My patient has severe lung disease but also has cirrhosis/coronary artery disease/renal insufficiency/previous cancer. Should I still refer?
These issues are evaluated on a case by case basis.
- Well-compensated cirrhosis affects risks but is not a contraindication.
- Hepatitis B and C virus infection are not contraindications if controlled.
- Coronary artery disease with demonstrable ischemia or a tenuous cardiac blood supply is a contraindication.
- However lesions may be amenable to percutaneous intervention pre-transplant (Bare metal stent only) followed by clopidogrel for at least 6 weeks
- Combined lung transplant with coronary artery bypass grafting or valve replacement may be considered in younger, otherwise excellent candidates.
- Renal insufficiency is a major concern but should not preclude assessment, particularly in otherwise low-risk patients.
- Patients with a history of solid organ cancer are generally not eligible for 5 years after cancer treatment.
- However if the treating oncologist advises that the risk of cancer recurrence is very low then patients may be assessed sooner.
My patient is ventilated for ARDS. Can they be transferred to TGH for urgent assessment and transplant?
- These situations are very difficult and they are not rare
- We do not think lung transplantation is the best acute management option in most cases:
Patients typically need to remain stable for several months to be assessed and transplanted. They need to avoid sepsis or serious dysfunction of other organs during this period.
- Patients with ARDS and no prior lung disease may make a good recovery despite weeks of mechanical ventilation. If they survive the episode then their prognosis will likely be better than it would have been with a transplant, as they will avoid the need for lifelong immunosuppression and its associated complications
- We are very reluctant to transplant a patient who is not able to consent or to understand the issues and potential complications they will face post transplant.
- Despite the above concerns, if you have a younger and otherwise well patient with ARDS we are certainly willing to discuss the situation and consider whether and when transplant might have a role in their management.
- We are also willing to assess chronically ventilated patients who are alert and ambulatory.
How long does the assessment process take?
From initial referral to listing will typically take 4 to 6 months.
In patients who are very ill or rapidly worsening the process can be expedited.
What does the assessment consist of?
What happens after the assessment?
Patients are discussed at an assessment meeting within a few weeks of the assessment. A group decision is made and possible outcomes include:
- Suitable for transplant, recommend listing
- Suitable for transplant but too early for listing, recommend periodic follow-up
- Possibly suitable for transplant but need to address specific issues first (comorbidities, BMI, social supports).
- Not a transplant candidate due to contraindications
Is financial assistance available for the costs of relocating to the Toronto area?
Yes. Limited assistance is provided through TPER (Transplant Patient Expenses Reimbursement Program).
Are Living Donor Lung Transplants Performed in Toronto?
Living donor lung transplants have been performed in children but not yet in adults.
The program would consider lobar donation by relatives in select cases.