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Lung transplantation 

Lung transplantation

Chapter:
Lung transplantation
Author(s):

P. Hopkins

and K. McNeil

DOI:
10.1093/med/9780199204854.003.1816_update_002

Update:

Lung donors—use of donation after cardiac death (DCD) and ex-vivo lung perfusion.

Surgical technique—discussion of approach to patients with severe lung hyperinflation.

Prevention of infection—new recommendations on prophylaxis against CMV after donor positive/recipient negative transplantation.

Transplant rejection—description of acute humeral rejection.

Updated on 30 May 2013. The previous version of this content can be found here.
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date: 24 April 2017

Lung transplantation offers the only therapeutic option for many patients with a variety of endstage pulmonary and cardiopulmonary diseases, but donors are scarce and the major challenge facing lung transplantation (as with all solid organ transplants) is the critical shortage of donor organs.

Recipient selection—emphysema/chronic obstructive pulmonary disease (COPD), cystic fibrosis, idiopathic pulmonary fibrosis, and pulmonary vascular disease are the main disease groups referred for lung transplantation. Most patients are listed for transplantation when their survival is estimated to be less than 2 years without a transplant. Exclusion criteria include malignancy (excluding localized skin malignancies) within the last 2 years, inability to cooperate or comply with medical therapy/instruction, recent substance addiction, active or noncurable extrapulmonary infection, significant chest wall/spinal deformity, and significant extrathoracic organ dysfunction.

Donor selection—most organs come from cadaveric donors who have sustained brainstem death, are free of systemic infection and disease, and who have satisfactory lung function (arterial oxygen level ≥35 kPa (300 mmHg) on 100% inspired O2, with airways free of purulent secretions, and chest radiograph free of consolidation). Increasingly however, more liberal acceptance criteria are being applied along with the use of lungs from non-heart beating donors, in an attempt to overcome the critical shortage of donor lungs. Donor/recipient matching is on the basis of ABO blood group, as in blood transfusion practice, and size.

Transplant (surgical) procedure—three types of transplant are performed: (1) single lung transplantation, (2) bilateral sequential single or double lung transplantation (required for septic lung diseases and preferred for younger patients with COPD), and (3) heart–lung transplantation (required for Eisenmenger’s syndrome or those with concurrent decompensated right heart failure).

Immediate post-transplantation management—important issues are early extubation, fluid (crystalloid) restriction and diuresis, early mobilization, ensuring adequate nutrition, and prevention of infection (with antibacterial, antifungal, antipneumocystis, and anticytomegalovirus prophylaxis).

Immunosuppression—most centres employ a combination of an induction regimen based on either (antithymocyte globulin (ATG) or interleukin-2 receptor (IL-2R) blocker, followed by triple therapy with a calcineurin inhibitor (ciclosporin or tacrolimus), a lymphocyte proliferation inhibitor (azathioprine or mycophenolate), and a corticosteroid (usually prednisolone).

Longer-term management—the incidence of acute rejection and infection are highest in the first 3 months. Acute rejection is diagnosed via transbronchial biopsy and defined by perivascular lymphocytic infiltrates of varying severity, graded from minimal (grade 1) to severe (grade 4): it is usually treated with intravenous methyprednisolone. Chronic rejection is defined histologically by airway fibrosis with/without accompanying vascular sclerosis (obliterative bronchiolitis). The bronchiolitis obliterans syndrome (BOS) is defined clinically, and graded by a fall in the forced expiratory volume in 1 s (FEV1), as measured from the patient’s baseline (best achieved after transplantation). This condition is the main cause of death in long-term survivors of lung transplantation, with complicating infection the most common terminal event. Gastro-oesophageal reflux contributes significantly to both acute and chronic allograft dysfunction and is likely to be a major contributor to the development and progression of the bronchiolitis obliterans syndrome, hence there should be a low threshold for investigation with oesophageal pH monitoring, and an equally low threshold for laparoscopic fundoplication if significant reflux is demonstrated. Solid organ and lymphoid malignancies affect up to 4% of recipients.

Prognosis—survival figures of 80 to 90% at 1 year and 60 to 70% at 5 years are achievable for all types of lung transplant and underlying disease categories. Many patients are able to return to work and live a near normal life. Several female recipients have undergone normal pregnancies without complications.

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