Saturday, May 6, 2017

LUNG TRANSPLANTATION

HISTORICAL PERSPECTIVE


Dr. James Hardy is credited with performing the first successful human lung transplant at the University of Mississippi in 1963. The recipient lived for only 18 days after the procedure and several other attempts around the world failed because of rejection and problems with healing. Lung transplantation has come a long way since then, with the introduction of many new anti-rejection medications, newer operative techniques and better patient and donor selection. Current data from the International Society for Heart and Lung Transplantation Registry reports a 1 year survival of 78 % and a 5 year survival rate of 51 %.


PATIENTS THAT BENEFIT FROM A LUNG TRANSPLANT


Advanced and irreversible lung disease which include chronic obstructive lung disease (COPD), restrictive lung diseases such as cystic fibrosis and pulmonary hypertension are the usual patients who are considered for this procedure provided they meet the following criteria:
  1. > 50 % risk of death in 2 years without the transplant
  2. > 80 % survival for at least 3 months after the transplant
  3. > 80 % 5 year survival from the general medical perspective provided the transplanted lung functions well


PATIENTS FOR WHOM LUNG TRANSPLANT IS NOT AN OPTION


Absolute contraindications for lung transplantation include:
  1. Cancer within the last two years (except non-melanoma localized skin cancer)
  2. Untreatable severe dysfunction of another major organ system (unless a combined procedure can be performed)
  3. Severe atherosclerotic heart disease
  4. Uncorrectable bleeding disorder
  5. Acute sepsis
  6. Active chronic infections such as TB
  7. Obesity with a BMI > 35
  8. Non-compliance with medical treatments
  9. Psychiatric issues
  10. Substance abuse
  11. Absence of reliable social support system


Relative contraindications include:
  1. Older age (> 75 years)
  2. BMI 30 to 34.9
  3. Severe malnutrition
  4. Prior chest surgery with lung resection
  5. Infections with resistant or virulent micro-organisms


WHAT IS THE USUAL WORK UP PRIOR TO THE TRANSPLANT


This includes laboratory studies and other tests.


Lab work includes:
  1. Complete blood count
  2. Liver and kidney function
  3. Viral studies to look for HIV, hepatitis B, hepatitis C, CMV, EBV
  4. Room air blood gas
  5. Coagulation profile


Imaging studies include:
  1. High resolution CT of the chest
  2. Echocardiogram
  3. Right and left heart catheterization
  4. Lung perfusion scan
  5. Bone density scan
  6. Pap smear/PSA
  7. Bronchoscopy
  8. Pulmonary function tests


HOW DOES THE WAITING LIST WORK FOR LUNG TRANSPLANTATION


The lung allocation system was recently revised in 2016. Each candidate 12 years or older receives an individualized score between 0 to100. The higher the score, the earlier a candidate is likely to receive a transplant in the geographic area of the patient’s residence. Criteria that go into calculating the score is the patient’s medical information (such as lab values, test results and disease diagnosis). The patient’s blood type and the distance from where they live to the hospital where they will receive the transplant are also factored in. This score is used to estimate the severity of the illness and the patient’s chances of success after the transplant has been received.


WHAT SPECIAL DRUGS ARE NEEDED AFTER THE TRANSPLANT

Special medications known as immunosuppressive drugs are started right away after the transplant procedure. These drugs fight the body’s immune system so that the transplanted lung does not suffer a rejection. These drugs are extremely powerful and need to be taken life long in order to avoid rejection. These drugs can themselves cause side - effects such as increased chances of infections, renal dysfunction, cancer, heart and vascular disease, to name a few.

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