS

We hypothesized that lung transplantation confers a 1-year QOL benefit in both physical and psychologic well-being; we further hypothesized that the magnitude of benefit would vary by sex, native disease, age, or type of transplant operation. To test these hypotheses, we conducted a secondary analysis using QOL data prospectively and serially measured with the Medical Outcomes Study 36-Item Short-Form Health Survey, version 2 (SF-36) in a multicenter cytomegalovirus prevention clinical trial. Linear mixed-effects models were used to assess the impact of transplantation on the recipient’s QOL.

RESULTS

Over the first year after lung transplantation, the SF-36 Physical Component Score significantly increased an average of 10.9 points from baseline levels (P < .0001). A positive benefit was observed for all native diseases; however, the magnitude varied slightly by native disease (P = .04) but not by sex (P = .35), age (P = .06), or transplant type (P = .30). In contrast, the SF-36 Mental Component Score did not change from baseline (P = .36) and remained well below population norms.

CONCLUSIONS

Our results demonstrate that lung transplantation confers clinically important QOL benefits in physical domains but not in psychologic well-being. A better understanding of the barriers to psychologic well-being after transplant is critical to enhancing the benefits of lung transplantation.

Quality of life in lung transplantation

Improving health-related quality of life is an important goal of lung transplantation. This review describes background concepts, including definitions, measurement and interpretation of health-related quality of life (HRQL), and other patient-reported outcomes. Lung transplantation is associated with dramatic and sustained improvements in HRQL, particularly in measures of physical health and functioning. Physical rehabilitation may augment the early improvements in HRQL, whereas bronchiolitis obliterans syndrome and psychological conditions have a negative impact. More research is needed, particularly longitudinal, multicenter studies, to better understand the trajectory and determinants of HRQL after lung transplantation, and the impact of targeted interventions to improve HRQL.

A thematic analysis of quality of life in lung transplant: the existing evidence and implications for future directions

Health-related quality of life (HRQL) has been assessed in various lung transplantation (LT) investigations but never analyzed systematically across multiple studies. We addressed this knowledge gap through a systematic literature review. We searched the PubMed, CINAHL and PsychInfo databases for publications from January 1, 1983 to December 31, 2011. We performed a thematic analysis of published studies of HRQL in LT. Using a comparative, consensus-based approach, we identified themes that consistently emerged from the data, classifying each study according to primary and secondary thematic categories as well as by study design. Of 749 publications initially identified, 73 remained after exclusions. Seven core themes emerged: (1) Determinants of HRQL; (2) Psychosocial factors in HRQL; (3) Pre- and posttransplant HRQL comparisons; (4) Long-term longitudinal HRQL studies; (5) HRQL effects of therapies and interventions; (6) HRQL instrument validation and methodology; (7) HRQL prediction of clinical outcomes. Overall, LT significantly and substantially improves HRQL, predominantly in domains related to physical health and functioning. The existing literature demonstrates substantial heterogeneity in methodology and approach; relatively few studies assessed HRQL longitudinally within the same persons. Opportunity for future study lies in validating existing and potential novel HRQL instruments and further elucidating the determinants of HRQL through longitudinal multidimensional investigation.

Patient-reported outcome 2 years after lung transplantation: does the underlying diagnosis matter?

Purpose

Transplantation has the potential to produce profound effects on survival and health-related quality of life (HRQL). The inclusion of the patient’s perspective may play an important role in the assessment of the effectiveness of lung transplantation. Patient perspectives are assessed by patient-reported outcome measures, including HRQL measures. We describe how patients’ HRQL among different diagnosis groups can be used by clinicians to monitor and evaluate the outcomes associated with transplantation.

Methods

Consecutive lung transplant recipients attending the lung transplant outpatient clinic in a tertiary institution completed the 15-item Health Utilities Index (HUI) questionnaire on a touchscreen computer. The results were available to clinicians at every patient visit. The HUI3 covers a range of severity and comorbidities in eight dimensions of health status. Overall HUI3 scores are on a scale in which dead = 0.00 and perfect health = 1.00; disability categories range from no disability = 1 to severe disability <0.70. Single-attribute and overall HUI3 scores were used to compare patients’ HRQL among different diagnosis groups. Random-effect models with time since transplant as a random variable and age, gender, underlying diagnoses, infections, and broncholitis obliterans syndrome as fixed variables were built to identify determinants of health status at 2-years posttransplantation.

Results

Two hundred and fourteen lung transplant recipients of whom 61% were male with a mean age of 52 (19–75) years were included in the study. Chronic obstructive pulmonary disease and cystic fibrosis patients displayed moderate disability, while pulmonary fibrosis and pulmonary arterial hypertension patients displayed severe disability. Patients with chronic obstructive pulmonary disease had the worst pain level, whereas patients with pulmonary fibrosis had the worst emotion and cognition levels. A random-effect model confirmed that development of broncholitis obliterans syndrome was the most important determinant of health status (P = 0.03) compared to other variables, such as cytomegalovirus infections and underlying diagnoses.

Conclusion

Descriptions of patients’ HRQL among different diagnosis groups could be used by clinicians to assist individualized patient care.

Defining patient-reported outcomes in chronic obstructive pulmonary disease: the patient-centered experience

Patients with COPD have reduced HRQOL, and HRQOL worsens as COPD progresses.Although long-term interventions such as smoking cessation, supplemental oxygen therapy for hypoxemia, LVRS, and lung transplantation may save lives, these and other therapies have variable but important effects on PROs. Measures of HRQOL can serve as measures of disease severity and predict outcome. Moreover, these measures are sensitive to change following interventions, and can thus be used as measures of intervention effect. Future research will provide a better understanding of the effects of COPD on HRQOL and the impact of various interventions.

The societal impact of single versus bilateral lung transplantation for chronic obstructive pulmonary disease

RATIONALE

Bilateral lung transplantation (BLT) improves survival compared with single lung transplantation (SLT) for some individuals with chronic obstructive pulmonary disease (COPD). However, it is unclear which strategy optimally uses this scarce societal resource.

OBJECTIVES

To compare the effect of SLT versus BLT strategies for COPD on waitlist outcomes among the broader population of patients listed for lung transplantation.

METHODS

We developed a Markov model to simulate the transplant waitlist using transplant registry data to define waitlist size, donor frequency, the risk of death awaiting transplant, and disease- and procedure-specific post-transplant survival. We then applied this model to 1,000 simulated patients and compared the number of patients under each strategy who received a transplant, the number who died before transplantation, and total post-transplant survival.

MEASUREMENTS AND MAIN RESULTS

Under baseline assumptions, the SLT strategy resulted in more patients transplanted (809 vs. 758) and fewer waitlist deaths (157 vs. 199). The strategies produced similar total post-transplant survival (SLT = 4,586 yr vs. BLT = 4,577 yr). In sensitivity analyses, SLT always maximized the number of patients transplanted. The strategy that maximized post-transplant survival depended on the relative survival benefit of BLT versus SLT among patients with COPD, donor interval, and waitlist size.

CONCLUSIONS

In most circumstances, a policy of SLT for COPD improves access to organs for other potential recipients without significant reductions in total post-transplant survival. However, there may be substantial geographic variations in the effect of such a policy on the balance between these outcomes.

Assessment of a novel lung sealant for performing endoscopic volume reduction therapy in patients with advanced emphysema

AeriSeal Emphysematous Lung Sealant is a novel endoscopic lung-volume reduction therapy designed to reduce hyperinflation and improve pulmonary function and quality of life in patients with advanced emphysema. The device is administered to the subsegmental bronchus via a catheter as a 20 ml volume of liquid-foam. It flows into the peripheral airways and alveoli where it polymerizes and functions as a tissue glue, forming a film of material on the lung surface that seals the target region to cause durable absorption atelectasis. The AeriSeal System received CE mark approval for the treatment of patients with advanced upper lobe predominant and homogeneous emphysema based upon favorable results from clinical studies, and is commercially available in Europe. Patient and treatment site selection algorithms have been developed to simplify product use and optimize outcomes. This manuscript summarizes how the device is used, its mechanism of action and clinical trial results supporting its safety and efficacy.

Survival and quality of life of patients undergoing lung transplant

Lung transplant offers the hope of prolonged survival and significant improvement in quality of life to patients with advanced lung disease. However, the medical literature lacks strong evidence and shows conflicting information regarding the effects of lung transplantation on these outcomes. Tools that integrate survival and quality-of-life information allow for more comprehensive evaluations of the benefits and risks of lung transplant. Higher-quality information leads to improved knowledge and more-informed decision making.

BODE index and quality of life in advanced chronic obstructive pulmonary disease before and after lung transplantation

BACKGROUND

The BODE index (Body mass index, Obstruction, Dyspnea, Exercise), predicts the risk of death in patients with chronic obstructive pulmonary disease (COPD), and is used to identify candidates for lung transplantation. We hypothesized that a higher BODE index would be associated with worse health-related quality of life (HRQL) in advanced COPD, and with larger improvements in HRQL after transplantation.

METHODS

In this cohort study (n = 112), we administered the St. George's Respiratory Questionnaire (SGRQ), 36-Item Short Form (SF-36), Visual Analog Scale, Standard Gamble and EuroQol Group 5-Dimension (EQ-5D) index to otherwise healthy COPD patients with a FEV(1) <50% predicted. We compared mean HRQL values across BODE score groups, and tested for linear trends. In patients who received lung transplants during the study period, we compared SGRQ scores before and early (mean 4 months) after transplantation.

RESULTS

BODE was directly associated with SGRQ and inversely related to all other HRQL measures (p < 0.05). Early post-transplant improvements in HRQL were also seen across the spectrum of BODE scores from 5 to 10.

CONCLUSIONS

The BODE score is a significant predictor of HRQL in patients with severe COPD. We noted dramatic improvements in HRQL after transplantation, which appeared similar in magnitude for patients with pre-transplant BODE scores of 5 or 6 and 7 to 10, despite the difference in expected survival between these two groups. The association of the BODE score with HRQL further supports its use in identifying potential candidates for lung transplantation.

Single-lung transplantation in the setting of aborted bilateral lung transplantation

Background. The outcome of patients undergoing a single-lung transplant in the setting of an aborted bilateral lung transplant is unclear. Methods. A retrospective review of single lung transplants at an institutional program. Results. Of the 543 lung transplants performed over the last 10 years, 31 (5.7%) were single-lung transplants. Nineteen of 31 (61%) were planned single-lung transplants, while 12/31 (39%) were intraoperatively aborted, double lung transplants converted to single-lung transplants. The aborted and planned groups were similar in age, lung allocation score and NYHA status. The reasons for aborted double lung transplantation were cardiac/hemodynamic instability 4/12 (33%), difficult pneumonectomy 3/12 (25%), size mismatch 4/12(33%), and technical issues 1/12 (8%). The aborted group had higher CPB utilization (5/12 versus 1/19, P = .02), similar ischemic times (260 versus 234 min) and similar incidence of grade 3 primary graft dysfunction (6/12 versus 3/19, P = .13). ECMO was required for graft dysfunction in 2 patients in the aborted group. The one and two-year survival was 84% and 79% in the planned group and 62% and 52% in the aborted group, respectively. Conclusions. Patients undergoing single-lung transplantation in the setting of an aborted bilateral lung transplant may be at a higher risk of worse outcomes.

Assessing the benefit of accepting a single lung offer now compared with waiting for a subsequent double lung offer

BACKGROUND

Comparisons of survival after single lung transplant (SLT) and bilateral lung transplant (BLT) are useful in making policy decisions, but a more relevant comparison for an individual patient is between accepting a single lung when offered and remaining on the waiting list with the potential to subsequently receive a suitable pair of lungs.

METHODS

U.K. data from a cohort of 1211 adult, first lung transplant candidates diagnosed with pulmonary fibrosis (PF) or chronic obstructive pulmonary disease (COPD), listed July 1995 to July 2006 and followed up till December 2007, were analyzed. A sequentially stratified proportional hazards model was used to assess mortality after SLT relative to continued waiting for BLT.

RESULTS

For patients with PF, SLT was associated with a significant reduction in hazard relative to waiting for BLT (hazard ratio 0.81, 95% confidence interval 0.68-0.97, P=0.021), particularly for older patients with body mass index less than 20 and forced expired volume in 1 sec is less than 1 L. In contrast, our results gave no support for accepting SLT rather than waiting for BLT for patients with COPD (hazard ratio 1.08, 95% confidence interval 0.92-1.29, P=0.35).

CONCLUSION

The high pretransplant risk of death for patients with PF, particularly older patients with low body mass index and poor lung function, suggests that they would benefit from taking an SLT if offered. However, there is no benefit of accepting SLT rather than waiting for BLT for patients with COPD; this reflects the low relative hazard in the absence of transplant for these patients.

Guidelines for the selection of lung transplantation candidates

The present guidelines have been prepared with the consensus of at least one representative of each of the hospitals with lung transplantation programs in Spain. In addition, prior to their publication, these guidelines have been reviewed by a group of prominent reviewers who are recognized for their professional experience in the field of lung transplantation. Within the following pages, the reader will find the selection criteria for lung transplantation candidates, when and how to remit a patient to a transplantation center and, lastly, when to add the patient to the waiting list. A level of evidence has been identified for the most relevant questions. Our intention is for this document to be a practical guide for pulmonologists who do not directly participate in lung transplantations but who should consider this treatment for their patients. Finally, these guidelines also propose an information form in order to compile in an organized manner the patient data of the potential candidate for lung transplantation, which are relevant in order to be able to make the best decisions possible.

Effect of inpatient rehabilitation on quality of life and exercise capacity in long-term lung transplant survivors: a prospective, randomized study

BACKGROUND

The purpose of this study was to examine the effect of an inpatient rehabilitation program on health-related quality of life (HRQOL) and exercise capacity (EC) in long-term (>1 year after lung transplantation) survivors (LTSs) in comparison to a control group (CG).

METHODS

Sixty LTSs, 4.5 ± 3.2 years after lung transplantation (LTx), were randomly assigned to two equally sized groups that were stratified for gender and underlying disease. Thirty LTSs (age 49 ± 13 years, 13 male and 17 females, 19 double LTxs, 7 BOS Stage ≥ 1) attended an inpatient rehabilitation program (intervention group, IG) for 23 ± 5 days. The CG (age 50 ± 12 years, 13 males and 17 females, 20 double LTxs, 2 BOS Stage ≥ 1) received medical standard therapy (physiotherapy). Patients were evaluated by cardiopulmonary exercise testing, 6-minute walk test (6MWT), SF-36, SGRQ and the Quality of Life Profile for Chronic Diseases questionnaire before and after (18 ± 3 days) the program.

RESULTS

The groups were statistically indistinguishable in terms of clinical data. Each treatment group significantly improved their sub-maximal EC (6MWT: IG, 493 ± 90 m vs 538 ± 90 m, p < 0.001; CG, 490 ± 88 m vs 514 ± 89 m, p < 0.001) and maximal EC (VO(2peak): IG, 17.0 vs 18.5 ml/min/kg, p = 0.039; CG, 18.0 vs 19.5 ml/min/kg, p = 0.005), without reaching statistical significance between the groups. In both study groups, patients HRQOL tended to improve. Significant correlations were found between EC parameters and HRQOL scales.

CONCLUSIONS

Our data suggest that structured physical training may improve exercise tolerance in LTS. Our study results did not demonstrate a significant benefit of an inpatient over an outpatient exercise program.

Improvement in health-related quality of life after lung transplantation

BACKGROUND/OBJECTIVE

Traditional survival outcomes do not reflect the effects on the health-related quality of life (HRQL) of patients. HRQL following lung transplantation has not been studied systematically. The Health Utilities Index (HUI) is a family (HUI2 and HUI3) of measures of HRQL that has not been previously used to assess HRQL in lung transplantation. The objective of the present study was to assess the impact of lung transplantation on patient's HRQL using the HUI.

METHODS

A total of 43 patients completed a battery of questionnaires before lung transplantation, and at three months and six months after lung transplantation. The 15-item questionnaire (HUI2 and HUI3) was used. Overall scores were based on a conventional scale (0.00 = dead, 1.00 = perfect health). Mental health was assessed by the Hospital Anxiety and Depression Scale. Adherence to medication and exercise were assessed by Morisky's and Godin's questionnaires, respectively.

RESULTS

Sixty-five per cent of the patients were men, with a mean age of 53 years (range 18 to 67 years). The mean overall HUI3 score for the lung transplant candidates (0.57) was much lower than for the lung transplant recipients (0.82) at six months post-transplantation. This difference was clinically important and statistically significant (P<0.05 [paired t test, degrees of freedom (df) = 35]). Differences in mean Hospital Anxiety and Depression Scale scores after transplantation were statistically significant (P<0.05 [paired t test, df=35]). After six months, transplant recipients were more adherent to medication (P<0.05 [X2 test, df=1]). Recipients were able to increase the duration of exercise at all levels of intensity.

CONCLUSION

Lung transplantation improved the patients' HRQL and adherence to medication. Anxiety levels persisted six months after transplantation but depression levels had decreased significantly.