Clinical lung and heart/lung transplantation
Lung Transplantation in Patients With Chronic Obstructive Pulmonary Disease in a National Cohort Is Without Obvious Survival Benefit

https://doi.org/10.1016/j.healun.2005.06.025Get rights and content

Background

The objective in lung transplantation is to prolong life, but the survival effect in patients with chronic obstructive pulmonary disease (COPD) or α1-anti-trypsin deficiency emphysema is still unresolved. This study assesses the impact of diagnosis, single-lung transplantation (SLT) vs bilateral lung transplantation (BLT) and timing of transplantation on survival in a national cohort.

Methods

In 219 consecutive patients accepted onto the lung transplantation waiting list in Norway, 1990 to 2003, we assessed predictors of death: (1) on the waiting list; (2) ≤90 days after transplantation; and (3) >90 days after transplantation. For each period we used Cox regression, including age, gender, diagnosis, baseline pulmonary function tests, cardiac catheterization data, exercise capacity and transplant type, as potential predictors. Survival benefit was assessed graphically by combining adjusted survival curves after transplantation with the curve for those waiting, modeling transplantation after 6, 12 or 24 months.

Results

Mean patient age was 49 years (SD 10), with 55% women. High forced expiratory volume in 1 second (FEV1) percentage predicted death on the waiting list. Diagnoses other than COPD/emphysema and receiving SLT were associated with death ≤90 days after transplantation. Only low forced vital capacity (FVC) percentage predicted death >90 days after transplantation. In COPD/emphysema, there was no clear survival benefit from BLT or SLT. For patients in the “Other” group, the data suggest a survival benefit from BLT.

Conclusions

In COPD/emphysema, there was no obvious survival benefit from lung transplantation, which questions prolongation of life as the primary motivation for the procedure.

Section snippets

Subjects

In 1990, a program for lung transplantation was started at the Norwegian National Hospital, the only transplant center in Norway, and the hospital established a register with core information on all patients evaluated for lung transplantation. Patients selected for the lung transplantation waiting list fulfilled the following criteria, in line with international recommendations19: (1) terminal chronic pulmonary disease with respiratory failure or marked desaturation during exercise2; expected

Results

The patients accepted onto the waiting list had a mean age of 49 years (SD 10), and 55% were women. Of the transplantation candidates, 132 (60%) had COPD/emphysema (Table 1). The patients generally had low spirometry values, with a mean FEV1 of 0.8 liter (25% of predicted), low Pao2 values and BMI. Further descriptive statistics for the patients at the time of acceptance onto the waiting list are shown in Table 1. The median waiting time until transplantation for those actually transplanted (n

Discussion

In COPD/emphysema, there was no obvious survival benefit from BLT or SLT compared with no transplantation. In addition, in COPD/emphysema, there was little difference in survival with transplantation after 6 compared with 24 months of waiting. The finding of no survival benefit in patients with COPD/emphysema supports a previous report of no survival benefit during 2 years of observation,11 but is in contrast to other studies suggesting a survival benefit.14, 16

Our data suggest a survival

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