Quality of life issues in transplantation: thoracic organ transplantation

Quality of life issues in transplantation: thoracic organ transplantation

Quality of Life Issues in Transplantation: Thoracic Organ Transplantation L.L. Schulman T HE IDEAL outcome of successful thoracic organ transplantat...

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Quality of Life Issues in Transplantation: Thoracic Organ Transplantation L.L. Schulman

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HE IDEAL outcome of successful thoracic organ transplantation is to prolong the life of the recipient and to enhance the quality of life of the recipient. In cardiac transplantation, there is general consensus that survival after transplantation is superior to current therapies for class III and Class IV heart failure.1 In contrast, some investigators have questioned whether there is a survival benefit associated with lung transplantation in the treatment of advanced lung disease, especially pulmonary emphysema.2 Data analysis from the International Society for Heart and Lung Transplantation (ISHLT) Thoracic Registry demonstrated that for patients with pulmonary emphysema, the relative risk of death from lung transplantation up to one year after surgery did not decline below the risk of continued waiting on the transplant waiting list.2 Under these circumstances, lung transplantation for the treatment of advanced pulmonary emphysema must be considered only in terms of quality rather than quantity of life. Once survival issues are clarified, the first step in studying quality of life related to thoracic organ transplantation is to precisely define the concept of quality of life.3– 8 Once defined, various instruments are used to measure quality of life.3,4,9 These instruments include health profiles, indices, or utility measures which may be generic or disease-specific. Once measured, the data are applied for the purpose of study, which include descriptive studies, predictive studies, treatment-effectiveness studies, and cost-effectiveness studies. Other than descriptive studies, quality of life serves as a study tool rather than an endpoint. In the realm of descriptive studies, several reports in the medical literature document significant improvements after thoracic organ transplantation in physical function, mobility, energy level, social function, health perceptions, mental and emotional health, as well as overall perception of greater life satisfaction.3– 8 Despite these perceived benefits, there are significant posttransplantation problems which limit improvements in quality of life. Many of these are medical complications such as osteoporosis and fracture, hypertension and weight gain, and acute and chronic allograft rejection.10,11 Other difficulties relate to anxiety, poor sleep quality, concern for body image, loss of sexual function, depression, fatigue, and lack of employment opportunities.7,12,13 Studies utilizing quality of life as a diagnostic tool have 0041-1345/01/$–see front matter PII S0041-1345(00)02733-0

identified individual characteristics such as stress, interaction with healthcare provider, anxiety, and depression as predictive of quality of life after transplant, even more than cardiopulmonary physiologic variables.4,7 In turn, these individual characteristics influence compliance with posttransplantation regimen, which directly affects acute rejection, chronic rejection, and survival.14 As such quality of life serves as a postoperative variable influencing other endpoints. There are vast potential applications of utilizing quality of life analysis in the study of thoracic organ transplantation. Future work needs to better describe quality of life in end-stage cardiopulmonary disease, determine the effectiveness of interventions to improve quality of life before transplantation, address use of quality of life to assess new technologies such as left ventricular assist device (LVAD) and lung volume reduction surgery (LVRS) as alternative treatments to transplantation, use quality of life to assess new immunosuppressant medications, and assess the impact of chronic allograft rejection on stability of quality of life. At the same time, health care providers must remain vigilant to prevent misinterpretation and misuse of quality of life data. Quality of life data are not applicable to decisions regarding individual patients. Thoracic organ transplant centers worldwide are currently directing major research efforts at diagnosing, treating, and preventing posttransplant medical problems. At the same time, transplant centers have recognized the importance and obligation of providing support groups, physical rehabilitation, nutritional counseling, psychotherapy, and even career guidance to improve quality of life after transplantation. REFERENCES 1. Hershberger RE: Am J Med Sci 314:129, 1997 2. Hosenpud JD, Bennett LE, Keck BM, et al: Lancet 351:24, 1998

From the Department of Medicine, College of Physicians and Surgeons of Columbia University, New York, New York, USA. Address reprint requests to Larry L. Schulman, Columbia University, College of Physicians & Surgeons, 630 West 168th Street, New York, New York 10032. © 2001 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010

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QUALITY OF LIFE ISSUES 3. Grady KL, Jalowiec A, White-Williams C: J Heart Lung Transplant 15:749, 1996 4. Grady KL, Jalowiec A, White-Williams C: J Heart Lung Transplant 18:202, 1999 5. Gross CR, Savik K, Bolman RM 3rd, et al: Chest 108:1587, 1995 6. Ten Vergert EM, Essink-Bot ML, Geertsma A, et al: Chest 113:358, 1998 7. Cohen L, Littlefield C, Kelly P, et al: Chest 113:633, 1998 8. van Den Berg JW, Geertsma A, van Der BIJ W, et al: Am J Respir Crit Care Med 161:1937, 2000

1879 9. Gross CR, Raghu G: Clin Chest Med 18:391, 1997 10. Shane E, Papadopoulos A, Staron RB, et al: Transplantation 68:220, 1999 11. Schulman LL: Chest Clinics North America (In press) 12. Rosenblum DS, Rosen ML, Pine ZM, et al: Arch Phys Med Rehabil 74:490, 1993 13. Limbos MM, Chan CK, Kesten S: Chest 112:1165, 1997 14. Dew MA, Kormos RL, Roth LH, et al: J Heart Lung Transplant 18:549, 1999