Transplant Flashcards
What is the 1 year survival of lung transplant ?
84%
What is the 5 year survival of lung transplant ?
55%
What are the non-urgent listing criteria for COPD pts for lung transplant ?
- FEV1<20% and DLCO <20% or homogenous distribution of emphysema
- Hx of hospitalizations for exacerbations associated with acute hypercapnia (pCO2 > 6.5kpa) and worsening hypoxia
- Pulmonary HTN or Cor Pulmonale
- BODE >7
What are the non-urgent listing criteria for ILD pts for lung transplant ?
Histiological and radiological diagnosis , plus:
- TLCO <40% predicted with clinical deterioration and/or fall in TLCO > 15% over 6 months
- Fall in FVC ≥ 10% over 6 months
- O2 desaturation < 88% on 6MWT
- Short rapid decline in sx pre diagnosis
What are the non-urgent listing criteria for CF / Bronchiectasis pts for lung transplant ?
-FEV1 < 30% predicted or FEV1 > 30% predicted but with rapid progressive deterioration (ie exacerbarion frequency , irreversible decline in FEV1)
- Hx of HDU/ICU admissions for exacerbation
- O2 dependent resp failure , hypercapnia or PH
- PTX in advanced disease
- Haemoptysis
- Young < 20 years patients with rapid deterioration
- Progressive increase in medical therapy to maintain survival including an increased frequency of the need for IV abx due to incr /worsening exacerbations
What are the non-urgent listing criteria for Pulmonary HTN pts for lung transplant ?
- WHO Class III/IV despite parenteral therapy for 3/12
- Worsening right heart failure with increased fluid retention despite optimal therapy
- Declining 6MWT <350m despite medical therapy
- Need for continuous IV inotropes support
- MAP >15mmHg and CI <2 on RHC despite optimal therapy (RHC must be within 3 months )
Who are the super urgent lung transplant patients ?
On VV ECMO or iLA
NB if deteriorates to point of needing IPPV will not be included
Need to be free from sepsis or other organ failure
What are the urgent listing criteria for COPD?
- worsening hypoxia (pO2 <7.5) despite 10L O2 on NIV and hypercapnia (>6.5)
- pH<7.3 despite optimal NIV
- refractory right heart failure despite all tx to support RV
What is the Urgent Lung Allocation ?
- Urgent patients suitable for transplant when survival without transplant is <90 days
- should be removed if patients via MDT not deemed to have appropriate survival post (ie 50% in 3-5 years)
Pts requiring re-transplant do not have access to ULAS
What are the urgent listing criteria for CF?
- worsening hypoxia (pO2 <7.5) and hypercapnia (pCO2 >6.5) despite 10L NIV
- worsening acidosis despite optimal NIV pH <7.3
- refractory right heart failure despite pharmacological tx
- massive haemoptysis despite bronchial embolisation
What are the urgent listing criteria for ILD?
- worsening hypoxia (pO2 <8) despite continuous O2 >10L
- Refractory right heart failure despite all pharmacological intervention
What are the urgent listing criteria for PH?
- worsening right heart failure with fluid retention despite optimal tx
- RAP >20mmHg and CI <2 despite IV treatment within 3 months
- Continuous inotropic support
What is the Super Urgent Lung Allocation Scheme?
Patients already known to lung transplant centre having been fully assessed that subsequently deteriorate requiring ECMO
Other suitable patient not already registered may be considered
** Re-transplant no access to SULAS
What are the absolute contraindications of Lung Transplant ?
- BMI > 35
- Solid Organ/Haematological malignancy within last 5 years excluding skin cancer
- Advanced organ dysfunction of another system
- Significant chest wall deformity
- Uncontrolled extra pulmonary manifestations of systemic disease that will present successful outocomes
- Substance abuse / addiction (Tobacco /EtOH /Narcotics) must be off 6/12
- Documented non adherence /non attendance
- Unstable mental health
- Absence of consistent or reliable social support
What are the relative contraindications of lung transplant?
- Age > 60 (suggested to be <65)
- BMI <17 or > 30
- Severely limited functional status with poor rehab potential
- Colonisation with burkholderia cepacia and M.Abscessus
- Chronic infection
- Severe symptomatic osteoporosis (>2SD less than predicted for patient age w or without low impact #)
- Mechanical ventilation
- Limited CAD without ventricular impairment - could have PCI
- Chronic renal impairment with eGFR <50
- Poorly controlled DM
- Other conditions causing end organ damage
- Regular corticosteroid dose >15mg/day
- V extensive pleural disease ; with or without previous surgery
- High burden of lung cavity with aspergilloma
- HIV /Hep B/Hep C
Outline retransplant
No access to ULAS or SULAS
Tx on NULAS need careful consideration as outcomes worse than for first , not to be done within 90 days of first
What are the early complications of lung transplant within first 96 hours
Primary Graft Dysfunction or Ischaemic Reperfusion Injury
- Characterised by lung injury (pulmonary infiltrates, hypoxaemia , alveolar damage or OP on biopsy) within first 72 hours after transplant
Tx : Diuresis, protective ventilation , ECMO
High mortality 40-60%
Outline Acute Cellular Rejection
- Results from all reactive T cells reacting to donor HLA and other antigens
- Occurs within 3/12 ; affects 60% in first year
- Can be asymptomatic can be associated with malaise, fever , cough
- CXR can show infiltrates (can be normal)
- Diagnosis: confirm with TBB
-Tx : IV methylpred
Post transplant a patient has a biphasic flow volume loop- what has happened ?
Anastomotic stenosis most common
- Weeks to months after
- Suggested by wheeze / recurrent pneumonia /suboptimal lung function
- Tx : Balloon dilatation or stent placement
Complete dehiscence of bronchial anastamoses is rare and needs urgent surgery; can be partial
What are the bacterial infections post lung transplant ?
May occur early (first month) or late (assoc w BOS)
Gram -ve particularly pseudomonas
What do we treat CMV seronegative recipients from CMV seropositive donors with?
Valganciclovir
What effect does Aspergillus have post transplant ?
Usually 2/12 after
Can affect airways / fresh bronchial anastamoses
Frequent colonises airways but not always clinically apparent until develops mucositis
What percentage of transplant patients develop Diabetes ?
40%
What are the late complications in lung transplant ?
CLAD: Chronic Lung Allograft Dysfunction
— Bronchiolitis Obliterans Syndrome
— Restrictive Allograft Syndrome
Outline Bronchiolitis Obliterans Syndrome in lung transplant patients
- delayed allograft dysfunction characterised by persistent FEV1 decline in absence of other causes
- Clinical dx as histologically difficult ; fall of FEV1 to <80% peak post transplant values
- HRCT shows air trapping
- Pseudomonas colonization is common
- Tx: modified immunosuppression ; investigate for infection
- Prognosis poor , mortality 40% in 2 years
Outline restrictive allograft syndrome in Lung transplant patients
- Restrictive spirometry and allograft upper lobe fibrosis (lower lobe or eosinophilia assoc with worse prognosis)
- Much less common than BOS but worse prognosis
What malignancies are transplant patients at risk of ?
Lymphoma (and other EBV related post transplant lymphoproliferative disorder)
Most appear in first year and lung allograft most common site of involvement with pulmonary nodules and lymphadenopathy
Lymphoma after first year more common disseminated or intra abdominal and patients should be transferred back to transplant centre
Treatment is usually reducing immunosuppression plus anti virals and for Rituximab
What are the ddx for lung nodule post transplant ?
PTLD
Infection (Pseudomonas, Nocardia , Aspergillus)
Disease recurrence
Lung Cancer
