Referral Criteria for Lung Transplant at UAB

Additional Info

• Audio File:uab/ua192.mp3
• Doctors:Kaleekal, Thomas
• Featured Speaker:Thomas Kaleekal, MD
• CME Series:Clinical Skill
• Post Test URL:https://cmecourses.som.uab.edu/mod/quiz/view.php?id=4768
• Guest Bio:Coming to us from Newark Beth Israel Medical Center, Dr. Kaleekal has over 22 years of medical experience. Dr. Thomas Kaleekal received his medical training from the All-India Institute of Medical Sciences in New Delhi, India in 1998. He completed his residency training in Internal Medicine at SUNY Health Sciences Center in Brooklyn, NY and spent and additional year as Chief Medical Resident in the program. 
  
  Learn more about Thomas Kaleekal, MD 
  
  Release Date: March 31, 2021
  Expiration Date: March 31, 2024
  
  Disclosure Information:
  
  Planners:
  Ronan O’Beirne, EdD, MBA
  Director, UAB Continuing Medical Education
  
  Katelyn Hiden
  Physician Marketing Manager, UAB Health System
  
  The planners have no relevant financial relationships with ineligible companies to disclose.
  
  Speakers:
  Thomas S. Kaleekal, MD
  Associate Professor in Critical Care Medicine & Transplant Pulmonology
  
  Dr. Kaleekal have no relevant financial relationships with ineligible companies to disclose.
  
  There is no commercial support for this activity.
• Transcription:Melanie:  Welcome to UAB MedCast. I'm Melanie Cole, and I invite you to listen as we examine the referral criteria for lung transplantation at UAB Medicine. Joining me is Dr. Thomas Kaleekal. He's an associate professor and medical director of the lung transplant program at UAB Medicine. Dr. Kaleekal, it's a pleasure to have you join us today. I'd like you to kind of start for other providers telling us how common lung transplant is and a little bit about your hospital's history with them.
  
  Dr Thomas Kaleekal: So a lung transplant is becoming more and more common in the United States and across the world, including in Europe and other countries in Asia. so roughly, based on the International Society of Heart and Lung Transplant databases, roughly about 4,000 to 4,200 lung transplants are currently being done.
  
  This is fairly large numbers compared to about 10 or 15 years ago where a few hundreds of these would be done a year. UAB has been doing lung transplants at least through the '90s. So it's an older program in the United States, very well established roots. Dr. Kirklin was one of the founding fathers of heart and lung transplantation and also mechanical devices. And under his guidance and leadership, this program has really taken off and is one of the only program in Alabama at this point. So definitely, a lot of history that has been created at this institution. And we continue to make our patients better.
  
  Melanie: Dr. Kaleekal, please give us some indications for referral to a transplant center. What is the referral criteria for lung transplant at UAB?
  
  Dr Thomas Kaleekal: We generally have very broad categories of diseases, advanced lung diseases that are referred for lung transplant. So the biggest categories are COPD and obstructive lung diseases. And other category would be the interstitial lung diseases and pulmonary fibrosis. I think pulmonary fibrosis would comprise about 65% of our referrals and about 25% would be our COPD group.
  
  So our usual criteria for referral is anytime you actually do see a patient with pulmonary fibrosis, idiopathic pulmonary fibrosis, that itself is a criteria to refer to the Lung Transplant Center. Particularly, if your forced vital capacity is less than 80% or your DLCO is heading towards less than 40%, or there is any kind of oxygen requirements that your patient is now having, to need any supplemental oxygen, these are all important criteria to kind of refer the patient to a lung transplant program because these patients can tend to deteriorate very quickly.
  
  Other things to highlight in terms of interstitial lung disease patients referrals would be things like they're developing pulmonary hypertension or they're actually de-saturating when they walk, during your six-minute walk test.
  
  Similarly in COPD, we generally tend to refer or prefer referrals where there is progressive worsening of the disease and the functional capacity of the patient is actually getting worse. They are not an LVRS candidate. So anytime your BODE index, which is a composite score of your BMI, obstructive defect, your dyspnea or exertional capacity is more than five, that's typically where most people would be referring to a lung transplant center.
  
  Any person with hypercapnia with a PCO2 of more than 50 or a PaO2 of less than 60 would actually be referred. And in general, if you're doing spirometries in your office, an FEV1 of less than 25% would be considered to be an appropriate referral to the transplant center. This allows us time to kind of evaluate these patients and actually get them ready for the transplant. We are able to have a few visits with them and explain the process rather than somebody who comes to us really late and now, they're in the hospital and they are on a ventilator and then we are referred. Yes, we can still do our evaluation and take care of these patients, but it doesn't allow us that time to interact with the patient to actually explain the process to them and actually get them through the process while they understand what they're going to be going through during this time
  
  So some other situations that we see are patients with pulmonary hypertension. And in those patients, the referral criteria, generally, if they have class III, class IV dypnea and NYHA class III, class IV dyspnea, or you're actually starting IV therapies for them. So this is considered to be pretty advanced pulmonary hypertension. So these kinds of patients should be actually referred to the lung transplant centers, so that we can actually complete the evaluation and get them ready for the listing. Oftentimes, if they continue to remain stable, we will not actually list them. We will just continue to follow them with you as their treating providers, until their condition does merit an actual listing in terms of going on the UNOS list.
  
  Melanie: Well, then give us the indications when it's an obstructive or restrictive lung disease, COPD and such. Tell us a little bit about importance of referral to UAB and how it differs from other types of transplant disease.
  
  Dr Thomas Kaleekal: Right. So the broad category of diseases that, you know, lung transplant can offer a benefit to the patient is usually either CLPD or interstitial lung disease. So we basically categorize them into obstructive lung diseases, which examples would be COPD, cystic fibrosis, alpha-1 antitrypsin. And then the other category would be the interstitial lung disease like pulmonary fibrosis, which is most of which is idiopathic or others which are associated with other diseases like connective tissue disease.
  
  Clearly, in these, groups of diseases, lung transplantations does offer a survival benefit. For example, I would say that if you were unfortunate enough to develop idiopathic pulmonary fibrosis, your five-year survival is very minimal. So usually the person who develops the disease pretty much passes away within five years.
  
  So broadly speaking, lung transplantation is an option for therapy in patients who either have high risk of death because of their underlying disease within two years, like 50% chance of dying from their disease in two years or less. And we expect that they have a reasonable survival after the lung transplantation, which means we expect that at least 80% survival at three months, or if they have at least 80% survival at five years after the transplant is completed as long as they have no other major medical issues that may compromise that survival.
  
  Melanie: And doctor, would you tell us about the program at UAB Medicine? What does the process look like for patients when they get to the transplant center and what's involved in management of patients on the list?
  
  Dr Thomas Kaleekal: Yeah, that's a great question. So actually, from a physician standpoint, the most important thing is to recognize that your patient is sick and needs to be referred to the transplant program. So once it happens, I think the referral with all the physician notes and radiology is usually sent to the transplant center. We usually make every attempt to see the patient within two to four weeks of the referral being made.
  
  Initially, the patient is seen by a transplant pulmonologist in the clinic. This is often followed by an evaluation process. The evaluation process includes a lot of testing, including blood work, laboratory tests and other diagnostics, including CT scans, including things like invasive tests, including heart caths.
  
  So once this is done, the patient also gets to meet the rest of the team, which are usually case managers that look into the social and the psychosocial aspects of the patient, the support systems that the patients have. We look at the financial supports that the patient may require during the transplant process and afterwards. And then the patient also gets to meet the rest of the consultants on the team, like the transplant infectious disease or the other cardiothoracic surgeons, who may be part of the process of the transplant.
  
  So once that's done, usually there is a listing meeting, where all the folks that have been involved in the evaluation process, all get together and we really get an assessment of whether the risk and benefit of the transplant is worth it for the patients. So clearly, the benefits of the transplant, including survival and their long-term survival should far outweigh any kind of risks that we take during the procedure, because of the patient's underlying condition.
  
  So once we kind of make that determination, we will offer the patient a listing. And once they're on the list, they're activated on the National UNOS list. And depending on where their scores on the LAS system lie, the patient could get the transplant, depending on how high their scores are on the LAS system.
  
  Melanie: So will you speak to other providers about the progress on the wait-list management of disease? So tell us what you feel the transplant centers may need to be doing that you are doing at UAB Medicine in management of whatever disease the patient has and helping the referring physician to manage while the patient waits.
  
  Dr Thomas Kaleekal: Right. So one of the most important things that UAB offers to all our patients is that we do have a large number of specialists in each and every advanced lung disease that are present at UAB. So, we have world-renowned people, who are very experienced in idiopathic pulmonary fibrosis have the latest medications and also part of many clinical trials that the patients may actually have access, during their referral process, to the transplant program.
  
  So we are also able to provide all kinds of advanced disease management. For example, in COPD, we may be able to offer transtracheal oxygen in patients with COPD who may be candidates for LVRS, we may be able to offer those kinds of advanced therapies. So just because you're referred to the transplant program does not necessarily mean that we may focus just on the transplant aspect of things, but we also will connect these patients to all other specialized physicians and services that the patient may actually need for the betterment of their health.
  
  So I think referring to UAB Transplant actually does help the patient in more than just the transplant process. They also may help in disease management and other areas of where the expertise of specialists may be needed.
  
  Melanie: What a great point and such a comprehensive approach. So tell us what you see exciting in your field? What's the future of lung transplant? Tell us a little bit about the search for alternative therapies and the annual demand for lungs. Tell us what's going on in all of that.
  
  Dr Thomas Kaleekal: Definitely, the ideal world would be where you would be able to do the lung transplant and the patients would actually be living well with these new lungs forever or as long as their lifespans would have been normally been. So unfortunately, that's not true right now. Even with the best of our medications, with a double lung transplant, we would expect a survival seven to 10 years or so, depending on the comorbidities the patient may have.
  
  So I think what's exciting out there in lung transplant rate now is essentially whether we can use the lungs of the patient themselves or their cells themselves to construct a new lung out of their own lungs. So that would be a great thing down in the future. There's a lot of research going on creating new lungs from the patient's own cells and own tissues. So that would be one way.
  
  So there's also lots of research going on xenotransplantation, which is use of lungs from say from pigs, I think, help our patients who might actually be having advanced lung diseases. Obviously, these are all in the research field right now. And reality is that's not exactly an option right now for our patients.
  
  At the end of the day, yes, I mean, you know, we definitely want to have the longest lifespan that we can actually provide with the lung transplant. And that means actually being able to develop newer drugs and medications that may actually prolong the lives of our patients even more, but at the same time, not making them prone to infection.
  
  So a lot of these are exciting research opportunities are being done all across the world, including at UAB and we look forward to be able to provide our patients with clinical trial opportunities as they arise in our program.
  
  Melanie: Thank you so much, Dr. Kaleekal, for being with us today and telling us about the program at UAB Medicine. A community physician can refer a patient to UAB by calling the MIST line at 1-800-UAB-MIST.
  
  And that concludes this episode of UAB MedCast. For more information on resources available at UAB Medicine, please visit our website at UABMedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole.
  
  
• Hosts:Melanie Cole, MS