lung transplantation
DESCRIPTION
LUNG TRANSPLANTATION. ISKANDER AL-GITHMI, M.D., FRCSC, FRCSC (Ts & CDs), FCCP. Assistant Professor of Surgery Division of Cardiothoracic Surgery King Abdulaziz University. History: - PowerPoint PPT PresentationTRANSCRIPT
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LUNG TRANSPLANTATION
ISKANDER AL-GITHMI, M.D., FRCSC, FRCSC (Ts & CDs), FCCP.
Assistant Professor of Surgery
Division of Cardiothoracic Surgery
King Abdulaziz University
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History:
First human lung transplantation was performed by Dr. James Hardy in June 1963 at the University of Mississippi.
Between 1963 & 1978, 38 lung transplant were done around the world. Two recipients live longer than one month.
Lung and heart-lung transplantation were introduced into clinical practice in 1981 CSA era.
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History (con’t.)
First successful transplantation in the world was done in 1983 at the University of Toronto. J. Cooper
Over 15,000 lung transplantation have now been performed worldwide. (ISHLT) statistics.
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What Are Lung Transplantation For?
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Indications:Obstructive air way disease (29%)
- COPD- Alpha 1 antitrypsin deficiency
Idiopathic pulmonary fibrosis (19%)Septic pulmonary disease (16%)
- Bronchiectasis- cystic fibrosis
Primary pulmonary hypertension (11%)
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Other Varieties (11%)
e.g. - sarcoidosis
- lymphangioliomyomatosis (LAM)
- eosinophilic granuloma
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Who are not transplantable?
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Contra-indications:
Age > 65 years
Active smoking
Poor compliance with the treatment
Severe active infections (HIV, Hepatitis B & C)
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Con’t.
Active malignancy within the past two years.
Drugs or alcohol abuse.
Dysfunction of major other organs
- renal dysfunction
- untreatable CAD or LV dysfunction
- liver dysfunction
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Recipient Selective Criteria:
End-stage pulmonary disease with life expectancy < 2 yrs.
Absence of severe extra pulmonary diseases.
Strong motivation towards the idea of lung transplantation.
Severe functional limitation, but potential for rehabilitation.
Excellent psychosocial support.
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Donor Selective Criteria:
Age < 65 years
No significant lung diseases
Acceptable CXR
PaO2 > 300mm Hg on F102 1.0 and PEEP 5 cm for 5 min.
Bronchoscopy - clear
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Con’t.
Viral studies are negative (HIV and Hepatitis B & C)
Donor – recipient size matching
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Medical Conditions – Impact on eligibility for treatment
Symptomatic osteoporosis
Corticosteroid
Nutritional issues
Psychosocial issues
Colonization of air ways with fungi or atypical mycobacteria
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Guidelines for Timing Referral
Chronic obstructive pulmonary disease and a1-antitrypsin deficiency amphysema
Postbronchodilator FEV1 < 25% predicted
Resting hypoxia: PaO2 < 55 to 60 mm HgHypercapniaSecondary pulmonary hypertension
Clinical course rapid rate of decline of FEV1 or life-threatening exacerbationsCystic fibrosis
Postbronchodilator FEV1 < 30% predicted
Resting hypoxia: PaO2 < 55 mm HgHypercapniaClinical course: increasing frequency and severity of exacerbations
Idiopathic pulmonary fibrosisVC, TLC < 60-65% predictedResting hypoxiaSecondary pulmonary hypertensionClinical, radiographic, or physiologic progression on medical therapy
Primary pulmonary hypertensionNew York Heart Association functional class III or IVMean right atrial pressure > 10 mm HgMean pulmonary arterial pressure > 50 mm HgCardiac index < 2.5 L/min/m2
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•Which transplantation procedure?
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Living Donor Lobar Lung Transplantation (LDLT)
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- The first living donor lung transplant was reported in 1990. Throughout the world there have been approximately 100 such procedure done to date.
- The outcomes for recipients are similar to those who have received lungs from Cadaveric donors.
- All living donor lung transplantation have been done utilizing a single lower lobe from each donor which account for about 25% of TLC for each.
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Recipients Selection for LDLT
- Similar as for cadaveric donors.- All candidates are first assessed and
listed for cadaveric lung transplantation.- Potential recipient must be large
enough to receive the lower lobe of an adult donor – at least the size of an average six year old (90 cm in height).
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Selection of Potential Donors
- Age 18 – 60 years- Blood group compatible with recipient- Of sufficient size- Have normal lungs by clinical, radiographic
and physiological assessment.
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Con’t.
- No other significant medical illnesses- No history of hepatitis or HIV- Be willing to undergo complete psychological
and psychiatric assessment.- Be willing to undergo complete physical
assessment.
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What Are the Benefits of LDLT?
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- To reduce the number of patient dying while awaiting cadaveric transplantation.
- Ability to schedule surgery on a non-urgent basis.
- Ability to time transplantation before the recipient becomes too ill.
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Con’t.
- Shorter ischemic times.- Avoidance of hemodynamic instability
associated with maintenance of cadaveric donor.
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Operative goals:
The operation should provide the highest degree of operative safety and the greatest cardio pulmonary rehabilitation.
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Is the lung transplantation safe?
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Complications:
Early graft dysfunction – is an acute lung injury that is related to preservation and ischemia reperfusion.
- referred to a clinical scenario as pulmonary infiltrate and poor oxygenation.
- main consideration are rejection and infection.
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Con’t.
Airway complications:
- Dehiscence
- Stenosis
- Bronchomalacia
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Con’t.
Rejection- is the single most important limitation to long-term survival.- Acute rejection
* incidence – high* infrequently fatal* the principal risk factor for
chronic rejection
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Why might the lung be prone to rejection?
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Con’t.
- The lung has an extensive vasculature and circulating immune system.
- The lung is constantly exposed to extrinsic infectious agents.
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Con’t.
Infection
- is the leading cause of early and late morbidity and mortality.
- wide spectrum of pathogens.
- bacterial pneumonia and CMV pneumonitis have been the most problematic.
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Why is the lung allograft so prone to infection?
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Con’t.
- The lung allograft is denervated – cough reflex is depressed.
- Mucociliary clearance is depressed.- Lymphatic drainage is disrupted.- Immunisystems are suppressed by anti
rejection medications.
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Con’t.
Lymphoproliferative Disease (PTLD)- the prevalence is 6%- most cases developed in the first year- the risk has been marked by increased in recipient who have had EBV-sero negative before transplantation and have acquired a primary EBV infection afterwards.
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Con’t.
Outcomes
- gauged by survival
- quality of life
- cost-effectiveness
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Con’t.
Quality of life
- the usual way of measuring the quality of life for lung transplantation is the improvement of pulmonary function test.
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Con’t.Cost and Cost-effectivenessAnalysis conducted at the University of Washington Medical Center- mean charge was $164,989- the average charges to post-transplantation care were $16, 628 per month during first 6 months and $5,440 per month during the 2nd month.- Lifetime cost was projected to be $424,853
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Con’t.
Conclusion:
- lung transplantation has expanded rapidly in the last decade.
- chronic allograft rejection is a major impediment to long term survival.
- progress in immunobiology will likely determine the state of the art.