Progressnotes - October/November 2012
- About MUSC Health
Long known for its strong programs in the transplant of solid organs, including the liver, heart, kidney, and pancreas, as well as bone marrow transplants, the Medical University of South Carolina put the final piece into place for a comprehensive multi-organ transplant center in 2011 by beginning to offer lung transplants. Recent approval by the Centers for Medicare & Medicaid Services (CMS), granted in 2013 after a rigorous review of the program’s outcomes, safety, resources, and management of the transplant waiting list, ensures Medicare and Medicaid reimbursement for lung transplant at MUSC and makes it likely that other insurers, which often take their cue from CMS, will follow suit.
All of this is good news for regional residents, who previously had to travel outside the state to undergo a lung transplant. Because a patient’s support system is vital to his or her recovery, undergoing an out-of-state transplant meant that several members of a family sometimes had to relocate temporarily, at considerable cost and inconvenience. The availability of a lung transplant program at MUSC means that these patients can receive care closer to home, where extended support structures are likely to be in place.
As the only lung transplant center in the state, MUSC receives first rights to any lungs donated by South Carolinians. The United Network for Organ Sharing (UNOS), the organization governing all organ placement in the United States, has established protocols that lungs from a donor are first offered to lung transplant centers in that state before being offered to institutions within a 500-mile radius. Prior to the initiation of MUSC’s Lung Transplant Program, South Carolinians being treated out of state had to compete for these organs with all others awaiting transplant within that radius.
“Because there is a transplant center here, the organ is offered to MUSC first. That organ from South Carolina will stay in South Carolina if there is an appropriate recipient for it, which could mean shorter times on the waiting list and fewer deaths,” notes Timothy P.M. Whelan, M.D., who sits on the UNOS thoracic committee and who was a member of the transplant program at the University of Minnesota before being recruited to MUSC in 2010 as Medical Director of the Lung Transplant Program.
Under the leadership of Dr. Whelan and Chadrick E. Denlinger, M.D., the Surgical Director for the program, MUSC performed its first lung transplant in 2011 and has since completed eight more, with excellent outcomes overall. Those outcomes can in part be attributed to the depth of the cardiovascular surgical team at MUSC supporting the lung transplant program, which includes John Ikonomidis, M.D., PhD, Chief of Cardiothoracic Surgery, and recent recruit Mario A. Castillo-Sang, M.D. Also key to these outcomes are MUSC’s many fine pulmonologists, some, like Luca Paoletti, M.D., with particular interest and expertise in lung transplant, as well as MUSC’s strong pulmonary rehabilitation program. Confident in the strength and depth of this team, Dr. Whelan ultimately hopes to perform 30 to 40 transplants per year. Although he wants to help as many patients as possible, he also wants to keep the program small enough to ensure individual attention to patients and to help maximize their chances to qualify for an organ donation.
The best candidates for lung transplant are patients with idiopathic pulmonary disease (IPF), chronic obstructive pulmonary disease, or cystic fibrosis who have exhausted all medical options and who are at high risk of death within two years without the transplant. MUSC is a major referral center for patients with all of these conditions, who receive the best in medical care from a team of highly experienced pulmonologists and then, if necessary, the option to be added to the transplant list. Even those who prove not to be good candidates for lung transplant can continue to receive superlative medical treatment by MUSC’s experienced pulmonologists.
Patients who undergo a successful lung transplant should enjoy a much-improved quality of life and be able to live independently, perform activities of daily living, and even reengage in favorite hobbies. According to Dr. Denlinger, “patients who were near death before transplant at MUSC are now out walking the streets and leading a normal life. They are hiking and running races whereas before they were on death’s doorstep.”
In patients with IPF, a progressive and ultimately fatal form of lung disease that is characterized by scarring of the framework of the lungs, survival is also substantially improved. Patients with IPF who do not undergo transplant live approximately three to five years with poor quality of life, whereas those who undergo transplant live on average longer than five years with a far better quality of life. Some live far longer; Dr. Whelan has patients he transplanted before coming to MUSC who are still alive twenty years after surgery.
To be considered for a transplant, patients must be able to verify that they have not smoked within the past six months.Based on evidence suggesting poorer outcomes in those who have smoked within the past twelve months, Dr. Whelan prefers that patients have been smoke-free for a full year before being added to the transplant list. In addition to remaining smoke free, the ideal candidate should not have evidence of other medical conditions that can adversely affect transplant outcome. For example, a patient with lung cancer would not be a good candidate because the lung transplant medications can make cancers more aggressive even if the lung is removed.
A successful lung transplant program requires close collaboration between pulmonologists and surgeons. According to Dr. Denlinger, pulmonologists not only select which patients to list for transplant but the optimal timing for their transplant: “Many patients are appropriate for transplant but just not at this time. The pulmonologist follows a patient’s lung function and decides the time to list him or her as a candidate.” The pulmonologist and surgeon also work closely together to evaluate the organs for suitability when they become available. Typically, only about 24 hours pass between notification that an organ could be available and the performance of the transplant. The transplant team at MUSC places countless calls and performs various online assessments to determine the size and health of the organs. If they are deemed suitable for someone on the list at MUSC, Dr. Denlinger travels to the donor’s hospital to collect the organs personally to ensure the best possible outcomes. Meanwhile, the recipient at MUSC is readied for surgery.
Lung transplant is a very complex operation that requires cardiopulmonary bypass. Having the expert perfusionists and other support from MUSC’s Heart and Vascular Center helps ensure that the operation is a success. The recipient’s own lungs must be carefully removed, which can be difficult with patients whose lungs have been scarred by disease. Close coordination among the surgeon, the pulmonologist, and the anesthesiologist is necessary to see the patient through the immediate perioperative period.
Recovery time after lung transplant surgery can be substantial, and patients at MUSC are provided the medical, emotional, and social support they need during this critical period. Nutritionists help ensure that the dietary requirements of patients are met, and pharmacists help them navigate the new medications that they will take for life to help guard against rejection of the transplant. However, the needs of patients can go beyond the merely physical. Months of recovery can be emotionally draining, and indeed a strong support system is one of the qualifying criteria for transplant. MUSC adds to this support by offering counseling by behavioral medicine specialists and the services of a social worker, who helps patients reintegrate into a more normal life, yet one that differs from the life before lung disease.
Although a large multidisciplinary team of specialists is needed to see the patient through both the surgery and recovery, Dr. Denlinger believes that “the most important part of that team is the patient and his or her family.” Dr. Whelan concurs, noting that “Here at MUSC, being a relatively small program, we are very patient-centered. We know the patients, their support team, their family–we are very much able to focus on individuals that we are listing for transplant and then help manage them during the perioperative period.”
Coordinated care of lung transplant patients is only possible when a close working relationship exists between the referring physician and the lung transplant team at MUSC. Referring physicians have an intimate knowledge of their patients’ health that can be invaluable to the lung transplant team, they help educate the patient about the intricacies of the waiting list protocols and help them understand the recommendations of the lung transplant team at MUSC, and they will resume care of the patients after their recovery from transplant. Dr. Whelan strives “to make sure the lines of communication stay open with referring physicians and that it’s fast communication.” With such open lines of communication, the referring physician will never feel blindsided by a patient’s question regarding an upcoming lung transplant and will be fully informed about how to follow up with that patient after surgery.
In short, MUSC’s Lung Transplant Program offers patients all of the expertise, life-saving technology, and excellent outcomes available at a very large transplant center combined with a more intimate, patient-centered approach that is possible only closer to home, family, and the referring physician. In Dr. Whelan’s words,“We are striving to be a high-tech hospital that to patients feels like it’s their local community hospital where we really get to know them and take good care of them.”
This article originally appeared in the May/June 2013 issue of Progressnotes.