Transcript Lung Transplantation - Coalition for Pulmonary Fibrosis

LUNG TRANSPLANTATION
and PULMONARY FIBROSIS
Maria L. Padilla, MD
Associate Prof. of Medicine
Director of ILD/IPF and Advanced Lung Disease
Program
MSSM/MSMC
Organ Transplantation
Lung Transplantation and IPF
• Important Questions:
– What is it?
– Why?
– For Whom?
– When?
– How?
– What are the results?
Lung Transplantation and IPF
• What is Lung Transplantation?
The operation that replaces
diseased, failing lungs with a functional
organ.
Lung Transplantation and IPF
• Thoracic Transplantation
– Heart-Lung Transplantation
– Single Lung Transplantation
– Bilateral Lung Transplantation
– Lobar Transplantation
Lung Transplantation and IPF
• WHY?
It offers the opportunity to return to a
better functional capacity when all medical
therapies have been ineffective.
Ultimate form of treatment
Lung Transplantation
• Process:
– Referral
– Evaluation
– Listing with UNOS
– Waiting time
– Transplantation
– Post transplantation care
Lung Transplantation and IPF
• For whom?
– Candidate Selection
•
•
•
•
•
•
Age less than 65y
Absence of other organ dysfunction
Non-smoker, non-drinker, no drug abuse
Appropriate weight
Good support system
Stable psychosocial and emotional status
Lung Transplantation
• CANDIDATE EVALUATION
– Blood type, biochemical panel, serologies
– Renal function determination
– Skin testing and sputum cultures
– PFT’s , ABG’s, 6-min walk, +/-exercise tests
– Imaging: CXR, HRCT, V/Q, bone densitometry
– Cardiac tests: echo; stress tests; RHC with
hemodynamics and LHC where indicated
Lung Transplantation and IPF
• When?
When patient is:
medically
physically
psychologically/emotionally,
READY! and lungs become available
Lung Transplantation
• LESS THAN 20% OF DONORS ARE
SUITABLE LUNG DONORS:
– AGE AND SMOKING HX EXCLUDE SOME
– LUNGS ARE FRAGILE--EDEMA, INFXN,
VENTILATOR COMPLICATIONS
– ALLOGRAFT INTOLERANCE TO
PROLONGED ISCHEMIA
Lung Transplantation and IPF
• When lungs become available, they are
offered on the basis of:
– Time on the waiting list
• No consideration for severity of illness or urgency
– Exception: 90 d credit when IPF patient listed
– Blood type
– Lung size
– Other factors (?)
Lung Transplantation and IPF
• While on Waiting List:
– Adhere to medical treatment
– Participate in pulmonary rehabilitation
– Maintain good nutrition and acceptable body
weight
– Attend support groups
– Keep a positive attitude and visualize a
brighter tomorrow
Lung Transplantation
• Registry:
– United Network for Organ Sharing and the
Organ Procurement and Transplantation
Network (UNOS/OPTN)
– 1988-2000
– 7764 lung transplants (7625 C, 139 LD)
– 719 heart-lung transplants
• Data as of Nov. 2000
Lung Transplantation
Lung Transplantation and ILD
• Activity (SLT and BLT)- 1988-1999
– IPF (LD 5)
– SARCOIDOSIS
– PF (OTHER)
– LAM
– OB (non-retransplant)
– OCCUP. LUNG DIS.
– RHEUMATOID DIS.
972
148
82
47
46
11
5
• From UNOS/OPTN data as of 2/17/2001
Lung Transplantation and IPF
• Idiopathic Pulmonary Fibrosis
– Waiting time too long for some patients
– At risk for developing 2* PHN
– Prior Thoracic surgeries (OLB, Ptx)
– High frequency of osteoporosis, obesity
– Documented survival benefit
– H-L, 2.9%; BLT, 7.1%; SL, 19.5% (ISHLT)
Lung Transplantation-IPF
Lung Transplantation-IPF
Lung Transplantation
• Issues and complicating factors
– Need for chronic immunosuppression
– Acute and chronic rejection
– Infection
– Side effects of medicines
– Cost of procedure and follow up care
Lung Transplantation and ILD
•
•
•
•
IMPROVED FUNCTIONAL STATUS
IMPROVED PHYSIOLOGY(pulm+ cv)
SURVIVAL BENEFIT (IPF)
COMPARABLE INCIDENCE OF AR, CR
INFECTION
• IMPROVED QUALITY OF LIFE
Lung Transplantation
100%
80%
60%
40%
20%
No Activity Limitations
Performs with Assistance
Total Assistance
0%
1 Year
3 Years
5 Years
Lung Transplantation
Lung Transplantation
Lung Transplantation and IPF/ILD
• LT is a therapeutic modality of great value
• Efforts to overcome LT limitations needed:
– Increase donor pool--review criteria
• Living donors---Lobar transplantation
– Prevent CR-improve treatment
• Earlier listing of candidates with ILD/IPF
• Explore new therapies as bridge to LT
– New IPF paradigm