Underestimating treatment benefit of lung transplantation for idiopathic pulmonary fibrosis

Dempsey and Miller drew attention to the inadequacy of medical treatments for idiopathic pulmonary fibrosis (IPF) and the optimism provided by the emergence of pirfenidone.1However, only a cursory note was given to lung transplantation, which seems to have been dismissed by the authors, who describe patients as “too frail or old” with “serious comorbidity.” We are worried that this viewpoint will foster a passive attitude to this successful treatment.

International Society for Heart and Lung Transplantation registry data from 2012 show that 37% of North American and 31% of worldwide lung transplants were performed for IPF, compared with only 13% in Europe. This discrepancy is hard to explain. However, the proportion of patients with IPF given transplants in the US increased after the introduction of the lung allocation scoring system,2 which prioritises patients on the basis of treatment benefit.

Although IPF has been associated with higher perioperative mortality than other conditions, this is probably because of delayed referral—long term outcomes have been shown to be excellent.3 In Ireland, five year survival in these patients is 79% after transplantation. Outcomes are similar in all age groups, including those over 65.4 5

Lung transplantation is the only intervention with a proved survival benefit in this disease. Although future drug development should be viewed optimistically, treatments that are known to enhance survival should be focused on. Increased referrals to transplant centres, allied to improved organ utilisation for these patients, should be measured as key performance indicators. Advocacy aimed at achieving transplant rates of 30%, akin to the US, would provide considerable benefits.