1. Lung Transplantation: What? Who? When? Marshall I. Hertz, MD University of Minnesota Medical School and Fairview-University Medical Center Medical Director, Lung Transplantation Director, Center for Advanced Lung Disease

2. Topics for Discussion Organ transplantation in the US Organ transplantation in the US Overview of lung transplantation Overview of lung transplantation Inadequate supply of lungs for transplantation Inadequate supply of lungs for transplantation University of Minnesota

3. Major Biomedical Advances 1954-2004 Vaccines Vaccines Antibiotics Antibiotics Life support technologies Life support technologies Open heart surgery Open heart surgery Molecular genetics Molecular genetics Organ transplantation Organ transplantation University of Minnesota

4. Organ Transplantation in the United States 1 Jan 1988 – 31 Jan 2005 OrganNumber Kidney201,846 Liver69,057 Pancreas*16,674 Intestine977 Heart36,764 Lung*13,322 Total338,640 www.unos.org University of Minnesota

5. 1963: First kidney transplant in Minnesota 1963: First kidney transplant in Minnesota 1966: First pancreas transplant in the world 1966: First pancreas transplant in the world 1966: First intestinal transplant in the world 1966: First intestinal transplant in the world 1968: First successful human bone marrow transplant 1968: First successful human bone marrow transplant 1978: First heart transplant in Minnesota 1978: First heart transplant in Minnesota 1978: First living-donor pancreas transplant in the world 1978: First living-donor pancreas transplant in the world 1981: First pediatric heart transplant in Minnesota 1981: First pediatric heart transplant in Minnesota 1986: First heart-lung transplant in Minnesota 1986: First heart-lung transplant in Minnesota 1988: First lung transplant in Minnesota 1988: First lung transplant in Minnesota 1991: First living-related lung transplant in Minnesota 1991: First living-related lung transplant in Minnesota 1996: First living donor liver transplant in Minnesota 1996: First living donor liver transplant in Minnesota U of M Firsts in Transplantation

6. Organization of Transplant Services in the United States Department of Health and Human Services Department of Health and Human Services –United Network for Organ Sharing –Scientific Registry of Transplant Recipients Organ Procurement Organizations (LifeSource) Organ Procurement Organizations (LifeSource) Transplant Centers Transplant Centers –Physicians and surgeons –Nurse coordinators –Social workers –Administrators, financial representatives University of Minnesota

7. Types of Organ Donors Non-living Non-living –Brain death –Cardiac death Living Living –Biologically related –“Emotionally” related –Non-directed (“Good Samaritan”) University of Minnesota

8. Living Donor Transplantation U.S. Donors by Organ Type (2004) UNOS

9. Types of Lung Transplants Non-living donor Non-living donor –Single lung –Bilateral (double) –Heart and lung Living donor Living donor –Bilateral (double) lobar University of Minnesota

10. NUMBER OF LUNG TRANSPLANTS REPORTED BY YEAR AND PROCEDURE TYPE 13 1546 83 189 418 708 922 1089 1229 1368 1377 1464 1457 1477 1564 16021767 1703 ISHLT 2005

11. Types of Lung Recipients Pulmonary fibrosis Pulmonary fibrosis Emphysema/Alpha-1 antitrypsin deficiency Emphysema/Alpha-1 antitrypsin deficiency Pulmonary hypertension Pulmonary hypertension –Primary –Congenital heart disease Cystic fibrosis Cystic fibrosis University of Minnesota

12. ADULT LUNG TRANSPLANTATION Indications By Year (Number) ISHLT 2005

13. Characteristics of Lung Transplant Recipients with Pulmonary Fibrosis Severe disease Breathing tests (PFT) Exercise limitation (6-min. walk) Pulmonary hypertension (Echo) Age <65 years (55 for bilateral, 45 for heart-lung) Capable of following complicated medication schedule No severe disease in other organs (kidney, heart) Non-smoking, non-drinking University of Minnesota

14. Problems after Organ Transplantation Immune system reacts against transplanted organ (rejection) Immune system reacts against transplanted organ (rejection) –Acute –Chronic Medication side effects Medication side effects University of Minnesota

15. Outcomes after Lung Transplantation Function Function Quality of life Quality of life Survival Survival University of Minnesota

16. “The Growing Need” Organ Donors vs. Wait Listed Patients Based on OPTN data as of January 26, 2004. www.life-source.org

17. The Donor Shortage: Possible Approaches Use more non-living donors Increased public awareness Presumed consent laws “Breakthrough collaborative” Use more living donors Xenotransplants, bioartificial lungs, stem cells Make better use of existing non-living donors University of Minnesota

18. Current Lung Allocation System (1990) Who? Who? –Based on active waiting time only –90 days of “ extra ” waiting time assigned to idiopathic pulmonary fibrosis patients (1995) Where? Where? –Lungs offered first to recipients within the donor OPO –Then to recipients within concentric 500 mile circles University of Minnesota

19. Goals of the new lung allocation plan Reduce waiting list deaths Reduce waiting list deaths Improve overall survival Improve overall survival University of Minnesota

20. New lung allocation plan (May 4, 2005) Based on disease type, disease severity, and expected survival after transplant Scores range from 1 to 100 Patient information has to be updated every 6 months Blood group, size, and geography still matter Time on wait list does not count University of Minnesota

21. Questions, answers?