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Lung transplant Flashcards

1
Q

What is the median survival for a patient who has undergone a double lung transplant?

A

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

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2
Q

What is the median survival for a patient who has undergone a single lung transplant?

A

4.8 years

7.8 for double

Nb. increases to 6.5 and 10.2 if survive first year

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3
Q

What are the indications for lung transplant in patient with COPD?

A

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
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4
Q

Does lung transplant increase survival in patients with COPD?

A

Controversial - may have survival benefit in those with lower FEV1 and higher PA pressures

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5
Q

What are lung transplant criteria for pt with IPF?

A

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

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6
Q

What are the lung transplant criteria for pt with CF?

A

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

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7
Q

What are lung transplant criteria for pt with PH?

A

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

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8
Q

What are the most common indications for lung transplant?

A

COPD & IPF

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9
Q

What are the contraindications for lung transplant?

A

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

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10
Q

What are the absolute contraindications for lung tx?

A

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

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11
Q

What are the relative contraindications for lung transplant?

A

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

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12
Q

What are the superurgent criteria for lung tx?

A

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

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13
Q

What are the urgent lung transplant criteria for pt with CF???

A
  • 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

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14
Q

What are the urgent lung transplant criteria for pt with COPD?

A

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

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15
Q

Is HLA matching required for lung transplant?

A

No - only blood group

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16
Q

What immunosuppression is used for lung transplant?

A

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)

17
Q

What are common SEs of calcineurin inhibitors?

A

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)

18
Q

What is hyperacute rejection in the context of lung tx?

A

Mismatched blood group - should never happen

19
Q

Pt with lung tx has CXR showing bilateral infiltrates 48hrs after tx. What is most likely cause?

A

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

20
Q

Pt with lung tx has CXR showing bilateral infiltrates 14 days after tx. What is most likely cause?

A

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

21
Q

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?

A

Likely infection
- treat with IV abx
- DON’T stop immunosuppression

22
Q

Pt with lung tx has steadily falling lung function 18months after lung tx. No symptoms/signs of ifx. What is most likely cause?

A

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

23
Q

What is chronic lung rejection - phenotypes, timing, treatment?

A

2 main phenotypes:
- bronchiolitis obliterans (obstructive spiro)
- fibrotic-like change - may be helped with pirfenidone

Revision (17 decks)

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