Lung Transplantation: The Breath of Life
George Haasler, MDMedical College of Wisconsin Cardiothoracic Surgeon
Named one of the “Best Doctors in America®” 2006 by Best Doctors, Inc.
A lung transplant is, quite literally, a life-saving operation. With five-year survival rates approaching 60 percent, lung transplantation enables patients to once again breathe freely. George Haasler, MD, discusses the leading causes of lung transplantation, organ rejection and the unique features of the Lung Transplant Program at Froedtert & the Medical College of Wisconsin.
Q. What critical functions do the lungs provide?The lungs provide the most important function, which is to make you breathe. Oxygen and carbon dioxide get exchanged in your lungs. The lungs give you the oxygen that you need for your vital organs and get rid of carbon dioxide, which is produced by your body.
Q. What are some of the most common causes for someone to require a lung transplant?There are four basic reasons. The most common reason nationwide right now is emphysema. Emphysema is one of a family of lung diseases that cause lung obstruction. Air can get in, but not much can get out. Then there are issues of scarring, called pulmonary fibrosis, which basically result in stiff lungs that won’t work. Sometimes smoking can cause that. Or other kinds of inflammation can cause it, like from an old virus syndrome. Next are a variety of infected lung diseases. These are people with end-stage lungs due to things like cystic fibrosis or bronchiectasis, where the lungs slowly get deteriorated and destroyed. The fourth reason is when people have heart disease that causes backward pressure in the lungs, called pulmonary hypertension, which causes scarring of the blood vessels. Primary pulmonary hypertension results in the same thing, scarring and thickening of the lungs. Sometimes you can help those people by doing lung transplants, which basically gives them a new, low-resistance circuit that blood can flow through.
Q. Is a lung transplant the last resort?It is. Because to some extent, a lung transplant substitutes a horrible pre-death condition for a condition that nevertheless requires medical care. It may involve trips back to the hospital, but ultimately gives people, hopefully, a better quality of life and gives them more ability to function, the ability to get off oxygen and, in many instances, the ability to live fairly long, productive lives, despite these terrible illnesses.
Q: What is organ rejection?It’s really just what it sounds like: the body, for one reason or another, does not accept those organs and fights against them with its immune system. When people have transplants, the body’s immune system wishes to reject anything that is foreign to the body. And so you have to trick the immune system, or suppress it, to prevent it from taking over a transplanted organ. To some extent that’s possible with medicines. There may still be either some very fast rejection, in cases where people have pre-formed antibodies against an organ, or there can be a slow, long-term rejection, where even though you’ve adjusted those medicines to what you think is a reasonable balance, the body either can’t tolerate having any more of those medicines, or there’s still some low-grade ability of the body’s immune system to break away at the transplanted organ.
Q: How is it treated?The kind that we call hyper-acute rejection, most of the time you can prevent by appropriately screening patients before the transplant. The slower, long-term rejection gets managed by careful manipulation of various medicines that we have at our disposal. Occasionally people will give radiation to the lymph node areas in the lung and in the body to decrease people’s overall lymph response. And there are a variety of other things that can be done. But the majority of it is treated by different doses of the medicines that are used to treat rejection.
There are three groups of medicines that treat rejection. There are medicines that work on all aspects of inflammation, and those are called corticosteroids. Prednisone is the prototype drug for that. Then there are other drugs, like Imuran® and CellCept®, which work on other aspects of white blood cell function. And then there are other inhibitors that inhibit various aspects of how the body responds to that. So there are a variety of different medicines that get used. The most important medicines are the steroids, a medicine called cyclosporine, another medicine called tacrolimus and Imuran® and CellCept®.
To some extent, you can give some medicines preoperatively to decrease the body’s immune response. That’s called induction therapy. Like all treatment with rejection medicines, induction therapy comes at some increased risk of infection, and induction regimens have a little more of a risk of viral problems afterwards, so it’s a careful balance. Anti-rejection therapy is always a combination of some very powerful medicines that suppress various aspects of your immune system but don’t suppress them so much that they don’t allow you to at least partially resist infection. You strike a new balance between your ability to fight the outside world and your ability to not reject your new organ.
Q: What are the short- and long-term outcomes for lung transplants?Overall the survival rates have improved yearly for the last ten years. At the moment, the five-year chances at survival are somewhere between 50 percent and 60 percent, depending on the exact disease that people have. Early post-operative survival is in the 80 to 90 percent range, with one- and two-year survival rates in the 70 percent to 80 percent range.
To some extent, the emphysema patients and some of the cystic fibrosis patients actually do better post-operatively. Patients with cystic fibrosis are usually young patients who don’t have some of the additional heart problems that some of the older patients might have. But as a group, the emphysema patients actually do very, very well after these transplants. The patients with pulmonary fibrosis and with heart-related problems don’t do as well but they can still do quite well.
Q: How is the Lung Transplant Program at Froedtert & the Medical College of Wisconsin different from other programs in the area?The group that has been doing lung transplants here has been doing them for a long time. 1991 was our first one. And while we’re not necessarily a high-volume program, we certainly have statistics that rival that of a lot of larger programs in the country. We’ve also taken on some people that other programs have turned down and done very well with them. The program at Froedtert & the Medical College of Wisconsin is a very conscientious overall transplant program in an institution that’s been dedicated to transplant for a long time. Another way in which our program is somewhat unique is that we have a large group of cystic fibrosis patients from Children’s Hospital who have come up into the adult service, so there’s a fair expertise with cystic fibrosis patients that may not exist in some other institutions.
Source: Every Day, interview with George Haasler, MD
Date: Jan - April 2007 issue