LUNG TRANSPLANTATION

Human lung transplantation was successfully performed in the early eig hties and is now an option for patients with endstage lung disease, wh ich is associated with poor survival. Most frequent indications for lu ng transplantation are emphysema, cystic fibrosis, fibrosing alveoliti s, primary pulmonary hypertension and Eisenmenger's syndrome. Single l ung transplantation (SLT) is most often performed in emphysema, fibros ing alveolitis and other diseases which are not associated with chroni c infection of the lung. Double lung transplantation was recently repl aced by the technique of sequential single lung or bilateral lung tran splantation (BLT). Cardiopulmonary bypass can often be avoided and pro blems of the airway anastomosis are less frequent using BLT. Main indi cations for this procedure are cystic fibrosis, bronchiectasis and pri mary pulmonary hypertension (PPH). In PPH often only SLT is performed. Cor pulmonale is reversible following SLT or BLT even if the heart is not replaced. Combined heart-lung transplantation (HLT) is reserved f or some cases of Eisenmenger's syndrome and few centers still prefer H LT in patients with cystic fibrosis. Patients are usually accepted for transplantation when they are considered to have life expectancy of 1 2 to 24 months. Quality of life and physical working capacity are seve rely decreased and patients suffer dyspnea NYHA grade III or IV. ,West of the patients are hypoxic and need continuous oxygen therapy. Hyper capnia is also a negative predictive factor for survival without trans plantation. In PPH cardiac index of less than 2 litres/m(2) is associa ted with poor outcome. Not only absolute values for FEV(1) and pO(2) h ave to be considered in finding the best moment for assessment for tra nsplantation but the clinical course of the disease during previous mo nths and years also has to be taken into account. Contraindications to transplantation include acute infection, concomitant diseases of othe r organs, bronchial carcinoma and psychiatric disorders if noncomplian ce is likely. To achieve good results after lung transplantation, prop er donor and recipient selection, experienced surgery and careful post operative management are essential. Complications must be diagnosed ea rly to provide effective treatment. Most complications occur within th e first months after surgery. Early complications include primary orga n failure, pleural bleeding, problems at the site of the airway anasto mosis, infection and acute rejection. Acute rejection is common but ca n be treated sucessfully if diagnosed early. Bacterial infections occu r predominantly within the first few weeks followed by viral, fungal a nd protozoal infections. Mortality of early bacterial infection is con siderable. It is often impossible to distinguish between rejection and infection on clinical grounds only. Bronchoscopy should be performed to start adequate treatment. Survival of patients after transplantatio n is mainly influenced by early complications and the development of o bliterative bronchiolitis months or years after transplantation. There is an irreversible decline in lung function in patients with oblitera tive bronchiolitis and this complication is very likely to be caused b y chronic rejection. As in transplantation of other organs, the incide nce of late infections and malignancies is increased by immunosuppress ive therapy. There are also specific side effects of longterm administ ered immunosuppressive agents such as nephrotoxicity, systemic hyperte nsion, diabetes mellitus, osteoporosis etc. Quality of life markedly i mproves after lung transplantation, especially in regard to energy and physical mobility.