Lung transplantation is an accepted therapeutic option for patients who have a number of end-stage pulmonary diseases.

Lung transplantation is an accepted therapeutic option for patients who have a number of end-stage pulmonary diseases. In calendar year 1999 the United Network for Organ Sharing reported (1) that 877 lung transplants and 49 heart-lung transplants had been performed in the United States alone, with a waiting list of 3491 living bodys During the same time period, > 2000 transplants were performed worldwide. (2) About 76% of lung transplant recipients will survive by the agency of the first year, and 56% make it to 3 years. (1) When assessing the efficacy of a given intervention forward outcomes for any end-stage organ disease, there is a growing emphasis not merely on improvements in survival, yet also on the associated health-related quality of life (HRQOL) Incorporating HRQOL and survival has outcomeed in the generation of quality-adjusted life years (QALY) as a measure of transplantation outcomes

In the area of lung transplantation, there is a growing carcass of literature attesting to improvements in patients' posttransplant HRQOL To illustrate this growing research effort, we performed a MEDLINE search for the years 1990 between the sides of March 2002 using the elucidation words "quality of life" and "lung transplantation," and we received 197 citations. In 27 of these citations, quality of life (QOL) was the major focus of the inquiry but in only 11 of the studies was QOL in the pretransplant candidates assessed. In single one of these articles was an intervention implemented to improve a patient's pretransplant QOL (3) to such a degree while there is an

increasing focus forward HRQOL posttransplant, there is a relative paucity of data onward the pretransplant population, with individual lone article looking at an intervention directed at optimizing QOL before lung transplantation. This apparent lack of research into this specific area is likely becoming to the commonly accepted notion that pulmonary rehabilitation does improve HRQOL There are many studies attesting to this, specifically in the COPD population. There is, however, a lack of data attesting to the utility of pulmonary rehabilitation in other patient arranges (4) Nonetheless, it is likely that greatest in number patients who are lung transplant candidates will derive a measure of benefit from pulmonary rehabilitation.

The issue of HRQOL is of particular importance in lung transplant candidates for a number of reasons. First, when subjecting patients to a operation with a potential 1-year mortality rate of approximately 24% it is incumbent forward the clinician to present this option in the words immediately preceding [i]or[/i] following of the impact on posttransplant survival as well as upon HRQOL. Indeed, there already has been a controversial report (5) showing that transplantation did not improve longevity in the COPD population. However, if these data were analyzed with honor to QALY, there is little doubt that the conclusions would have favored transplantation.

An essential aspect of posttransplant care is the optimization of the patient's HRQOL Aside from routine medical care, this is usually further facilitated between the walls of pulmonary rehabilitation, continued education, and participation in support form into groupss However, the listed patients frequently are not fully ensconced within the transplant center's theory and do not, therefore, have access to the same plain of support services prior to undergoing transplantation. Whereas posttransplant patients are seen excessively frequently at the respective transplant center pretransplant patients be attentive to to be seen less repeatedly with the responsibility for their medical care falling forward their primary pulmonologists. Although many programs put forward pretransplant support groups, listed patients ofttimes are unable to attend them owing to logistical issues.

in the greatest degree programs require that their listed patients be actively engaged in a pulmonary rehabilitation program. the same cannot understate the important part that pulmonary rehabilitation plays in optimizing the patient's pretransplant status, including providing about measure of psychosocial support. However, not all pulmonary rehabilitation programs are created equal, and, indeed, it is not noteworthy for patients in smaller metropolitan areas to suffer rehabilitation at a cardiac rehabilitation facility. Furthermore, patients in distant pulmonary rehabilitation programs may be the single patients listed for transplant and may be excited isolated, thereby limiting their subjective understanding of support. Although some transplant center insist onward their patients relocating closer as they put in motion up the list, this may alone be at a point when the patient already has been forward list for many months. Therefore, the nature of the classification of care before transplantation and the relative rarity of the transaction contribute to the lack of support that is available to listed patients for in the greatest degree of their time on the list. The lading of care for transplant center is focused forward the transplant recipients. With the end scrutiny on transplant outcomes, it is understandable that greatest in quantity resources are so directed.

A number of questions therefore arise. First, who should bear the onus for optimizing a patient's QOL during the pretransplant waiting period? Can we do more than pulmonary rehabilitation alone? And last, what is the magnitude of this burden? With regard to the latter question, as of June 2000 there were 3691 patients onward the US waiting list for lung transplants. (6) mostly of these patients will have to wait up to 2 years before receiving an organ. Therefore, at any common time, there could be > 7000 QALYs that could be impacted favorably according to an additional effective support intervention. If QALY is to be the issue measure by which the efficacy of lung transplantation is to be judg then it is incumbent upon us as physicians at transplant center to raise the bar as high as possible with regard to pretransplant HRQOL This is necessary to guarantee that any HRQOL improvements posttransplant are to be paid to allograft function alone and not to a mechanism of support that could have been implemented in the pretransplant period.

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