ROLE OF TRANSPLANTATION (LUNG, LIVER, AND HEART) IN SARCOIDOSIS

Failure of a single vital organ is the usual indication for which to consider transplantation. Examples of disorders commonly leading to lung transplantation include emphysema, cystic fibrosis, pulmonary hypertension, and interstitial lung disease. Cardiomyopathy is the most frequent indication for heart transplantation. Biliary cirrhosis and fulminant hepatitis are common indications for liver transplantation. Patients with systemic disorders pose a challenge because the disease may involve vital organs other than the one being considered for transplantation. The reasons such patients are frequently not suitable for transplantation are: Other vital organs affected by the disorder may also fail, transplant recipients may not experience improved quality of life or their rehabilitation may be hindered because of disease in the other organs, other organ involvement can increase the risk of infection, or the immunosuppressive medications may precipitate or worsen dysfunction of other organs. Patients with systemic disorders such as severe diabetes, systemic vasculitides, such as lupus erythematosus, and common variable hypogammaglobulinemia therefore are typically not candidates for transplantation. Many transplant centers, however, do not categorically exclude patients with systemic or multisystem disorders, including sarcoidosis, from becoming candidates for organ transplantation and selection criteria are still in evolution. 20 The ideal time to refer a patient for transplantation remains relatively imprecise. It is recommended that referral should occur sometime before the patient's condition has deteriorated to the point at which survival would be less than the anticipated time necessary to stay on a transplant waiting list. In addition, the patient's condition should not be allowed to deteriorate to the point that his or her ability to tolerate surgery would become too risky. The timing for referral is usually based upon a constellation of factors that include organ availability, the natural history and prognosis of the disease process, the rapidity of deterioration despite maximum management, failure of therapy, the overall physical and nutritional status of the candidate, and the laboratory findings assessing the severity and functional status of the failing organ. Clearly, the potential candidate has to be able to survive the waiting period for the specific organ while under maximum medical management. The waiting period for cadaveric organ transplantation varies with the organ donor pool. The waiting period for lung transplantation is between 1 and 2 years. During the waiting period, the patient and referring physician must aggressively strive to prepare the candidate to be in the best condition possible prior to transplantation. The objective is to reduce the risk of surgery and expedite recovery and rehabilitation. That may involve maximizing therapy, improving nutritional status, attaining near-ideal body weight, or participating in an organized rehabilitation program. Patients with systemic disorders are often being treated with immunosuppressive agents prior to transplantation. The use of corticosteroids is a relative contraindication to transplantation and is not encouraged, mainly because of the risks of infection, delayed wound healing, and uncontrolled diabetes. Doses less than or equal to 10 mg per day or 20 mg every other day is a goal suggested for patients who are dependent upon corticosteroids.