Lung Transplant - Provider Focused
From the Show: UK HealthCast
Summary:
Air Date: 7/7/20
Duration: 10 Minutes
Sravanthi Nandavaram, MD and Maher Baz, MD discuss conditions that would lead to a lung transplant. They share indications for referral to a transplant center, what the process looks like when a patient gets to the center and why UK HealthCare stands apart.
Transcription:
Introduction: Another informational resource from UK Healthcare. This is UK HealthCast be trained conversations with our physicians and other healthcare providers. Here's Melanie Cole.
Melanie Cole: This is UK HealthCast with the University of Kentucky Healthcare. I'm Melanie Cole. And today we're talking about lung transplant at UK Health. Joining me in this panel is Dr. Sravanthi Nandavaram. She's a Transplant Pulmonologist and Dr. Maher Baz. He's the Medical Director of Lung Transplant. And they're both at UK Health. Dr. Baz, I'd like to start with you. Tell us a little bit about how common lung transplant is and give us a little history at UK Health with lung transplants.
Dr. Baz: So lung transplant is a treatment modality we apply for patients with advanced lung diseases. My definition of advanced lung disease is when all medical and surgical options have been exhausted. And the patient is on oxygen. That early stage, when they're on oxygen, across all lung problems across the spectrum from coal workers lung to smoker’s lung, and those patients, the majority were able to give him extended life. If we transplant them. In emphysema patients, we aim for improved quality of life. UK specifically has been doing lung transplants since 1991. And we have recently been doing 25 to 30, the last two or three years, which is a little bit of increase in the number with one year outcome above the national average in the low nineties. And that is because of the multi disciplinary team approach. That includes our thoracic surgeons, our transplant pulmonologist, our nurse coordinators, our physical therapists our social workers.
Host: Dr. Baz, sticking with you for just a second. What's exciting in the field? That's changed that you feel that other providers really want to know about what, what are some of the very exciting technologies, changes, medications, things going on in your field that you want other providers to know about?
Dr. Baz: So I've been in this field close to 27, 28 years. So the few things that have changed recently is now we're able to place patients on mechanical ventilation or ECMO if they're on the waiting list, good transplant candidates, and we can't find them lungs, we can keep them alive with modalities, such as a ventilator or ECMO. ECMO is a machine that can support the patient's breathing until we can find them lungs. This is relatively new in the last few years. The other relatively new thing that we're doing at UK is we are part of multicenter research efforts in addressing chronic lung rejection, which is a complication that happens in many patients several years after transplant being inhaled cyclosporine and photophoresis. They are part of multicenter trials to try to study the lung functions, to try to control the chronic lung rejection, which is new and unique in the last year or two we've been part of. And the third thing is with repetition, you know, the team gets better at handling complications, recognizing them early and preventing hospitalizations and bad outcomes. And I think we have all three here at the University of Kentucky.
Host: Dr. Nandavaram for providers that are looking for referral. Tell us a little bit about patient selection criteria and some general indications for transplantation for patients that they may have that have been dealing with lung issues for a while.
Dr. Nandavaram: Lung transplant is a treatment option for anyone with advanced lung disease. So I usually say anyone who's requiring oxygen needs to be referred to a transplant pulmonologist. If the lung disease is irreversible. And the reason I say that is lung transplant is a complex procedure, which needs a multidisciplinary and a multiorgan assessment, which is not going to happen overnight. And we need some time to evaluate the patient and assess if the patient is a good candidate for surgery or not. So again, I would say that anyone who is requiring oxygen should be referred to a transplant pulmonologist if the primary physician thinks that the disease is irreversible.
And some of the indications for lung transplant include COPD or emphysema, pulmonary fibrosis, any kind of unofficial lung disease, bronchiectasis, cystic fibrosis, pulmonary hypertension, occupational lung disease, like coal workers pneumoconiosis, or silicosis are other rare pulmonary diseases like Lam or lymphangioleiomyomatosis or any other vasculitis disorders. These are all indications for lung transplant. And we usually urge the tertiary physicians or the community physicians to refer the patients to us as soon as possible, so that we have enough time to evaluate these patients and put them on the list. It's not just the evaluation and listing the patients. Once the patients are on the list, we need to wait for the lungs. So we do need enough time.
Host: What's involved in that wait time? How's it calculated? What's involved in the management of patients on the waitlist, Dr. Nandavaram?
Dr. Nandavaram: So once the patients are evaluated by our multidisciplinary team, and once they undergo all the based on some of those test results, we calculate a score called lung allocation score, which is a universal score wherein it tells us how sick the patient is. Certain variables that are used to calculate the score include like the type of lung disease, how much oxygen they are on? What are their pulmonary artery systolic pressures? How are their lung volumes? So this calculator basically calculates a score based on certain variables. And that score tells us how sick the patient is higher, the score, the patient lower, the score, less sick. So usually patients with higher score, their wait time is less. And the patients with lower score, their wait time is long. And once we put this patients on the wait list, we start looking for lungs and we do have a donor coordinator whose job is just to find donors for the patients who are on the waiting list.
And while the patients are on the waiting list, our job is to make sure they are doing well in terms of their general health status. Making sure they're strong enough, so that we make sure patients are attending pulmonary rehab even before the transplant so that their muscle strength is good enough. And they are in a better shape to go for the surgery. And while the patients are on the wait list, we bring them to the clinic every couple of months to make sure they're doing well. We keep an eye on their pulmonary function tests. We do a blood work like blood gases. We do echocardiograms to monitor the progression of disease, and we update the score because while they are waiting on the list, we need to make sure they're not getting sicker and we keep updating the score. And if they are getting sicker, they'll get the lungs sooner.
Host: Dr. Baz, and thank you, Dr. Nandavaram for that very comprehensive answer. Dr. Baz tell us a little bit about the future of lung transplantation and the several issues such as ongoing shortage of donor organs that's fueled the search for alternative therapies for failing lungs, challenges, an organ shortage, chronic rejection. Some of the things that we've mentioned in this podcast speak about what you see happening in the future and what you hope will happen. You've been in this business a very long time. What do you hope to see happen in the future?
Dr. Baz: So what I would hope is it's a two sided equation. One is, you know, get more patients transplanted. The corollary to that is decrease the deaths on the waiting list in the nineties and early part of the century. It used to be first come first serve. So the waiting list was by waiting time, it didn't matter how sick you were. And we realized that, you know, we were losing patients. So in thousand and five, this new lung allocation score that Dr. Nandavaram talked about, came into being in May of 2005 and it prioritizes the sicker patients. So if you are sicker, you could score higher. You could be on the top of the list from day one, rather than waiting time, but we still lose patients. I think the way around it is to keep advertising word of mouth in any way we can about, we need more organ donors, more organ donors, more organ donors. Only about 20% of organ donors can donate lungs compared to about 70, 80% kidney.
The other thing I see that's exciting in the organ donation is we're learning more and more about how to better preserve the lung. So, the travel time could potentially be longer. Meaning, you know, a center could maybe five or 10 years from now when we perfect the technology could fly three, four hours, get a lung and come back. Now we'd like to fly no more than two hours. If we can help it. There is also what we call a profusion runs. For lungs, we're not sure, you know, we can use it or not. We can put it on a lung profusion machine and monitor the function of the lung, the next four to six hours before we decide, you know, we can use it. Those are all technologies. I think in five to 10 years, we will know if they will bear fruit. We're hoping they will, but in five or 10 years, we'll know better. That's on the front end.
On the backend after transplant we want to transplant healthier, successful transplant. Once we do transplant, we're hoping with the research we're doing, whether it is photopheresis, whether it is inhaled cyclosporine or any other, you know, study that could be coming down the pike that will decrease chronic lung rejection. But we're really hopeful that between photophoresis or inhaled cyclosporine, we'll be able to make a dent in the outcomes of chronic lung rejection. If chronic lung rejection happens few years later, and for long survival, further than the average of five or six years that we have right now.
Host: While you're summarizing Dr. Baz, what makes the transplantation program at UK stand apart from others in the State?
Dr. Baz: I think access, I mean, we have clinics every day. We can see patients on a few days notice. When we send letters out to referring physicians, we always include our cell numbers. We always try to call patients. So we try to give out our cell number to physicians. So I think access is important for patients and for physicians, physicians to find us quickly and patients to get in the clinic quickly. I think repetition like I mentioned, between the surgeon, myself and my partner Dr. Nandavaram, we probably have 50 years of experience between us. So when you have repetition, you're more likely to recognize things quicker. Minimize complications, minimize the poor outcomes or one of your survival is higher than the national average. And the last thing is, you know, we have the two research projects that I've talked about. Multicenter one is sponsored by CMS, and another one is sponsored by pharmaceutical. The photophoresis is a Medicare sponsored study and the inhaled cyclosporine by pharmaceutical, each about 15 centers in each study. So I think access, I think experience, excellent more year survival and the research into the complication.
Host: Dr. Nandavaram last word to you. What would you like other providers to know about the importance of early referral and your team at the University of Kentucky Healthcare?
Dr. Nandavaram: I would like them to know that we are easily accessible. They can call us any time they can send the patients any time. And even if it's a question, whether to send a patient to us or not, they can send us. And if the patient doesn't need lung transplant, that's all right. We will tell them, but I urge everyone each and every physician not to delay the referral for lung transplant. That's where we lose the patients. And early referral is the key and referral doesn't mean that the patient is going to go on the list. We will do our diligent workup before we put a patient on the list. So again, early referral, once a patient does requiring oxygen, once they are deemed to have advanced lung disease or irreversible lung disease, the patient needs to be referred to a transplant pulmonologist. That would be the one thing, one point that I would tell regarding the lung transplant, referrals.
Host: Thank you both so much for joining us today and sharing your expertise, and telling us about the transplantation program at the University of Kentucky Healthcare. And that wraps up another episode of UK HealthCast. For more information about the lung transplant program, or to find a UK Healthcare specialist, a community physician can refer a patient to UK Healthcare with UK MDs at 1 800-888-5533, or you can visit our website at ukhealthcare.uky.edu. Please remember to subscribe, rate and review this podcast and all the other University of Kentucky Healthcare podcasts. I'm Melanie Cole.
Introduction: Another informational resource from UK Healthcare. This is UK HealthCast be trained conversations with our physicians and other healthcare providers. Here's Melanie Cole.
Melanie Cole: This is UK HealthCast with the University of Kentucky Healthcare. I'm Melanie Cole. And today we're talking about lung transplant at UK Health. Joining me in this panel is Dr. Sravanthi Nandavaram. She's a Transplant Pulmonologist and Dr. Maher Baz. He's the Medical Director of Lung Transplant. And they're both at UK Health. Dr. Baz, I'd like to start with you. Tell us a little bit about how common lung transplant is and give us a little history at UK Health with lung transplants.
Dr. Baz: So lung transplant is a treatment modality we apply for patients with advanced lung diseases. My definition of advanced lung disease is when all medical and surgical options have been exhausted. And the patient is on oxygen. That early stage, when they're on oxygen, across all lung problems across the spectrum from coal workers lung to smoker’s lung, and those patients, the majority were able to give him extended life. If we transplant them. In emphysema patients, we aim for improved quality of life. UK specifically has been doing lung transplants since 1991. And we have recently been doing 25 to 30, the last two or three years, which is a little bit of increase in the number with one year outcome above the national average in the low nineties. And that is because of the multi disciplinary team approach. That includes our thoracic surgeons, our transplant pulmonologist, our nurse coordinators, our physical therapists our social workers.
Host: Dr. Baz, sticking with you for just a second. What's exciting in the field? That's changed that you feel that other providers really want to know about what, what are some of the very exciting technologies, changes, medications, things going on in your field that you want other providers to know about?
Dr. Baz: So I've been in this field close to 27, 28 years. So the few things that have changed recently is now we're able to place patients on mechanical ventilation or ECMO if they're on the waiting list, good transplant candidates, and we can't find them lungs, we can keep them alive with modalities, such as a ventilator or ECMO. ECMO is a machine that can support the patient's breathing until we can find them lungs. This is relatively new in the last few years. The other relatively new thing that we're doing at UK is we are part of multicenter research efforts in addressing chronic lung rejection, which is a complication that happens in many patients several years after transplant being inhaled cyclosporine and photophoresis. They are part of multicenter trials to try to study the lung functions, to try to control the chronic lung rejection, which is new and unique in the last year or two we've been part of. And the third thing is with repetition, you know, the team gets better at handling complications, recognizing them early and preventing hospitalizations and bad outcomes. And I think we have all three here at the University of Kentucky.
Host: Dr. Nandavaram for providers that are looking for referral. Tell us a little bit about patient selection criteria and some general indications for transplantation for patients that they may have that have been dealing with lung issues for a while.
Dr. Nandavaram: Lung transplant is a treatment option for anyone with advanced lung disease. So I usually say anyone who's requiring oxygen needs to be referred to a transplant pulmonologist. If the lung disease is irreversible. And the reason I say that is lung transplant is a complex procedure, which needs a multidisciplinary and a multiorgan assessment, which is not going to happen overnight. And we need some time to evaluate the patient and assess if the patient is a good candidate for surgery or not. So again, I would say that anyone who is requiring oxygen should be referred to a transplant pulmonologist if the primary physician thinks that the disease is irreversible.
And some of the indications for lung transplant include COPD or emphysema, pulmonary fibrosis, any kind of unofficial lung disease, bronchiectasis, cystic fibrosis, pulmonary hypertension, occupational lung disease, like coal workers pneumoconiosis, or silicosis are other rare pulmonary diseases like Lam or lymphangioleiomyomatosis or any other vasculitis disorders. These are all indications for lung transplant. And we usually urge the tertiary physicians or the community physicians to refer the patients to us as soon as possible, so that we have enough time to evaluate these patients and put them on the list. It's not just the evaluation and listing the patients. Once the patients are on the list, we need to wait for the lungs. So we do need enough time.
Host: What's involved in that wait time? How's it calculated? What's involved in the management of patients on the waitlist, Dr. Nandavaram?
Dr. Nandavaram: So once the patients are evaluated by our multidisciplinary team, and once they undergo all the based on some of those test results, we calculate a score called lung allocation score, which is a universal score wherein it tells us how sick the patient is. Certain variables that are used to calculate the score include like the type of lung disease, how much oxygen they are on? What are their pulmonary artery systolic pressures? How are their lung volumes? So this calculator basically calculates a score based on certain variables. And that score tells us how sick the patient is higher, the score, the patient lower, the score, less sick. So usually patients with higher score, their wait time is less. And the patients with lower score, their wait time is long. And once we put this patients on the wait list, we start looking for lungs and we do have a donor coordinator whose job is just to find donors for the patients who are on the waiting list.
And while the patients are on the waiting list, our job is to make sure they are doing well in terms of their general health status. Making sure they're strong enough, so that we make sure patients are attending pulmonary rehab even before the transplant so that their muscle strength is good enough. And they are in a better shape to go for the surgery. And while the patients are on the wait list, we bring them to the clinic every couple of months to make sure they're doing well. We keep an eye on their pulmonary function tests. We do a blood work like blood gases. We do echocardiograms to monitor the progression of disease, and we update the score because while they are waiting on the list, we need to make sure they're not getting sicker and we keep updating the score. And if they are getting sicker, they'll get the lungs sooner.
Host: Dr. Baz, and thank you, Dr. Nandavaram for that very comprehensive answer. Dr. Baz tell us a little bit about the future of lung transplantation and the several issues such as ongoing shortage of donor organs that's fueled the search for alternative therapies for failing lungs, challenges, an organ shortage, chronic rejection. Some of the things that we've mentioned in this podcast speak about what you see happening in the future and what you hope will happen. You've been in this business a very long time. What do you hope to see happen in the future?
Dr. Baz: So what I would hope is it's a two sided equation. One is, you know, get more patients transplanted. The corollary to that is decrease the deaths on the waiting list in the nineties and early part of the century. It used to be first come first serve. So the waiting list was by waiting time, it didn't matter how sick you were. And we realized that, you know, we were losing patients. So in thousand and five, this new lung allocation score that Dr. Nandavaram talked about, came into being in May of 2005 and it prioritizes the sicker patients. So if you are sicker, you could score higher. You could be on the top of the list from day one, rather than waiting time, but we still lose patients. I think the way around it is to keep advertising word of mouth in any way we can about, we need more organ donors, more organ donors, more organ donors. Only about 20% of organ donors can donate lungs compared to about 70, 80% kidney.
The other thing I see that's exciting in the organ donation is we're learning more and more about how to better preserve the lung. So, the travel time could potentially be longer. Meaning, you know, a center could maybe five or 10 years from now when we perfect the technology could fly three, four hours, get a lung and come back. Now we'd like to fly no more than two hours. If we can help it. There is also what we call a profusion runs. For lungs, we're not sure, you know, we can use it or not. We can put it on a lung profusion machine and monitor the function of the lung, the next four to six hours before we decide, you know, we can use it. Those are all technologies. I think in five to 10 years, we will know if they will bear fruit. We're hoping they will, but in five or 10 years, we'll know better. That's on the front end.
On the backend after transplant we want to transplant healthier, successful transplant. Once we do transplant, we're hoping with the research we're doing, whether it is photopheresis, whether it is inhaled cyclosporine or any other, you know, study that could be coming down the pike that will decrease chronic lung rejection. But we're really hopeful that between photophoresis or inhaled cyclosporine, we'll be able to make a dent in the outcomes of chronic lung rejection. If chronic lung rejection happens few years later, and for long survival, further than the average of five or six years that we have right now.
Host: While you're summarizing Dr. Baz, what makes the transplantation program at UK stand apart from others in the State?
Dr. Baz: I think access, I mean, we have clinics every day. We can see patients on a few days notice. When we send letters out to referring physicians, we always include our cell numbers. We always try to call patients. So we try to give out our cell number to physicians. So I think access is important for patients and for physicians, physicians to find us quickly and patients to get in the clinic quickly. I think repetition like I mentioned, between the surgeon, myself and my partner Dr. Nandavaram, we probably have 50 years of experience between us. So when you have repetition, you're more likely to recognize things quicker. Minimize complications, minimize the poor outcomes or one of your survival is higher than the national average. And the last thing is, you know, we have the two research projects that I've talked about. Multicenter one is sponsored by CMS, and another one is sponsored by pharmaceutical. The photophoresis is a Medicare sponsored study and the inhaled cyclosporine by pharmaceutical, each about 15 centers in each study. So I think access, I think experience, excellent more year survival and the research into the complication.
Host: Dr. Nandavaram last word to you. What would you like other providers to know about the importance of early referral and your team at the University of Kentucky Healthcare?
Dr. Nandavaram: I would like them to know that we are easily accessible. They can call us any time they can send the patients any time. And even if it's a question, whether to send a patient to us or not, they can send us. And if the patient doesn't need lung transplant, that's all right. We will tell them, but I urge everyone each and every physician not to delay the referral for lung transplant. That's where we lose the patients. And early referral is the key and referral doesn't mean that the patient is going to go on the list. We will do our diligent workup before we put a patient on the list. So again, early referral, once a patient does requiring oxygen, once they are deemed to have advanced lung disease or irreversible lung disease, the patient needs to be referred to a transplant pulmonologist. That would be the one thing, one point that I would tell regarding the lung transplant, referrals.
Host: Thank you both so much for joining us today and sharing your expertise, and telling us about the transplantation program at the University of Kentucky Healthcare. And that wraps up another episode of UK HealthCast. For more information about the lung transplant program, or to find a UK Healthcare specialist, a community physician can refer a patient to UK Healthcare with UK MDs at 1 800-888-5533, or you can visit our website at ukhealthcare.uky.edu. Please remember to subscribe, rate and review this podcast and all the other University of Kentucky Healthcare podcasts. I'm Melanie Cole.
