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Transplant Services

UCLA performs lung transplants in select older patients with encouraging clinical outcomes

10/01/2008

The UCLA Division of Cardiothoracic Surgery is home to the western United States' busiest and most aggressive lung transplant program for older patients. While many lung transplant programs exclude patients age 65 years and older
due to the shortage of donor organs and presumed lower survival rates, UCLA's experience demonstrates that transplantations can be performed in select patients older than 65 with acceptable short- and medium-term survival outcomes.
To avoid competition with younger patients for life-saving organs, UCLA seeks to match older patients with so-called nonstandard lungs whenever possible. Experience shows that these recipients have done well at UCLA.

Program history

Withholding life-saving therapy on the basis of advanced age is not ethically supportable. Yet many transplant programs impose an upper age limit of 65 years for single-lung transplantation and 60 years for double-lung transplantation.
In 1999, UCLA discontinued using advanced age as an absolute contraindication in the selection of lung transplant recipients. Between 2000 and 2006, patients aged 65 and older accounted for nearly 25 percent of the 217 total lung transplantations performed at UCLA. This percentage has been steadily increasing. Before 2003, about 14 percent of lung transplantation patients were 65 and older.

Study results

The Journal of Thoracic and Cardiovascular Surgery(1) recently published the results of a UCLA study1 — the largest yet comparing lung-transplantation outcomes in older and younger patients. The authors reviewed the transplant histories of 50 patients who were 65 years or older when they underwent transplants between March 2000 and September 2006 at UCLA. Using a propensity score analysis, researchers matched each older patient with a recipient younger than 65.

The study revealed that the 30-day survival for older patients was 95.7 percent, compared with 95.9 percent in the younger cohort. The one-year survival was 79.7 percent for the older group and 91.2 percent for the younger group, while the three-year survival was 73.6 percent and 74.2 percent, respectively. Infection was the predominant cause of mortality in the older group at the oneyear mark. These infections may have been due to over-immunosuppression. Lowering the immunosuppression regimen in these patients will likely reduce the infection rate.

Single-lung transplantation was the treatment of choice for older patients, who seem to fare better with this procedure than with double-lung transplantation. What is a nonstandard lung? Donor lungs were defined as nonstandard due to lobar infiltrate, hypoxemia (below-normal oxygen content in arterial blood), donor age greater than 55 years, or a smoking history greater than 20 pack-years. Forty-six percent of donor lungs for older recipients were classified as nonstandard, compared with 28 percent of donor lungs in the younger group.

Important caveats

The UCLA researchers emphasized several important caveats and study limitations. Older patients were not accepted unless they were otherwise in good physiological health. (Grounds for exclusion included: body mass index below 18 or above 30; renal insufficiency; debilitation; presence of obstructive coronary artery disease; and presence of peripheral vascular or cerebrovascular disease.)

Also, clinical management protocols (donor and recipient selection and management) and the small sample size may be factors in the similarity of outcomes between the older and younger patients.

Researchers also noted that it was impossible to match older and younger patients on the basis of a single or double transplantation as there were more double-lung recipients in the younger group and more single-lung transplants in the older group. Had that comparison been possible, the short-term outcomes might have been different. Matching of older and younger patients was based on factors such as diagnoses and severity of disease.

Lastly, researchers noted that they did not collect data on quality of life—an important consideration in any transplant.

UCLA lung transplantation expertise

This year marks two decades of lung transplants at UCLA, with more than 408 patients having undergone the procedure. The 30-member lung transplant team includes highly skilled and experienced transplant surgeons, pulmonologists, nurse coordinators, cardiologists, infectious disease specialists, dieticians, social workers and other specialists. The UCLA Lung Transplant Program is Medicare certified.  

Since May 2005, the median waiting time for lung transplants at UCLA has decreased from 107 days to 47 days.

Contact
Call (310) 825-6068 to schedule an appointment.
The Transplant Clinic, where an evaluation will take place, is located at:
200 UCLA Medical Plaza, Suite 265
Los Angeles, Ca 90095

Medical Directors
Abbas Ardehali, M.D., F.A.C.S.,
Associate Professor of Surgery
Division of Cardiothoracic Surgery
David Geffen School of Medicine at UCLA

David Ross, M.D.
Professor of Medicine
Pulmonary and Critical Care Medicine
David Geffen School of Medicine at UCLA

(1) Lung transplantation in older patients? J Thorac Cardiovasc Surg. 2008 Feb;135(2): 412-20. Epub 2007 Dec 26. PMID: 18242277





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