LUNG TRANSPLANTATION LUNG TRANSPLANTATION and PULMONARY FIBROSISand PULMONARY FIBROSIS

Maria L. Padilla, MDMaria L. Padilla, MDAssociate Prof. of MedicineAssociate Prof. of MedicineDirector of ILD/IPF and Advanced Lung Disease Director of ILD/IPF and Advanced Lung Disease ProgramProgramMSSM/MSMCMSSM/MSMC

Organ TransplantationOrgan Transplantation

Lung Transplantation and IPFLung Transplantation and IPF

• Important Questions:– What is it?– Why?– For Whom?– When?– How?– What are the results?

Lung Transplantation and IPFLung Transplantation and IPF

• What is Lung Transplantation?

The operation that replaces diseased, failing lungs with a functional organ.

Lung Transplantation and IPFLung Transplantation and IPF

• Thoracic Transplantation– Heart-Lung Transplantation– Single Lung Transplantation– Bilateral Lung Transplantation– Lobar Transplantation

Lung Transplantation and IPFLung Transplantation and IPF

• WHY?

It offers the opportunity to return to a better functional capacity when all medical therapies have been ineffective.

Ultimate form of treatment

Lung TransplantationLung Transplantation

• Process:– Referral– Evaluation– Listing with UNOS– Waiting time– Transplantation– Post transplantation care

Lung Transplantation and IPFLung Transplantation and IPF

• For whom?– Candidate Selection

• Age less than 65y• Absence of other organ dysfunction• Non-smoker, non-drinker, no drug abuse• Appropriate weight• Good support system• Stable psychosocial and emotional status

Lung TransplantationLung Transplantation

• CANDIDATE EVALUATION– Blood type, biochemical panel, serologies– Renal function determination– Skin testing and sputum cultures– PFT’s , ABG’s, 6-min walk, +/-exercise tests– Imaging: CXR, HRCT, V/Q, bone

densitometry– Cardiac tests: echo; stress tests; RHC with

hemodynamics and LHC where indicated

Lung Transplantation and IPFLung Transplantation and IPF

• When?

When patient is:

medically

physically

psychologically/emotionally,

READY! and lungs become available

Lung TransplantationLung Transplantation

• LESS THAN 20% OF DONORS ARE SUITABLE LUNG DONORS:– AGE AND SMOKING HX EXCLUDE SOME– LUNGS ARE FRAGILE--EDEMA, INFXN,

VENTILATOR COMPLICATIONS– ALLOGRAFT INTOLERANCE TO

PROLONGED ISCHEMIA

Lung Transplantation and IPFLung Transplantation and IPF

• When lungs become available, they are offered on the basis of:– Time on the waiting list

• No consideration for severity of illness or urgency– Exception: 90 d credit when IPF patient listed

– Blood type– Lung size– Other factors (?)

Lung Transplantation and IPFLung Transplantation and IPF

• While on Waiting List:– Adhere to medical treatment– Participate in pulmonary rehabilitation– Maintain good nutrition and acceptable body

weight– Attend support groups– Keep a positive attitude and visualize a

brighter tomorrow

Lung TransplantationLung Transplantation

• Registry:– United Network for Organ Sharing and the

Organ Procurement and Transplantation Network (UNOS/OPTN)

– 1988-2000– 7764 lung transplants (7625 C, 139 LD)– 719 heart-lung transplants

• Data as of Nov. 2000

Lung TransplantationLung Transplantation

Lung Transplantation and ILDLung Transplantation and ILD

• Activity (SLT and BLT)- 1988-1999– IPF (LD 5) 972– SARCOIDOSIS 148– PF (OTHER) 82– LAM 47– OB (non-retransplant) 46– OCCUP. LUNG DIS. 11– RHEUMATOID DIS. 5

• From UNOS/OPTN data as of 2/17/2001

Lung Transplantation and IPFLung Transplantation and IPF

• Idiopathic Pulmonary Fibrosis– Waiting time too long for some patients– At risk for developing 2* PHN– Prior Thoracic surgeries (OLB, Ptx)– High frequency of osteoporosis, obesity– Documented survival benefit

– H-L, 2.9%; BLT, 7.1%; SL, 19.5% (ISHLT)

Lung Transplantation-IPFLung Transplantation-IPF

Lung Transplantation-IPFLung Transplantation-IPF

Lung TransplantationLung Transplantation

• Issues and complicating factors– Need for chronic immunosuppression– Acute and chronic rejection– Infection– Side effects of medicines

– Cost of procedure and follow up care

Lung Transplantation and ILDLung Transplantation and ILD

• IMPROVED FUNCTIONAL STATUS

• IMPROVED PHYSIOLOGY(pulm+ cv)

• SURVIVAL BENEFIT (IPF)

• COMPARABLE INCIDENCE OF AR, CR INFECTION

• IMPROVED QUALITY OF LIFE

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0%

20%

40%

60%

80%

100%

1 Year 3 Years 5 Years

No Activity Limitations Performs with Assistance Total Assistance

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Lung Transplantation and IPF/ILDLung Transplantation and IPF/ILD

• LT is a therapeutic modality of great value

• Efforts to overcome LT limitations needed:– Increase donor pool--review criteria

• Living donors---Lobar transplantation

– Prevent CR-improve treatment

• Earlier listing of candidates with ILD/IPF

• Explore new therapies as bridge to LT– New IPF paradigm