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Lung Transplant Flashcards

1
Q

Fill in the blank for the indications of the following for transplant in COPD and A1AT:

BODE score > ___

or 1 of the following:

____ with acute PaCO2 >50mmHg
___ and/or cor pulmonale despite oxygen use
___ <20% and either DLCO <20% or homogenous distribution of emphysema

A

BODE score > 7

or 1 of the following:

Hosptialization for exacerbation with acute PaCO2 >50mmHg
Pulmonary HTN and/or cor pulmonale despite oxygen use
FEV1<20% and either DLCO <20% or homogenous distribution of emphysema

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2
Q

Fill in the blank for the indications of the following for transplant in CF:

  • ___<30% or rapid decline
  • Exacerbation requiring __ stay
  • Increased frequency of ___
  • Refractory or recurrent ___
  • Recurrent ___ not controlled with embolization
  • Oxygen-dependent respiratory failure or PaO2 < __mmHg on room air
  • Hypercapnia with PaCO2 > __mmHg
  • ___ HTN
A 
-FEV1<30% or rapid decline
Exacerbation requiring ICU stay
-Increased frequency of exacerbations
-Refractory or recurrent pneumothorax
-Recurrent hemoptysis not controlled with embolization
-Oxygen-dependent respiratory failure or PaO2 < 55mmHg on room air
-Hypercapnia with PaCO2 > 50mmHg
-Pulmonary HTN
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3
Q

Fill in the blank for the indications of the following for transplant in IPF:

___ desaturation (SpO2 <89%)
Long term ___ therapy
>__% decline in FVC over 6 months
DLCO 2)

A

6MWT desaturation (SpO2 <89%)

Long term oxygen therapy
>10% decline in FVC over 6 months

DLCO <39%

Honeycoming on HRCT (fibrosis score >2)

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4
Q

Fill in the blank for the indications of the following for transplant in IPAH:

Functional class __ or __ despite maximal therapy (IV epoprostenol or equivalent)
Cardiac index < __ L/min/m3
Mean __ >15mmHg
Low (

A

Functional class III or IV despite maximal therapy (IV epoprostenol or equivalent)

Cardiac index < 2L/min/m3

Mean RAP >15mmHg

Low (<350m) or declining 6MWT

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5
Q

Fill in the blank for the following RELATIVE contraindications to lung transplant:

  • Age > _
  • Critical or unstable clinical condition
  • Severely limited __ __ or poor rehab potential
  • Chronic colonization of highly resistant or virulent __
  • Obesity (BMI > __) or poor nutritional status
  • Severe or symptomatic osteoporosis
  • Mechanical __
  • Extrapulmonary comorbidities without significant end-organ damage
A
  • Age > 65
  • Critical or unstable clinical condition
  • Severely limited functional status or poor rehab potential
  • Chronic colonization of highly resistant or virulent oragnisms (B. cepacia, M. abscessus, pan-resistant P. aeruginosa)
  • Obesity (BMI > 30) or poor nutritional status
  • Severe or symptomatic osteoporosis
  • Mechanical ventilation
  • Extrapulmonary comorbidities without significant end-organ damage
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6
Q

Fill in the blank for the following ABSOLUTE contraindications to lung transplant:

  • Untreated advanced dysfunction of another __
  • Untreatable chronic extrapulmonary __
  • __ in the last 2 years
  • ___ use in the last 6 months
  • Significant chest wall or spinal deformity
  • Absence of reliable __ support system
  • History of __ or untreatable psychiatric illness associated with inability to comply with treatment.
A
  • Untreated advanced dysfunction of another organ (cirrhosis, CHF, ESRD)
  • Untreatable chronic extrapulmonary infections
  • Malignancy in the last 2 years
  • Tobacco use use in the last 6 months
  • Significant chest wall or spinal deformity
  • Absence of reliable social support system
  • History of noncompliance or untreatable psychiatric illness associated with inability to comply with treatment.
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7
Q

True/False: suppurative lung diseases such as CF and bronchiectasis always require bilateral lung transplant (BLT) rather than single lung transplant (SLT)

A

TRUE

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8
Q

True/False: BLT is usually performed in PAH

A

TRUE

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9
Q 
Colonization with what
organism is a relative
contraindication to lung
transplantation in patients
with CF?
A

Burkholderia cenocepacia

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10
Q

What are the major

benefits of SLT vs. BLT?

A 
SLT: shorter
ischemia/operative time,
possibly shorter waiting list
time, and more efficient
use of limited organ supply.
BLT: improved long-term
outcome and life
expectancy.
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11
Q

Labs to get for transplant workup?

A

Renal and liver function
Infectious serologies (HIV, viral hepatitis, CMV, EBV)
HLA typing
Sputum cultures

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12
Q

Imaging to get for transplant workup?

A

PFTs
6MWT
Cardiac eval (EKG, TTE, stress, and coronary angiography for high risk patietns)
CT chest for nodules
Eval for GETD and gastroparesis in high risk patients

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13
Q

Fill in the blank for the following donor selection criteria:

  • Age __mmHg on 5cmH2O PEEP
  • No active ___
  • No history of __
  • Minimal or no chest trauma
A
  • Age <55-70
  • No significant pulmonary disease or pulmonary infection
  • Limited smoking history
  • Clear lung fields on CXR, minimal or no evidence of aspiration
  • PaO2/FiO2 > 300mmHg on 5cmH2O PEEP
  • No active infection, including HIV or hepatitis
  • No history of malignancy
  • Minimal or no chest trauma
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14
Q

Tell me the immunosupressant given the following mechanism and adverse effects:

Mechanism: polyclonal antibody against T and B cells

Adverse effects: leukopenia, thrombocytopenia, serum sickness, infusion reactions (CRS, anaphylaxis)

A

ATG/ALG

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15
Q

Tell me the immunosupressant given the following mechanism and adverse effects:

Mechanism: Antagonize IL-2-induced T cell proliferation

Adverse effects: relatively well tolerated with rate infusion reactions

A

IL-2 receptor antagonists

basiliximab/daclizumab

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16
Q

Tell me the immunosupressant given the following mechanism and adverse effects:

Mechanism: decreased T-cell activation and proliferation via inhibition of calcineurin-dependent induction of IL-2 expression

Adverse effects: nephrotoxic, neurotoxic, TMA, HLD, HTN, hypomagnesemia, hyperkalemia, GI disturbance, gingival hyperplasia, hypertrichosis

A

Cyclosporine

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17
Q

Tell me the immunosupressant given the following mechanism and adverse effects:

Mechanism: decreased T-cell activation and proliferation via inhibition of calcineurin-dependent induction of IL-2 expression

Adverse effects: nephrotoxic, neurotoxic, TMA, HLD, HTN, hypomagnesemia, hyperkalemia, GI disturbance, hyperglycemia

A

Tacrolimus

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18
Q

Tell me the immunosupressant given the following mechanism and adverse effects:

Mechanism: antagonizes purine metabolism and DNA synthesis

Adverse effects: pancytopenia, hepatotoxicity, pancreatitis

A

Azathioprine

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19
Q

Tell me the immunosupressant given the following mechanism and adverse effects:

Mechanism: inhibits the de novo pathway of purine synthesis

Adverse effects: pancytopenia, diarrhea, abdominal pain, nausea

A

Mycophenolate mofetil

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20
Q

Tell me the immunosupressant given the following mechanism and adverse effects:

Mechanism: decreases inflammation through multiple mechanisms

Adverse effects: hyperglycemia, weight gain, hyperlipidemia, osteoporosis, myopathy, insomnia, cataracts

A

Prednisone

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21
Q

Tell me the immunosupressant given the following mechanism and adverse effects:

Mechanism: decreases cell cycle progression via inhibition of mTOR-dependent cyclin D1 synthesis

Adverse effects: pancytopenia, anastomotic dehiscence and poor wound healing, interstitial pneumonitis, HLD, arthralgia, LE edema, acne, stomatitis

22
Q

This is the development of radiographic opacitis and hypoxemia with decreased lung compliance and increased pulmonary vascular resistance in the first 72 hours after transplantation

A

Primary Graft Dysfunction (PGD)

23
Q

What are the PaO2/FiO2 in each grade (0-3) in PGD?

A

0 - >300
1 - > 300 (with pulmonary edema on CXR)
2 - 200-300
3 - <200

24
Q 
Which immunosuppressive
agent is most likely to
cause poor wound healing
and anastomotic
dehiscence?
25
Which immunosuppressive agents are known to cause thrombotic microangiopathy (TMA)?
Tacrolimus and cyclosporine (calcineurin inhibitors). Neurotoxicity is also common with both agents.
26
Which immunosuppressive agent can cause pancreatitis and cholestatic hepatitis?
Azathioprine
27
What are the treatment for PGD?
Supportive care and diuresis Can also try protective ventilator strategies, iNO, ECMO
28
What infections (fungal or bacterial) can happen at anastomotic sites?
Fungal- aspergillus and candida Bacterial- staph and pseudomonas
29
Treatment of anastomotic strictures?
Balloon dilation, stent placement, "laser" therapy, and surgery
30
Treatment of acute rejection of lung transplant?
Methylpred 10-15 mg/kg/day x3 days followed by pred 0.5-1mg/kg/day with taper over several weeks
31
What are the findings of each (grade 0-4) in acute cellular A grade rejection?
Grade 0 - normal lung Grade 1 - small amount of mononuclear perivascular infiltrates Grade 2 - more frequent mononuclear perivascular infiltrates +/- eosinophils Grade 3 - dense mononuclear perivascular infiltrates with extension into the interstitium +/- endothealitis, eosinophils, and neutrophils Grade 4 - diffuse perivascular, interstitial, and air space mononuclear infiltrates with lung injury annd endothelialitiis +/- neutrophils
32
What are the findings of each (grade 0, 1R, 2R, X) in acute cellular B grade rejection?
Grade 0 - no airway inflammation Grade 1R- scattered mononuclear submucosal and peribronchiolar infiltrates with epithelial infiltrates Grade 2R- extensive mononuclear submucosal and peribronchiolar infiltrates with epithelial infiltrates and damage Grade X - ungradable, no bronchiolar tissue available
33
What are the findings of each (grade 0 and 1) in chronic airway rejection?
Grade 0 - normal airways | Grade 1/present - obliterative bronchiolitis with dense, eosinophilic, hyaline fibrosis
34
What are the findings in chronic vascular rejection?
Accelerated vascular sclerosis of the grade with fibrointimal thickening of pulmonary arteries and veins
35
What is the most important risk factor for chronic rejection?
Episodes of acute rejection
36
This is the presentation of cough and dyspnea with hyperinflation, air trapping, and bronchiectasis after infection, medication noncompliance, or organizing pneumonia in a transplant
Chronic rejection/bronchiolitis obliterans syndrome (BOS)
37
Staging of BOS based on PFT results?
``` 0 - FEV1 >90% and FEF25-75%>75% 0-p - FEV1 81-90% and/or FEF 25-75% <75% 1 - FEV1 66-80% 2 - FEV1 51-65% 3 - FEV1 <50% ``` (FYI the FEV1 values are compared to the baseline values)
38
True/False: there's no established treatment for BOS, but most people try altering immunosupressants, steroids, extracorporeal photophoresis, azitho, and extrapulmonary support
TRUE
39
This is the graft dysfunction with new or increasing antibodies to donor HLA or other graft epitopes and histologic findings of acute lung injury with complement deposition and neutrophilic capillaritis
Antibody mediated rejection (AMR)
40
Treatment of AMR?
High dose steroids, IVIG, plasmapharesis, anti-CD20 antibodies (rituximab), and bortezzomib
41
What is the leading cause of posttransplant mortality after the first year?
BOS
42
True or False. BOS can be diagnosed with transbronchial biopsies.
``` False. Unlike AR, transbronchial biopsy has low sensitivity for diagnosing BOS and is used primarily to exclude other diagnoses. ```
43
How is the diagnosis of CMV pneumonia made?
Bronch with transbronchial biopsy and BAL with large CMV PCR findings of intranucelar inclusions (owl's eyes)
44
As fungal infections carry a high mortality post-transplant, which medications are used in the treatment of invasive asperegillus?
Voriconazole
45
What can happen to the levels of immunosupressants with the use of azoles?
Increase cyclosporine and tacro levels
46
What is the most important risk factor for CMV infection in posttransplant patients?
Donor seropositivity and recipient seronegativity for CMV
47
This is the development of malignancies (mostly EBV lymphoma) after transplant
PTLD
48
Treatment of PTLD?
REDUCTION in immunosuppression Other- rituximab, antivirual therapy, chemotherapy, radiation, adaptive immunotherapy, or surgical intervention
49
Most common cancer to develop in anyone who gets a transplant?
Skin cancer
50
Tell me the following survival outcomes for lung transplants: ``` 3 months 1 year 3 years 5 years 10 years ```
``` 3 months - 88% 1 year - 79% 3 years - 64% 5 years - 54% 10 years - 30% ```

Pulmonary Review (14 decks)

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