L36 Lung Transplantation

Card Set Information

Author:
jknell
ID:
202849
Filename:
L36 Lung Transplantation
Updated:
2013-02-23 18:10:52
Tags:
Pulmonary II
Folders:

Description:
Lung transplantation data
Show Answers:

Home > Flashcards > Print Preview

The flashcards below were created by user jknell on FreezingBlue Flashcards. What would you like to do?


  1. Common indications for lung transplantation
    • Diseases:
    • 1. COPD/Emphysema
    • 2. Idiopathic Pulmonary Fibrosis
    • 3. Cystic Fibrosis
    • 4. Alpha-1 antitrypsin deficiency
    • 5. Pulmonary Fibrosis, other
    • 6. Bronchiectasis
    • 7. Sarcoidosis...

    • Quality of life
    • -expected post-transplant quality must exceed pre-transplant

    • Quantity of life
    • -Risk of death without transplant must exceed risk of death after transplant (expectancy <2 years)

    • Other:
    • -failed medical/other surgical therapy
    • -severe functional limitations, but ambulatory
    • -Age <65 for SLT, <60 for BLT
  2. Adult Lung tansplant survival
    • Double lung:
    • -1/2 life of 6.7 years
    • -conditional 1/2 life 9.4 years

    • Single lung:
    • -1/2 life 4.6 years
    • -Conditional 1/2 life 6.5 years

    *Conditional survival is based on those who make it past first few months

    • Disease:
    • -CF has best outcomes
    • -COPD tend not to do as well
    • -IPAH does well on conditional survival

    • Age:
    • -younger = better
  3. Recipient selection
    • Social support
    • Absence of other other life-threatening disease
    • Abscence of substance abuse problems
    • Financial support
    • Body habitus
    • Adherence to therapy/lifestyle
  4. Recipient Contraindications
    • Relative:
    • -Mechanical ventilation
    • -Extensive pleural adhesions
    • -Aiway colonization with bacterial

    • Absolute:
    • -malignancy in last 5 years
    • -recent cigarette smoking (last 6 months)
    • -BMI >30
    • -nonambulatory, poor reabilitation potential
  5. "sweet spot"
    • Well enough to tolerate a major surgery
    • Sick enough to merit a major surgery
  6. Donor
    • -Brain dead (optimum) - need OR prep time
    • -Good oxygenation (pO2 > 300mmHg on FiO2)
    • -Young (ideally <55 years)
    • -Absence of malignancy (nonsmoker, no nodules or masses)
    • -Absence of infection
  7. UNOS Allocation Score
    Scored by severity

    • "Points" for severity indicators:
    • -Mechanical ventilation
    • -O2 requirement, especially >10Lpm
    • -Elevated pCO2
    • -Biased toward COPD and bronchiectasis
  8. Surgical Techniques
    • Single lung transplant
    • - 2 recipients
    • - decreased immediate surgical morbidity
    • - more common in older/sicker recipient population

    • Bilateral lung transplant
    • - better outcomes on whole
    • - Nearly always chosen with suppurative disease (CF) - protection from infection or rejection
    • - PAH/PH

    • Heart-lung transplant
    • -PH with irreparable structural heart disease
    • -Significant coronary artery disease
    • -End-stage lung disease with LV failure

    • Living lobar transplant
    • - relatively rare
    • - CF, parents
    • -pt gets 2 lobes from 2 donors
    • -Can do HLA matching; tend to better than other transplant methods
  9. Immunosuppression
    • Glucocorticoids (Prednisone, Methylprednisolone)
    • Calcineurin inhibitors (Cyclosporine A, Tacrolimus)
    • MTOR inhibitors (Sirolimus, aka rapamycin)
    • Other (Azathioprine, Mycophenolate mofetil)
    • **difficult to immunosuppress; lungs have increased exposure to environment and pathogens...
  10. Infection
    • Very common immediately post-tranplant
    • -All recipients are treated with broad spectrum antibiotics

    • Long-term infections
    • -Repeat pneumonias
    • -CMV reactivation
    • -Sino-pulmonary disease
    • -Invasive fungal infections
    • -PCP
    • -Non-pulmonary infections
  11. Anastomosis complications
    • Site of invasive fungal infections
    • -we don't transplant the bronchial arteries... poor blood supply at the suture line

    • Dehiscence - air leak
    • -Surgical emergency
    • -less common with bronchial anastomosis than tracheal


    • Bronchial stenosis -
    • -can develop years following tranplantation
    • -May require balloon dilation, stenting, electrocautery, etc...
    • -often get infection/obstruction distal to the stenosis

  12. Rejection
    • 1. Primary graft dysfunction
    • -immediately following engraftment
    • -Ab mediated reaction
    • -Very high mortality

    • 2. Acute
    • -sudden onset
    • -often triggered by infection (or medication lapse)

    • 3. Chronic - common
    • -Bronchiolitis obliterans syndrome (BOS) - different from BOOP (Distal airways start to disappear)
    • -Very common several years out (everyone eventually gets this)
    • -Manifest by obstructive changes on spirometry

    **All types of disease have similar rates of rejections
  13. Transplantation and malignancy
    Increased risk for survivals (immunosuppression)

    • Types:
    • -Skin
    • -Lymphoma
    • -other

    • PTLD - post-tranplant lymphoproliferative disease
    • -Non-Hodkin's lymphoma related to immunosuppression
    • -EBV reactivation
    • -Can involve chest, mediastinal LN, gut
    • Tx: temporary reduction in immunosuppression
    • -Rituximab (anti-CD20)
  14. Cause of death
    • Bronchiolitis
    • Acute rejection
    • lymphoma
    • malignancy, non-lymphoma
    • CMV
    • infection, non-CMV
    • Graft failure
    • Cardiovascular
    • Technical

What would you like to do?

Home > Flashcards > Print Preview