LUNG TRANSPLANTATION LUNG TRANSPLANTATION and PULMONARY FIBROSISand PULMONARY FIBROSIS
Maria L. Padilla, MDMaria L. Padilla, MDAssociate Prof. of MedicineAssociate Prof. of MedicineDirector of ILD/IPF and Advanced Lung Disease Director of ILD/IPF and Advanced Lung Disease ProgramProgramMSSM/MSMCMSSM/MSMC
Organ TransplantationOrgan Transplantation
Lung Transplantation and IPFLung Transplantation and IPF
• Important Questions:– What is it?– Why?– For Whom?– When?– How?– What are the results?
Lung Transplantation and IPFLung Transplantation and IPF
• What is Lung Transplantation?
The operation that replaces diseased, failing lungs with a functional organ.
Lung Transplantation and IPFLung Transplantation and IPF
• Thoracic Transplantation– Heart-Lung Transplantation– Single Lung Transplantation– Bilateral Lung Transplantation– Lobar Transplantation
Lung Transplantation and IPFLung 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 TransplantationLung Transplantation
• Process:– Referral– Evaluation– Listing with UNOS– Waiting time– Transplantation– Post transplantation care
Lung Transplantation and IPFLung 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 TransplantationLung 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 IPFLung Transplantation and IPF
• When?
When patient is:
medically
physically
psychologically/emotionally,
READY! and lungs become available
Lung TransplantationLung 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 IPFLung 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 IPFLung 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 TransplantationLung 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 TransplantationLung Transplantation
Lung Transplantation and ILDLung Transplantation and ILD
• Activity (SLT and BLT)- 1988-1999– IPF (LD 5) 972– SARCOIDOSIS 148– PF (OTHER) 82– LAM 47– OB (non-retransplant) 46– OCCUP. LUNG DIS. 11– RHEUMATOID DIS. 5
• From UNOS/OPTN data as of 2/17/2001
Lung Transplantation and IPFLung 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-IPFLung Transplantation-IPF
Lung Transplantation-IPFLung Transplantation-IPF
Lung TransplantationLung 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 ILDLung Transplantation and ILD
• IMPROVED FUNCTIONAL STATUS
• IMPROVED PHYSIOLOGY(pulm+ cv)
• SURVIVAL BENEFIT (IPF)
• COMPARABLE INCIDENCE OF AR, CR INFECTION
• IMPROVED QUALITY OF LIFE
Lung TransplantationLung Transplantation
0%
20%
40%
60%
80%
100%
1 Year 3 Years 5 Years
No Activity Limitations Performs with Assistance Total Assistance
Lung TransplantationLung Transplantation
Lung TransplantationLung Transplantation
Lung Transplantation and IPF/ILDLung 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