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An update on lung transplantation

Julia Fuller, Andrew J. Fisher
Breathe 2013 9: 188-200; DOI: 10.1183/20734735.001913
Julia Fuller
1Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne
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Andrew J. Fisher
1Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne
2Institute of Cellular Medicine, Newcastle University Medical School, Newcastle Upon Tyne, UK
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  • For correspondence: a.j.fisher@newcastle.ac.uk
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  • Figure 1
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    Figure 1

    The number of adult lung transplants reported to the ISHLT each year since 1985. Reproduced from [1] with permission from the publisher.

  • Figure 2
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    Figure 2

    Photographs taken at bronchoscopy to show a) anastomotic narrowing due to organised mucous plug and b) the final result after bronchial toileting.

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    Figure 3

    A chest radiograph depicting an episode of acute rejection.

Tables

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  • Table 1 Disease-specific indication for transplant
    DiagnosisIncidence (n total = 34 102)
    COPD/emphysema11 587 (34.0%)
    Idiopathic pulmonary fibrosis7925 (23.2%)
    Cystic fibrosis5688 (16.7%)
    Alpha-12073 (6.1%)
    Idiopathic pulmonary arterial hypertension1064 (3.1%)
    Pulmonary fibrosis, other1157 (3.4%)
    Bronchiectasis945 (2.8%)
    Sarcoidosis865 (2.5%)
    Re-transplant: obliterative bronchiolitis513 (1.5%)
    Connective tissue disease421 (1.2%)
    Obliterative bronchiolitis (not re-transplant)351 (1.0%)
    LAM363 (1.1%)
    Re-transplant: not obliterative bronchiolitis357 (1.0%)
    Congenital heart disease293 (0.9%)
    Cancer34 (0.1%)
    Other466 (1.4%)
    • Data are presented as n (%) of a total 34,102. LAM: lymphangioleiomyomatosis. Table reproduced from [1] with permission from the publisher.

  • Table 2 Absolute and relative contraindications for transplant
    Absolute contraindications to lung transplantationRelative contraindications to lung transplantation
    Active malignancy within the last 2 to 5 years dependent on tumour type# Advanced, untreatable disease of any other organ system Non-curable, chronic extra-pulmonary infection Significant chest wall or spinal deformity Documented non-concordance with therapy Untreatable psychiatric or psychological condition associated with the inability to concord with treatment No reliable social support Substance addiction including smoking (currently or within the last 6 months)Age >65 years Poor functional status with low potential for rehabilitation Colonisation with highly resistant micro-organisms Obesity (BMI >30) Severe symptomatic osteoporosis Mechanical ventilation
    • #: not including basal/squamous cell skin carcinomas.

  • Table 3 ISHLT Consensus for the “ideal” lung donor
    Age <55 years
    ABO compatibility
    Clear chest radiograph
    PaO2 >40 kPa (FiO2 100% and 5 cmH2O PEEP)
    Smoking history <20 pack years
    Absence of chest trauma
    No evidence of aspiration or sepsis
    No prior cardiopulmonary surgery
    Absence of organisms on sputum Gram stain
    Absence of purulent secretions at bronchoscopy
  • Table 4 Common post-transplant infections, their sequelae and management
    Post-transplant infectionClinical features
    Pseudomonas aeruginosa
    • Can cause asymptomatic colonisation, infective exacerbations or pneumonia

    • Occurs anytime but especially in the first year

    • Colonised patients often treated with maintenance nebulised antibiotics

    • Associated with increased risk of developing Bronchiolitis Obliterans Syndrome

    Cytomegalovirus
    • Can cause primary infection or re-activation in a previously infected host

    • Typically occurs in first few months, though the first year carries greatest risk

    • Higher risk recipients given anti-CMV prophylaxis for 3–6 months after transplant

    • Associated with increased risk of developing bronchiolitis obliterans syndrome

    Epstein-Barr virus
    • Re-activation most common within the first year when immunosuppression at highest levels

    • Reactivation known to drive development of post-transplant lymphoproliferative disorder (PTLD)

    </item-list>
    Aspergillus
    • Can cause asymptomatic colonisation, airway infection, invasive or cavitatory disease

    • Occurs anytime but especially in the first year

    • Those colonised with Aspergillus pre-transplant require anti-fungal prophylaxis for 6–12 weeks after transplant

    • Data taken from [16, 17].

  • Table 5 Classification of transbronchial lung biopsy results
    Classification systemInterpretation
    A0No evidence of acute rejection
    A1Minimal acute cellular rejection
    A2Mild acute cellular rejection (treatment required)
    A3Moderate acute cellular rejection
    A4Severe acute cellular rejection
    B0No airway inflammation
    B1RMild airway inflammation
    B2RModerate–severe airway inflammation
    C0No evidence of obliterative bronchiolitis
    C1Presence of obliterative bronchiolitis
  • Table 6 Stages of bronchiolitis obliterans syndrome
    BOS stageLung Function parameters
    BOS-0FEV1 >90% and FEF25–75 75% of baseline
    BOS-0pFEV1 81–90% and FEF25–75 <75% of baseline
    BOS-1FEV1 66–80% of baseline
    BOS-2FEV1 51–65% of baseline
    BOS-3FEV1 <50% of baseline
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An update on lung transplantation
Julia Fuller, Andrew J. Fisher
Breathe Mar 2013, 9 (3) 188-200; DOI: 10.1183/20734735.001913

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An update on lung transplantation
Julia Fuller, Andrew J. Fisher
Breathe Mar 2013, 9 (3) 188-200; DOI: 10.1183/20734735.001913
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  • Article
    • Abstract
    • What does lung transplant offer patients with advanced lung disease?
    • Who should be referred for lung transplant assessment and when?
    • What are the disease specific indications for referral for lung transplant assessment?
    • How are suitable donor lungs identified for patients on the waiting list?
    • What can be done to increase the availability of donor lungs for transplantation?
    • How do airway complications present after lung transplantation?
    • What are the common infections seen after lung transplantation?
    • How is immunosuppressive therapy used after lung transplant?
    • What are the long-term consequences of immunosuppressive therapy use?
    • How does lung transplant rejection present and what can be done for it?
    • What new on the horizon for lung transplantation?
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    • References
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