Lung Transplantation: What? Who? When? Marshall I. Hertz, MD University of Minnesota Medical School and Fairview-University Medical Center Medical Director,
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Lung Transplantation:Lung Transplantation:What? Who? When?What? Who? When?
Marshall I. Hertz, MD
University of Minnesota Medical School and Fairview-University Medical Center
Medical Director, Lung Transplantation
Director, Center for Advanced Lung Disease
Topics for DiscussionTopics for Discussion
Organ transplantation in the USOrgan transplantation in the US
Overview of lung transplantationOverview of lung transplantation
Inadequate supply of lungs for Inadequate supply of lungs for
transplantationtransplantation
University of Minnesota
Major Biomedical Advances Major Biomedical Advances 1954-20041954-2004
VaccinesVaccines AntibioticsAntibiotics Life support technologiesLife support technologies Open heart surgeryOpen heart surgery Molecular geneticsMolecular genetics Organ transplantationOrgan transplantation
University of Minnesota
Organ Transplantation in the United StatesOrgan Transplantation in the United States1 Jan 1988 – 31 Jan 20051 Jan 1988 – 31 Jan 2005
OrganOrgan NumberNumber
KidneyKidney 201,846201,846
LiverLiver 69,05769,057
Pancreas*Pancreas* 16,67416,674
IntestineIntestine 977977
HeartHeart 36,76436,764
Lung*Lung* 13,32213,322
TotalTotal 338,640338,640
www.unos.orgUniversity of Minnesota
1963: First kidney transplant in Minnesota1963: First kidney transplant in Minnesota 1966: First pancreas transplant in the world1966: First pancreas transplant in the world 1966: First intestinal transplant in the world1966: First intestinal transplant in the world 1968: First successful human bone marrow transplant1968: First successful human bone marrow transplant 1978: First heart transplant in Minnesota1978: First heart transplant in Minnesota 1978: First living-donor pancreas transplant in the world1978: First living-donor pancreas transplant in the world 1981: First pediatric heart transplant in Minnesota1981: First pediatric heart transplant in Minnesota 1986: First heart-lung transplant in Minnesota1986: First heart-lung transplant in Minnesota 1988: First lung transplant in Minnesota1988: First lung transplant in Minnesota 1991: First living-related lung transplant in Minnesota1991: First living-related lung transplant in Minnesota 1996: First living donor liver transplant in Minnesota1996: First living donor liver transplant in Minnesota
U of M Firsts in TransplantationU of M Firsts in Transplantation
Organization of Transplant Services Organization of Transplant Services in the United Statesin the United States
Department of Health and Human ServicesDepartment of Health and Human Services– United Network for Organ SharingUnited Network for Organ Sharing
– Scientific Registry of Transplant RecipientsScientific Registry of Transplant Recipients
Organ Procurement Organizations (LifeSource)Organ Procurement Organizations (LifeSource) Transplant CentersTransplant Centers
– Physicians and surgeonsPhysicians and surgeons
– Nurse coordinatorsNurse coordinators
– Social workersSocial workers
– Administrators, financial representativesAdministrators, financial representatives
University of Minnesota
Types of Organ DonorsTypes of Organ Donors
Non-livingNon-living– Brain deathBrain death– Cardiac deathCardiac death
LivingLiving– Biologically relatedBiologically related– ““Emotionally” relatedEmotionally” related– Non-directed (“Good Samaritan”)Non-directed (“Good Samaritan”)
University of Minnesota
Living Donor TransplantationLiving Donor TransplantationU.S. Donors by Organ Type (2004)U.S. Donors by Organ Type (2004)
0
10002000
30004000
50006000
70008000
900010000
Kidney Liver Pancreas Intestine Lung
Non-living donation Living donation
UNOS
Types of Lung TransplantsTypes of Lung Transplants
Non-living donorNon-living donor– Single lungSingle lung– Bilateral (double)Bilateral (double)– Heart and lungHeart and lung
Living donorLiving donor– Bilateral (double) lobarBilateral (double) lobar
University of Minnesota
NUMBER OF LUNG TRANSPLANTS REPORTED BY YEAR AND PROCEDURE TYPE
0
200
400
600
800
1000
1200
1400
1600
1800
Num
ber
of T
rans
plan
ts
Bilateral/Double LungSingle Lung
13 15 46 83189
418
708
922
1089
1229
13681377
14641457
14771564
1602 17671703
ISHLT 2005
Types of Lung RecipientsTypes of Lung Recipients
Pulmonary fibrosisPulmonary fibrosis Emphysema/Alpha-1 Emphysema/Alpha-1
antitrypsin deficiencyantitrypsin deficiency Pulmonary hypertensionPulmonary hypertension– PrimaryPrimary– Congenital heart diseaseCongenital heart disease
Cystic fibrosisCystic fibrosis
University of Minnesota
ADULT LUNG TRANSPLANTATIONIndications By Year (Number)
0
250
500
750
1000
1250
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Transplant Year
Nu
mb
er o
f T
ran
spla
nts
Cystic Fibrosis IPF Emphysema A1A PPH
ISHLT 2005
Characteristics of Lung Transplant Characteristics of Lung Transplant Recipients with Pulmonary FibrosisRecipients with Pulmonary Fibrosis
•Severe disease
•Breathing tests (PFT)
•Exercise limitation (6-min. walk)
•Pulmonary hypertension (Echo)
•Age <65 years (55 for bilateral, 45 for heart-lung)
•Capable of following complicated medication schedule
•No severe disease in other organs (kidney, heart)
•Non-smoking, non-drinking
University of Minnesota
Problems after Organ TransplantationProblems after Organ Transplantation Immune system reacts against Immune system reacts against
transplanted organ (rejection)transplanted organ (rejection)– AcuteAcute– ChronicChronic
Medication side effectsMedication side effects
University of Minnesota
Outcomes after Lung TransplantationOutcomes after Lung Transplantation
FunctionFunction Quality of lifeQuality of life SurvivalSurvival
University of Minnesota
1995 1996 1997 1998 1999 2000 2001 2002 20030
10,00020,00030,00040,00050,00060,00070,00080,00090,000
Donors Transplants Wait List
““The Growing Need”The Growing Need”Organ Donors vs. Wait Listed PatientsOrgan Donors vs. Wait Listed Patients
Based on OPTN data as of January 26, 2004. www.life-source.org
The Donor Shortage:The Donor Shortage:Possible ApproachesPossible Approaches•Use more non-living donors
•Increased public awareness
•Presumed consent laws
•“Breakthrough collaborative”
•Use more living donors
•Xenotransplants, bioartificial lungs, stem cells
•Make better use of existing non-living donors
University of Minnesota
Current Lung Allocation System (1990)Current Lung Allocation System (1990)
Who?Who?– Based on active waiting time onlyBased on active waiting time only– 90 days of “extra” waiting time assigned to 90 days of “extra” waiting time assigned to
idiopathic pulmonary fibrosis patients (1995)idiopathic pulmonary fibrosis patients (1995) Where?Where?– Lungs offered first to recipients within the Lungs offered first to recipients within the
donor OPOdonor OPO– Then to recipients within concentric 500 mile Then to recipients within concentric 500 mile
circlescircles
University of Minnesota
Goals of the new lung allocation planGoals of the new lung allocation plan
Reduce waiting list deathsReduce waiting list deaths Improve overall survivalImprove overall survival
University of Minnesota
New lung allocation planNew lung allocation plan(May 4, 2005)(May 4, 2005)
• Based on disease type, disease severity, and expected survival after transplant
•Scores range from 1 to 100
•Patient information has to be updated every 6 months
•Blood group, size, and geography still matter
•Time on wait list does not count
University of Minnesota
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