Organ Transplantation Rosa Malo de Molina Ruiz , MD Pulmonary Department University Hospital Puerta de Hierro
Organ Transplantation
Rosa Malo de Molina Ruiz , MD Pulmonary Department University
Hospital Puerta de Hierro
Alpha 1-antitrypsin deficiency
EMPHYSEMA
Normal Lung
Emphysematic Lung
PROGRESS / DISABILITY / MORTALITY
TRASNFER TO
TRANSPLANT
CENTER
INCLUSION IN WAITING
LIST
PRIORITIZATION IN
TRANSPLANTATION
WAITING LIST
Lung transplant
Lung transplant
• The process of assessing lung transplantation in a specific patient aims to answer three fundamental questions:
It is necessary? It can be done? Does the patient want it?
TRASNFER TO
TRANSPLANT
CENTER
Lung Trasplant
Indication
No contraindication
• Recent tumor history (> 5 years disease free) • Dysfunction of another major organ • Coronary Disease with no possibility of
revascularization • Hemorrhagic diathesis • Deformities of the thoracic wall • Morbid obesity • Infection by TBC or by highly resistant germs • Altered functional status w/o rehabilitation
possibility • Psychiatric disorders, lack of social support • Non-adherence
It can be done? Absolute contraindication
J Heart Lung Transplant. 2015;34(1):1-15.
• Age> 65 years • Obesity (BMI 30-34.9) or severe malnutrition • Severe symptomatic osteoporosis • Anterior thoracic surgery with pulmonary
resection • Extracorporeal support or mechanical
ventilation • B or C virus infection with evidence of
significant hepatic injury and / or portal hypertension
• HIV Infection • Infection by multiresistant germs.
J Heart Lung Transplant. 2015;34(1):1-15.
It can be done?: Relative contraindications
Transplant window
TRASNFER TO
TRANSPLANT
CENTE
“Primum non nocere” Hipocrates
Test
Distance walked in 6 minutes
Celli B; N Engl J Med .2004;350:1005-12
• BMI (weight and hight) • Dyspnea
The BODE Index For COPD
Ecocardiography
COPD: Criteria for transfer to a transplant
center
Progressive disease despite treatment Non suitable for LVRS or ELVR BODE 5-7 FEV 1
COPD: Inclusion waiting list
• BODE index ≥7 • FEV1
Survival BODE Transplant: ISHLT
B. Celli. N Engl J Med. 2004 Mar 4;350(10):1005-12 www. ISHLT
ADULT LUNG TRANSPLANTATION: Indications for Single Lung Transplants (Transplants: January 1995 - June 2010)
*Other includes: Pulmonary Fibrosis, Other: 3.4%
Sarcoidosis: 1.9%
Bronchiectasis: 0.4%
Congenital Heart Disease: 0.3%
LAM: 0.8%
Connective Tissue Disease: 1.0%
OB (non-ReTx): 0.6%
Miscellaneous: 0.9%
ISHLT 2011 ISHLT
J Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
Gráfico1
Alpha-1Alpha-1Alpha-1Alpha-1Alpha-1Alpha-1
COPDCOPDCOPDCOPDCOPDCOPD
CFCFCFCFCFCF
IPFIPFIPFIPFIPFIPF
IPAHIPAHIPAHIPAHIPAHIPAH
Re-TxRe-TxRe-TxRe-TxRe-TxRe-Tx
Other*Other*Other*Other*Other*Other*
Single
0.059
0.4675
0.0173
0.3238
0.0063
0.0308
0.0952
Sheet1
Single
Alpha-15.90%
COPD46.75%
CF1.73%
IPF32.38%
IPAH0.63%
Re-Tx3.08%
Other*9.52%
ADULT LUNG TRANSPLANTATION: Indications for Bilateral/Double Lung Transplants (Transplants: January 1995 - June 2010)
26%
16%
17%
7%
27%
5% 2%
Alpha-1 COPD CF IPF IPAH Re-Tx Other*
*Other includes:
Pulmonary Fibrosis, Other: 2.9%
Sarcoidosis: 3.0%
Bronchiectasis: 4.4%
Congenital Heart Disease: 1.2%
LAM: 1.1%
Connective Tissue Disease: 1.3%
OB (non-ReTx): 1.3%
Miscellaneous: 1.7%
ISHLT 2011 ISHLT J Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
Lung transplant
• The process of assessing lung transplantation in a specific patient aims to answer three fundamental questions:
It is necessary? It can be done? Does the patient want it?
Lung transplant: Disadvantages
• It is not a curative treatment • Limited duration • Accurate self-care • Immunosuppressive therapy
indefinite • Adverse effects • Permanent risk of rejection
and / or infection
Pre-transplant follow-up
• Vaccinations • Dietary Tips • Treatment exacerbations • Deactivate / Activate in
waiting list • Rehabilitation • Exercise
“From fighting for my live, to lifting for my live”
www.alpha-1-1-athlete.com
Surgery and perioperative care
Cause of death after transplant ISHLT Registry (1992 – 2013)
Yusen J Heart Lung Transplant 2014 Oct; 33(10): 1009-1024
Gráfico1
0-30 Days (N=2,905)0-30 Days (N=2,905)0-30 Days (N=2,905)0-30 Days (N=2,905)0-30 Days (N=2,905)
31 Days – 1 Year (N=5,098)31 Days – 1 Year (N=5,098)31 Days – 1 Year (N=5,098)31 Days – 1 Year (N=5,098)31 Days – 1 Year (N=5,098)
>1 Year – 3 Years (N=4,797)>1 Year – 3 Years (N=4,797)>1 Year – 3 Years (N=4,797)>1 Year – 3 Years (N=4,797)>1 Year – 3 Years (N=4,797)
>3 Years – 5 Years (N=2,746)>3 Years – 5 Years (N=2,746)>3 Years – 5 Years (N=2,746)>3 Years – 5 Years (N=2,746)>3 Years – 5 Years (N=2,746)
>5 Years – 10 Years (N=3,263)>5 Years – 10 Years (N=3,263)>5 Years – 10 Years (N=3,263)>5 Years – 10 Years (N=3,263)>5 Years – 10 Years (N=3,263)
>10 Years (N=1,092)>10 Years (N=1,092)>10 Years (N=1,092)>10 Years (N=1,092)>10 Years (N=1,092)
Bronchiolitis
Malignancy (non-Lymph/PTLD)
Infection (non-CMV)
Graft Failure
Cardiovascular
% of Deaths
0.3
0.2
18.9
24.2
11.3
4.6
2.8
35.4
16.6
5
25.6
7.9
21.7
18.9
4.4
29.3
10.9
18.4
18
5
24.7
13.7
18
17.1
5.6
20.1
12.4
16.7
16.6
7.6
Sheet1
Time0-30 Days (N=2,905)31 Days – 1 Year (N=5,098)>1 Year – 3 Years (N=4,797)>3 Years – 5 Years (N=2,746)>5 Years – 10 Years (N=3,263)>10 Years (N=1,092)
Bronchiolitis0.34.625.629.324.720.1
Malignancy (non-Lymph/PTLD)0.22.87.910.913.712.4
Infection (non-CMV)18.935.421.718.41816.7
Graft Failure24.216.618.91817.116.6
Cardiovascular11.354.455.67.6
Normal results • Adequate lung function • Improved quality of life • Lack of infection and rejection • Increased exercise capacity
What is the job of a transplanted patient?
• Periodic controls to detect early • Active participation • Good adhesion to treatment
Nebulized treatment
It is recommended , as soon as possible to include the physical exercise in the daily routine that will progressively increase
Graft Failure Adverse event
due to treatment
Inmunosupresive Equilibrium
New techniques in lung transplantation
Selection criteria Standard Extended AB0 compatibility Identical Compatible Age < 55 years > 55 years Smoking < 20 pack-years > 20 pack-years acceptable
Thoracic trauma Abscense Localized Intubation time < 7 days > 7 days acceptable Asthma No Yes acceptable Cancer No (except for skin) Primary central nervous
system tumour
Secretion culture Negative Positive acceptable (with prophylaxis
PaO2/FiO2 ratio > 300 < 300 acceptable Chest X-ray Normal Focal or unilateral
abnormality
Bronchoscopy Normal Secretion in principal airway acceptable
Cardiothoracic surgery Absent Occasionally acceptable
Serological test Negative Cytomegalovirus and toxoplasmosis tolerated
Expanding donor criteria
Ex vivo lung perfussion
Living-donor lung transplantation
Inclusion bodys in the liver
Alpha-1 deficiency, uncommon indication for Liver Transplantation
73/5246
1.4%
History of liver disease
• Chronic
liver disease
Compensated cirrhosis
Development of complications:
Variceal hemorrhage
Ascites Encephalopathy
Jaundice
Deconmpensate
Cirrosis Death
Goals
• Provides maximum benefit to patients with liver failure who have no other option
• Likely prolongs life
• Restores patient to normal or near normal functional status
Contraindications to Liver Transplant
ABSOLUTE Active infection Spontaneus Bacterial
Peritonitis Pulmonary HTN Extrahepatic
malignancy Active alcoholism Substance abuse Non compliance
RELATIVE CRF Advanced cachexia Large Hepatocelular
carcinoma Multisystem organ
failure states HIV ?
Pre-transplant Work-up Liver function tests, total protein,
albumin
Hepatitis screen (A, B, C)
Serologies - Cytomegalovirus (CMV), herpes simplex virus (HSV),
Epstein-Barr virus (EBV), HIV Tumor markers Alpha-fetoprotein, cholinesterase Arterial blood gases Others (selective) - Carbohydrate
antigen 19-9, cancer antigen 125
CT scan whole body Colonoscopy Cardiopulmonary clearance Psychiatrist and social worker
consultations
MELD SCORE MELD score based on 3
biochemical variables, (1) serum bilirubin, (2) serum creatinine, and (3) INR
Highly predictive 3-month
mortality of patients with ESLD
Minimum score for LT: 15
points Maximum score: 40 points
Living Donor Living-donor Liver
Transplant: part of the liver from a living donor is resected and transplanted into a recipient
Complications liver transplant
Acute rejection (up to 40 % in first 3 months) Chronic rejection: ductopenia, fibrosis Primary graft failure ( up to 7 %) Biliary complications (strictures) Hepatic Artery Thrombosis Infections (viral and fungal) Post transplantation lymphoproliferative
disorder (PTLD): EBV
Thank you!!!
Organ Transplantation Slide Number 2Slide Number 3Lung transplantSlide Number 5It can be done? �Absolute contraindication �It can be done?: Relative contraindicationsSlide Number 8Slide Number 9Slide Number 10Slide Number 11Slide Number 12The BODE Index For COPDSlide Number 14Slide Number 15EcocardiographyCOPD:�Criteria for transfer to a transplant center COPD:�Inclusion waiting listSurvival�ADULT LUNG TRANSPLANTATION: Indications for Single Lung Transplants (Transplants: January 1995 - June 2010)ADULT LUNG TRANSPLANTATION: Indications for Bilateral/Double Lung Transplants (Transplants: January 1995 - June 2010)Lung transplantLung transplant:� DisadvantagesPre-transplant follow-up“From fighting for my live, to lifting for my live”Surgery and perioperative careCause of death after transplant�ISHLT Registry (1992 – 2013)Normal resultsWhat is the job of a transplanted patient?�Nebulized treatmentSlide Number 31Slide Number 32Slide Number 33Slide Number 34Slide Number 35Slide Number 36New techniques in lung transplantationExpanding donor criteriaEx vivo lung perfussionLiving-donor lung transplantation�Slide Number 41Inclusion bodys in the liverAlpha-1 deficiency, uncommon indication for �Liver TransplantationHistory of liver diseaseGoalsContraindications to Liver TransplantPre-transplant Work-upLiving DonorComplications liver transplantSlide Number 50Slide Number 51