Ontario s Referral and Listing Criteria for Adult Lung Transplantation

Transcription

1 Ontari s Referral and Listing Criteria fr Adult Lung Transplantatin Versin 2.0 Trillium Gift f Life Netwrk

2 Adult Lung Transplantatin Referral & Listing Criteria PATIENT REFERRAL CRITERIA: The patient referral criteria are guidelines which a Health Care Prvider wuld utilize t refer a patient t a transplant center fr assessment. In general, referral fr lung transplantatin assessment is advisable when patients have a less than 50%, 2- t 3-year predicted survival r New Yrk Heart Assciatin (NYHA) class III r IV level f functin, r bth. The criteria identified belw are the agreed upn cnditins fr which a patient shuld be referred fr lung transplant assessment. 1) Chrnic Obstructive Pulmnary Disease (COPD): Referral fr lung transplantatin shuld be cnsidered fr patients with a Bdy-Mass Index, Airflw Obstructin, Dyspnea, and Exercise (BODE) index scre f greater than 5. 2) Cystic Fibrsis and Other Causes f Brnchiectasis: Referral fr lung transplantatin shuld be cnsidered fr patients with cystic fibrsis and ther causes f brnchiectasis. Such patients wuld have ne r mre f the fllwing: Frced Expiratry Vlume (FEV1) belw 30% predicted r a rapid decline in FEV1, especially in yung female patients; Exacerbatin f pulmnary disease requiring ICU stay; Increasing frequency f exacerbatins requiring antibitic therapy; Refractry and/r recurrent pneumthrax; r Recurrent hemptysis nt cntrlled by emblizatin. 3) Idipathic Pulmnary Fibrsis and Nn-Specific Interstitial Pneumnia: Referral fr lung transplantatin shuld be cnsidered fr patients with histlgic r radigraphic evidence f Usual Interstitial Pneumnia (UIP) irrespective f vital capacity. Patients with histlgic evidence f fibrtic Nn-Specific Interstitial Pneumnia (NSIP) may als be referred fr lung transplant assessment. 4) Pulmnary Arterial Hypertensin: Patients with a New Yrk Heart Assciatin (NYHA) functinal class f III r IV, irrespective f nging therapy and rapidly prgressive disease, may be referred fr lung transplant assessment. 5) Sarcidsis: Referral fr lung transplantatin shuld be cnsidered fr patients with sarcidsis if they are NYHA functinal class III r IV. 6) Lymphangilei-mymatsis: Referral fr lung transplantatin shuld be cnsidered fr patients with lymphangilei-mymatsis if they are NYHA functinal class III r IV. 7) Pulmnary Langerhans Cell Histicytsis (Esinphilic Granulma): Referral fr lung transplantatin shuld be cnsidered fr patients with pulmnary Langerhans cell histicytsis if they are NYHA functinal class III r IV. 2

3 PATIENT LISTING INDICATIONS: Each patient is assessed individually fr their suitability fr transplantatin by the transplant prgram. The criteria identified belw are the cnditins fr which a patient may be eligible t be waitlisted fr lung transplantatin in Ontari. 1) Chrnic Obstructive Pulmnary Disease (COPD): Listing fr lung transplantatin may be cnsidered fr patients with COPD. Such patients wuld meet the fllwing criteria: Bdy-Mass Index, Airflw Obstructin, Dyspnea, and Exercise (BODE) capacity index f 7-10, r at least ne f the fllwing: Histry f hspitalizatin fr exacerbatin assciated with acute hypercapnia (PCO 2 exceeding 50 mm Hg); Pulmnary hypertensin r cr pulmnale, r bth, despite xygen therapy; r, Frced Expiratry Vlume (FEV1) f less than 20% and either Carbn Mnxide Diffusing Capacity (DLCO) f less than 20% r hmgenus distributin f emphysema. 2) Cystic Fibrsis and Other Causes f Brnchiectasis: Listing fr lung transplantatin may be cnsidered fr patients with cystic fibrsis r ther causes f brnchiectasis. Such patients wuld have ne f the fllwing: Oxygen-dependent respiratry failure; Hypercapnia; r, Pulmnary hypertensin. 3) Idipathic Pulmnary Fibrsis and Nn-Specific Interstitial Pneumnia: Listing fr lung transplantatin may be cnsidered fr patients with idipathic pulmnary fibrsis r nn-specific interstitial pneumnia. Such patients wuld have: Histlgic r radigraphic evidence f UIP and any f the fllwing: A DLCO f less than 39% predicted; A 10% r greater decrement in frced vital capacity (FVC) during 6 mnths f fllw-up; A decrease in pulse ximetry belw 88% during a 6-Minute Walk Test (MWT); r, Hneycmbing n High Reslutin Cmputed Tmgraphy (HRCT) (fibrsis scre f >2). Histlgic evidence f NSIP and any f the fllwing: A DLCO f less than 35% predicted; r, A 10% r greater decrement in FVC r 15% decrease in DLCO during 6 mnths f fllwup. 4) Pulmnary Arterial Hypertensin: Listing fr lung transplantatin may be cnsidered fr patients with pulmnary arterial hypertensin. Such patients wuld have ne f the fllwing: Persistent NYHA class III r IV n maximal medical therapy; Lw r declining 6-MWT; Failing therapy with intravenus epprstenl, r equivalent; Cardiac index f less than 2 liters/min/m 2 ; r, Right atrial pressure exceeding 15 mm Hg. 5) Sarcidsis: Listing fr lung transplantatin may be cnsidered fr patients with sarcidsis. Such patients wuld meet the fllwing criteria: Impairment f exercise tlerance (NYHA functinal class III r IV) and any f the fllwing: Hypxemia at rest; Pulmnary hypertensin; r, Elevated right atrial pressure exceeding 15 mm Hg. 3

4 6) Lymphangilei-mymatsis: Patients with lymphangilei-mymatsis may be cnsidered fr lung transplantatin. Such patients wuld have ne f the fllwing: Severe impairment in lung functin and exercise capacity (e.g., VO 2 max < 50% predicted); r, Hypxemia at rest. 7) Pulmnary Langerhans Cell Histicytsis (Esinphilic Granulma): Patients with pulmnary langerhans cell histicytsis may be cnsidered fr lung transplantatin. Such patients wuld have ne f the fllwing: Severe impairment in lung functin and exercise capacity; r, Hypxemia at rest. 8) General: Patients nt included in the preceding categries but have a pr quality f life (based n the clinical judgment f the care team at the time f assessment) may be cnsidered fr lung transplantatin. ABSOLUTE LISTING CONTRAINDICATIONS: The fllwing are cnditins relating t the lung transplant candidate that cnstitute abslute cntraindicatins t lung transplantatin. As such, they prevent a transplant frm being dne until the cnditin is reslved. 1) Psychscial Issues: Patients must underg a cmplete psychscial evaluatin prir t listing fr transplant. Patients wh display the fllwing are nt candidates fr lung transplantatin: Dcumented nn-adherence r inability t fllw thrugh with medical therapy r ffice fllw-up, r bth; Untreatable psychiatric r psychlgic cnditin assciated with the inability t cperate r cmply with medical therapy; Absence f a cnsistent r reliable scial supprt system; r, Active alchl r ther substance misuse within last 6 mnths. RELATIVE LISTING CONTRAINDICATIONS: The fllwing are cnditins relating t the lung transplant candidate that cnstitute relative cntraindicatins t lung transplantatin. While each patient is evaluated n an individual basis, the presence f ne r mre f the fllwing may preclude a candidate frm being listed n the lung transplantatin wait list. 1) Age: Patients lder than 65 years may nt be eligible fr lung transplantatin. Older patients have less ptimal survival, likely due t cmrbidities, and therefre recipient age shuld be a factr in candidate selectin. Althugh there cannt be endrsement f an upper age limit as an abslute cntraindicatin, the presence f several relative cntraindicatins can cmbine t increase the risks f transplantatin abve a safe threshld. 2) Medical Stability: Patients with critical r unstable clinical cnditins (e.g., shck, mechanical ventilatin r extra-crpreal membrane xygenatin) may nt be eligible fr lung transplantatin. 3) Functinal Status: Patients with severely limited functinal status with pr rehabilitatin ptential may nt be eligible fr lung transplantatin. 4) Infectin: Patients with clnized and highly resistant r highly virulent bacteria, fungi, r mycbacteria infectin may nt be eligible fr lung transplantatin. Patients with nn-curable chrnic extrapulmnary 4

5 infectin including chrnic active viral hepatitis B, hepatitis C, and human immundeficiency virus may nt be eligible fr lung transplantatin. 5) Obesity: Patients with severe besity defined as a bdy mass index (BMI) exceeding 30 kg/m 2 may nt be eligible fr lung transplantatin. 6) Osteprsis: Patients with severe r symptmatic steprsis may nt be eligible fr lung transplantatin. 7) Mechanical Ventilatin: Patients with mechanical ventilatin may nt be eligible fr lung transplantatin. Hwever, carefully selected candidates n mechanical ventilatin withut ther acute r chrnic rgan dysfunctin, wh are able t actively participate in a meaningful rehabilitatin prgram, may be successfully transplanted. 8) Disease: Patients with untreatable advanced dysfunctin f anther majr rgan system (e.g. heart, liver, r kidney) may nt be eligible fr lung transplantatin. Crnary artery disease nt amenable t percutaneus interventin r bypass grafting, r assciated with significant impairment f left ventricular functin, is an abslute cntraindicatin t lung transplantatin, but heart-lung transplantatin culd be cnsidered in highly selected cases. Other medical cnditins that have nt resulted in end-stage rgan damage, such as diabetes mellitus, systemic hypertensin, peptic ulcer disease, r gastresphageal reflux shuld be ptimally treated befre transplantatin. Patients with crnary artery disease may underg percutaneus interventin befre transplantatin r crnary artery bypass grafting cncurrent with the prcedure. 9) Malignancy: Patients with malignancy in the last 2 years, with the exceptin f cutaneus squamus and basal cell tumrs, may nt be eligible fr lung transplantatin. In general, a 5-year disease-free interval is prudent. The rle f lung transplantatin fr lcalized brnchialvelar cell carcinma remains cntrversial. 10) Defrmity: Patients with significant chest wall/spinal defrmity may nt be eligible fr lung transplantatin. 5

6 Versin Cntrl: Name f Dcument Ontari s Referral and Listing Criteria fr Lung Transplantatin Versin 1.0 Created May 2011 Versin 2.0 Updated February 2015 Recmmended Next Review February 2017 Apprved By Prvincial Heart and Lung Wrking Grup Transplant Steering Cmmittee 6