Chapter 292 - Lung Transplantation Flashcards
Most common indications for Lung transplantation in recent years in decreasing order of frequency
IPF (30%) COPD (27%) CF (15%) a1 AT (3%) IPAH (2.5%)
primary motive for transplantation for many patients
QOL
Conditions such as systemic hypertension, diabetes mellitus, gas- troesophageal reflux, and osteoporosis are not unusual, but if uncom- plicated and adequately managed, they do not disqualify patients from transplantation.
True
Upper age limit at most centers for Lung Transplant
70-75yo
Standard exclusions of Lung Transplant
- HIV infection
- chronic active hepatitis B or C - uncontrolled or untreatable pulmonary or extrapulmonary infection
- uncured malignancy
- active cigarette smoking
- drug or alcohol dependency
- irreversible physical deconditioning
- chronic nonadherence with medical care
- significant disease of another vital organ (e.g., heart, liver, or kidney)
- psychiatric or psychosocial situations
If the potential recipient is allosensitized with antibodies to any human leukocyte antigen (HLA), the donor also has to be HLA compatible.
True
most lungs are procured from where?
deceased donors after brain death
How many percent of brain death organ donors yielding or two lungs suitable for lung transplant
only 20%
Patient groups according to the Lung Allocation Score system for LT
A - COPD and emphysema
B - IPAH
C - CF
D - IPF
What is the basis of the Lung Allocation Score system
risk of death during 1 year on the waiting list and tlikelihood of survival for 1 year after transplantation
Which patient group has the highest LAS score?
D
In 2014, 50% of the patients on the waiting list were in group D What is the median waiting time to transplantation?
3.7 months
Overall death rate on the wait list
10 per 100 waitlist years
death rate on the waitlist for lung transplant by diagnostic group
A, 4
B, 11
C, 12
D, 18
Which Transplant procedure is mandatory for Cystic Fibrosis and other forms pdf bronchiectasis?
Bilateral transplantation
Which Transplant procedure is obligatory for Eisenmenger syndrome with complex anomalies?
Heart-lung transplantation
this interleukin-2 receptor antagonist is the widely used drug for induction therapy
Basiliximab
Maintenance immunosuppressive regimen includes which agents?
calcineurin inhibitor
purine synthesis antagonist
prednisone
The most commonly used maintenance immunosuppressive regimen for lung transplant recipients
Tacrolimus
Mycophenolate
Prednisone
After lung transplantation, if recovery is uncomplicated, lung function rapidly improves and then stabilizes how many months after transplantation?
3-6 months
Sustained decline by how much of the spirometric measurement signals a potentially significant problem post lung transplant?
≥10–15%
Median survival for Lung transplant recipients
IPF 4.7 years COPD 5.5 years IPAH 5.7 years Sarcoidosis 6.1 years CF 8.6 years
Long-term survival has been significantly better after bilateral transplantation than after unilateral transplantation for all of the major indications
True
Median survival for lung transplant recipients by age
18–49 years: 7.2 years
50–59 years: 5.5 years
≥60 years: 4.5 years
What are the three parameters of the recipients with the lowest survival rates?
group D
≥65 years old
had an LAS ≥60
Causes of death after lung transplantation during the first 30 days.
graft failure (24%) infection (19%) cardiovascular events (11%) technical problems (11%)
Causes of death after lung transplantation during the remainder of the first year
Infection 37%
Graft failure 17%
Causes of death after lung transplantation AFTER the first year
bronchiolitis and other forms of late graft failure 40–45%
infection 16–20%.
FACTORS associated with an increased risk of death in the first year AFTER transplantation
- Hospitalized during transplantation
- supported by mechanical ventilation
- extracorporeal membrane oxygenation
- dialysis at the time of transplantation
- undergoing retransplantation
Mortality risk have been higher at centers with an annual volume below?
below 30 transplants/year
T/F
After bilateral transplantation, pulmonary function tests are typically normal.
True
The average length of stay after bilateral transplantation in the United States days
29.5 days
Rehospitalization rate in the first year after transplntation is higher than any other solid organ transplant except intestine.
True
Complication of Lung transplantation presenting with diffuse pulmonary infiltrates and hypoxemia within 72 h of transplantation
Primary graft dysfunction
Severity of Primary graft dysfunction based on PF ration
Grade 1: >300
Grade 2: 200-300
Grade 3: <200
Complication of Lung transplant caused by T lymphocyte inter- actions with donor alloantigens, mainly in the major histocompatibility
Acute Cellular rejection
Incidence of acute cellular rejection is highest when?
6-12 months after transplant
Diagnosis of ACR after transplantation is confirmed how?
transbronchial biopsies showing lymphocytic infiltrates around arterioles or bronchioles
At what grade of ACR is treatment started regardless of the clinical situation
≥A2
Lung transplantation complication occurring when lung function never reaches expected values due to early complications or when there is a sustained decrement in lung function below previously normal baseline measurements
Chronic Lung Allograft Dysfunction
CLAD must persist how many weeks before diagnosis is entertained?
≥3 weeks
2 types of CLAD
Bronchiolitis obliterates syndrome
Restrictive Allograft Syndrome
Severity of BOS
)is cat- egorized by the decrement in FEV1 from the average of the two best posttransplant values
20–35%, stage 1; 35–50%, stage 2; >50%, stage 3
Median survival after onset of BOS
3-4 years
Median survival of RAS
1.5 years
Which CLAD
FEV1 <80% Air trapping is usually present with minimal, if any, infiltrates
BOS
Which CLAD
FEV 1 <80%
TLC <90%
RAS
Which CLAD
Infiltrates are usually present
± air trapping
± bronchiectasis
RAS
Criteria for Humoral/Antibody mediated rejection
- graft dysfunction
- serologic detection of donor-specific antibodies,
- pathologic pattern of graft injury with evidence of antibody deposition
2 most common organisms in bronchitis with BOS
pseudomonas aeruginosa
MRSA
Most common complication of lung transplantation related to the side effect of the immunosuppressive drugs
Hypertension
Referral for Evaluation for COPD
Progressive Sx
FEV1 <25%
PaO2 <60 or PaCO2 >50
BODE 5-6
Listing for transplantation for COPD
- BODE ≥7
- FEV1 <15–20%
- Moderate to severe pulmonary hypertension
- 3 or more severe exacerbations in preceding year
- One severe exacerbation with acute hypercapnic respiratory failure
Referral for evaluation for IPF
- Pathologic or radiographic evidence of UIP or NSIP
- FVC <80% or DLCO <40%
- Dyspnea or functional limitation
- Any oxygen requirement (rest or exercise)
Listing for transplantation for IPF
- Decrement in FVC ≥10% or in DLCO >15% during 6 months of follow-up
- Pulmonary hypertension
- Desaturation to SpO2 <88% during 6-min walk test
- 6-min walk test distance <250 m or decrement >50 m over 6 months
- Hospitalization for acute exacerbation
