Lung Transplantation - UI Health Care

1

Lung Transplantation2020Tahuanty Peña, MD, MSDivision of Pulmonary, Critical Care and Occupational Medicine

I will not discuss off label use and/or investigational use of the following drugs/devices.

NO relevant financial relationships exist related to this presentation.

Relevant Financial Relationship Disclosure Statement

1

2

2

Objectives

Overview of Lung Transplantation

Lung Transplant at UIHC

Case Studies

Objectives



Case Studies

3

4

3

Who needs a transplant?Severe end stage lung disease

Ineffective/maximal medical therapy

Limited life expectancy (< 2 yrs)

Capable of full rehabilitation post transplantation

Adequate psychosocial profile

Recipient Selection Diseases

Obstructive: Emphysema, Alpha 1 anti-trypsin, COPD

Suppurative: Cystic fibrosis, bronchiectasis

Restrictive: interstitial lung diseases

Vascular: Pulmonary hypertension

5

6

4

Lung function after transplant

4/13/2016 6/6/2018

FVC 1.25 3.36

FVC %Predicted

35% 100%

FEV1 0.29 3.03

FEV1% Predicted

10% 113%

FEV1/FVC 23 90

FEF 25-75% 0.10 3.34

FEF 25-75% % Predicted

4 122

Recipient Selection

J Heart Lung Transplant. 2015 Jan;34(1):1-15. doi: 10.1016/j.healun.2014.06.014. Epub 2014 Jun 26

Absolute Contraindications Recent history of Malignancy.

Untreatable significant organ system dysfunction (heart, liver, kidney, brain) Combined transplantation.

CAD non amenable to revascularization.

Acute Medical instability (non-pulmonary).

Uncorrectable bleeding diathesis.

Chronic infection with highly virulent/resistant microbes.

7

8

5

Recipient Selection


Absolute Contraindications Class II or III obesity (BMI>35).

Non-adherence to medical therapy.

Uncontrolled Psychiatric/Psychological conditions.

Absence of reliable social support.

Poor rehabilitation potential.

Substance abuse or dependence.

Recipient Selection


Relative Contraindications Age >65 Class I obesity (BMI 30-35) Malnutrition, Osteoporosis Prior chest surgery Mechanical Ventilation or ECLS Infections Hepatitis B or C HIV B. Cepacia M. Abscessus

9

10

6

Surgical Choices

Bilateral TransplantMandatory for suppurative lung disease

Preferred for pulmonary HTN

Better choice for younger patients.

Single TransplantExtends a limited donor pool

Shorter operation with fewer peri operative complications

Lung Allocation Score

Replaced prior time-based system.

Active as of May 2005.

Intended to facilitate allocation of available donors (short supply) to individuals with more urgent need.

Patients ≥ 12 years of age.

Has reduced waitlist mortality in IPF, COPD, CF.

11

12

7


FVC Pulmonary Hemodynamics O2 at rest Age BMI DM Functional status 6MW distance Assisted ventilation Creatinine Diagnosis PCO2 Bilirubin


Score from 0 to 100.

Tries to balance severity of illness (risk of mortality) and chances of success following transplant (survival probability).

Provides a rank on waitlist based on blood group.

13

14

8



Donor identified family consents for donation.

Organ offered to programs in a 250 nautical miles radius (Zone A).

1 Offered to patients listed in Zone A, ABO identical.

2 Offered to patients listed in Zone A, ABO compatible.

3 Zone B, ABO identical.

4 Zone B, ABO compatible.

Etc…

15

16

9


17

18

10

Surgery

19

20

11

21

22

12

23

24

13

Adult and Pediatric Lung TransplantsNumber of Transplants by Year and Location

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000N

um

ber

of

tran

spla

nts

Other

North America

Europe

2018JHLT. 2018 Oct; 37(10): 1155-1206

NOTE: 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.

Adult and Pediatric Lung TransplantsNumber of Transplants by Year and Procedure Type

5 7 35 74167

408

709923

110512131391

13921512

15501568

1708178519792018

2228

2583

281129503025

3313

3587

38693852

417740984261

4661

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

Nu

mb

er o

f Tr

ansp

lan

ts

Bilateral/Double Lung

Single Lung

NOTE: 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.

2018JHLT. 2018 Oct; 37(10): 1155-1206

25

26

14

42

30

45

2819

1015

0

6

12

18

24

30

36

0

10

20

30

40

50

60

1-4 5-9 10-19 20-29 30-39 40-49 50+

% o

f Tr

ansp

lan

ts (

red

lin

e)

Nu

mb

er o

f C

ente

rs

Average number of lung transplants per year

Number of centers Percentage of transplants

Adult and Pediatric Lung TransplantsAverage Center Volume (Transplants: January 2004 – June 2017)

2018JHLT. 2018 Oct; 37(10): 1155-1206

Adult Lung TransplantsMajor Diagnoses by Year (Number)

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

Nu

mb

er o

f Tr

ansp

lan

ts

Transplant Year

COPD A1ATD CF IIP ILD-not IIP Retransplant

2018JHLT. 2018 Oct; 37(10): 1155-1206

27

28

15

Europe North America Other0%

20%

40%

60%

80%

100%

% o

f Tr

ansp

lan

ts

Other

Sarcoidosis

Retransplant

Non CF-bronchiectasis

IPAH

ILD-not IIP

IIP

COPD

CF

A1ATD

Adult Lung TransplantsDiagnosis Distribution by Location

(Transplants: January 2004 – June 2017)

2018JHLT. 2018 Oct; 37(10): 1155-1206

Objectives



Case Studies

29

30

16

Lung Transplantation at the University of Iowa

First and only lung transplant program in Iowa

Originally active 1988-1996

Reactivated May 2007

198 lung transplants and counting…

UNOS Zones

73 centers doing adult lung transplants

31

32

17

Multidisciplinary Approach to Transplantation

Pulmonary MedicineThoracic Surgery PharmacyNursingRespiratory TherapyPulmonary RehabilitationSocial WorkNutritionTransplant Financial

University of Iowa Lung Transplantation Program

Thoracic SurgeryKalpaj Parekh, Surgical DirectorJohn KeechEvgeny Arshava

Pulmonary MedicineJulia Klesney-Tait, Medical DirectorMichael EberleinTahuanty PeñaLakshmi Durairaj

Lung Transplant CoordinatorsAbigail MackRebecca HoranDani Slaughter

Transplant PharmacySarah MinnerHeather Bream-Rouwenhorst

Transplant Social WorkEmily MathewsStephanie Rauckhorst

Pulmonary RehabilitationCarol McCaffertyKim EppenJane GreinerJulie Wiebold

Transplant OfficeDebbie HunterKent BeckerRob Huber

Organ Transplant CenterHeart and Vascular Center

33

34

18

— 35 —

Program Highlights

• Kalpaj Parekh, MD hired in August 2006

• Julia Klesney-Tait, MD hired in January 2007

• First transplant May 1, 2007

• 198 patients transplanted

• Medicare approved on April 2, 2009

• Only program in Iowa

• Catchment areao Iowao Nebraskao South Dakotao Western Illinoiso Northern Missourio Southern Minnesota

0

5

10

15

20

25

2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Transplants

UIOWA Survival

35

36

19

0

25

50

75

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Su

rviv

al (

%)

Years

Bilateral/Double Lung (N=40,623)

Single Lung (N=20,034)

Adult Lung TransplantsKaplan-Meier Survival by Procedure Type for Primary

Transplant Recipients

Median survival (years): Double Lung = 7.8; Conditional = 10.2 Single Lung = 4.8; Conditional = 6.5

p<0.0001

(Transplants: January 1992 – June 2017)

2019citation

2019citation

Adult Lung TransplantsFunctional Status of Surviving Recipients by

Karnofsky Score (Follow-ups: January 2010 – June 2018)

0%

20%

40%

60%

80%

100%

1 Year(N = 13,896)

2 Year(N = 11,520)

3 Year(N = 9,510)

Moribund, fatal processes progressingrapidly

Very sick, hospitalization necessary:active treatment necessary

Severely disabled: hospitalization isindicated, death not imminent

Disabled: requires special care andassistance

Requires considerable assistance andfrequent medical care

Requires occasional assistance but isable to care for needs

Cares for self: unable to carry on normalactivity or active work

Normal activity with effort: somesymptoms of disease

Able to carry on normal activity: minorsymptoms of disease

Normal, no complaints, no evidence ofdisease

37

38

20

Objectives



Case Studies

IPF

71 y/o male

Diagnosed with IPF in 2016.

First transplant clinic 3/2017.

Declined for transplant at 2 other centers in the region.

O2: 4lpm at rest, 10lpm with activity.

BMI 34

CAD: 50% LAD, 50% RCA.

39

40

21

IPF

Decision to list for a SLT.

Weight loss to a BMI<30.

Listed 8/2017, Txp 9/2017

CF 32 y/o male with CF (2008)

BMI 20

Multiple exacerbations per year

2lpm at rest, 4lpm with activity

Listed for BLT

Transplanted on Jan/2008

41

42

22

CF

COPD

54 y/o female with COPD

FEV1 0.56L

PCO2 – 62

4lpm at rest, 6lpm with activity

CAD: 80% occlusion of LAD, stent placed.

Hepatitis C positive, underwent treatment.

Listed for txp on 4/2014, transplanted on 8/2015.

43

44

23

LAM 28 y/o female with

Lymphangiomyomatosis

Dx while pregnant in 2008

Rapid decline after stopping sirolimus for txp.

6lpm at rest, 15lpm with activity.

Listed on Jan/2011, transplanted on May/2011

Waited for Txp in the hospital, 4 chest tubes, 10lpm at rest.

LAM

45

46

24

Melanie P. Lung Transplant 2011

Andrea S. Lung Transplant 2011Lance S. Lung Transplant 2014

Andrea S. Lung Transplant 2011Lance S. Lung Transplant 2014

47

48

25

Don R. Lung Transplant 2013

Destiny R. Lung Transplant 2009

49

50

26

2016 Annual Picnic- Lung recipients

51

52

27

Thank You

53

Lung Transplantation - UI Health Care

Documents

Transcript of Lung Transplantation - UI Health Care