Lung Transplantation in Patients with Cystic Fibrosis
David Weill, M.D.Director, Lung and Heart -Lung TransplantationDirector, Adult Cystic Fibrosis ProgramStanford University Medical Center
NUMBER OF LUNG TRANSPLANTS REPORTED BY YEAR AND PROCEDURE TYPE
5 7 36 78190
419
704
921
10881223
1336145214621490
16291693
188219322071
23842448
2769
1357
2716
0
250
500
750
1000
1250
1500
1750
2000
2250
2500
2750
3000
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Nu
mb
er o
f Tr
ansp
lan
ts
Bilateral/Double LungSingle Lung
NOTE: This figure includes only the lung transplants that are reported to the ISHLT Transplant Registry. As such, this should not be construed as representing changes in the number of lung transplants performed worldwide.
ADULT LUNG RECIPIENTSCross-Sectional Analysis
Functional Status of Surviving Recipients(Follow-ups: April 1994 – June 2009)
0%
20%
40%
60%
80%
100%
1 Year (N = 6,845) 3 Year (N = 4,381) 5 Year (N = 2,516) 10 Years (N = 430)
No Activity Limitations Performs with Some Assistance Requires Total Assistance
Lung Transplantation Procedure Options
• Double-lung transplantation – Donor hearts could serve other patients– Avoids risk of accelerated atherosclerosis
• Heart-lung transplantation – Less commonly performed in the US– Fewer airway complications
• Bilateral living lobar transplantation – Reduced incidence and intensity of rejection– Circumvents the donor shortage problem– Considerable risk to donors
• Split-lung transplantation– Single donor can serve multiple recipients– Technically difficult procedure
Shennib H. Arch Intern Med. 1992.Starnes VA, et al. J Thorac Cardiovasc Surg. 1994.
Boehler A. Swiss Med Wkly. 2003.
Double-Lung Transplantation
Photos courtesy of Woo MS.
CF and Lung Transplant
• The course of CF is very unpredictable, and that makes the timing for transplant more difficult
• About 1600 CF recipients since 1991• 120-150 recipients each year • Second largest group to get transplanted• CF recipients do better in general than
non-CF recipients
Transplantation Window of Opportunity—in an Ideal World
Time
Cli
nic
al c
ou
rse
TOO SOON TOO LATE
Marshall SE, et al. Chest. 1990.
“Transplant window”
Transplantation Window of Opportunity—in Reality
Time
Cli
nic
al c
ou
rse
TOO SOON? TOO LATE?
“Transplant window??”
Difficult Questions to Ask Before Organ Transplantation
• When should a patient be referred for evaluation?
• When should a patient be placed on the waiting list?
• When should a patient have a transplant?
Referral for Lung Transplant
• Patient readiness
• Transplant team readiness and comfort level
• Local transplant center culture
• Wait times (less important now because of LAS)
Lung Allocation Score
• New scoring system since May 2005
• “How bad you need it + How well you’ll do with it”
• Applies to transplant candidates > 12 yrs
• Scores range from 0-100
• Scores can be updated
Lung Allocation Score: Clinical Information
• Diagnosis• Age• Height and Weight
(BMI)• Diabetes• Use of supplemental
oxygen• Six minute walk
distance
• PASP• PCWP• FVC• Serum Creatinine• Functional Status• Assisted Ventilation
Lung Allocation Score:CF Variables That Are Not Included
• FEV1
• pCO2
• Infections
• Antibiotic Sensitivity of Infections
• Hemoptysis
• Frequency of Exacerbations
The Kerem Survival Model
Significant predictors of 2-year survival
Single covariate analysis Multiple covariate analysis
FEV1 and FVC FEV1
Female gender Female gender
Low arterial pO2 Age
High arterial pCO2
Low weight-for-height
Kerem E, et al. N Engl J Med. 1992.
Consensus Guidelines for Referral of Lung Transplant Candidates with CF
• FEV1 ≤30% of predicted with rapid, progressive respiratory deterioration– Increasing number of hospitalizations– Massive hemoptysis– Recurrent pneumothorax– Increasing cachexia– Rapid fall in FEV1
• Hypoxemia: PaO2 <55 mm Hg• Hypercapnia: PaCO2 >50 mm Hg• <50% survival in 2 years• Early referral is recommended for young female patients,
who have particularly poor prognosis
American Thoracic Society. Am J Respir Crit Care Med. 1998.Boehler A. Swiss Med Wkly. 2003.
The Validated Predictive 5-Year Survival Model of CF
FEV1 % equivalency*
Increased survival:
• Pancreatic sufficiency +12
• Higher weight-for-age z-score +10
• Staphylococcus aureus infection +6
• Higher FEV1% +1
Decreased survival:
• Burkholderia cepacia infection –48
• Diabetes mellitus –13
• Acute pulmonary exacerbation –12
• Female gender –6
• Increasing age –0.7*Difference in FEV1 (% predicted) required for equivalent effect on survival
Liou TG, et al. Am J Epidemiol. 2001.
Equivocal Survival Benefit of Lung Transplantation in Patients with FEV1 ≤30%
Liou TG, et al. JAMA. 2001.
ControlLung Transplant
0
20
40
60
80
100
0 1 2 3 4 5Time (yr)
Su
rviv
al (
%)
Predicting the “Right Time” for Transplant
• Study to look at who was listed too late
• Evaluated who was listed for transplant but died before receiving new lungs
• Rationale is that there are things that the transplant centers integrate with the variables collected by the CFF Registry and UNOS
• Four transplant centersBelkin et al. AJRCCM 2006
Predicting the “Right Time” for Transplant
Variables that increased risk of death• FEV1 < 30% predicted• Shorter height• PaCO2 > 50mmHg• Need for nutritional intervention
Variables that decreased risk of death• Referral from a CF Center • Listing after 1996
Belkin et al. AJRCCM 2006
International Guidelines for the Selection of Lung Transplant Candidates: 2006 Update
• Guidelines for referral:– FEV1 below 30% predicted or a rapid decline in FEV1
– in particular young female patients– Exacerbation of pulmonary disease requiring ICU stay– Increasing frequency of exacerbations requiring abx– Refractory/recurrent pneumothorax– Recurrent hemoptysis not controlled by embolization
International Guidelines for the Selection of Lung Transplant Candidates: 2006 Update
• Guidelines for transplant:– Oxygen-dependent respiratory failure– Hypercapnia– Pulmonary hypertension
Absolute Contraindications to Lung Transplantation
Cystic Fibrosis Foundation. Clinical Practice Guidelines for Cystic Fibrosis. 1997.American Thoracic Society. Am J Respir Crit Care Med. 1998.
LungTransplant
Other major organ dysfunction
Infections affectinglong-term survival
Cardiovascular diseaseHIV
Liver disease: hepatitis CHepatitis B or C
Tuberculosis
Active malignancy <5 years
Renal failure: ClCr <50 mL/min
Other organ damage
Relative Contraindications to Lung Transplantation
Symptomatic osteoporosis
Substance addiction
Psychosocial problems
Nutritional status (<70% or >130% IBW)
High-dose corticosteroid use
Kyphoscoliosis
Invasive ventilation
Fungi or atypical mycobacteria
Pan-resistant organisms
American Thoracic Society. Am J Respir Crit Care Med. 1998.
LungTransplant
CF-relatedarthropathy
Postoperative Issues specific to CF Lung Transplant Recipients
Excess Mortality Associated with Preoperative B cepacia Infection
Chaparro C, et al. Am J Respir Crit Care Med. 2001.
0
20
40
60
80
100
0 1 3 4 5Year
2
Pro
po
rtio
n s
urv
ivin
g (
%)
No infection
B cepacia
P = 0.003
Post-transplant Survival Influenced by B cepacia Genomovar Type
Aris RM, et al. Am J Respir Crit Care Med. 2001.De Soyza A, et al. Lancet. 2001.
Deaths (N) in patients infected with
Study Genomovar III Non-genomovar III P value*
Aris 5 0 0.035
De Soyza 4 0 0.007
*Genomovar III vs non-genomovar III
Lung Transplantation in Adult CF Patients with History of Acute Respiratory Failure
n = 17 (40%) Received lung transplants
n = 14 (82%) Alive at 1 year postoperation
N = 42 Admitted to ICU with hypercapnic respiratory failure
n = 19 (45%) Died in ICU
n = 3 (7%) Died within 6 months
of ICU discharge
n = 3 (7%) Alive at 1 year
without lung transplant
Sood N, et al. Am J Respir Crit Care Med. 2001.
Potential Surgical Complications of Lung Transplantation
Zuckerman JB, et al. Clin Chest Med. 1998.Trulock EP. Am J Respir Crit Care Med. 1997.
Akindipe OA, et al. Chest. 2000.
Complication Prevalence (%)
Most serious
•Primary graft failure due to ischemia-reperfusion injury/diffuse alveolar damage
15-35
•Anastomotic complications: vascular or airway
7
Most common
•Phrenic/vocal cord paresis 3-30
•Gastroparesis 25-30
Potential Medical Complications Following Lung Transplantation
• Obliterative bronchiolitis (BOS/chronic rejection)• Acute rejection• Infection: viral, bacterial, fungal, protozoal• Toxicity of immunosuppressives
– Nephrotoxicity– Hypertension– Hirsutism, gingival hyperplasia
• Diabetes• Hyperlipidemia• Post-transplant lymphoproliferative disease (EBV)
Zuckerman JB, et al. Clin Chest Med. 1998.Kurland G, et al. Curr Opin Pediatr. 1994.
Recommended Follow-up of Transplant Recipients
• Regular monitoring of PFTs, chest x-rays, and blood tests – Creatinine, complete blood count, liver function tests,
CMV infection
• Post-transplant bronchoscopy; surveillance with BAL and transbronchial biopsy following:– Decline in PFTs – Change in chest x-ray– Onset of new symptoms– Acute rejection
Photo courtesy of Woo MS.
Special Issues for the CF Patient
• Colonization vs. infection• Sinus disease• GI Issues:
– GERD– Pancreatic Insufficiency– Nutrition– DIOS
• CFRD• Osteoporosis• Psychosocial
French Lung Transplant Experience for CF
• Compared two five year periods (2000-2005 and 2005-2010)– Improved one year survival (75% to 88%) due
to: extensive use of thoracic epidurals leading to increased early extubations
Mordant et al. European Journal of Cardiothoracic Surgery. 2010
Survival of Transplant Recipients by Procedure Type
Trulock EP, et al. J Heart Lung Transplant. 2004.
0
20
40
60
80
100
Su
rviv
al (
%)
0 2 4 6 8 10 12 14 16 18 20
Years
Bilateral lung (N = 6686)
Single lung (N = 8581)
All lungs (N = 15,267)
Causes of Death in Lung Transplant Recipients
Trulock EP, et al. J Heart Lung Transplant. 2004.
0
10
20
30
40
50
60
70
80
90
0-30 days 31 days-1 year >1-3 years >3-5 years >5 years
Time after transplantation
Pe
rce
nt
of
de
ath
s
Technical complication Graft failure Cardiovascular disease
Infection – Non-CMV Chronic rejection Malignancy – Non-lymphoma
Early complications Late complications
Summary
• CF is the third most common indication for lung transplant
• Decision of transplantation is derived from a comprehensive evaluation that MUST take into account several indicators of disease severity: FEV1, increase in O2 need, hypercapnia, need for non-invasive ventilation, functional status & pulmonary hypertension.
Summary
• Post-transplant survival of CF patients is similar or even greater than survival of patients w/ other conditions