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Lung Transplantation Role of chest physician. Esen Kıyan İstanbul Üniversitesi İstanbul Tıp Fakültesi Göğüs Hastalıkları Anabilim Dalı. Content. -Disease specific transplantation indications (2006 ISHLT concensus) -Contraindications -Preoperative preperation - PowerPoint PPT Presentation
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Lung Transplantation
Role of chest physicianEsen Kıyan
İstanbul Üniversitesi İstanbul Tıp Fakültesi
Göğüs Hastalıkları Anabilim Dalı
Content
-Disease specific transplantation indications (2006 ISHLT concensus)
-Contraindications
-Preoperative preperation
-Postoperative follow-up (therapy and complications)
Factors affecting survival and waiting time on the waiting list
Blood group, height, BMI Type of pulmonary
disease Age Systemic dis. (DM) 6MWT, functional status MV PHT
Early referral for consideration of Tx is highly desirable
Timing of referral
-Two-three year predicted survival <%50
-NYHA class III or IV
COPD
Timing of referral BODE index >5
BODE indx of 7 to 10 or at least one of the following:
-History of hospitalization for exacerbation associated with acute hypercapnia (PaCO2 exceeding 50mmHg)
-PHT or cor pulmonale or both (despite oxygen therapy)
-FEV1<%20 + DLCO<%20 or homogenous emphysema
TP
IPF and NSIP
Histologic or radiographic evidence of UIP (irrespective of VC) or histologic evidence of NSIP
Histologic or radiographic evidence of UIP and any of the following:
-DLCO<39% predicted-A 10% or more decrease in FVC during 6 months of follow-up-A decrease in pulse oximetry below 88% during a 6MWT-Honeycombing on HRCT (fibrosis score >2)
TP
Pulmonary arterial hypertension
NYHA class III or IV (irrespective of ongoing therapy)Rapidly progressive disease
Persistent NYHA class III or IV on maximal therapy
Low (<350 meter) or declining 6-MWT
CI<2L/dk/m2
Right atrial pressure>15mmHg
Failing therapy with iv epoprostenol or equivalent
TP
Cystic Fibrosis/Other causes of Bronchiectasis
FEV1<30% pred. or a rapid decline in FEV1(in particular young female patients)Exacerbations requiring ICU stayIncrease in the frequency of exacerbations requiring antibiotic therapyRefractory and/or recurrent pneumothoraxRecurrent hemoptysis not controlled by embolization
Oxygen-dependent RFHypercapniaPHT
TP
Sarcoidosis
NYHA class III or IV
Hypoxemia at restPHTRight atrial pressure>15mmHg
TP
Contraindications-I
Absolute Contraindications
Active malignancy (<2 years)Extrapulmonary organ failure (liver, renal, hearth)Chronic active hepatitis, hepatitis C, HIV(+)Severe chest wall and spinal deformityNonadherence to treatment and follow-upUntreatable psychiatric conditionsAbsence of social support systemSubstance addiction (tobacco, alcohol, narcotics)
Contraindications-II
Relative contraindications
-Age>65, BMI>30kg/m2 or <17kg/m2-Critical or unstable clinical condition (shock, MV, ECMO)-Severely limited functional status with poor rehabilitation potential-Colonization with highly resistant or virulent bacteria, fungi, or mycobacteria-Severe or symptomatic osteoporosis-Systemic diseases (without organ dysfunction)-Retransplantation
Basic evaluation for referral to the transplantation center
-Indications/contraindications
-LTOT-NMV requirement
-LFT, ASG, 6MWT
-Basic laboratory tests
-ECG and Echocardiography
-Torax CT (last 6 months) + HRCT
-Dental evaluation, gynecological and breast check-up, PSA
Special tests for evaluation before listing
-Viral serology (HIV, HBV, HCV, CMV, EBV)
-Sputum culture, ENT examinetion (bronchiectasis, CF)
-Carotid US (>45)
-Coronary angiography (>45)
-Colonoscopy (>50 yaş)
-Quantitative V/Q scan (mandatory for SLTx)
-Right hearth catheterisation (PHT)
Immunosuppressive therapy
Cyclosporine A (Tacrolimus)
AND
Azathioprine (Mycophenolate M)
AND
Steroid
Induction therapy (OKT3, ATG, Daclizumab, Basiliximab)
Cyclosporine
Tacrolimus Azathioprine
MycophenolateMofetil
Steroid
Preop 5mg/kg PO 0.05mg/kg PO 2.5 mg/kg PO
If <50kg, 750mgIf >50kg, 1000mg
500mg iv
Intraope. ---- ---- ---- ------ 500mg iv/each lung
Postop (PO)
4mg/kg, 2x1 po
0.05mg/kg 2x1 po
2.5mg/kg 1x1 po
2x1 poIf<50kg, 1000mgIf>50kg, 1500mg
125mg3x1 po, later 1mg/kg 2x1
Postop (IV)
40mcg/kg/hr continuous inf.
1mcg/kg/hr continuous inf.
1-1.25 mg/kg/day
1-1.5g, 2x1 125mg, iv, 3x1, later 2mg/kg/day iv ( in 3 doses)
P. Carinii prophylaxyAzitromycin (after one week)
Fungal prophylaxy (first 2 weeks voriconazole 200mg iv/po, 2x1And inhaler Amphotericin B (3 months)
Postop antibiotic prophylaxy (7-14 days)
VIRAL PROPHYLAXY
CMV status Prophylaxis Time
D (-) /R (-) Valacyclovir po 1x500mg Lifi time
D (+) /R (+) or D (-) /r (+)
Gancyclovir 5mg/kg iv 2x1Valgancyclovir po 2x900mg
1-14 days
Valgancyclovir 1x900mg 15-180 days
Valacyclovir 1x500mg 181-life time
D (+) /R (-) Gancyclovir 5mg/kg iv 2x1 1-14 days
Valgancyclovir po 2x900mg 15-45
Valgancyclovir po 1x900mg 46-180
Valgancyclovir po 1x500mg 181-life time
Irrespective of CMV status
CMV Ig 200mg/kg Days:0,3,14,28 ve 56
Chest X ray/day
IS drug level monitorization/day
Bronchoscopy Postop 1st day, prolonged entubation, just before extubation (BAL)
CMV-PCR and fungal serologySputum culture
ICU PERIOD
Chest X ray, laboratory tests, IS drug level
CMV-PCR + fungus serology/week
Thorax CT+ PFT
Bronchoscopy during follow-upBefore e.ternationx 2, 4., 8, 12th weeks; 6. and 12th weeksLater if you think rejection
B) AFTER ICU
Outpatient clinic follow-up
LFT, ABG, blood tests, Ches X ray
Sputum culture, CMV-PCR
Bronchoscopy (2,4,8,12. weeks, 6 and 12th months, once in a year or if acute or chronic rejection)
Osteoporosis evaluation (bone densitometry/ year)
Fever, leucocytosis, infiltration
Infection?
Acute rejection?
BAL + TBB
Start tretament for both condition
Rejection? or infection?
Post-transplant problems
Hemorrhage
Primary graft dysfunction
Anastomose problems
Hyperacute rejection (HLA antibody)
Arytmia
Acute rejection
Infection (bacterial, viral, fungal)
Airway complications
PE
Chronic rejection (BOS)
Complication <72h 72h-1 week >1 week >1 month
Bleeding x
Technical x
PGD x(COMMON)
Arythmia x X
Infection X X X
Rejection X (uncommon) X X
Pulmonary emboli X X
BO/BOS X
Post-transplant problems
Reaction between IS drug and other drugs
Renal failure, DM, KV (HT, HL)
Osteoporosis, avascular necrosis of femur
Bone marrow suppression
Malignancy and PTLPD
GER
CONCLUSION
To decrease postop mortality:
-Select candidate
-Be careful for timing of referral
-Correct diagnosis and treatment of postop early and late complications
Recommended