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Lung Transplantation

Lung Transplantation. Alper Toker, M.D. Istanbul University Istanbul Medical School Department of Thoracic Surgery. 1963 (Hardy). First successful heart lung transplantation 1981. Single lung transplantation 1985. Sequential bilateral lung transplantation.

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Lung Transplantation

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  1. Lung Transplantation Alper Toker, M.D. Istanbul University Istanbul Medical School Department of Thoracic Surgery

  2. 1963 (Hardy)

  3. First successful heart lung transplantation1981

  4. Single lung transplantation 1985

  5. Sequential bilateral lung transplantation

  6. Lung transplantations region/year

  7. 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

  8. Survival after lung transplantaion (1983-2000) Bilateral 1/2-life = 4.5 Yıl Single: 1/2-life = 3.6 Yıl All Transplantations: 1/2-life = 3.8 Yıl

  9. Indications in years

  10. Discussions in the country

  11. Transplantation and Turkey until January 2004Karakayalı 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

  12. Outmoded attitudes toward organ donation among Turkish Health Care professionalsTopbas 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.

  13. 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

  14. 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.

  15. Standart Donor

  16. 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)

  17. 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

  18. Indications • Emphysema / Alpha-1 AT deficiency FEV1< 25% predicted PaCO2 > 55 mmHg +/- cor pulmonale

  19. Indications • Cystic Fibrozis /Bronchiectasis FEV1 < 30% predicted If FEV1 > 30% predicted, Decline in FEV1 or increased number of hospitalistions and periods or • PaCO2 > 50 mmHg • PaO2 < 55 mmHg

  20. 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

  21. 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 IV CI < 2 L/min/m2 RA pressure > 15 mmHg Mean PA pressure >55 mmHg Increased Bilirubin

  22. Indications • Pulmonary hypertension and congenital heart diseases Eisenmenger Physiology (right to left shunt) • Timing is difficult. • Symptomatology. • Syncope, hemoptyzis, chest pain, arryhtmia, cyanosis, polycythemia.

  23. Contrindications • Multisystem diseases • Active infection • Hepatic and renal disease (creatine clearance 50 mg/ml/min) • >20mg prednisolone/daily • Malignancy (in 2 to 5 years)

  24. Contrindications • Obesity or Cachexia: 20% of ideal weight • Drug abuse or alcoholism • Severe psychiatric disease • Smoking • CAD or valve disease

  25. Contrindications • Severe chest wall deformity • Previous thoracic surgery* • Hepatitis B or C infection • Symptomatic osteoporozis

  26. Contrindications and age • Single lung 65years • Bilateral lung60 years • Heart - Lung 55 years

  27. 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.

  28. Surgical procedures • Single lung transplantation • Less morbidity, unilateral thoracotomy • Problems (Hyperinflation /infection/ cancer risk of the native lung)

  29. 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

  30. Surgical procedures • Bilateral lung transplantations • Bilateral sequential lung Tx • Bilateral lung Tx • Cystic Fibrozis, • Bronchiectasis, • PPH, • COPD.

  31. 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)

  32. Short waiting list Simple operation Long waiting list Risky and long operation Better survival Single lungvs Double Lung (Emphysema) Bando et al. Comparison of outcomes after single & bilateral lung transplantation in obstructive lung disease. J of Heart & Lung Txp 1995;14:692-8 Meyer et al. Single Vs Bilateral, Sequential Lung Txp for End-Stage Emphysema… J Heart & Lung Txp 2001;20:935-941

  33. 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

  34. 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

  35. Complications • EarlyTheatre (hemorrhage ) Ischemia/reperfusion injury Hyperacute rejection (HLA abs) Anastomosis problems Acute rejection (+/- changes in PFT) Infection (bacterial, viral, fungal)

  36. 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

  37. Prognostic factors in PGD • PaO2/FiO2 posttransplant 6th hour • Increasing CVP in first posttransplant 3 days

  38. 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

  39. 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.

  40. Complications • Early • Side effects of the medication • (Hypertension, Renal failure,tremor, hair growth, bone marrow suppression, hypercholesterolemia, diabetes, osteoporosis) • Delayed gastric emptying, aspiration.

  41. Complications Late • Chronic rejection /obliterative bronchiolitis (FEV1, FEF25-75, FEF50, Slope of N2 washout) • Infection(generally Pseudomonasaeruginosa) • Post-transplant lymphoma • Persistant side effects

  42. Results after transplantation

  43. Conclusion • Lung transplantation is not something magic • The leading cause of mortality is PGD . • < 50% 5 years survival • Immune-mediated rejection is limiting factor • Progress in immonology will dominate the results in lung transplantation

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