lung transplantation 2012 דר ' לקסר אורי מכון הראה בית החולים...
TRANSCRIPT
LUNG TRANSPLANTATION
2012
דר' לקסר אורימכון הראה
בית החולים האוניברסיטאי הדסה
INDICATION
Lung transplantation is indicated for patients with
chronic, end-stage lung disease who are failing maximal
medical therapy, or for whom no effective medical
therapy exists.
•COPD
•IPF
•PPH
•CF
.
.
The Journal of Heart and Lung TransplantationJuly 2006
Ideally, listing for transplantation should occur when
life expectancy is greatly reduced but nonetheless
greater than the expected waiting time for a suitable
organ, and transplantation should be performed when
life expectancy after transplantation exceeds life expectancy without the procedure.
TIMING
The Journal of Heart and Lung TransplantationJuly 2006
AIMS
Survival benefit
Quality of life
Palliation
Absolute contraindications
• Malignancy in the last 2 years.
•. Untreatable advanced dysfunction of another major organ system •. Non-curable chronic extrapulmonary infection including HBV HCV HIV•. Significant chest wall/spinal deformity.•. Documented nonadherence •. Untreatable psychiatric or psychologic condition •. Absence of a consistent or reliable social support•. Substance addiction (e.g., alcohol, tobacco, or narcotics) The Journal of Heart and Lung Transplantation
July 2006
Relative contraindications
• Age >65y• Unstable condition• Limited functional condition• 18 >bmi>30• Colonization with resistant organism• Ventilation • Osteoporosis• IHD,D.M.,GERD,HTN….
The Journal of Heart and Lung Transplantation
July 2006
COPD
Guidelines for Referral
•. BODE index exceeding 5
Guidelines for Transplantation
•. Patients with a BODE index* of 7 to 10 or at least 1
of the following:
•. History of hospitalization for exacerbation associated
with acute hypercapnia (PCO2 exceeding 50 mm Hg).
• Pulmonary hypertension or cor pulmonale, or both,
despite oxygen therapy.
•. FEV1 of less than 20% and either DLCO of less than 20%
or homogenous distribution of emphysema.
The Journal of Heart and Lung Transplantation
July 2006
Cystic fibrosis and bronchiectasis
Guidelines for Referral
•. FEV1 below 30% predicted or a rapid decline in FEV1.
•. Exacerbation of pulmonary disease requiring ICU stay.
•. Increasing frequency of exacerbations requiring antibiotic
therapy.
•. Refractory and/or recurrent pneumothorax.
•. Recurrent hemoptysis not controlled by embolization.
Guideline for Transplantation
•. Oxygen-dependent respiratory failure.
•. Hypercapnia.
•. Pulmonary hypertension. The Journal of Heart and Lung TransplantationJuly 2006
PULMONARY FIBROSISGuideline for Referral early,do not wait to treatment•. Histologic or radiographic evidence of UIP irrespective of vital capacity.
•. Histologic evidence of fibrotic NSIP.
Guideline for Transplantation
•. Histologic or radiographic evidence of UIP and any of the following:
•. A DLCO of less than 39% predicted.
•. A 10% or greater decrement in FVC during 6 months of follow-up.
•. A decrease in pulse oximetry below 88% during 6-MWT.
•. Honeycombing on HRCT (fibrosis score of 2).
•. Histologic evidence of NSIP and any of the following:
•. A DLCO of less than 35% predicted.
• . A 10% or greater decrement in FVC or 15% decrease
in DLCO during 6 months of follow-up.
The Journal of Heart and Lung Transplantation
July 2006
PULMONARY ARTERIAL HYPERTENSION
Guideline for Referral•. NYHA functional class III or IV, irrespective of ongoing therapy.
•. Rapidly progressive disease.
Guideline for Transplantation•. Persistent NYHA class III or IV on maximal medical therapy.
•. Low (350 meter) or declining 6-MWT.
•. Failing therapy with intravenous epoprostenol, or equivalent.
•. Cardiac index of less than 2 liters/min/m2.
•. Right atrial pressure exceeding 15 mm Hg.
The Journal of Heart and Lung Transplantation
July 2006
NUMBER OF LUNG TRANSPLANTS REPORTED BY YEAR AND PROCEDURE TYPE
5 7 36 78190
419
704
922
10871223
13581338145014601491
16281690
187919302071
23862448
2708
0
250
500
750
1000
1250
1500
1750
2000
2250
2500
2750
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
Nu
mb
er
of
Tra
ns
pla
nts
Bilateral/Double LungSingle Lung
ISHLTNOTE: This figure includes only the lung transplants that are reported to the ISHLT Transplant Registry. As such, this should not be construed as representing changes in the number of lung transplants performed worldwide.
2009
LUNG TRANSPLANTS: Transplant Recipient Age by Year of Transplant
Transplants: January 1, 1987 – June 30, 2008
0%
20%
40%
60%
80%
100%
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
0
10
20
30
40
50
60
0-11 12-17 18-34 35-49 50-59 60-65 66+ Mean Age
Mea
n r
ecip
ien
t ag
e (y
ears
)
% o
f T
ran
sp
lan
tsrs
Year of Transplant
ISHLT
2009
AGE DISTRIBUTION OF LUNG TRANSPLANT RECIPIENTS (1/1985-6/2008)
0
5
10
15
20
25
30
35
0-11 12-17 18-29 30-39 40-49 50-59 60-65 66+
Recipient Age
% o
f tr
an
sp
lan
ts
ISHLT
2009
DONOR AGE DISTRIBUTION FOR LUNG TRANSPLANTS (1/1985-6/2008)
0
5
10
15
20
25
30
35
0-11 12-17 18-29 30-39 40-49 50-59 60-65 66+
Donor Age
% o
f tr
an
sp
lan
ts
ISHLT
2009
ADULT LUNG TRANSPLANTATIONKaplan-Meier Survival (Transplants: January 1994 - June 2007)
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10
Years
Su
rviv
al
(%)
.
Bilateral/Double Lung (N=12,246)
Single Lung (N=10,081)
All Lungs (N=22,328)
Double lung: 1/2-life = 6.6 Years; Conditional 1/2-life = 9.0 YearsSingle lung: 1/2-life = 4.6 Years; Conditional 1/2-life = 6.4 YearsAll lungs: 1/2-life = 5.4 Years; Conditional 1/2-life = 7.4 Years
P < 0.0001
ISHLT
2009
ADULT LUNG TRANSPLANTATION: Indications for Single Lung Transplants (Transplants: January 1995 - June 2008)
ISHLT
*Other includes:
Sarcoidosis: 2.1%
Bronchiectasis: 0.4%
Congenital Heart Disease: 0.2%
LAM: 0.8%
OB (non-ReTx): 0.5%
Miscellaneous: 6.3%
49%
29%
3%1%
2%
6%
10%
Alpha-1 COPD CF IPF IPAH Re-Tx Other*
2009
ADULT LUNG TRANSPLANTATIONKaplan-Meier Survival by Procedure Type (Transplants: January 1990 – June 2007)
Diagnosis: Emphysema/COPD
0
25
50
75
100
0 1 2 3 4 5 6 7 8 9 10 11 12
Years
Su
rviv
al
(%)
COPD/Single lung (N=5,683)
COPD/Double lung (N=3,129) N=138
N=60
P < 0.0001
N at risk at 5 years = 744
N at risk at 5 years = 1,786
ISHLT
2009
ADULT LUNG TRANSPLANTS (1/1995-6/2007) Risk Factors for 1 Year Mortality
Recipient Age
0
0.5
1
1.5
2
25 30 35 40 45 50 55 60 65
Recipient Age
Re
lati
ve
Ris
k o
f 1
Ye
ar
Mo
rta
lity
p < 0.0001
ISHLT
2009
ADULT LUNG RECIPIENTSFunctional Status of Surviving Recipients
(Follow-ups: April 1994 – June 2008)
0%
20%
40%
60%
80%
100%
1 Year (N = 6,820) 3 Year (N = 4,333) 5 Year (N = 2,492) 10 Years (N = 422)
No Activity Limitations Performs with Some Assistance Requires Total Assistance
ISHLT
2009
ADULT LUNG RECIPIENTSEmployment Status of Surviving Recipients
(Follow-ups: April 1994 – June 2008)
0%
20%
40%
60%
80%
100%
1 Year (N=8,937) 3 Year (N=5,452) 5 Year (N=3,386) 10 year (N=704)
Working (FT/PTStatus unknown)
Working Part Time
Working Full Time
Retired
Not Working
ISHLT
2009
0
20
40
60
80
100
Year 1 (N = 6,105) Year 5 (N = 2,573)
% o
f P
atie
nts
Other
Rapa + Cellcycle
Rapa + Calcineurin
Tacrolimus
Tacrolimus + MMF
Tacrolimus + AZA
Cyclosporine + MMF
Cyclosporine + AZA
ADULT LUNG RECIPIENTS Maintenance Immunosuppression Drug Combinations at Time of Follow-up
For follow-ups between January 2002 through June 2008 Analysis limited to patients receiving prednisone
ISHLT
Analysis is limited to patients who were alive at the time of the follow-up
2009
POST-LUNG TRANSPLANT MORBIDITY FOR ADULTS Cumulative Prevalence in Survivors within 10 Years Post-Transplant (Follow-ups: April
1994 - June 2008)
Outcome Within 10
Years
Total number with known response
Hypertension 97.30% (N = 337)
Renal Dysfunction 42.10% (N = 484)
Abnormal Creatinine < 2.5 mg/dl 24.20% Creatinine > 2.5 mg/dl 7.40% Chronic Dialysis 7.60% Renal Transplant 2.90%
Hyperlipidemia 68.50% (N = 410)
Diabetes 37.40% (N = 374)
Bronchiolitis Obliterans Syndrome 50.20% (N = 297)
ISHLT
2009
FREEDOM FROM BRONCHIOLITIS OBLITERANS SYNDROME
For Adult Lung Recipients (Follow-ups: April 1994-June 2008)Conditional on Survival to 14 days
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10
Years
Freedom from Bronchiolitis ObliteransSyndrome (N = 10,835)
N at risk at 5 years = 1,329
N at risk = 61
% F
ree
do
m f
rom
Bro
nc
hio
litis
O
blit
era
ns
Sy
nd
rom
e
ISHLT
2009
FREEDOM FROM SEVERE RENAL DYSFUNCTION*For Adult Lung Recipients (Follow-ups: April 1994-June 2008)
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10
Years
% F
ree
do
m f
rom
Se
ve
re R
en
al
Dy
sfu
nc
tio
n
Freedom from Severe RenalDysfunction (N=11,463)
N at risk at 5 years = 1,910
N at risk = 110
* Severe renal dysfunction = Creatinine > 2.5 mg/dl (221 μmol/L), dialysis or renal transplant
ISHLT
2009
FREEDOM FROM MALIGNANCYFor Adult Lung Recipients (Follow-ups: April 1994-June 2008)
50
60
70
80
90
100
0 1 2 3 4 5 6 7 8 9 10
Years
% F
ree
fro
m M
ali
gn
an
cy
All malignancy Lymph Skin Other
ISHLT
2009
ADULT LUNG TRANSPLANT RECIPIENTS: Relative Incidence of Leading Causes of Death
(Deaths: January 1992 - June 2008)
0
10
20
30
40
50
0-30 Days (N= 1,621 )
31 Days – 1Year (N =
3,110)
>1 Year – 3Years (N=2,776 )
>3 Years – 5Years (N =
1,593 )
>5 Years – 10Years (N=1,797 )
>10 Years (N= 392)
Bronchiolitis Malignancy (non-Lymph/PTLD)
Infection (non-CMV) Graft Failure
Cardiovascular
Pe
rce
nta
ge
of
De
ath
s
ISHLT
2009
?מה קורה בישראל
: שקלול -LAS SCOREרשימה ארצית לפי • חומרת המחלה וסכויי הצלחת ההשתלה
פרמטרים המרכיבים את הנקוד-תפקודי11 • ראה,מחלות רקע,מחלת היסוד,מצב תפקודי וכ'•תרומה מתורם עם מוות מוחי מוכרז•אין תרומה מהחי• STATUS ONEאין • שעות4-6ריאה מאופיינת בזמן איסכמיה קצר • חולים על70זמן המתנה עד שנה לערך-•
הרשימהאין שיתוף פעולה אזורי או בינלאומי•
תודה