Transcript Lung Transplantation Guidelines For Selection Milpark Hospital Transplant Unit

Lung Transplantation
Guidelines For Selection
Milpark Hospital Transplant Unit
Johannesburg, South Africa
SATS Controversies Meeting
May 2011
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%
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
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.
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.
Disease Specific Criteria – cont.
IPF
•
•
•
•
Symptomatic disease.
Exercise desaturation.
VC < 60 – 75% predicted.
DLCO < 50 – 60% predicted.
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.
Disease Specific Criteria – cont.
PPH
•
NYHA Class III/IV on optimal treatment –
Epoprostanol/Sildenafil/Bosentan.
•
Declining Functional Capacity.
Disease Specific Criteria – cont.
EISENMENGERS SYNDROME
(2° PAT)
•
NYHA Class III/IV and Declining Functional
Capacity.
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.
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).
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.
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.
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.