Chapter 292 - Lung Transplantation

Question 1

Most common indications for Lung transplantation in recent years in decreasing order of frequency

Answer 1

IPF (30%)
COPD (27%)
CF (15%)
a1 AT (3%)
IPAH (2.5%)

Question 2

primary motive for transplantation for many patients

Answer 2

QOL

Question 3

Conditions such as systemic hypertension, diabetes mellitus, gas- troesophageal reflux, and osteoporosis are not unusual, but if uncom- plicated and adequately managed, they do not disqualify patients from transplantation.

Answer 3

True

Question 4

Upper age limit at most centers for Lung Transplant

Answer 4

70-75yo

Question 5

Standard exclusions of Lung Transplant

Answer 5

• HIV infection
• chronic active hepatitis B or C - uncontrolled or untreatable pulmonary or extrapulmonary infection
• uncured malignancy
• active cigarette smoking
• drug or alcohol dependency
• irreversible physical deconditioning
• chronic nonadherence with medical care
• significant disease of another vital organ (e.g., heart, liver, or kidney)
• psychiatric or psychosocial situations

Question 6

If the potential recipient is allosensitized with antibodies to any human leukocyte antigen (HLA), the donor also has to be HLA compatible.

Answer 6

True

Question 7

most lungs are procured from where?

Answer 7

deceased donors after brain death

Question 8

How many percent of brain death organ donors yielding or two lungs suitable for lung transplant

Answer 8

only 20%

Question 9

Patient groups according to the Lung Allocation Score system for LT

Answer 9

A - COPD and emphysema
B - IPAH
C - CF
D - IPF

Question 10

What is the basis of the Lung Allocation Score system

Answer 10

risk of death during 1 year on the waiting list and tlikelihood of survival for 1 year after transplantation

Question 11

Which patient group has the highest LAS score?

Answer 11

D

Question 12

In 2014, 50% of the patients on the waiting list were in group D What is the median waiting time to transplantation?

Answer 12

3.7 months

Question 13

Overall death rate on the wait list

Answer 13

10 per 100 waitlist years

Question 14

death rate on the waitlist for lung transplant by diagnostic group

Answer 14

A, 4
B, 11
C, 12
D, 18

Question 15

Which Transplant procedure is mandatory for Cystic Fibrosis and other forms pdf bronchiectasis?

Answer 15

Bilateral transplantation

Question 16

Which Transplant procedure is obligatory for Eisenmenger syndrome with complex anomalies?

Answer 16

Heart-lung transplantation

Question 17

this interleukin-2 receptor antagonist is the widely used drug for induction therapy

Answer 17

Basiliximab

Question 18

Maintenance immunosuppressive regimen includes which agents?

Answer 18

calcineurin inhibitor
purine synthesis antagonist
prednisone

Question 19

The most commonly used maintenance immunosuppressive regimen for lung transplant recipients

Answer 19

Tacrolimus
Mycophenolate
Prednisone

Question 20

After lung transplantation, if recovery is uncomplicated, lung function rapidly improves and then stabilizes how many months after transplantation?

Answer 20

3-6 months

Question 21

Sustained decline by how much of the spirometric measurement signals a potentially significant problem post lung transplant?

Answer 21

≥10–15%

Question 22

Median survival for Lung transplant recipients

Answer 22

IPF 4.7 years
COPD 5.5 years
IPAH 5.7 years
Sarcoidosis 6.1 years
CF 8.6 years

Question 23

Long-term survival has been significantly better after bilateral transplantation than after unilateral transplantation for all of the major indications

Answer 23

True

Question 24

Median survival for lung transplant recipients by age

Answer 24

18–49 years: 7.2 years
50–59 years: 5.5 years
≥60 years: 4.5 years

Question 25

What are the three parameters of the recipients with the lowest survival rates?

Answer 25

group D ≥65 years old had an LAS ≥60

Question 26

Causes of death after lung transplantation during the first 30 days.

Answer 26

``` graft failure (24%) infection (19%) cardiovascular events (11%) technical problems (11%) ```

Question 27

Causes of death after lung transplantation during the remainder of the first year

Answer 27

Infection 37% | Graft failure 17%

Question 28

Causes of death after lung transplantation AFTER the first year

Answer 28

bronchiolitis and other forms of late graft failure 40–45% infection 16–20%.

Question 29

FACTORS associated with an increased risk of death in the first year AFTER transplantation

Answer 29

- Hospitalized during transplantation - supported by mechanical ventilation - extracorporeal membrane oxygenation - dialysis at the time of transplantation - undergoing retransplantation

Question 30

Mortality risk have been higher at centers with an annual volume below?

Answer 30

below 30 transplants/year

Question 31

T/F | After bilateral transplantation, pulmonary function tests are typically normal.

Answer 31

True

Question 32

The average length of stay after bilateral transplantation in the United States days

Answer 32

29.5 days

Question 33

Rehospitalization rate in the first year after transplntation is higher than any other solid organ transplant except intestine.

Answer 33

True

Question 34

Complication of Lung transplantation presenting with diffuse pulmonary infiltrates and hypoxemia within 72 h of transplantation

Answer 34

Primary graft dysfunction

Question 35

Severity of Primary graft dysfunction based on PF ration

Answer 35

Grade 1: >300 Grade 2: 200-300 Grade 3: <200

Question 36

Complication of Lung transplant caused by T lymphocyte inter- actions with donor alloantigens, mainly in the major histocompatibility

Answer 36

Acute Cellular rejection

Question 37

Incidence of acute cellular rejection is highest when?

Answer 37

6-12 months after transplant

Question 38

Diagnosis of ACR after transplantation is confirmed how?

Answer 38

transbronchial biopsies showing lymphocytic infiltrates around arterioles or bronchioles

Question 39

At what grade of ACR is treatment started regardless of the clinical situation

Answer 39

≥A2

Question 40

Lung transplantation complication occurring when lung function never reaches expected values due to early complications or when there is a sustained decrement in lung function below previously normal baseline measurements

Answer 40

Chronic Lung Allograft Dysfunction

Question 41

CLAD must persist how many weeks before diagnosis is entertained?

Answer 41

≥3 weeks

Question 42

2 types of CLAD

Answer 42

Bronchiolitis obliterates syndrome Restrictive Allograft Syndrome

Question 43

Severity of BOS )is cat- egorized by the decrement in FEV1 from the average of the two best posttransplant values

Answer 43

20–35%, stage 1; 35–50%, stage 2; >50%, stage 3

Question 44

Median survival after onset of BOS

Answer 44

3-4 years

Question 45

Median survival of RAS

Answer 45

1.5 years

Question 46

Which CLAD FEV1 <80% Air trapping is usually present with minimal, if any, infiltrates

Answer 46

BOS

Question 47

Which CLAD FEV 1 <80% TLC <90%

Answer 47

RAS

Question 48

Which CLAD Infiltrates are usually present ± air trapping ± bronchiectasis

Answer 48

RAS

Question 49

Criteria for Humoral/Antibody mediated rejection

Answer 49

1. graft dysfunction 2. serologic detection of donor-specific antibodies, 3. pathologic pattern of graft injury with evidence of antibody deposition

Question 50

2 most common organisms in bronchitis with BOS

Answer 50

pseudomonas aeruginosa MRSA

Question 51

Most common complication of lung transplantation related to the side effect of the immunosuppressive drugs

Answer 51

Hypertension

Question 52

Referral for Evaluation for COPD

Answer 52

Progressive Sx FEV1 <25% PaO2 <60 or PaCO2 >50 BODE 5-6

Question 53

Listing for transplantation for COPD

Answer 53

- BODE ≥7 - FEV1 <15–20% - Moderate to severe pulmonary hypertension - 3 or more severe exacerbations in preceding year - One severe exacerbation with acute hypercapnic respiratory failure

Question 54

Referral for evaluation for IPF

Answer 54

- Pathologic or radiographic evidence of UIP or NSIP - FVC <80% or DLCO <40% - Dyspnea or functional limitation - Any oxygen requirement (rest or exercise)

Question 55

Listing for transplantation for IPF

Answer 55

- Decrement in FVC ≥10% or in DLCO >15% during 6 months of follow-up - Pulmonary hypertension - Desaturation to SpO2 <88% during 6-min walk test - 6-min walk test distance <250 m or decrement >50 m over 6 months - Hospitalization for acute exacerbation