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lung transplantation

In 1998, wait period for lung transplantation was 2 years. Indications: 1) severe chronic obstructive pulmonary disease - history of COPD exacerbation with PaCO2 > 50 mm Hg - pulmonary hypertension, cor pulmonale despite oxygen therapy - homogeneously distributed pulmonary emphysema 2) end-stage restrictive lung disease 3) pulmonary vascular disease (pulmonary hypertension) resistant to medical therapy 4) BODE index of 7-10 & at least one or a) history of hospitalization for COPD exacerbation with hypercapnia b) pulmonary hypertension, cor pulmonale or both despite oxygen therapy c) FEV1 < 20% of predicted d) DLCO < 20% of predicted or homegeneous distribution of pulmonary emphysema [1,3] Contraindications: 1) significant psychiatric illness 2) poor compliance with medical therapy &/or follow-up 3) lack of adequate social support 4) continued smoking [1,3] 5) illicit drugs 6) alcohol abuse 7) infection with pan-antibiotic-resistant Pseudomonas cepacia 8) hepatic or renal disease 9) HIV infection 10) corticosteroids (> 15 mg prednisone QD) 11) mediastinal fibrosis 12) patients with malignancy 13) bedridden patients * most transplant centers use 65 years of age as arbitrary cutoff for eligibility [1] single lung transplantation is not a consideration for patients with cystic fibrosis - chronic infection with Pseudomonas would quickly colonize & infect the transplanted lung in the presence of the recipients native chronically infected lung Prior chest tube insertion or pleurodesis is NOT a contraindication. Procedure: Donors: 1) must be declared brain dead 2) have family consent 3) no history of chronic respiratory or malignant disease 4) < 55 years of age at death 5) normal chest X-ray 6) adequate oxygenation (PO2 > 300 mm Hg on fiO2 of 1.0) 7) free of purulent secretions by fiberoptic bronchoscopy 8) HIV negative 9) hepatitis serology negative 10) blood type compatible 11) lung size compatible Modalities: 1) single lung transplant a) generally modality of choice b) simpler procedure c) fewer complications 2) bilateral lung transplant a) chronically infected bilateral pulmonary disease 1] cystic fibrosis 2] bronchiectasis b) severe primary heart disease 3) heart-lung transplant a) severe primary pulmonary hypertension with secondary end-stage right heart failure b) pulmonary hypertension with noncorrectable Eisenmenger's syndrome c) end-stage pulmonary disease accompanied by cardiac disease Laboratory: 1) screening for hepatitis 2) HIV1 serology Complications: 1) postoperative infections 2) rejection 3) bronchiolitis obliterans 4) drug-related toxicity 5) post-transplant lymphoproliferative disorders 6) lung cancer [2] Management: 1) immunosuppression maintained for lifetime 2) prognosis: a) single lung transplant 1] 1 year survival is 70-90% 2] 3 year survival for single lung transplant in patients with COPD is 60-70% 3] 45% 5 year survival 4] 35% 7 year survival b) bilateral lung & heart-lung transplant - 1 year survival is 60-80% c) 10-12 years survival of transplanted lung?

Related

guidelines for timing initial screening for lung transplantation lung volume reduction surgery; lung resection (LVRS)

Specific

heart/lung transplantation

General

organ transplantation cardiothoracic surgery

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17 American College of Physicians, Philadelphia 1998, 2012, 2015
  2. Engels EA et al. Spectrum of cancer risk among US solid organ transplant recipients. JAMA 2011 Nov 2; 306:1891. PMID: 22045767
  3. Kreider M, Kotloff RM. Selection of candidates for lung transplantation. Proc Am Thorac Soc. 2009 Jan 15;6(1):20-7. PMID: 19131527
  4. Weill D, Benden C, Corris PA et al A consensus document for the selection of lung transplant candidates: 2014--an update from the Pulmonary Transplantation Council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2015 Jan;34(1):1-15. Review. PMID: 25085497
  5. National Heart, Lung, and Blood Institute (NHLBI) Lung Transplant https://www.nhlbi.nih.gov/health-topics/lung-transplant