Lung Transplant

Question 1

BODE Score

Answer 1

Predicts survival in COPD patients.

BMI, airflow Obstruction, Dyspnea and Exercise

Question 2

CLAD - acronym (in lung transplant)

Answer 2

Chronic lung allograft dysfunction (chronic rejection)
* RAS restrictive allograft syndrome
* BOS bronchiolitis obliterans syndrome

Question 3

Which virus is PTLPD post transplant lymphoproliferative disease (lymphoma) associated with

Answer 3

EBV

Question 4

Lung transplant criteria

Answer 4

High (>50%) risk of death due to lung disease within 2 years if lung transplantation is not performed.

High (>80%) likelihood of 5-year post-transplant survival from a general medical perspective provided there is adequate graft function.

Question 5

Absolute CI lung transplant

Answer 5

• Severely limited functional status with poor rehabilitation potential
• Recent history of malignancy with a high risk of recurrence or death
• Extra pulmonary or disseminated infection or active TB or HIV Infection (detectable viral load)
• Major organ dysfunction
• GFR <40 (unless multi organ transplant)
• Liver cirrhosis or synthetic dysfunction
• Acute coronary syndrome within 30 days
• CVA within 30 days
• Progressive cognitive impairment
• Repeated nonadherence without evidence of improvement (Pediatric patients)
• Active substance use or dependence (tobacco, vaping, marijuana smoking) or IV drug use)

Question 6

Relative Contraindications for transplant

Answer 6

• Age > 65 with low physiologic reserve
• BMI > 30 (particularly truncal obesity)
• Progressive or severe malnutrition
• Severe, symptomatic osteoporosis.
• Extensive prior chest surgery with lung resection.
• Colonization or infection with highly resistant or highly virulent bacteria, fungi, and certain strains of mycobacteria (chronic extra pulmonary infection expected to worsen after transplantation)
• Hepatitis B and C
• Coronary artery disease

Question 7

Immunsuppresion regime in lung transplant

Answer 7

1. Calcineurine Inhibitors
   * Tacrolimus or Cyclosporine
   * Require TDM

Cell cycle inhibitors
* Azathioprine of MMF

Prednisone
* Aim for 5-7.5mg daily by 9 months

Question 8

Common AE of calcineurin inhibitors

Answer 8

renal impairment, hypertension,

hyperglycemia (TAC), hair loss and tremors (Tac)

hirsutism (Cyclosporin),

Question 9

Common AE with cell cycle inhibitors in lung transplant

Answer 9

Reduced white blood count,

LFT derangement and nausea (AZA),

nausea and diarrhea (MMF)

Question 10

Antiviral and Antimicrobial prophylaxis in lung transplant

Answer 10

CMV
* For all at risk patients: CMV R+ and CMV R-/D+
* Valganciclovir: myelosuppression, adjust for renal function

EBV
* If not covered by CMV prophylaxis (CMV R-/D-)
* Valacyclovir prophylaxis
* Most at risk EMB R-/D+ (EBV PTLPD)

PCP Prophylaxis
* Cotrimoxazole 480mg thrice weekly (Dapsone 100mg daily if allergic)

CLAD prophylaxis - Chronic lung allograft dysfunction (chronic rejection)
* Azithromycin

Question 11

Long-term complications of lung transplant

Answer 11

Chronic lung allograft dysfunction (CLAD, chronic rejection)
• Restrictive Allograft Syndrome (RAS)
• Bronchiolitis Obliterans Syndrome (BOS)
* By 5 years 40% will have some degree of allograft dysfunction

Renal Dysfunction

Malignancy
* Skin cancers geography dependent
* Voriconazole can exacerbate the problem
* Reduce immunosuppression