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Lung Transplantation Role of chest physician

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

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Lung Transplantation Role of chest physician

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  1. Lung Transplantation Role of chest physician Esen Kıyan İstanbul Üniversitesi İstanbul Tıp Fakültesi Göğüs Hastalıkları Anabilim Dalı

  2. Content -Disease specific transplantation indications (2006 ISHLT concensus) -Contraindications -Preoperative preperation -Postoperative follow-up (therapy and complications)

  3. 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

  4. Timing of referral -Two-three year predicted survival <%50 -NYHA class III or IV

  5. 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

  6. 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

  7. 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

  8. Cystic Fibrosis/Other causes of Bronchiectasis FEV1<30% pred. or a rapid decline in FEV1(in particular young female patients) Exacerbations requiring ICU stay Increase in the frequency of exacerbations requiring antibiotic therapy Refractory and/or recurrent pneumothorax Recurrent hemoptysis not controlled by embolization Oxygen-dependent RF Hypercapnia PHT TP

  9. Sarcoidosis NYHA class III or IV Hypoxemia at rest PHT Right atrial pressure>15mmHg TP

  10. 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 deformity Nonadherence to treatment and follow-up Untreatable psychiatric conditions Absence of social support system Substance addiction (tobacco, alcohol, narcotics)

  11. 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

  12. 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

  13. 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)

  14. Immunosuppressive therapy Cyclosporine A (Tacrolimus) AND Azathioprine (Mycophenolate M) AND Steroid Induction therapy (OKT3, ATG, Daclizumab, Basiliximab)

  15. Postop antibiotic prophylaxy (7-14 days) P. Carinii prophylaxy Azitromycin (after one week) Fungal prophylaxy (first 2 weeks voriconazole 200mg iv/po, 2x1 And inhaler Amphotericin B (3 months)

  16. VIRAL PROPHYLAXY

  17. ICU PERIOD Chest X ray/day IS drug level monitorization/day Bronchoscopy Postop 1st day, prolonged entubation, just before extubation (BAL) CMV-PCR and fungal serology Sputum culture

  18. B) AFTER ICU Chest X ray, laboratory tests, IS drug level CMV-PCR + fungus serology/week Thorax CT+ PFT Bronchoscopy during follow-up Before e.ternationx 2, 4., 8, 12th weeks; 6. and 12th weeks Later if you think rejection

  19. 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)

  20. Rejection? or infection? Fever, leucocytosis, infiltration Infection? Acute rejection? BAL + TBB Start tretament for both condition

  21. 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)

  22. 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

  23. 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

  24. CONCLUSION To decrease postop mortality: -Select candidate -Be careful for timing of referral -Correct diagnosis and treatment of postop early and late complications

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