Nina Ireland Distinguished Professor of Clinical Medicine and Surgery
University of California, San Francisco
San Francisco, California

Question: How are donated lungs allocated for transplantation and what does this mean for patients with Idiopathic Pulmonary Fibrosis (IPF)?

Answer: In May 2005, the Lung Allocation Score (LAS) was initiated. It gives priority to patients on the waiting list who are most severely ill (medical urgency) and who have the best expected outcome during the first year after transplantation. Of these two parameters, medical urgency is given more weight than post transplantation survival. Survival is considered so that futile procedures in particularly impaired patients are not performed. Prior to the LAS system, potential recipients were prioritized only by accrued time on the waiting list. The impetus for LAS was the scarcity of donor lungs and consequent deaths of patients on the waiting list. Before the LAS system, IPF patients had the highest percentage of waiting list deaths (33%) of all diagnostic categories (Egan, 2006).

Question: A recently diagnosed patient with IPF is being treated with steroids. What is the medically appropriate time to begin evaluation for lung transplantation? The patient has modest income and high-deductible insurance; if the steroids are effective, when is the expense of the lung transplant evaluation justifiable?

Answer: If the patient has a clear diagnosis of IPF there is little reason to employ steroids. In some cases, steroids may alleviate the symptoms of cough but the dose should eventually be reduced to about 10 mg/day.