Lung transplant Flashcards
What is the median survival for a patient who has undergone a double lung transplant?
7.8 years
4.8 for single lung
Nb. increases to 10.2 and 6.5 if survive first year
Overall: 1 year 85% 5 year 59% survival
What is the median survival for a patient who has undergone a single lung transplant?
4.8 years
7.8 for double
Nb. increases to 6.5 and 10.2 if survive first year
What are the indications for lung transplant in patient with COPD?
Symptomatic & BODE <5
- BODE is a COPD survival score made up of FEV1, 6MWT, MRC score and BMI
- The affect on survival is controversial (ie. no good evidence that increases survival) - may have survival benefit in those with lower FEV1 and higher PA pressures
Does lung transplant increase survival in patients with COPD?
Controversial - may have survival benefit in those with lower FEV1 and higher PA pressures
What are lung transplant criteria for pt with IPF?
1 of:
FEV1 decrease by 10% in 6 months
DLCO decrease by 15% in 6 months AND DLCO <40%
Rapid decrease in SATS on 6MWT
Rapid decline in symptoms pre-diagnosis
–> clear survival benefit from tx
What are the lung transplant criteria for pt with CF?
Chronic T1 or T2RF despite treatment
Frequent hospitalisation
Rapid decline in lung function or FEV1 <30%
1xICU or HDU admission
–> clear survival benefit with tx
What are lung transplant criteria for pt with PH?
Class 3/4 that don’t improve with medications (class 3 = lung, class 4 = CTEPH)
Worsening RHF despite treatment
Continuous IV therapy
–> clear survival benefit with tx
What are the most common indications for lung transplant?
COPD & IPF
What are the contraindications for lung transplant?
Absolute:
BMI >35
Advanced organ dysfunction of another system
Significant chest wall deformity
Substance addiction (incl. nicotine replacement) in last 6 months
Unstable mental health
Poor social support
Cancer within 5 years
Burkholderia
Relative:
Age >60
BMI ≥30 or <17
Severe osteoporosis
eGFR <50
1 vessel CAD
Steroids >15mg/day
Extensive pleural disease
Aspergillus/HIV/Hepatitis
What are the absolute contraindications for lung tx?
Absolute:
BMI >35
Advanced organ dysfunction of another system
Significant chest wall deformity
Substance addiction (incl. nicotine replacement) in last 6 months
Unstable mental health
Poor social support
Cancer within 5 years
Burkholderia
Relative:
Age >60
BMI ≥30 or <17
Severe osteoporosis
eGFR <50
1 vessel CAD
Steroids >15mg/day
Extensive pleural disease
Aspergillus/HIV/Hepatitis
What are the relative contraindications for lung transplant?
Relative:
Age >60
BMI ≥30 or <17
Severe osteoporosis
eGFR <50
1 vessel CAD
Steroids >15mg/day
Extensive pleural disease
Aspergillus/HIV/Hepatitis
Absolute:
BMI >35
Advanced organ dysfunction of another system
Significant chest wall deformity
Substance addiction (incl. nicotine replacement) in last 6 months
Unstable mental health
Poor social support
Cancer within 5 years
Burkholderia
What are the superurgent criteria for lung tx?
VV ECMO or interventional lung assist device
Urgent:
IPF
- worsening pO2 despite 10L NIV
- refractory RHF
CF
- above 2 and also
- pH <7.3 despite NIV
- massive haemoptysis despite embolisation
COPD
- worsening T2RF despite 10L NIV
- pH <7.3
- refractory RHF
PH
- RAP >10 + CI <2
- IV inotropic support
- Refractory RHF
What are the urgent lung transplant criteria for pt with CF???
- worsening pO2 despite 10L NIV
- refractory RHF
- pH <7.3 despite NIV
- massive haemoptysis despite embolisation
COPD - same as top 3 for CF except T2RF instead of pO2
IPF - same as top 2 for CF
PH - RAP >10 + CI <2
- IV inotropic support
- Refractory RHF
Super urgent: VV ECMO or interventional lung assist device
What are the urgent lung transplant criteria for pt with COPD?
For CF:
- worsening pO2 despite 10L NIV
- refractory RHF
- pH <7.3 despite NIV
- massive haemoptysis despite embolisation
COPD - same as top 3 for CF except T2RF instead of pO2
IPF - same as top 2 for CF
PH - RAP >10 + CI <2
- IV inotropic support
- Refractory RHF
Super urgent: VV ECMO or interventional lung assist device
Is HLA matching required for lung transplant?
No - only blood group
What immunosuppression is used for lung transplant?
Triple immunosuppression
1) Steroids
2) Cell cycle inhibitor (MMF/azathioprine)
3) Calcineurin inhibitor (Cyclosporin/Tacrolimus)
Nb. common SEs of (3) = renal failure and PRES (presents with acute confusion)
What are common SEs of calcineurin inhibitors?
Renal failure and PRES (presents with acute confusion)
CIs used for lung tx as part of triple immunosuppression:
1) Steroids
2) Cell cycle inhibitor (MMF/azathioprine)
3) Calcineurin inhibitor (Cyclosporin/Tacrolimus)
What is hyperacute rejection in the context of lung tx?
Mismatched blood group - should never happen
Pt with lung tx has CXR showing bilateral infiltrates 48hrs after tx. What is most likely cause?
Primary graft dysfunction (also called ischaemia reperfusion injury)
- occurs within 72hrs
- treat with diuretics , protective ventilation or ECMO
- tends to be worse if higher RA pressures
Nb. acute rejection and ifx can look similar on CXR to the above
- 3days-1 years = acute rejection (peak 3 weeks)
- Infection anytime
- >3months (usually >1year) = chronic rejection
Pt with lung tx has CXR showing bilateral infiltrates 14 days after tx. What is most likely cause?
Acute rejection
- bilateral infiltrates on CXR and loss of lung function
- treat with IV methylpred +/- plasmaphoresis or ATG
- peak at 3 weeks but can occur 3days-1year
- may be asymptomatic
Nb. primary graft dysfunction (ischaemia-reperfusion injury) looks the same on CXR but happens <72hrs.
Nb2. Ifx can also look the same
Chronic rejection generally after 1 year (but can be after 3 months) and see declining lung function w/o other cause
Pt with lung tx has cough productive of green sputum, fevers and declining lung function. What is most likely cause and how should it be treated?
Likely infection
- treat with IV abx
- DON’T stop immunosuppression
Pt with lung tx has steadily falling lung function 18months after lung tx. No symptoms/signs of ifx. What is most likely cause?
Chronic rejection
- tends to occur >1year but can be 3 months
- declining lung function without another reason
- will do bronch and transbronchial biopsy
- treatment hard: can try increase immunosuppression, azithromycin or total lymphoid irradiation
- 50% will die
2 main phenotypes:
- bronchiolitis obliterans (obstructive spiro)
- fibrotic-like change - may be helped with pirfenidone
What is chronic lung rejection - phenotypes, timing, treatment?
2 main phenotypes:
- bronchiolitis obliterans (obstructive spiro)
- fibrotic-like change - may be helped with pirfenidone
