*Indications:
COPD, restrictive lung diseases including idiopathic pulmonary fibrosis (IPD), cystic fibrosis (CF), alpha1-antitrypsin disease, primary pulmonary hypertension, and various less common causes. Patients with life expectancy is not predicted to exceed 24-36 months despite optimal and maximal medical management
Guidelines for timing referrals:
Chronic obstructive pulmonary disease (COPD) and alpha1-antitrypsin deficiency emphysema
o BODE index >5
o Postbronchodilator FEV1 <25% predicted
o Resting hypoxemia, ie, PaO2 <55-60 mm Hg
o Hypercapnia (PaCO2 >50 mm Hg)
o Secondary pulmonary hypertension
o Clinical course - Rapid rate of decline in FEV1 or life-threatening exacerbations.
*Contraindication:
• Malignancy in the last 2 years, with the exception of cutaneous squamous and basal cell tumors (A 5-y disease-free interval is prudent.)
• Noncurable chronic extrapulmonary infection including chronic active hepatitis B, hepatitis C, and HIV.
• Untreatable advanced dysfunction of another major organ system
• Current cigarette smoking
• Poor nutritional status
• Poor rehabilitation potential
• Significant psychosocial problems, substance abuse, or history of medical noncompliance
*Treatment:
Medical Therapy: Immune suppression. Most centers use a combination of tacrolimus, mycophenolate mofetil (MMF), and glucocorticoids as the 3-drug regimen for immunosuppression.
Surgical Therapy:
*Complications:
+Surgical Complications:

-Acute complications: Reperfusion edema, hemothorax, pleural effusions, chylothorax (a result of perioperative injury to the thoracic duct), and pneumothorax, full or partial dehiscence of the bronchial anastomosis.
-Delayed surgical complications: stenosis of the anastomotic site, formation of granulation tissue, or bronchomalacia, bronchopleural fistulas, loculated pleural effusions, and hemothorax or fibrothorax, pulmonary embolus.

+Graft Rejection includes:

-Hyperacute graft rejection 72 hours postoperatively, Primary graft failure results from ischemia-reperfusion injury and presents similarly to acute respiratory distress syndrome. Early mortality may reach up to 60%, and patients who survive to hospital discharge additionally have a protracted course of recovery with significant impairments in pulmonary function.
-Acute graft rejection: is highest in the first 3 months, with rare cases occurring 1 year post transplantation The clinical course is variable and depends on the severity of rejection; mild cases of rejection may even be asymptomatic. Diagnosis of acute graft rejection can be confirmed with bronchoscopic lung biopsy, which reveals perivascular lymphocytic infiltrates. Treatment for acute graft rejection is high-dose parenteral steroids (methylprednisolone 0.5-1 g/d IV) and should be started in consultation with a pulmonologist.
-Chronic rejection (Bronchiolitis obliterans syndrome)
The risk of BOS increases to 60-80% 5-10 years after the lung transplantation procedure. It is the most important complication that adversely affects the long-term survival of graft recipients
Symptoms occur secondary to the airflow obstruction that progresses over time. These patients develop exertional dyspnea, a nonproductive cough, wheezing, and/or low-grade fever. Although the symptoms resemble bronchial asthma, the limited response to bronchodilator and corticosteroid therapy makes these ineffective. No specific treatment exists for chronic graft rejection, and efforts are aimed toward immunosuppression and primary prevention.

*Immunosuppression-related Complications.
*Infection in the Immunosuppressed Patient.

To sum up, in the first 30 days, graft failure, noncytomegalovirus (CMV) infections, cardiovascular complications, and technical problems account for most of the mortality. After the first year, bronchiolitis obliterans syndrome (BOS) and nonCMV infections were the predominant causes of death. Patients are referred for transplantation at a point in the course of their disease at which death is considered likely within 2-3 years. Therefore, transplantation would be expected to confer a survival advantage.

Lung transplant - series