Treatment of Asbestos-Related ILD with Lung Transplantation
Indications for Transplant Referral
- The European Respiratory Society recommends lung transplantation for patients with asbestos-related ILD who have severe or progressive disease, with referral recommended for patients under age 65 years who demonstrate functional impairment, oxygen dependency, or deteriorating course 1
- Patients with age <65 years, DLCO <39% predicted, FVC decline >10% over 6 months, severe functional impairment with oxygen dependency, or progressive physiologic deterioration despite optimal medical management should be referred for transplant evaluation 1, 2
Pre-Transplant Medical Management
- The European Respiratory Society recommends long-term oxygen therapy for patients with severe hypoxemia at rest 1
- Oxygen saturation should be monitored at rest and with exertion at 3-6 month intervals, and supplemental oxygen should be prescribed for desaturation below 88% during 6-minute walk test 5
- Respiratory rehabilitation programs should be initiated in patients with exercise limitation causing significant impairment, and may include exercise training, smoking cessation, psychosocial assistance, and supportive care 1
- Annual influenza vaccination and anti-pneumococcal vaccination using polysaccharide pneumococcal vaccine are recommended 1
Transplant Procedure Considerations
- Single lung transplantation is currently the preferred surgical operation for fibrotic ILD, including asbestosis, according to the American Thoracic Society 2, 3, 4
- The decision between single versus bilateral lung transplantation must consider organ scarcity, as bilateral transplantation uses organs that could potentially benefit two patients with single-lung procedures 6
Contraindications to Transplantation
- Unstable or inadequate psychosocial profile/stability, significant extrapulmonary disorders, and age >60-65 years are relative contraindications to transplantation 2, 3, 4
Expected Outcomes
- Arterial oxygen tension is sufficiently improved to alleviate supplemental oxygen requirement, lung volumes and DLCO are increased, and pulmonary hypertension and right ventricular dysfunction are reversed after transplantation 2, 3, 4
- 5-year survival approximates 50-60% after transplantation, with early mortality causes including graft failure, infection, and heart failure, and late mortality causes including bronchiolitis obliterans, infection, and malignancy 2, 3, 4