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WHO and WHEN TO REFER FOR LUNG TRANSPLANTATION?

Geert M. Verleden Medical Director Lung Transplant Programme Leuven, Belgium. WHO and WHEN TO REFER FOR LUNG TRANSPLANTATION?. Patient selection : indications for LTx. Patients with chronic end-stage lung disease , such as COPD, CF, PAH, Pulmonary fibrosis Max 50-55 y for HLTx

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WHO and WHEN TO REFER FOR LUNG TRANSPLANTATION?

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  1. Geert M. Verleden Medical Director Lung Transplant Programme Leuven, Belgium WHO and WHEN TO REFER FOR LUNG TRANSPLANTATION?

  2. Patientselection: indicationsforLTx • Patientswithchronicend-stagelungdisease, such as COPD, CF, PAH, Pulmonaryfibrosis • Max 50-55 y forHLTx • 60-65 y forLTx • Failingmedicaltreatment • Ornomedicaltreatmentexists • Needfor • Information • Demonstration of adequate healthbehavior • Willingness to adhere to guidelines Aim of LTx: survival benefit and increase in QOL

  3. Meaning of failingmedicaltreatment? • COPD • Rehabilitation • LVRS?? • Bullectomy • IPF and ILD • Studyprotocols? • CF • WhataboutmulitiresistentPseudomonasorCepacia?

  4. Regarding PAH • Need expertise in treatmentwith • Prostaglandins • PDE inhibitors • Endothelin receptor blockers • …

  5. Absolute contra-indications • Malignancy in the last 2 years, exceptcutaneoussquamous and basalcell tumors • Remainsquestionnableregardingforinstancebreastcancer, renalcancer. How long tumor free? • Untreatableadvanceddysfunction of otherorgans (kidney, liver, …) • Unlesscombinedtransplantation • Untreatablecoronaryarterydisease • What is nowadaysuntreatable? • Non-curablechronicextrapulmonaryinfections (hep B, hep C, HIV) • Alsoquestionnable

  6. Absolute contra-indications • Significant chestwall/spinaldeformity • To bediscussedwithsurgeons • Documentednon-adherence • Specificproblem in young CF patients • Untreatablepsychiatricorpsychologicconditionwithinability to complywithmedicaltherapy • Absence of social support • Difficulties to adhere to strictfollow up protocols • Substanceaddiction: tobacco, alcohol, narcotics, drug abusethat is activeorwithin the last 6 months • Is sixmonthsenoughdelay?

  7. Relativecontra-indications • Age > 60-65 y • Criticalorunstableclinicalcondition (invasiveventilation, ECMO)

  8. Risk Factors for 1 Year Mortality (N=11,079) J Heart Lung Transplant 2008;27: 937-983

  9. Risk Factors for 1 Year MortalityRecipient Age J Heart Lung Transplant 2008;27: 937-983

  10. Risk Factors for 5 Year MortalityRecipient Age J Heart Lung Transplant 2008;27: 937-983

  11. Risk Factors for 1 Year MortalityCenter Volume J Heart Lung Transplant 2008;27: 937-983

  12. Relativecontra-indications • Colonizationwithhighlyresistantor virulent bacteria, fungi ormycobacteria • CF patientsspecifically • Mycobacterialcolonization/infectionremainsproblematic

  13. ADULT LUNG TRANSPLANTATIONSurvival By Diagnosis CF vs. COPD: p < 0.0001 CF vs. IPF: p < 0.0001 CF vs. PPH: p < 0.0001 CF vs. Sarcoidosis: p < 0.0001 J Heart Lung Transplant 2008;27: 937-983

  14. Relativecontra-indications • BMI > 30 • Severeorsymptomaticosteoporosis • Diabetes • arterialhypertension • peptic ulcer • GER (50% or more preTx) • … ShouldbeadequatelytreatedbeforeTx

  15. When to refer? • Disease-specific criteria: • Orens et al. International guidelinesfor the selection of lung transplant candidates: 2006 update--a consensus report from the PulmonaryScientificCouncil of the International Society forHeart and LungTransplantation. J HeartLung Transplant 2006; 25: 745. • Takinginto account severalcentrecharacteristics: • Donor availability • Localwaiting time

  16. Increasingrole of DCD donors N=17 N=126

  17. Time windowreferral - transplantation Referral Transplantation < expected survival before Tx Waiting time If estimated WT > expected survival Decline for Tx ? Urgent Tx ?

  18. Meanwaitingtime in Leuven

  19. Waiting time is bloodgroupdependent Days Blood Group P<0.001

  20. 300 200 100 0 …and heigthdependent days p < 0.05 219 167 (175 ± 6 cm) (160 ± 7 cm) > 168 cm < 168 cm Adaptedfrom D. Van Raemdonck, Leuven 2003

  21. How to refer: role of the Tx Team Transplantation protocol Describing procedures, localresponsabilities, treatmentmodalities, … Collaborationwith other MD disciplines Director(s) of the program Pulmonologist Surgeon Other MD Establisha Networkwith Referring physicians Collaborationwith paramedics, such as Nurses, physiotherapists, Dieticians, socialworkers, Psychologist, … Collaborationwith Transplant coordinators

  22. How to refer? • Telephone call • Withreferringphysician • To discusscurrentpatientsituation • First outpatientvisit • To see the patientpersonally and to givefurherinformationonwhat to expect • Ifnoclearcontra-indicationssofar • Pretransplantwork-upperformedbyreferringphysician • Afterwards team discussion and short admission to the transplant hospital • Onwaiting list Promoteearlyreferral !!

  23. SurgeonPulmonologist

  24. PulmonologistSurgeon

  25. Survival results

  26. Survival Results (2)

  27. Conclusions • General indications and contra-indications provide guidelinesforTx • Specificdisease-based criteria willbehelpfull • No single criteria is enough to predict prognosis • Best option: • Contact transplant center and discuss the patient • Refer the patientfor a first “physical” contact whenin doubt Be on time !!! Do not let the referringphysiciandecide to transplant ornot

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