שקופיות נבחרות למתמחים.

שקופיות נבחרות למתמחים. -2013

History of Lung Transplantation First LTx performed in 1963 prisoner with Ca Lung survived 18 days ( died of renal failure) 36 LTx from 1963-1974 2 survived > 1 month Cyclosporine developed in the 1970 s First successful HLTx in 1981** LTx is now an accepted option for end-stage lung disease

NUMBER OF LUNG TRANSPLANTS REPORTED BY YEAR AND PROCEDURE TYPE ISHLT 2012 J Heart Lung Transplant. 2012 Oct; 31(10): 1045-1095 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.

WHO to refer for lung transplantation?

General Indications Predicted survival benefit from transplantation Quality of life also an important consideration Less than 50%, 2- to 3-year predicted survival or NYHA class III or IV level of function or both

Contraindications *Dysfunction of major organs other than the lung Kidneys: CrCl<50mg/ml/min Heart: consider CABGS/Angioplasty *Active malignancy within the last 2 years except BCC and SCC of the skin 5 years for extracapsular renal cell cancer, Ca Breast stage 2, Ca Colon > Dukes A, Melanoma Recent malignancy we may consider if very favorable prognosis *Active infection with HIV,HBV,HCV (+histological evidence of damage) *Drug/Alcohol abuse

RELATIVE contraindications Age>65 Critical or unstable clinical condition (e.g., shock, mechanical ventilation or ECMO) Severely limited functional status with poor rehabilitation potential Colonization with highly resistant or highly virulent bacteria, fungi, or mycobacteria BMI <70% or >130% ideal Psychiatric disease affecting comprehension and compliance Colonization by Burkholderia cepacia genomovar-3

Increased risk by other medical condition: Severe or symptomatic osteoporosis. DM GERD IHD Prior thoracic surgery and pleurodesis

Contraindications? Chronic hepatitis or HIV Other untreatable advanced organ dysfunction but combined transplant may be possible The role of lung transplantation for localized bronchoalveolar cell carcinoma remains controversial

Referral vs. Listing Referral: no downside to early referral! Optimize suitability for lung transplant (weight reduction, taper steroids, rehab) Educate patient on outcomes and commitments Complete evaluation testing Listing When patient imminently needs and wants a transplant ( when the lung disease limits basic activities and pose a high risk of death in the short term ) New guidelines include when to refer and when to transplant (JHLT 2006 25:745-755)

ADULT LUNG TRANSPLANTS Indications for Single Lung Transplants (Transplants: January 1995 - June 2011) ISHLT 2012 J Heart Lung Transplant. 2012 Oct; 31(10): 1045-1095

ADULT LUNG TRANSPLANTS Indications for Bilateral/Double Lung Transplants (Transplants: January 1995 - June 2011) ISHLT 2012 J Heart Lung Transplant. 2012 Oct; 31(10): 1045-1095

Type of Lung Transplantation Unilateral Bilateral, sequential Interstitial Fibrosis Bronchiectasis COPD Cystic Fibrosis Pulmonary Hypertension COPD (young patients) Pulmonary Hypertension Eisenmenger s Syndrome (correctable) Heart Lung transplant Living donor bi lobar

ADULT LUNG TRANSPLANTS Kaplan-Meier Survival (Transplants: January 1994 - June 2010) p < 0.0001 ISHLT 2012 J Heart Lung Transplant. 2012 Oct; 31(10): 1045-1095

ADULT LUNG TRANSPLANTS Kaplan-Meier Survival by Era (Transplants: January 1988 - June 2010) 1988-95 vs. 1996-2003: p < 0.0001 1988-95 vs. 2004-6/2010: p <0.0001 1996-2003 vs. 2004-6/2010: p <0.0001 ISHLT 2012 J Heart Lung Transplant. 2012 Oct; 31(10): 1045-1095

ADULT LUNG TRANSPLANTS Kaplan-Meier Survival by Diagnosis Conditional on Survival to 3 Months (Transplants: January 1990 - June 2010) All comparisons are statistically significant at 0.05 except Alpha-1 vs. COPD and CF vs. IPAH ISHLT 2012 J Heart Lung Transplant. 2012 Oct; 31(10): 1045-1095

ADULT LUNG TRANSPLANTS Kaplan-Meier Survival by Diagnosis Conditional on Survival to 1 Year (Transplants: January 1990 - June 2010) All comparisons are statistically significant at 0.05 except Alpha-1 vs. Sarcoidosis, CF vs. IPAH and COPD vs. IPF ISHLT 2012 J Heart Lung Transplant. 2012 Oct; 31(10): 1045-1095

COPD

Prognostic Factors: BODE Criteria Recurrent hospitalizations with CO2 retention (less then 49% 2 years survival) Severity of hypoxemia and CO2 retention DLCO decrease General condition and BMI reduction. Homogenous emphysema with FEV1 and DLCO less then 20% of predicted.

50% of COPD patients undergoing single lung Tx and 66% DL Tx will have survival benefit Nearly 80% of COPD with FEV1 less then 16%,and 11% of COPD with FEV1 >25% are predicted to gain at least a year of life with DL Tx

Summary of guidelines for COPD Referral: BODE > 5 Transplantation: BODE 7-10 OR at least one of the following: History of hospitalization for exacerbation with acute hypercapnia Pulmonary hypertension and/or cor pulmonale despite oxygen therapy FEV1<20% and either DLCO<20% or homogenous distribution of emphysema

ADULT LUNG TRANSPLANTS Kaplan-Meier Survival By Procedure Type (Transplants: January 1990 - June 2010) Diagnosis: Emphysema/COPD p < 0.0001 ISHLT 2012 J Heart Lung Transplant. 2012 Oct; 31(10): 1045-1095

Interstitial Lung Disease

IPF: Guidelines for Transplantation DLco < 39% predicted 10% or greater fall in FVC over 6 months Decrease in O2 sat to 88% on 6MWT Honeycombing on HRCT (fibrotic score > 2) Practice :Refer to transplant center when you think to start treatment.

CYSTIC FIBROSIS

Median survival increased from less then 16 years to more then 35 years. Controversial about lung transplant survival benefit.

CF WHEN to Refer for Transplant? FEV1 below 30% predicted or a rapid decline in FEV1 in particular in young female patients 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

CF WHEN to Transplant? Oxygen-dependent respiratory failure Hypercapnia Pulmonary hypertension

PULMONARY ARTERIAL HYPERTENSION

Lung Transplantation Number of LT for PH has declined in the last 10 years Now indicated for PPH, CTEPH and PVOD who fail medical treatment Highest early and late mortality

PAH Guidelines for Referral NYHA functional class III or IV, irrespective of ongoing therapy Rapidly progressive disease

PAH Guidelines 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

To Summarize WHO Guidelines have changed Practices are still changing WHAT Lung disease compromising function and survival WHEN (by Diagnosis) Early referral is best List when survival is likely to be improved by transplant or for very poor quality of life? WHY Transplant saves lives, and makes them better

85% 50-80% 35% 28-40% 30% דיספנאה במאמץ פנאומוטורקס ספונטני תפליט פלאורלי המופטיזיס אנגיומיוליפומות

D.D.-Cystic lung disease LAM-Diffuse round bil. Thin walled cysts of varying sizes. internal septa in the border of the cyst-never seen plch-thicker walled cysts, mid and upper lung zone, more irregularly shaped. nodular changes Emphysema-Upper lung zone. internal septa in the border of the cyst >SJorgen's, CASTLEMAN'S, Follicular bronchiolitis,lymphocytic interstitial pneumonitis, Hypersensitivity pneumonitis, Amyloidosis,Lymphoma,Light chain deposition dis, Bronchopulmonary dysplasia/barotrauma, Metastaic:genitourinary,leiomyoma/leioyomyosarcoma

Pathology Macro cystic honeycomb appearance pale, sausage-like thoracic duct Micro proliferation of smooth muscle cells in the thorax and abdomen Immunohistochemistry α-smooth actin and desmin HMB-45 (+)

Diagnosis Indication for lung biopsy (isn t always necessary)-cystic pulmonary changes without corroborating features of known TSC or angiomyolipoma. In smokers lung biopsy may be required to distinguish LAM from emphysema and plch. TBB with HMB-45 stain

Treatment Hormonal manipulation: Effective:Medroxyprogesterone, Progesterone, oopho-rectomy + progesterone therapy Mixed results:tamoxifen, GnRH agonist Lung transplantation: Recurrence has been described in allografts (thus progesterone therapy is continued in some patient after transplant )

Treatment Sirolimus: Rapamycin complex 1 inactivator. FEV1 and FVC improvement, but no difference on DLCO and 6 min walk

89 חולות חולקו לשתי קבוצות פלסבו מול סירולימוס. שיעור החולות שהראה שיפור ב- FEV1 היה גבוה יותר משמעותית בקבוצת הסירולימוס. החמרה ב- FEV1 נצפתה משמעותית יותר בקבוצת הפלסבו. לא נמצא הבדל בין קב' הטיפול לקב' הפלסבו בדיפוזיה ובמבחן 6 ד' הליכה. בשנת המעקב )ללא טיפול( הייתה ירידה ב- FEV1 בשתי הקבוצות.

PAP-Pulmonary Alveolar Proteinosis

PAP-Pulmonary Alveolar )Phospholipo)proteinosis Heterogeneous group sharing a common pathology of alveolar lipoproteinaceous exudates and having in common an alteration of the surfactant metabolism 1.Congenital (2%) 2.Secondary (<10%) 3.Acuired/Adult/Idiopathic (90%)

Epidemiology Worldwide Incidence:0.37/100,000. Prevalence:3.7/1,000,000 Median age at diagnosis-40 years Men>Women 75% smoking history

Pathophysiology Idiopathic: Defect of alveolar macrophages in processing the surfactant proteins. Impaired response to GM-CSF Neutralizing IgG antibodies against GM-CSF (The sensitivity of serum anti GM CSF is 100% and specificity 100% when cutoff value of 1:400)

Treatment: