Question: Recently I referred a patient with IPF for evaluation for lung transplantation. The center prefers to perform only single lung transplants. I have heard that other centers would consider bilateral lung transplantation for this condition. What is the current best practice for IPF lung transplantation, and are the considerations the same for all the major ILDs?

Answer: This is an interesting question that touches upon several aspects of lung transplantation. The increasing numbers of candidates awaiting lung transplantation far outstrip the supply of available organs. To optimize the use of this resource, single lung transplantation would serve the greatest number of recipients. However, another principle of lung transplantation is to improve survival and quality of life for the recipients. Suppurative lung diseases, such as cystic fibrosis or diffuse bronchiectasis, are absolute indications for bilateral lung transplantation, but for most diseases data on the ideal procedure are not that clear.

 

In the past several years there has been an increase in the number of bilateral lung transplants performed for diseases previously considered to be indications for single lung transplantation. When the ISHLT (International Society for Heart and Lung Transplantation) registry data for outcomes are compared for single and bilateral lung transplantation, there appears to be a long-term survival advantage for bilateral lung transplant recipients but this is dependent on many factors, such as age of recipient, donor quality and the disease. In patients with COPD under 60 years of age, bilateral lung transplantation had greater survival benefit at 5 years when compared to single. Registry data for patients with IPF undergoing lung transplantation showed a survival advantage at 3 years for single lung transplant recipients younger than 60. There was a higher morbidity and mortality associated with bilateral lung transplantation in the early perioperative period, but when conditional survival (survival to 30d) was evaluated this difference was no longer present.

More recent reports from single centers which use the new allocation system (accounting for increased acuity) and extend the period of observation to 5 years, do show a survival advantage of bilateral lung transplantation in the IPF population. In one study, risk factors for mortality following lung transplant for IPF included single lung transplant and elevated wedge pressure. Some centers advocate the use of bilateral lung transplant for IPF patients who have associated pulmonary hypertension, are under the age of 60, and/or receive organs from an extended donor. This practice is based on extrapolated data from COPD patients and the previously noted higher mortality of bilateral lung transplantation in patients with IPF who tend to be older. However, some authors report good safety results with bilateral lung transplantation in patients older than 60, suggesting that age alone should not exclude bilateral lung transplantation.

Center-specific factors may influence the decision to perform one or the other procedure in the patient with IPF and other interstitial lung diseases such as collagen vascular-associated pulmonary fibrosis or sarcoidosis. The ideal procedure remains an area of controversy.

Selected References

Chang AC, Chan KM, Lonigro RJ, et al. Surgical patient outcomes after the increased use of bilateral lung transplantation. J Thorac Cardiovasc Surg. 2007;133:532-40.

Mason DP, Brizzio ME, Alster JM, et al. Single vs double lung transplantation for idiopathic pulmonary fibrosis. Ann Thorac Surg. 2007;84:1121-1128.

Meyers BF, Lynch JP, Trulock EP, Guthrie T, Cooper JD, Patterson GA. Single versus bilateral lung transplantation for idiopathic pulmonary fibrosis: A ten-year institutional experience. J Thorac Cardiovasc Surg. 2000;120:99-107.

Meyer DM, Bennett LE, Novick RJ, Hosenpud JD. Single vs bilateral, sequential lung transplantation for end-stage emphysema: influence of recipient age on survival and secondary endpoints. J Heart Lung Transplant. 2001;20:935-941.

Rinaldi M, Sansone F, Boffini M, et al. Single versus double lung transplantation in pulmonary fibrosis: a debated topic. Transplant Proc. 2008;40:2010-2012.