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J Chest Surg 2023; 56(1): 14-15

Published online January 5, 2023 https://doi.org/10.5090/jcs.22.159

Copyright © Journal of Chest Surgery.

Commentary: Referral for Lung Transplantation Should Be Carefully Decided for Patients with COVID-19 Acute Respiratory Distress Syndrome

Jin Gu Lee, M.D.

Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea

Correspondence to:Jin Gu Lee
Tel 82-2-2228-2140, Fax 82-2-393-6012, E-mail csjglee@yuhs.ac, ORCID https://orcid.org/0000-0003-2767-6505

Received: December 27, 2022; Accepted: December 28, 2022

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Linked Article: J Chest Surg. 2023;56(1):6-13 https://doi.org/10.5090/jcs.22.055

See Article page 6.

Lung transplantation is the only option for end-stage lung disease. However, the long-term outcomes are not favorable compared to other types of solid organ transplantation, with an expected survival of 6 to 7 years after lung transplantation. The donor shortage is also always a problem. Accordingly, candidates for lung transplantation should be carefully selected.

Common disease entities in lung transplantation candidates are idiopathic pulmonary fibrosis, cystic fibrosis, and chronic obstructive pulmonary disease, which lead to irreversible end-stage lung disease. Acute respiratory distress syndrome (ARDS) involves potentially reversible lung damage, as many patients with ARDS can recover. Patients with coronavirus disease 2019 (COVID-19)-related ARDS also should be considered as having potentially reversible damage at the time of diagnosis. The mortality rate of COVID-19-associated ARDS was 45% in the early pandemic [1].

Data and experience regarding lung transplantation in patients with ARDS are limited compared to lung transplantation for other diseases [2,3]. Lung transplantation can rescue patients with irreversibly damaged lungs from ARDS. However, the possibility of recovery from ARDS is a reason to wait before referral for lung transplantation. Case reports have stated that the inflammatory response in COVID-19 ARDS might last longer than the inflammatory response in other types of ARDS. Accordingly, referrals for lung transplantation in patients with COVID-19 ARDS should be more deliberate. Although limited data exist, experts in the field recommend waiting at least 4–6 weeks after the onset of respiratory failure due to COVID- 19 prior to considering lung transplantation [4].

The authors’ experience described here is similar to that reported from centers in Europe and North America [5]. However, the decision for referral to transplantation was quite fast. Five of 10 patients (50%) underwent lung transplantation within 50 days on extracorporeal membrane oxygenation. Given the average of 16.8 days on the waiting list, it was decided to list these 5 patients within 6 weeks. Other teams have reported lung transplantation in COVID patients many months after the original insult [6,7]. This raises a question: how did the authors know at the time of lung transplant listing that the lung injury was totally irreversible? Did these 5 patients not have the chance to recover from ARDS?

Lung transplantation is the only therapeutic option for chronic progressive end-stage lung disease. Many patients who need lung transplantation die on the waitlist because of the donor shortage. Lung transplantation could be considered for patients with COVID-19 ARDS, but sufficient time should be allowed before the referral to account for the possibility of lung recovery.

Author contributions

All the work was done by Jin Gu Lee.

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

  1. Tzotzos SJ, Fischer B, Fischer H, Zeitlinger M. Incidence of ARDS and outcomes in hospitalized patients with COVID-19: a global literature survey. Crit Care 2020;24:516. https://doi.org/10.1186/s13054-020-03240-7.
    Pubmed KoreaMed CrossRef
  2. Frick AE, Gan CT, Vos R, et al. Lung transplantation for acute respiratory distress syndrome: a multicenter experience. Am J Transplant 2022;22:144-53. https://doi.org/10.1111/ajt.16759.
    Pubmed KoreaMed CrossRef
  3. Harano T, Ryan JP, Chan EG, et al. Lung transplantation for the treatment of irreversible acute respiratory distress syndrome. Clin Transplant 2021;35:e14182. https://doi.org/10.1111/ctr.14182.
    Pubmed KoreaMed CrossRef
  4. Leard LE, Holm AM, Valapour M, et al. Consensus document for the selection of lung transplant candidates: an update from the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2021;40:1349-79. https://doi.org/10.1016/j.healun.2021.07.005.
    Pubmed KoreaMed CrossRef
  5. Kim SA, Yun JK, Lee GD, Kim DK, Choi S. Early outcomes of COVID-19 lung transplantation recipients in Korea: a single-center study. J Chest Surg 2023;56:6-13. https://doi.org/10.5090/jcs.22.055.
    Pubmed CrossRef
  6. Lang C, Jaksch P, Hoda MA, et al. Lung transplantation for COVID-19-associated acute respiratory distress syndrome in a PCR-positive patient. Lancet Respir Med 2020;8:1057-60. https://doi.org/10.1016/S2213-2600(20)30361-1.
    Pubmed CrossRef
  7. Bharat A, Machuca TN, Querrey M, et al. Early outcomes after lung transplantation for severe COVID-19: a series of the first consecutive cases from four countries. Lancet Respir Med 2021;9:487-97. https://doi.org/10.1016/S2213-2600(21)00077-1.
    Pubmed KoreaMed CrossRef

Article

Commentary

J Chest Surg 2023; 56(1): 14-15

Published online January 5, 2023 https://doi.org/10.5090/jcs.22.159

Copyright © Journal of Chest Surgery.

Commentary: Referral for Lung Transplantation Should Be Carefully Decided for Patients with COVID-19 Acute Respiratory Distress Syndrome

Jin Gu Lee, M.D.

Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea

Correspondence to:Jin Gu Lee
Tel 82-2-2228-2140, Fax 82-2-393-6012, E-mail csjglee@yuhs.ac, ORCID https://orcid.org/0000-0003-2767-6505

Received: December 27, 2022; Accepted: December 28, 2022

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Linked Article: J Chest Surg. 2023;56(1):6-13 https://doi.org/10.5090/jcs.22.055

Body

See Article page 6.

Lung transplantation is the only option for end-stage lung disease. However, the long-term outcomes are not favorable compared to other types of solid organ transplantation, with an expected survival of 6 to 7 years after lung transplantation. The donor shortage is also always a problem. Accordingly, candidates for lung transplantation should be carefully selected.

Common disease entities in lung transplantation candidates are idiopathic pulmonary fibrosis, cystic fibrosis, and chronic obstructive pulmonary disease, which lead to irreversible end-stage lung disease. Acute respiratory distress syndrome (ARDS) involves potentially reversible lung damage, as many patients with ARDS can recover. Patients with coronavirus disease 2019 (COVID-19)-related ARDS also should be considered as having potentially reversible damage at the time of diagnosis. The mortality rate of COVID-19-associated ARDS was 45% in the early pandemic [1].

Data and experience regarding lung transplantation in patients with ARDS are limited compared to lung transplantation for other diseases [2,3]. Lung transplantation can rescue patients with irreversibly damaged lungs from ARDS. However, the possibility of recovery from ARDS is a reason to wait before referral for lung transplantation. Case reports have stated that the inflammatory response in COVID-19 ARDS might last longer than the inflammatory response in other types of ARDS. Accordingly, referrals for lung transplantation in patients with COVID-19 ARDS should be more deliberate. Although limited data exist, experts in the field recommend waiting at least 4–6 weeks after the onset of respiratory failure due to COVID- 19 prior to considering lung transplantation [4].

The authors’ experience described here is similar to that reported from centers in Europe and North America [5]. However, the decision for referral to transplantation was quite fast. Five of 10 patients (50%) underwent lung transplantation within 50 days on extracorporeal membrane oxygenation. Given the average of 16.8 days on the waiting list, it was decided to list these 5 patients within 6 weeks. Other teams have reported lung transplantation in COVID patients many months after the original insult [6,7]. This raises a question: how did the authors know at the time of lung transplant listing that the lung injury was totally irreversible? Did these 5 patients not have the chance to recover from ARDS?

Lung transplantation is the only therapeutic option for chronic progressive end-stage lung disease. Many patients who need lung transplantation die on the waitlist because of the donor shortage. Lung transplantation could be considered for patients with COVID-19 ARDS, but sufficient time should be allowed before the referral to account for the possibility of lung recovery.

Article information

Author contributions

All the work was done by Jin Gu Lee.

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

There is no Figure.

There is no Table.

References

  1. Tzotzos SJ, Fischer B, Fischer H, Zeitlinger M. Incidence of ARDS and outcomes in hospitalized patients with COVID-19: a global literature survey. Crit Care 2020;24:516. https://doi.org/10.1186/s13054-020-03240-7.
    Pubmed KoreaMed CrossRef
  2. Frick AE, Gan CT, Vos R, et al. Lung transplantation for acute respiratory distress syndrome: a multicenter experience. Am J Transplant 2022;22:144-53. https://doi.org/10.1111/ajt.16759.
    Pubmed KoreaMed CrossRef
  3. Harano T, Ryan JP, Chan EG, et al. Lung transplantation for the treatment of irreversible acute respiratory distress syndrome. Clin Transplant 2021;35:e14182. https://doi.org/10.1111/ctr.14182.
    Pubmed KoreaMed CrossRef
  4. Leard LE, Holm AM, Valapour M, et al. Consensus document for the selection of lung transplant candidates: an update from the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2021;40:1349-79. https://doi.org/10.1016/j.healun.2021.07.005.
    Pubmed KoreaMed CrossRef
  5. Kim SA, Yun JK, Lee GD, Kim DK, Choi S. Early outcomes of COVID-19 lung transplantation recipients in Korea: a single-center study. J Chest Surg 2023;56:6-13. https://doi.org/10.5090/jcs.22.055.
    Pubmed CrossRef
  6. Lang C, Jaksch P, Hoda MA, et al. Lung transplantation for COVID-19-associated acute respiratory distress syndrome in a PCR-positive patient. Lancet Respir Med 2020;8:1057-60. https://doi.org/10.1016/S2213-2600(20)30361-1.
    Pubmed CrossRef
  7. Bharat A, Machuca TN, Querrey M, et al. Early outcomes after lung transplantation for severe COVID-19: a series of the first consecutive cases from four countries. Lancet Respir Med 2021;9:487-97. https://doi.org/10.1016/S2213-2600(21)00077-1.
    Pubmed KoreaMed CrossRef

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