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Lung T Ransplantation Lung t ransplantation 9 Jonathan E Spahr 1 and Keith C Meyer 2 1 Children ’ s Hospital of Pittsburgh and the University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA 2 University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA Allotransplantation of the human lung was fi rst per- prevent them have extended survival and provided formed in 1963 by Dr James Hardy at the University most recipients with an improved quality of life after of Mississippi. It did not become successful enough lung transplantation. to achieve acceptance as a treatment for end - stage This chapter focuses on the three main aspects of lung disease (ESLD) until the mid - 1980s to the early optimizing the outcome of lung transplantation: fi rst, 1990s when improved surgical techniques, advances patient selection and appropriate timing and criteria in organ preservation, and the development and clini- for lung transplantation is reviewed; the focus then cal implementation of novel immunosuppressive turns to the technical aspects of the procedure; fi nally, drugs allowed long - term survival of lung allograft attention focuses on perioperative and postoperative recipients. Lung transplantation has evolved consid- complications and strategies to prevent or treat such erably over the past two decades and is now a defi ni- complications. tive treatment for ESLDs that do not respond to other therapeutic interventions. As lung transplantation has become accepted as a life - prolonging therapy for Selection of p atients for ESLD and performed at various centers world - wide, l ung t ransplantation many complications have been identifi ed, and methods Indications and c ontraindications for monitoring and treating those complications have arisen. Despite considerable progress in preventing Indications for lung transplantation include the broad and treating complications, only half of recipients categories of obstructive, restrictive, suppurative, and survive more than 5 years after receiving a lung trans- vascular pulmonary diseases. Older adults undergo plant. The risks and benefi ts of lung transplantation transplantation much more frequently for chronic must be carefully weighed for each patient. In addi- obstructive pulmonary disease (COPD) and intersti- tion, the timing of the procedure is of critical impor- tial lung disease (ILD) than children and young adults, tance. Thus, a great deal of attention has been focused who undergo lung transplantation predominantly for on appropriate referral criteria and timing for this suppurative lung diseases, of which cystic fi brosis procedure in order to maximize its benefi t. (CF) is the most common. Improvements in surgical technique and immunosup- The task of determining eligibility for lung trans- pressive regimens combined with a growing aware- plantation should be the responsibility of a multidis- ness of common complications and the measures to ciplinary team that evaluates both the physiologic and psychosocial characteristics of individuals referred for transplantation. This team typically consists of physi- Primer on Transplantation, 3rd edition. cians (medical and surgical), nurses, pharmacists, Edited by Donald Hricik. © 2011 American Society of mental health specialists, and social workers. Patients Transplantation. and families should be informed of the rigors inherent 205 CHAPTER 9 in undergoing lung transplantation. Candidates for (SLT) and 60 years for bilateral lung transplantation lung transplantation must have the ability to deal (BLT). At the other end of the age spectrum, children with these challenges physically, psychologically, and are limited by the size of their thorax and the size of fi nancially. available donor lungs. In 1998, the American Thoracic Society (ATS) and Of particular importance in deciding whether a the European Respiratory Society (ERS) developed a patient with ESLD is a candidate for lung transplanta- consensus statement for the selection of candidates tion is the status of native lung function. As lung for lung transplantation. This statement, updated in transplantation candidates generally wait an average 2006, considers both general and disease - specifi c of 18 – 24 months before they can be transplanted, the factors, which include age, expected survival without referring physician is charged with the diffi cult task lung transplantation, and quality of life. In general, of predicting 2 - year mortality for their patients with most transplant centers would agree that the upper ESLD so that the effectiveness of this potentially life - age limit is 65 years for single lung transplantation prolonging procedure can be optimized. Table 9.1 Table 9.1 Indications for disease - specifi c patient referral and transplantation Recipient indication Referral Transplantation Obstructive lung • BODE index > 5 (BODE is a composite Patients with a BODE index of 7 – 10 or at least one disease score based on BMI, FEV1 , dyspnea of: index, and exercise capacity) • COPD • history of hospitalization for exacerbation • Criteria used before the creation of the associated with acute hypercapnia • Obliterative/ BODE index: ( P CO > 50 mmHg) constrictive 2 bronchiolitis • Post - bronchodilator FEV1 < 25% of • pulmonary hypertension or cor pulmonale (or predicted normal value both) despite supplemental oxygen therapy • P aCO2 > 7.3 kPa (55 mmHg) • FEV1 < 20% predicted and either D LCO < 20% predicted or homogeneous distribution of • Associated pulmonary arterial emphysema hypertension/cor pulmonale Pulmonary fi brosis Histologic or radiologic evidence of UIP IPF or fi brotic NSIP: irrespective of VC • IPF D LCO < 39% predicted (IPF) or < 35% (fi brotic Histologic evidence of fi brotic NSIP NSIP) • Fibrotic NSIP Other characteristic with predictive value ≥ 10% decline in FVC during 6 - month follow - up • Sarcoidosis (IPF): (IPF, NSIP) • Other ILD • VC < 60 – 70% predicted Decrease in oxyhemoglobin saturation to < 88% during 6MWT • DLCO < 50 – 60% predicted Honeycomb change on HRCT (fi brosis score > 2) • Resting hypoxemia ( P aO2 < 7.3 kPa [55 mmHg]) Sarcoidosis: NYHA class III/IV and any of: • Hypercapnia ( P aCO2 > 6 kPa [45 mmHg]) • resting hypoxemia • Desaturation during 6 - MWT to < 88% • pulmonary hypertension • Secondary pulmonary arterial hypertension • right atrial pressure > 15 mmHg • NYHA functional class III/IV for other • LAM or PLCH: severe impairment in lung function ILD (sarcoidosis, LAM, PLCH) and exercise capacity and/or resting hypoxemia 206 LUNG TRANSPLANTATION Table 9.1 (Continued) Recipient indication Referral Transplantation Septic obstructive Post - bronchodilator FEV1 < 30% (especially • Oxygen - dependent respiratory failure lung disease young females) • Hypercapnia • Cystic fi brosis Exacerbation of pulmonary disease requiring • Pulmonary hypertension ICU stay • Non - CF bronchiectasis Increasing frequency of exacerbations requiring intravenous antibiotics Refractory and/or recurrent pneumothorax Recurrent hemoptysis not controlled by embolization Other factors with predictive value for CF: • hypercapnia ( P aCO2 > 6 kPa [45 mmHg]) • rapidly progressive decline in lung function • resting hypoxemia ( P aO2 < 7.3 kPa [55 mmHg]) Pulmonary vascular • NYHA class III/IV regardless of ongoing • Persistent NYHA class III/IV on maximal medical disease therapy therapy • Primary • Rapidly progressive disease (e.g. • Low ( < 350 m) or declining 6MWT pulmonary worsening functional capacity despite • Failing therapy with intravenous epoprostenol or hypertension (PPH) escalating doses of vasodilator therapy) equivalent (PPH) • Chronic • Not a surgical candidate if indication is • Cardiac index < 2 L/min per m2 thromboembolic chronic thromboembolic disease disease • Right atrial pressure > 15 mmHg Heart and lung • NYHA class III/IV despite optimal therapy • Persistent NYHA class III/IV on maximal medical disease a therapy • Progressive symptoms • Eisenmenger ’ s • Low ( < 350 m) or declining 6MWT distance • Other factors to consider: cor pulmonale, syndrome declining cardiac output, presence of • Other cyanosis cardiopulmonary disease 6MWT, 6 - minute walk test; BODE, body mass index, airfl ow obstruction, dyspnea, and exercise capacity index in COPD; CF, cystic fi brosis; COPD, chronic obstructive pulmonary disease; D LCO, diffusion capacity of the lung for carbon monoxide; FVC, forced vital capacity; FEV1 , forced expiratory volume in 1 s; HRCT, high - resolution computed tomogra- phy of the thorax; ILD, interstitial lung disease; IPF, idiopathic pulmonary fi brosis; LAM, lymphangioleiomyomatosis; NSIP, non - specifi c interstitial pneumonia; NYHA, New York Heart Association; PLCH, pulmonary Langerhans ’ cell histiocytosis; PPH, primary pulmonary hypertension; VC, vital capacity; UIP, usual interstitial pneumonia. a Heart – lung transplant usually required. See Orens, et al. J Heart Lung Transplant 2006; 25 :745 – 55. 207 CHAPTER 9 summarizes referral criteria and ideal timing of trans- Non - curable chronic extrapulmonary infection plantation according to specifi c indications for the Signifi cant chest wall and/or spinal deformity procedure. For each indication, guidelines for listing Documented non - adherence or inability to follow are discussed separately below. through with medical therapy and monitoring As the primary goal of lung transplantation is to Untreatable psychiatric or psychologic condition that prolong life rather than to permanently cure an ESLD, will impair compliance with medical therapy consideration of how the patient will benefi t from No
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