Transplant Process Evaluation
Patients who may be helped by a lung transplant undergo an extensive evaluation by the Penn Lung Transplant Team. Based on the evaluation results, the lung transplant team decides whether or not a lung transplant is the best therapeutic option. Sometimes, lung transplant is not recommended because of the risks for the individual.
At Penn, evaluation for a lung transplant occurs on an outpatient basis and typically takes place over three days. During the evaluation, patients meet the various members of the lung transplant team who provide information about lung transplant and the impact it may have on patients and their families. Having a transplant is a major undertaking for everyone. It is very important for patients and their support network to fully understand the dramatic lifestyle changes before making the commitment to a lung transplant.
Throughout the transplant evaluation, the lung transplant team intends to accomplish four things:
- Make sure the lung disease is treatable by transplant.
- Better understand the current status of lung disease to make sure it is the right time to consider a transplant.
- Confirm that no other medical problems exist that would decrease the chances a successful transplant.
- Provide all the information patients need to make an informed decision about lung transplantation.
Scheduling the Evaluation
The first step in the transplant process is the consultation visit, where patients meet the lung transplant pulmonologist and lung transplant nurse practitioner. The pulmonologist and nurse practitioner work with them throughout their course of care. Patients deemed appropriate for formal evaluation then proceed to our comprehensive outpatient evaluation. The scheduling of all the evaluation tests and consultations is facilitated by transplant patient service representatives. Patients receive a written copy of the schedule describing the time and location of the tests and consultations.
The typical evaluation consists of three days of outpatient testing and consultation with the lung transplant team members. Patients who have had recent testing at another facility, are asked to send that information to their transplant nurse practitioner so it can be determined if any tests need to be repeated.
It is also important to continue routine health screening tests, such as dental exams, PSA and prostate exams for men, Pap smears and mammograms for women and colonoscopy for patients over age 50. Copies of these reports should also be given to the nurse coordinator working with the patient.
What to Bring to the Evaluation
- A list of all current medications, including dosages and frequency, including:
- Prescription medications including breathing treatments, eye drops, ointments, creams
- Supplements and herbals
- Over-the-counter medications used on a regular basis
- Any medications to be taken during the evaluation including oxygen and nebulizer equipment, if necessary. Patients spending the night away from home should call their oxygen supply company at least one week prior to their stay so equipment can be delivered to their hotel. Patients with liquid oxygen tanks can have their tank refilled while at the hospital.
- A list of questions
- Insurance card(s)
- Referral form, if required, from a primary care physician
- Comfortable clothes and shoes
- A friend or family member to assist in getting to each testing area throughout the hospital and to attend the patient education session
- Food. There is a cafeteria in the hospital and restaurants in the vicinity, but patients may also want to bring snacks or a bagged lunch.
The Evaluation Team
Throughout the evaluation process questions may arise about the various tests and what to expect after the evaluation is complete. The members of the transplant team are prepared to answer all questions and concerns. The team members include:
- Transplant pulmonologist
- Nurse practitioner (nurse coordinator)
- Cardiothoracic surgeon
- Pulmonary rehabilitation team
- Social worker
- Finance Coordinator
Special consultations are performed as needed and include, but are not limited to, the following:
- Infectious disease specialist
Standard Evaluation Testing
- Lab work
Blood tests are an important part of the evaluation and can help determine how the kidneys, liver, pancreas and other parts of the body are working. Blood tests can also identify patients' exposure to infections.
The analysis of blood and tissue typing is a crucial part of the evaluation. Usually, about 18 vials of blood (drawn by one needle) are needed for all of the required testing. Drawing all of this blood at one time is a safe process. It is very important to match compatible blood types between organ donors and recipients so patients' blood type is checked twice before being listed for a lung transplant.
All lab work results are kept confidential and patients may have a copy of the results for their own records.
- Ventilation/Perfusion Scan
The "V/Q Scan" looks at the blood supply to the lungs (perfusion) and the movement of air both in and out of the lungs (ventilation). The results of this test provide important information on the function of each lung and help the surgeons decide which lung to transplant, or in the case of both lungs being transplanted, which lung should be transplanted first.
The ventilation portion of the test is done first and requires patients to wear a tight-fitting mask through which they breathe a tasteless, odorless gas while the movement of air through the lungs is monitored.
The perfusion scan measures blood flow through the lungs. A small amount of radioactive protein is through an intravenous line (IV) and patients are positioned near a camera that is much like an X-ray machine that detects how the blood is brought to the lungs. The pictures need to be taken in several positions, so patients are asked to move side-to-side and to lie flat.
- Pulmonary Function Tests
This series of breathing tests, also known as pulmonary function tests (PFTs), show patients' ability to move air into and out of their lungs. Patients are asked not to use their inhalers for about six hours prior to the test to allow the team to see how inhalers targeted at opening the airways affect breathing. Patients breathe through a mouthpiece that is attached to a computer and are asked to perform several breathing maneuvers during this test. It is important for patients to do their best with each breath.
- Six-Minute Walk Test and Pulmonary Rehabilitation Consult
This test determines exercise tolerance. A physical therapist and respiratory therapist walk alongside patients to evaluate their muscle strength and endurance throughout this test. Since it is important for lung transplant patients to remain in the best health, the test is repeated often while patients are waiting for a transplant as a way to monitor their physical status. Typically the walk and pulmonary rehabilitation team consultation are done at the same time.
- Arterial Blood Gas
Better known as an ABG, this test takes a sample of artery blood to determine the amounts of oxygen and carbon dioxide being delivered to the body. The sample is typically drawn during the pulmonary function test (PFTs). Because the blood must be from an artery (rather than a vein where most blood tests are drawn) it may be uncomfortable. The area from where the sample is taken is numbed before the test.
Commonly referred to as an echo, this test measures the function of the heart muscle and the heart valves. Gel is applied to the skin on the chest and a rounded instrument that transmits high-frequency sound waves is placed on the ribs near the breast bone and directed toward the heart. The sensor picks up the echoes of the sound waves and transmits them as electrical impulses that are converted to moving pictures of the heart. A cardiologist interprets these pictures to determine how the heart is working.
An ECG/EKG shows the electrical activity in the heart. Stickers covered with gel are placed on the chest, arms and legs and then attached to electrical sensors. The test only takes a few minutes and is usually done at the same time as the echocardiogram.
- Chest X-Ray
A chest X-ray provides the transplant team a picture of the structures in the chest. Patients stand upright in front of the X-ray machine and hold a deep breath for a couple of seconds while the picture is being taken.
- CT Scan
A computed tomography or CT scan provides a three-dimensional picture of the anatomy of the chest. This study is usually done without contrast dye. During the procedure, patients lie flat on a table that moves in and out of the scanner that takes cross-sectional pictures of the body.
- Barium Swallow
This X-ray procedure is designed to examine the esophagus, the tube from the mouth to the stomach. After distending the esophagus with gas, patients swallow a thin barium suspension (syrup). This allows the radiologist to see the outline of the inner surface of the esophagus, providing important information about the anatomy and function of the esophagus. This is important to assess patients for reflux disease, which can increase the risk for infection, rejection and certain complications following lung transplant.
- Cardiac Catheterization
Cardiac catheterization is typically done on the last day of testing. The catheterization shows the blood flow to the muscle of the heart and is ordered to look for any narrowed or clogged arteries around the heart (coronary arteries). Pressure readings are measured to provide information about whether the lung disease is adding a burden to the heart. During the test, a cardiologist inserts a small catheter into blood vessels in the groin. The catheter passes through the blood vessels to the heart. Once the catheter is in the proper place, patients may experience a warm sensation dye as dye is injected. The dye helps create a picture of the vessels surrounding the heart and provides a map of the arteries. Patients remain awake during the test, but may be given medication to help them relax.
Patients are not allowed to eat or drink after midnight the night before the test. Patients should also be sure the nurse practitioner or pulmonologist is aware of any allergies they may have to shellfish or iodine before the test begins. Patients with those allergies may need to begin a special preparation of steroids a few days before the test or have the test rescheduled. It is important to tell the pulmonologist or nurse practitioner if patients are taking blood thinners such as Coumadin®, Lovenox® or aspirin, Pradaxa® or Plavix®.
After the procedure, patients are required to remain in bed from four to six hours to prevent any bleeding from the groin site where the catheter was inserted. They will be instructed to drink plenty of fluid in order to flush the dye through their kidneys. Patients are discharged after the procedure, but should not drive until the following day. For this reason, patients must have another adult to drive them home from the hospital or the procedure will be canceled.
In addition to the studies performed during the outpatient evaluation, patients are asked to see their primary care provider for the following health maintenance measures and provide a written report of these tests to their lung transplant coordinator.
- DEXA Scan
- Colonoscopy (if over age 50 years)
- Mammogram and Pap smear (for women, only)
- Prostate specific antigen (for men, only)
- Hepatitis B vaccine series
- Pneumonia vaccine (every five years)
- Seasonal flu vaccine
- Dental evaluation
Patient Selection Committee
After the evaluation, every patient case is reviewed in detail by the members of the Lung Transplant Team. These doctors, nurses, surgeons, therapists and consultants are responsible for decisions on listing for transplant, review of patients already listed as new issues arise and discussion of listing parameters with the United Network of Organ Sharing. All members of the care team contribute to the discussion. Patients are usually presented one to two weeks after the evaluation is completed.
A return visit with the transplant pulmonologist and nurse practitioner is scheduled to occur shortly after the evaluation testing is performed. Results of the evaluation are reviewed with the patient in detail, with recommendations for care. A letter describing the evaluation results and recommendations is sent to the patient's primary physician and referring pulmonologist.
Selection criteria varies from one lung transplant center to another, but at Penn Medicine patients are evaluated and potentially listed for transplant if:
- Non-cancerous disease is limited to lungs and treatable with transplantation
- Lung disease is advanced or at end stage
- Patient faces a high risk of death within a few years
- Lung disease severely impairing quality of life
- Under the age of 71 for single-lung transplant
- Under the age of 66 for bilateral (both) lung transplant
Penn does not list or transplant patients who have:
- Smoked cigarettes within the past six months
- Active alcohol or drug abuse
- Documented history of repeated medical non-compliance
- No identified care giver(s) or support network
- Severe and on-going psychiatric problems that interfere with self-care
- Inadequate means to pay for health costs including medications
- Age of 71 or older
- Unhealthy body weight
- Morbid obesity
- Severe malnutrition
- Extremely poor fitness level
- Lack of demonstrated rehabilitation potential
- Failure to interact effectively with all members of the lung transplant program
- Recent history of malignancy with risk for recurrence (excludes non-melanoma skin cancers)
- Infections that could threaten life post-transplant
- CF patients colonized with Burkholderia cepacia (except Burkholderia multivorans)
- Hepatitis B or C with biopsy evidence for significant liver injury/cirrhosis
- Significant heart disease
- Extensive coronary artery disease
- Left ventricular dysfunction
- Severe esophageal disease
- Reflux and aspiration
- Esophageal dysmotility
Transplant risks are assessed individually for every patient. Because of the associated risks, the Penn Lung Transplant program may not be willing to list or transplant a patient who has one or more of the following conditions:
- Poor fitness level
- Significant heart, vascular, kidney or liver problems
- Poorly controlled diabetes mellitus or permanent damage from diabetes
- Collagen-vascular disease that affects health systems other than the lungs
- Presence of lung infection (e.g. aspergilloma) that would make it difficult to safely remove the diseased lung
- Previous surgery of the chest that would make it difficult to safely remove the diseased lung
- Poorly controlled hypertension or seizures
- Chronic hepatitis B or C without cirrhosis
- Over the age of 66 with other health problems
- High levels of antibody against potential organ donor tissue
- Osteoporosis with prior fractures, chronic pain, and/or need for continuous narcotic medication
- Dependence on mechanical ventilation, not including nighttime, noninvasive support such as CPAP or BIPAP
- Chronic daily steroid requirements over 20mg/day of prednisone (or equivalent)
- Significant health or lifestyle conditions that could threaten survival and/or quality of life post-transplantation
The Waiting List
If the lung transplant team determines that transplantation is the best option to improve the patient's health and wellness, and the patient and family agree, the patient's name and select clinical information is registered with the United Network for Organ Sharing (UNOS).