Lung Transplant

Question 1

Transplant Criteria: Restrictive Lung Disease/ILD

Answer 1

Mainly for IPF and fibrotic NSIP.

1. FVC <60% or 10% drop in 6 months
2. DLCO <40% OR 15% drop in 6mo
3. 6MWT <250m or decline by 50m in 6 mos
4. 6MWT desat to <89%
5. Longterm O2 therapy
6. Hosp for worse symptoms
7. Fibrosis score >2

Question 2

COPD

Answer 2

refer BODE >5
List for Trx BODE 7-10
OR
Hosp, acute PaCO2 >50, PH despite O2 therapy, FEV1 <20% AND DLCO <20% or homogeneous emphysema

Question 3

Cystic Fibrosis

Answer 3

FEV1 <30% or rapid decline

• Exac requiring ICU
• Increased frequency of exac
• refractory/recurrent PTX
• recurrent hemoptysis
• O2 dependent Resp failure
• Hypercapnia PaCO2 >50%
• PH

Question 4

PAH

Answer 4

1. Functional Class III or IV despite maximal medical therapy (IV epo)
2. Cardiac index <2
3. Mean RAP >15mmHg
4. Low (<350m) or declining 6MWT

Question 5

Cancer prohibits Transplant when:

Answer 5

Malignancy within last 2 years (except non-melanoma skin cancer), extended to 5 years for some cancers (melanoma, sarcoma, hematologic, breast, bladder, kidney)

Question 6

Maintenance Immunosuppression after Transplant:

Answer 6

Calcineurin inhib (cyclosporine or tacro) + antimetabolite (MMF, AZT) + steroid

Question 7

Sirolimus postop associated with:

Answer 7

Poor wound healing, wound dehiscence (up to 1 year)

Question 8

Early Post-transplant complications:

Answer 8

PGD (ischemia/reperfusion)
Airway/anastamotic dehiscence or stenosis
Infection

Question 9

Leading cause of early death after lung transplant:

Answer 9

PGD (ischemia/reperfusion) like ARDS

Question 10

Immunosuppression agents that can cause thrombotic microangiopathy

Answer 10

calcineurin inhibitors (tacrolimus and cyclosporine)

Question 11

Risk factors for primary graft dysfunction

Answer 11

female donor, PAH, time on bypass (?)

Question 12

Acute (cellular) Rejection

Answer 12

Usually occurs within 3mo

-perivascular inflammation and lymphocytic bronchiolitis

Question 13

Chronic Rejection/BOS

Answer 13

obliterative bronchiolitis

-does not show up well on tbbx

Question 14

After the first year, #1 cause of death post transplant is:

Answer 14

BOS

Question 15

Antibody mediated rejection

Answer 15

Hyperacute if within 24h
Less well-defined in lung transplant than other types of transplant
-new Ab to donor HLA
-ALI with complement deposition and neutrophilic capillaritis

Question 16

Infection:

-timing of OI

Answer 16

• early HAP

- at risk for OI within first 6 months

Question 17

PTLD:
cell type
assoc with virus
peak incidence
treatment

Answer 17

• most are b-cell lymphoma
• EBV
• peak incidence withing first year
• reduce immunosuppression

Question 18

Mortality:
Early <30d
30d-1yr
Late >1 yr

Answer 18

• PGD
• infection
• BOS