Lung transplantation: implications for the general internist

The modern era of lung transplantation was ushered in on the wings of discoveries in new immunosuppressive agents and surgical technique. It has allowed those with end-stage organ disease to have a second chance at life. Even though still in its youth relative to other solid organ transplants, it is gaining momentum and promises to be a continuing area of growth and development. Although over 2,700 lung transplants have been done in the last 13 years worldwide, the lack of availability of donor organs is the major factor slowing the rapid expansion of this field of endeavor. Primary care physicians may have an impact on this problem by raising the awareness for organ donation in their patients and patients' families. Although initially performed almost exclusively for those with pulmonary vascular disease, indications have now expanded to include interstitial disease, septic lung disease, and emphysema, with the latter being the major reason for transplantation today. Unfortunately, at experienced institutions with long waiting lists, 20% or more of candidates do not survive to transplantation. With proper care and selection of transplant candidates it is hoped that more will survive to benefit from this treatment. The primary care physician will likely be assuming a greater role in the management of transplant candidates as their numbers increase. The care of transplant recipients, although often complex, is frequently rewarding. For the most part it is performed at transplant centers, but a role for the recipient's local physician in this process is also growing in the era of managed care. This chapter has also highlighted how the recipient's local physician can participate in postoperative care. Strict attention needs to be paid to any and all signs of organ rejection or infection because both can have devastating consequences. Awareness of the medications used in this population, their side effects, and drug interactions is essential. Despite the recent advances in pharmacologic therapy, organ rejection continues to be problematic. This is especially the case with the entity of chronic rejection because it frequently fails to respond long-term to therapy and accounts for a significant percentage of late mortality. Although infections continue to be the primary cause of both early and late mortality in these recipients, proper care and postoperative prophylaxis can lessen the incidence. Likewise, early and aggressive treatment of infections in recipients can be lifesaving. Despite all the potential problems, patients receiving lung transplants are living longer and return to productive lives. Between 50% and 60% are now living between 3 and 4 years, and one can only anticipate that this will continue to climb as our understanding of infections, medications, and the body's immunoregulatory system improves. As techniques for donor organ allocation and organ preservation improve, it is hoped that all those with end-stage lung disorders may have the opportunity to benefit from this expanding technology.