Lung transplantation: An overview
- Ramsey R Hachem, MD
Ramsey R Hachem, MD
- Professor of Medicine
- Washington University School of Medicine
Over the past 25 years, lung transplantation has become a viable treatment option for patients with a variety of end-stage lung diseases. The first human lung transplant procedure was performed in 1963, and the recipient survived 18 days, ultimately succumbing to renal failure and malnutrition . Despite the outcome, this demonstrated that lung transplantation was technically feasible and that rejection could be averted with the available immunosuppressive agents, at least for a short time.
Over the ensuing 15 years, few lung transplant procedures were performed, and the majority of recipients died perioperatively because of bronchial anastomotic complications. However, in 1981, the first successful heart-lung transplantation was performed for idiopathic pulmonary arterial hypertension . This was followed in 1983 by the first successful single lung transplantation for idiopathic pulmonary fibrosis  and in 1986 by the first double lung transplantation for emphysema . These successes were attributed to improved surgical techniques and the advent of cyclosporine. Over the following several years, the number of lung transplant procedures performed rapidly increased, and the operation became an accepted treatment for end-stage lung disease.
An overview of lung transplantation, including a discussion of outcomes, is presented here. Lung transplantation indications, recipient selection, choice of procedure, post-operative management and complications are presented separately. (See "Lung transplantation: General guidelines for recipient selection" and "Lung transplantation: Disease-based choice of procedure" and "Lung transplantation: Procedure and postoperative management" and "Noninfectious complications following lung transplantation" and "Evaluation and treatment of acute lung transplant rejection".)
Between 1988 and 1993, the number of lung transplants performed worldwide increased dramatically from 89 to 1160 annually (figure 1) . Between 1993 and 2000, the number of transplants reported to the International Society for Heart and Lung Transplantation (ISHLT) Registry increased modestly as activity appeared to plateau around 2000 procedures annually . However, there has been a steady growth in the number of procedures performed annually since 2000, and over 3700 transplants were reported in 2012 . While part of this increase may be attributable to greater participation in the ISHLT Registry, the rapid rise in activity since 2005 suggests that the lung allocation system implemented in the US in 2005 has increased the number of transplants performed.
Donor lung shortage has been the major limiting factor to the number of transplants performed. Lung organ procurement rates from deceased donors have consistently been substantially lower than kidney, liver, and heart procurement rates. Lungs are harvested from only 15 percent of all cadaveric donors, whereas kidneys and livers are harvested from 88 percent and hearts from 30 percent of deceased donors . These disparities are likely due to the lung's vulnerability to potential complications that often arise before and after donor brain death such as thoracic trauma, aspiration, ventilator associated lung injury, pneumonia, and neurogenic pulmonary edema. Nonetheless, as many as 40 percent of rejected donor lungs may have been suitable for transplantation . In addition, studies suggest that ex vivo lung perfusion and reconditioning may ameliorate lung injury in some cases and allow transplantation from donors previously deemed unsuitable [8,9]. Standard and extended criteria for donor lung selection and their impact on short and long-term outcomes are presented separately. (See "Lung transplantation: Donor lung preservation".)
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