Lung Transplantation
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Transcript of Lung Transplantation
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Lung Transplantation
Alper Toker, M.D.Istanbul University
Istanbul Medical SchoolDepartment of Thoracic Surgery
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Lung transplantations region/year
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Lung transplantation in the world
Report of ISHLT year 2003 : • 931 bilateral lung transplantation• 772 single lung transplantation• 74 heart-lung transplantation
3 years survival• 1994-1998: % 55.7• 2000-2003: % 63.3
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Survival after lung transplantaion (1983-2000)
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Years Post Transplantation
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Bilateral lung tx
Single lung tx
All kind of lung tx
Bilateral 1/2-life = 4.5 YılSingle: 1/2-life = 3.6 YılAll Transplantations: 1/2-life = 3.8 Yıl
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Indications in years
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Myopathy
19821983198419851986198719881989199019911992199319941995
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Cystic Fibrozis IPF Emphysema A1A PPH
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Transplantation and Turkey until January 2004 Karakayalı H and Haberal M. Transplant Proc, 2005
In 28 centers• 6686 renal• 696 liver• 13278 cornea• 2883 bone marrow• 132 Heart• 185 Cardiac Valve• 15 Pancreas
» Coordinating organ transplantation in Turkey:effects of national coordination center. Tokalak I, Prog Transplant 2005
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Outmoded attitudes toward organ donation among Turkish Health Care professionals
Topbas M,Transplant Proc, 2005
• Residents, nurses and interns• Rate of organ donation % 2.2
• No idea (%28.7)• Organ trading (%22.1)• Religious reasons (% 21.6)
• % 59 of the attendes would ask for an organ for himself if he needs.• % 57.6 of the attendes would not donate his realtive’s organ• This population should be the leading people in organ donation.
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Solution to organ shortage• The solution of Organ shortage in Turkey: Trained
transplant coordinators. Yücetin L, Transplant Proc 2004– 14 hospitals have tx coordinators – 88 % of donors are from these 14 hospitals– 65 % of donors are from 2 cities– There should be 1675 donors – In year 2002 there were 100 donors– 200 coordinators
• The role of the transplant coordinator on tissue donation in Turkey. Yücetin L. Transplant Proc, 2004
– 50 different tissues from a single donor– No coordinator for tissue transplantation– Skin, tendon, valve, cornea and bone
• How to improve organ donation in Mesot Countries Shaheen FA, Ann Transplant 2004
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Middle East Society for organ transplantation (MESOT) Transplant Registry, Masri MA ve ark. Exp. Clin Transplant, 2004
• 1986 Muslim theologist Al Aloma declared that donation from a cadaver is allowed (Amman Declaration)
• Transplantaion begin in Mesot Area except Egypt• The rate of organ donation card in Saudia is 10%• 5088 renal transplant per year• Liver, heart, pancreas and lung transplantion.
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Changing indications in donors
Marginal Donor Low PaO2: (225 – 300 mmHg)
High PaO2: 300 mmHg and over
Age over 50 years
Hbs Ag
Non-heart beating (9 – 12 hours ischemia)
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Indications of lung transplantation
• Obstructive Lung diseases– Emphsema– Alfa 1 antitripsin deficiency– Obliterative bronchiolitis
• Suppurative lung diseases– Cystic Fibrozis – Bronchiectasis
• Fibrotic lung diseases– IPF– Sarcoidozis– Collagen vascular diseases– Alveoler microlithiasis– Lymphangioleiomyomitosis
• Pulmonary hypertension– Primary pulmonary hypertansion– Eisenmenger Syndrom– Thromboembolic pulmonary hypertansion– Pulmoner veno occlusive diseases
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Indications
• Emphysema / Alpha-1 AT deficiency FEV1< 25% predicted
PaCO2 > 55 mmHg+/- cor pulmonale
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Indications
• Cystic Fibrozis / BronchiectasisFEV1 < 30 % predictedIf FEV1 > 30% predicted, Decline in
FEV1 or increased number of hospitalistions and periods or
• PaCO2 > 50 mmHg
• PaO2 < 55 mmHg
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Indications
• Pulmonary fibrozisUnsuccessful immunosuppressive therapy
• VC (TLC) 60-70% predicted• Diffusing Capacity of Lung for Carbon Monoxide• (DLCO) < 50% predicted• Early acceptance for the tx programme
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Indications
• Primary Pulmonary Hypertension– 2 years survival %60 and median time 2.8 years– NYHA Class 1 ve 2; median survival 6 years
NYHA III or IVCI < 2 L/min/m2RA pressure > 15 mmHgMean PA pressure >55 mmHgIncreased Bilirubin
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Indications
• Pulmonary hypertension and congenital heart diseases
Eisenmenger Physiology(right to left shunt)
• Timing is difficult.
• Symptomatology.• Syncope, hemoptyzis, chest pain, arryhtmia,
cyanosis, polycythemia.
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Contrindications
• Multisystem diseases• Active infection• Hepatic and renal disease (creatine clearance
50 mg/ml/min)• >20mg prednisolone/daily• Malignancy (in 2 to 5 years)
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Contrindications
• Obesity or Cachexia: 20% of ideal weight • Drug abuse or alcoholism• Severe psychiatric disease• Smoking• CAD or valve disease
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Contrindications
• Severe chest wall deformity• Previous thoracic surgery*• Hepatitis B or C infection
• Symptomatic osteoporozis
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2 single lung transplantations vs. 1 bilateral lung transplantation ?
Anyanwu AC et al. Does splitting the lung block into 2 SL grafts equate to doubling the societal benefit from bilateral lung donors?… Transplant Int 2000;13:S201-2.
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Surgical procedures
• Single lung transplantation
– Less morbidity, unilateral thoracotomy – Problems (Hyperinflation /infection/ cancer
risk of the native lung)
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Hyperventilation of the native lung
• Does donor lung cause a detoriation in the functions of native lung ?
Weill D et al. Acute native lung hyperinflation is not associated with poor outcomes after single lung transplant for emphysema. J Heart & Lung Transplant 1999;18:1080-7
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Surgical procedures
• Bilateral lung transplantations• Bilateral sequential lung Tx• Bilateral lung Tx
– Cystic Fibrozis,– Bronchiectasis,– PPH,– COPD.
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Surgical Procedures
• Heart Lung Transplantation; En-bloc– PPH, – Congenital heart disease
Survival is short, waiting list is long
( Avoidance from Heart – Lung transplantation in PPH)
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Single lung vs Double Lung (Emphysema)
• Short waiting list• Simple operation
• Long waiting list• Risky and long
operation • Better survival
Meyer et al. Single Vs Bilateral, Sequential Lung Txp for End-Stage Emphysema… J Heart & Lung Txp 2001;20:935-941
Bando et al. Comparison of outcomes after single & bilateral lung transplantation in obstructive lung disease. J of Heart & Lung Txp 1995;14:692-8
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Immunosuppresion (induction)
• Azathioprine 3-4 mg/kg pre-op
• Methylprednisone 500 mg with first lung transplatation, 125 mg iv x 3 for 24 hours
• Rabbit anti-thymocyte globulin (RATG) 2 mg/kg x 3 post-op
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Immunosuppresion (maintanence)
• Prednisolone (From 0.6 mg/kg to 0.2 mg/kg after 2nd day)
• Cyclosporine A: 3-5 mg/kg acc. to serum level
• Azathioprine 2-3 mg/kg
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Complications
• EarlyTheatre (hemorrhage )Ischemia/reperfusion injuryHyperacute rejection (HLA abs)Anastomosis problems
Acute rejection (+/- changes in PFT)
Infection (bacterial, viral, fungal)
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Ischemia reperfusion injury
Primary graft disfonction (PGD)• Leading cause of early posttransplant mortality• UNOS/ISHLT PGD % 10.2• Mortality % 42• No PGD rate of mortality is %6
Risk factors• Ischemic time more than 330 minutes• PaO2/FiO2 in posttransplant 6th hour • Recipients need for inotropics• PaO2/FiO2 of donor• Age of Donor
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Prognostic factors in PGD
• PaO2/FiO2 posttransplant 6th hour• Increasing CVP in first posttransplant 3 days
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Acute rejection
• Bronchoscopic follow ups (2,4,8, 12 weeks & 6 and 12 months)
• Methylprednisone bolus 500-1000 mg X 3
• Rebronchoscopy 2-3 weeks later
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Infectious complications
• Bacterial, viral, fungal• >50% bacterial, 10-35 % within first two weeks• Cultures of donor lung• If recipient was a cystic fibrozis patient treatment
acc. to last culture.
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Complications
• Early • Side effects of the medication• (Hypertension, Renal failure, tremor, hair growth,
bone marrow suppression, hypercholesterolemia, diabetes, osteoporosis)
• Delayed gastric emptying, aspiration.
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Complications
Late– Chronic rejection / obliterative bronchiolitis (FEV1,
FEF25-75, FEF50, Slope of N2 washout)
– Infection (generally Pseudomonas aeruginosa)
– Post-transplant lymphoma– Persistant side effects
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Results after transplantation
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1 Year (N = 4,188) 3 Years (N = 2,486) 5 Years (N = 1,368)
Retired
Not Working
Working Part Time
Working Full Time