Lung Transplantation

Question 0

Median survival after lung transplant?

Answer 0

5 years.

Question 1

The “big 4” indications for lung transplant?

Answer 1

End stage COPD.
IPF.
CF.
Pulmonary HTN.

Question 2

Does lung transplantation improve survival?

Answer 2

It depends on the indication.
For CF, yes - net benefit after 30 days.
For emphysema, no, there doesn’t seem to be a benefit in mortality.
(But mortality =/= quality of life)

Question 3

Does lung transplant improve quality of life?

Answer 3

Yes… (lecture didn’t show data about before vs. after, but people do pretty well afterward)

Question 4

How does IPF prognosis relate to when you should refer for transplant?

Answer 4

In IPF, you should refer right away - declines in IPF can be precipitous.

Question 5

Why is a ventilation-perfusion scan useful when evaluating for transplant?

Answer 5

Can help determine if you can do a single lung transplant.

Question 6

Some absolute contraindications for lung transplant?

Answer 6

After 66th birthday for double-lung, after 71st birthday for single-lung Txp.
Lung infection.
Systemic diseases (e.g. scleroderma).
Extremes of weight (BMI < 15 or > 35).
CAD or LV dysfunction.
Other organ failure.

Question 7

What’s the lung allocation score? What is it based upon?

Answer 7

LAS is a measure of how much a patient would be expected to benefit from from transplant, in terms of life expectancy.
(but, given that QoL can improve without increased life expectancy, this may be problematic)

Question 8

Why might giving a single lung transplant for IPF be tricky?

Answer 8

If the PVR is too high, all the blood flow will go to the new lung… and destroy it.

Question 9

Most complications of lung transplant have to do with…

Answer 9

Immunosuppression (infections / malignancy) or rejection.

Question 10

What’s the timeframe for primary lung rejection?
What’s the problem?
How common a problem is this?

Answer 10

Lungs rejected within 72 hours.
Due to injury from ischemia / reperfusion (due to explant, transport, storage).

This happens in 10-25% of cases.

Question 11

3 reasons why anastomoses from lung txp have trouble healing?

Answer 11

Steroids.
Ischemic time.
Hypotension.

Question 12

5 complications that can happen to anastomoses post lung txp?

Answer 12

Dehiscense (stitches unravel).
Malacia. (softening)
Stenosis.
Granulation.
Infection (esp. aspergillus).

Question 13

How does chronic rejection of a lung transplant manifest, pathologically speaking?
Typical time to onset?

Answer 13

Bronchiolitis Obliterans Syndrome (BOS).

Onset is in months to years - it’s heterogenous.

Question 14

Histologic appearance of bronchiolitis obliterans syndrome (BOS)?

Answer 14

Airway obstruction due to: Lymphocytic infiltrate, fibrosis, and granulation tissue.

Question 15

Treatment for post-transplant BOS?

Answer 15

Re-transplantation… which is ethically fraught.

Question 16

Ex-vivo lung perfusion is cool.

Answer 16

Yeah, and it even seems to work well.