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Contemporary lung transplantation: the UCLA experience.

Lung transplantation has evolved considerably over the past decade and is now considered an effective form of therapy for end-stage lung diseases. Several factors have contributed to the improved survival of lung transplant recipients including better donor management/ preservation, less waiting list deaths due to the new allocation system, improved surgical/peri-operative care, and improved immunosuppression. Despite these advances, the discipline of lung transplantation faces several challenges in the next decade: donor shortage, acute rejection, and chronic allograft dysfunction. Despite improvements in donor management and routine use of "non-standard" lungs, there remains a shortage of donor lungs. Further expansion of acceptable donor lung criteria and integration of lungs after cardiac death may further expand the donor pool. Despite improvements in immunosuppressive protocols, acute rejection remains a major cause of morbidity and an important risk factor for chronic allograft dysfunction. Development of more focused immunosuppressive medications and better diagnostic tools (i.e. peiripheral blood-based tests) may further improve the survival of lung transplant recipients. Lastly, chronic allograft dysfunction is the leading cause of late death among lung transplant recipients and is caused by both immune and non-immunefactors. Early diagnosis and eradication of the causes (GERD, infections, or immune-mediated factors) is critical to control this entity. Until donor-specific tolerance becomes a clinical reality, efforts need to be directed to control acute rejection and chronic allograft dysfunction after lung transplantation.