Lung Transplantation

1. Lung Transplantation Guidelines For Selection Milpark Hospital Transplant Unit Johannesburg, South Africa SATS Controversies Meeting May 2011

2. South African Guidelines based on: • ATS - International Guidelines for the selection of Lung Transplant Candidates – 1998 • ISHLT – Update – 2006 • GENERAL - Patient should be receiving or have received maximal medical therapy, but nevertheless have declining function, with a limited life expectancy ( <50% - 2-3 year survival). - The patient should have ambulatory and rehabilitation potential. - A satisfactory psycho-social profile with support systems is essential. AGE - Older patients have a significantly worse prognosis. - HLT <55 years. - BSLT <60 years. - SLT <65 years. BMI - 18 – 30%

3. Lung Transplantation as the sole form of therapy is potentially indicated in any irreversible condition, resulting in either one or both of the following disease entities: • END STAGE RESPIRATORY FAILURE. (ICD 10 CODE: J96.1) • PULMONARY ARTERIAL HYPERTENSION. (ICD 10 CODE: I27.0) (ICD 10 CODE: Q20 – 28) Refer for Assessment at this Stage and Exclude Unsuitable Recipients following Review of Disease Specific Guidelines

4. A. End Stage Respiratory Failure Conditions grouped as follows: •COPD (ICD 10 Code: J40 -J46) - Acquired. - Congenital (Alpha1 – Antitrypsin def.). • Idiopathic Pulmonary Fibrosis (IPF). (ICD 10 Code: J80-J84) • Infective/Inflammatory. (ICD 10 Code: J47 .xx, J60-J70,J85-J86 E84 & other) - Cystic Fibrosis (CF). - Bronchiectasis. - Sarcoidosis. - Other e.g. – LAM etc. B. Pulmonary Hypertension - Primary (PPH). - Secondary.

5. Disease Specific Criteria COPD • FEV¹ <25% of predicted. • PaCO² > 55/PHT. • Progressive deterioration on Domiciliary Oxygen. • Frequent admissions with declining function. • Patients with a high BODE index. • Patients not better served by LVRS.

6. Disease Specific Criteria – cont. IPF • Symptomatic disease. • Exercise desaturation. • VC < 60 – 75% predicted. • DLCO < 50 – 60% predicted.

7. Disease Specific Criteria – cont. Infective/Inflammatory (CF) • FEV¹ < 30% predicted. • High Risk Patients: - Young Females with a rapidly declining FEV¹. - Weight Loss. - Frequent Infective Exacerbations. - Haemoptysis.

8. Disease Specific Criteria – cont. PPH • NYHA Class III/IV on optimal treatment – Epoprostanol/Sildenafil/Bosentan. • Declining Functional Capacity.

9. Disease Specific Criteria – cont. EISENMENGERS SYNDROME (2° PAT) •NYHA Class III/IV and Declining Functional Capacity.

10. Contra-indications • HIV+ve/AIDS. • Hepatitis B, Ag+ve. • Hepatitis C with biopsy proven liver disease. • Active malignancy. • Dysfunction of one or more major organ. systems other than lungs, e.g. renal failure.

11. Relative Contra-indications In combination – increases risk of Tx • Severe Osteoporosis. • Hypertension. • Diabetes Mellitus. • Peptic Ulcer Disease. • Musculo-skeletal Disease eg. Kypho-scoliosis • Long term, high dose corticosteroids. • Poor nutritional status. • Substance abuse. • Psychological disorders. • Mechanical ventilation. • Microbial colonisation. • T.B. (untreated).

12. Conclusions • Most patients with diagnosis of IPF/UIP SHOULD be considered for EARLY transplant listing – due to rapid progression of disease. • Very FEW patients with COPD/Airway obstruction WOULD be considered suitable for listing – advanced age with co-morbid disease.

13. Conclusions •Worldwide the percentage of patients undergoing transplantation with PAH is DIMINISHING due to improved prognosis with medical therapy. • A large and increasing percentage of CYSTIC FIBROSIS patients could potentially qualify for listing, although some patients currently elect not to follow this route.

14. Conclusions • Meeting disease specific criteria generally implies transplant ASSESSMENT is indicated. Certain percentage will be excluded by Transplant Panel. • It is in the interest of the Transplant Team to rigorously accept only ideal recipient.