lung transplantation and pulmonary fibrosis maria l. padilla, md associate prof. of medicine...

LUNG TRANSPLANTATION LUNG TRANSPLANTATION and PULMONARY FIBROSISand PULMONARY FIBROSIS

Maria L. Padilla, MDMaria L. Padilla, MDAssociate Prof. of MedicineAssociate Prof. of MedicineDirector of ILD/IPF and Advanced Lung Disease Director of ILD/IPF and Advanced Lung Disease ProgramProgramMSSM/MSMCMSSM/MSMC

Organ TransplantationOrgan Transplantation

Lung Transplantation and IPFLung Transplantation and IPF

• Important Questions:– What is it?– Why?– For Whom?– When?– How?– What are the results?

Lung Transplantation and IPFLung Transplantation and IPF

• What is Lung Transplantation?

The operation that replaces diseased, failing lungs with a functional organ.

Lung Transplantation and IPFLung Transplantation and IPF

• Thoracic Transplantation– Heart-Lung Transplantation– Single Lung Transplantation– Bilateral Lung Transplantation– Lobar Transplantation

Lung Transplantation and IPFLung Transplantation and IPF

• WHY?

It offers the opportunity to return to a better functional capacity when all medical therapies have been ineffective.

Ultimate form of treatment

Lung TransplantationLung Transplantation

• Process:– Referral– Evaluation– Listing with UNOS– Waiting time– Transplantation– Post transplantation care

Lung Transplantation and IPFLung Transplantation and IPF

• For whom?– Candidate Selection

• Age less than 65y• Absence of other organ dysfunction• Non-smoker, non-drinker, no drug abuse• Appropriate weight• Good support system• Stable psychosocial and emotional status

Lung TransplantationLung Transplantation

• CANDIDATE EVALUATION– Blood type, biochemical panel, serologies– Renal function determination– Skin testing and sputum cultures– PFT’s , ABG’s, 6-min walk, +/-exercise tests– Imaging: CXR, HRCT, V/Q, bone

densitometry– Cardiac tests: echo; stress tests; RHC with

hemodynamics and LHC where indicated

Lung Transplantation and IPFLung Transplantation and IPF

• When?

When patient is:

medically

physically

psychologically/emotionally,

READY! and lungs become available

Lung TransplantationLung Transplantation

• LESS THAN 20% OF DONORS ARE SUITABLE LUNG DONORS:– AGE AND SMOKING HX EXCLUDE SOME– LUNGS ARE FRAGILE--EDEMA, INFXN,

VENTILATOR COMPLICATIONS– ALLOGRAFT INTOLERANCE TO

PROLONGED ISCHEMIA

Lung Transplantation and IPFLung Transplantation and IPF

• When lungs become available, they are offered on the basis of:– Time on the waiting list

• No consideration for severity of illness or urgency– Exception: 90 d credit when IPF patient listed

– Blood type– Lung size– Other factors (?)

Lung Transplantation and IPFLung Transplantation and IPF

• While on Waiting List:– Adhere to medical treatment– Participate in pulmonary rehabilitation– Maintain good nutrition and acceptable body

weight– Attend support groups– Keep a positive attitude and visualize a

brighter tomorrow

Lung TransplantationLung Transplantation

• Registry:– United Network for Organ Sharing and the

Organ Procurement and Transplantation Network (UNOS/OPTN)

– 1988-2000– 7764 lung transplants (7625 C, 139 LD)– 719 heart-lung transplants

• Data as of Nov. 2000

Lung TransplantationLung Transplantation

Lung Transplantation and ILDLung Transplantation and ILD

• Activity (SLT and BLT)- 1988-1999– IPF (LD 5) 972– SARCOIDOSIS 148– PF (OTHER) 82– LAM 47– OB (non-retransplant) 46– OCCUP. LUNG DIS. 11– RHEUMATOID DIS. 5

• From UNOS/OPTN data as of 2/17/2001

Lung Transplantation and IPFLung Transplantation and IPF

• Idiopathic Pulmonary Fibrosis– Waiting time too long for some patients– At risk for developing 2* PHN– Prior Thoracic surgeries (OLB, Ptx)– High frequency of osteoporosis, obesity– Documented survival benefit

– H-L, 2.9%; BLT, 7.1%; SL, 19.5% (ISHLT)

Lung Transplantation-IPFLung Transplantation-IPF

Lung Transplantation-IPFLung Transplantation-IPF

Lung TransplantationLung Transplantation

• Issues and complicating factors– Need for chronic immunosuppression– Acute and chronic rejection– Infection– Side effects of medicines

– Cost of procedure and follow up care

Lung Transplantation and ILDLung Transplantation and ILD

• IMPROVED FUNCTIONAL STATUS

• IMPROVED PHYSIOLOGY(pulm+ cv)

• SURVIVAL BENEFIT (IPF)

• COMPARABLE INCIDENCE OF AR, CR INFECTION

• IMPROVED QUALITY OF LIFE

Lung TransplantationLung Transplantation

0%

20%

40%

60%

80%

100%

1 Year 3 Years 5 Years

No Activity Limitations Performs with Assistance Total Assistance

Lung TransplantationLung Transplantation

Lung TransplantationLung Transplantation

Lung Transplantation and IPF/ILDLung Transplantation and IPF/ILD

• LT is a therapeutic modality of great value

• Efforts to overcome LT limitations needed:– Increase donor pool--review criteria

• Living donors---Lobar transplantation

– Prevent CR-improve treatment

• Earlier listing of candidates with ILD/IPF

• Explore new therapies as bridge to LT– New IPF paradigm