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Pulmonary Review > Lung Transplant > Flashcards

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

A

Sirolimus

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?
A

Sirolimus

25
Q

Which immunosuppressive
agents are known to cause
thrombotic microangiopathy
(TMA)?

A

Tacrolimus and cyclosporine
(calcineurin inhibitors).
Neurotoxicity is also common
with both agents.

26
Q

Which immunosuppressive
agent can cause
pancreatitis and cholestatic
hepatitis?

A

Azathioprine

27
Q

What are the treatment for PGD?

A

Supportive care and diuresis

Can also try protective ventilator strategies, iNO, ECMO

28
Q

What infections (fungal or bacterial) can happen at anastomotic sites?

A

Fungal- aspergillus and candida

Bacterial- staph and pseudomonas

29
Q

Treatment of anastomotic strictures?

A

Balloon dilation, stent placement, “laser” therapy, and surgery

30
Q

Treatment of acute rejection of lung transplant?

A

Methylpred 10-15 mg/kg/day x3 days followed by pred 0.5-1mg/kg/day with taper over several weeks

31
Q

What are the findings of each (grade 0-4) in acute cellular A grade rejection?

A

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
Q

What are the findings of each (grade 0, 1R, 2R, X) in acute cellular B grade rejection?

A

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
Q

What are the findings of each (grade 0 and 1) in chronic airway rejection?

A

Grade 0 - normal airways

Grade 1/present - obliterative bronchiolitis with dense, eosinophilic, hyaline fibrosis

34
Q

What are the findings in chronic vascular rejection?

A

Accelerated vascular sclerosis of the grade with fibrointimal thickening of pulmonary arteries and veins

35
Q

What is the most important risk factor for chronic rejection?

A

Episodes of acute rejection

36
Q

This is the presentation of cough and dyspnea with hyperinflation, air trapping, and bronchiectasis after infection, medication noncompliance, or organizing pneumonia in a transplant

A

Chronic rejection/bronchiolitis obliterans syndrome (BOS)

37
Q

Staging of BOS based on PFT results?

A 
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
Q

True/False: there’s no established treatment for BOS, but most people try altering immunosupressants, steroids, extracorporeal photophoresis, azitho, and extrapulmonary support

A

TRUE

39
Q

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

A

Antibody mediated rejection (AMR)

40
Q

Treatment of AMR?

A

High dose steroids, IVIG, plasmapharesis, anti-CD20 antibodies (rituximab), and bortezzomib

41
Q

What is the leading cause
of posttransplant mortality
after the first year?

A

BOS

42
Q

True or False. BOS can be
diagnosed with
transbronchial biopsies.

A 
False. Unlike AR,
transbronchial biopsy has
low sensitivity for
diagnosing BOS and is
used primarily to exclude
other diagnoses.
43
Q

How is the diagnosis of CMV pneumonia made?

A

Bronch with transbronchial biopsy and BAL with large CMV PCR findings of intranucelar inclusions (owl’s eyes)

44
Q

As fungal infections carry a high mortality post-transplant, which medications are used in the treatment of invasive asperegillus?

A

Voriconazole

45
Q

What can happen to the levels of immunosupressants with the use of azoles?

A

Increase cyclosporine and tacro levels

46
Q

What is the most important
risk factor for CMV
infection in posttransplant
patients?

A

Donor seropositivity and
recipient seronegativity for
CMV

47
Q

This is the development of malignancies (mostly EBV lymphoma) after transplant

A

PTLD

48
Q

Treatment of PTLD?

A

REDUCTION in immunosuppression

Other- rituximab, antivirual therapy, chemotherapy, radiation, adaptive immunotherapy, or surgical intervention

49
Q

Most common cancer to develop in anyone who gets a transplant?

A

Skin cancer

50
Q

Tell me the following survival outcomes for lung transplants:

3 months
1 year
3 years
5 years
10 years
A 
3 months - 88%
1 year - 79%
3 years - 64%
5 years - 54%
10 years - 30%

Pulmonary Review (14 decks)

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