lung transplantion: indications in 2016 - … · lung transplantion: indications in 2016 john-david...
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Lung Transplantion: Indications in 2016
John-David Aubert Ilhan InciCHUV, Lausanne USZ Zurich
SSP/SSC Lausanne 2016
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Adult Lung TransplantsNumber of Transplants by Year and Procedure Type
5 6 32 69 160384
664874
10551160 1296
13011417
14401483
1630171119011934
2129
24812699
28382901
3177
34503745 37503893
0
500
1000
1500
2000
2500
3000
3500
4000
Nu
mb
er o
f Tr
ansp
lan
ts Bilateral/Double Lung
Single Lung
JHLT. 2014 Oct; 33(10): 1009-1024
2015JHLT. 2015 Oct; 34(10): 1264-1277
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Adult Lung TransplantsMajor Indications by Year (%)
0
20
40
60
80
100
% o
f Tr
ansp
lan
ts
Transplant Year
CF IPF COPD Alpha-1 IPAH Retx
JHLT. 2014 Oct; 33(10): 1009-1024
2015JHLT. 2015 Oct; 34(10): 1264-1277
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CURT : 2004-2015 (n=200) Zurich (USZ: 2004-2015, N=316)
0
5
10
15
20
252
00
4
20
06
20
08
20
10
20
12
20
14
other
COPD
Fibrosis
CF0
5
10
15
20
25
30
35
OTH
IPF
EMP
PPH
CF
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Specific constraints for organ transplantation from a deceaseddonor
• Limited availability of the treatment
• Unknown time frame
• Non reversible therapy
• A disease is replaced by another one
• Quality control of the therapy = the organ?
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Questions raised about a lungtransplant candidate
• Life expectancy withstandard of care ?
• Life expectancy aftertransplantation ?
• Expecting time on the waiting list ?
Complete work-up. Predictive equation of survival
Comorbidities. Local results, inernational data
Allocation system
Height, blood group
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Indications
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D’après “International guidelines for the selection of lung transplant candidates: 2013 update”. JHLT 2014
General indications: consensus
•Chronic and progressive lung disorders
•Failure of established therapies
(pharmacological, surgical and others)
•The main goal of lung tx is to give the
patient a survival benefit
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Practical case 1
•63 yr-old woman
•COPD since1998
•Presently GOLD IV, FEV1 23% pred.
•2010: mechanical ventilation in the ICU for acute exacerbation
•2-3 exacerbations/year
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Case 1 (continued)Actual treatment:Acide folique 5mg 2X/semaine, calcium Sandoz D3 1cpr 2Xj, Neo-mercazole 5mg 1Xj, Solmucol 600mg 1Xj, Zithromax 250mg 3Xsemaine, Seretide 1 dose 2Xj, Spiriva 0.018mg/j, lisinopril 10 mg/j,Nexium 20 1xj, lexotanil 1,5 mg en R, prednisone 10 mg 1x j à sevrer progressivemnt, Ensure plus 2xj,.
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Would you refer this patient to a LuTx Centre ?
1. Yes
2. No
3. I need further information
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Would you refer this patient to a LuTx Centre ?
1. Yes
2. No
3. I need further information
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Check list before LuTx referral (COPD)
• BODE Index ?
• Smoking abstinence ?
• Rehabilitation attended ?
• Previous thoracic surgery ?
• Any obvious comorbidity/ risk factor ?
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Check list before LuTx referral (COPD)
• BODE Index ? 7/10• Smoking abstinence ? Yes, since 9 years, verified• Rehab attended ? Yes, in and oupatient• Previous thoracic surgery ?
Yes, right thoracotomy for suspicion of cancer dg: COP
• Any obvious comorbidity/ risk factor ?Hypertension, Hypothyroid,
Osteoporosis
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COPDTX referral
• BODE > 5• Worsening despite therapy• PaCO2>50 mmHg• PaO2<60 mmHg• FEV1 <25% of PV• LVRS not feasible
Listing• BODE ≥ 7• FEV1 <20% (DLCO<20% or
homogenous emphysema)• > 3 hospitalisations/yr• Severe Exacerbations with
acute hypercapnic resp failure• PH > 35 mmHg mPAP
A consensus document for the selection of lung transplant candidates:2014- an update from the Pulmonary Transplantation Concil of the ISHLT, D Weill and all, Journal of heart and lung transplantation,2015,34:1-15
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Case 2
• 30 years old, female
• Cystic fibrosis (CF) (ΔF508/G542X)
• CF-associated chronic sinusitis
• CF-associated arthritis
• Exocrine pancreatic insufficiency
• FEV1 before transplantation: 1.14L (34%)
• Respiratory failure 02.March.2012
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Transplantation Window of Opportunity:
ideal world and the reality
Time
Cli
nic
al co
urs
e
TOO SOONTOO LATE
Marshall SE, et al. Chest. 1990.
“Transplant window”
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Cystic fibrosisReferral
• FEV1 < 30% or fast ↘ c/o patientinfected with par NTM, B CepaciaComplex and/or diabetes
• 6’mwt:<400m• PH MPAP>35 mmHg• Clinical deterioration with:
- NIV- ↗ exacerbations: ATB+ R- pneumothorax- recurrent hemoptysis despite
embolisation
Listing
• Respiratory failure:- PaO2 < 60 mmHg- PaCO2 > 50 mmHg
• NIV• PH• Frequent hospitalisations• Fast ↘ PFT• World Health Organisation Functional
Class IV
A consensus document for the selection of lung transplant candidates:2014- an update from the Pulmonary Transplantation Concil of the ISHLT, D Weill and all, Journal of heart and lung transplantation,2015,34:1-15
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Cystic Fibrosis
Impact of the new medications (Ivacaftor, lumacaftor) on listing ?
No data so far
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mesuré predit % predit
FEV1 1.54 3.35 46
FVC 2.15 4.19 51
TLC 3.77 6.74 56
DLCO 4.5 9.6 47
Weigth/Heigth: 96 kg 175 cm BMI: 31 kg/m2
Lungs
NYHA: III
PaO2 62 mmHg SaO2 88% PaCO2 24 mmHg
6 mwt: 270 mètres : Sa02 : 90 ( 4lt d’O2) Borg : 5 (2)
Case 3 Sarcoïdosis stage IV
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Would you refer this patient for Lung Tx evaluation ?
• No, sarcoïdosis has a slow mostly begninecourse
• No, I would first try anti-TNF and Cellcept
• I do not know
• Yes, this patient is at high risk
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Would you refer this patient for Lung Tx evaluation ?
• No, sarcoïdosis has a slow mostly begninecourse
• No, I would first try anti-TNF and Cellcept
• I do not know
• Yes, this patient is at high risk
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RISK FACTORS•African-American•Hypoxemia•Pulmonary hypertension with high RAP
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Case 3 sarcoidosis
RISK FACTORS•African-American•Hypoxemia•Pulmonary hypertension
•No•Yes: SaO2 88%•No: mPAP 17 mmHg
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mesuré predit % predit
FEV1 1.54 3.35 46
FVC 2.15 4.19 51
TLC 3.77 6.74 56
DLCO 4.5 9.6 47
poids/taille: 96 kg 175 cm BMI: 31 kg/m2
Lungs
NYHA: III
PaO2 62 mmHg SaO2 88% PaCO2 24 mmHg
6 mwt: 270 mètres : Sa02 : 90 ( 4lt d’O2) Borg : 5 (2)
Case 3 Sarcoïdosis stage IV
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Contra-indications
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Contre-indications absolues (1)
•Cancer avec rémission < 2 ans•Dysfonction grave d’un autre organe: cœur, rein,
foie…•Athérosclérose avancée• Instabilité hémodynamique•Troubles sévères de la coagulation• Infection non contrôlée à germes résistants,
tuberculose active
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Contre-indications absolues (2)•Déformation thoracique sévère•Obésité avec BMI >35 kg/m2
•Non adhérence thérapeutique « réfractaire »•Maladie psychiatrique invalidante•Absence de tout soutien social•Fragilité (frailty) rendant une récupération post
greffe hypothétique•Tabagisme dans les 6 derniers mois, toxicomanie
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The impact of BMI
JHLT 2009;28:989-1049
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How to deal withsmokers ?
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Substance abuse or dependence (e.g., alcohol, tobacco, marijuana, or other illicit substances). In many cases, convincing evidence of risk reduction behaviors, such as meaningful and/or long-term participation in therapy forsubstance abuse and/or dependence, should be required before offering lung transplantation. Serial blood and urine testing can be used to verify abstinence from substances that are of concern.
The Journal of Heart and Lung Transplantation, Vol 34, No 1, January 2015 4
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Practical attitude(CURT)
• TX work-up only when > 6 months abstinence
• When abstinece is < 2 yrs, and in fragile patients, a specilaizedconsultation is requested
• Ex smokers are infomred that unscheduled tests will beperformed (cotinine, anabasine, CO ex)
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Inci I et al.Transplantation, 2015
Zurich Experience (Jan 2007 – Oct 2013, N=26)
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Case 4: COPD
• 63 year-old male
• 170 cm, 60 kg,
• BMI: 21 kg/m2
• 150 py (gave up 2001)
• CT Thorax: Diffuse emphysema
• September 2008: FEV1 0.78 L(26%), TLCO 21%PaO2 7.67 kPaPaCO2 4.61 kPamPAP : 29 mmHg6MWT: 375 mLung perfusion: r/l:34%/66%
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Case: LVRS bridge to TPL
• 18.12.2008: LVRS rechts
• Listed for TPL: 08/2011
(68kg, BMI:23.5 kg/m2)
– FEV1:24%
– TLCO: 15%
– mPAP: 21 mmHg
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Case: LVRS bridge to TPL
• 02/2012: bilateral lung transplantation
• 68 years old
• 38 months after LVRS
• Survived 3 years (37 months)
• Cause of death: CLAD
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Lung transplantation and diseaserecurrence
• CF No
• COPD No time enough!
• Sarcoidosis Yes - benign
• IPF Very rare
• LAM Yes
• Histiocytosis XYes - severe
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Spare case if time permit• A1AT deficiency, born 1949• Listed for double lung Tx in nov 2008• Blood group 0. 186 cm 61 kg• January 2012, still on the waiting list!• Meanwhile: dyspnea III IV
New hypercapniaIncrease in oxygen needBut no admission in emergency
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Case 5 continued
• The patient:« Doctor, am I still on the wating list ?Why so many patients listed after me have alreadybeen transplanted ? »
• The referring pulmonologist:« John-David, I know you are a nice guy: can you pleasepush up my patient on the list; he deserves it »
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= invasive mechanical ventilation in the ICU
= when donor < 40 yrs : priority to recipient < 40 yrs
SOAS = Swiss OrganAllocation System
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Benchmarking
0
10
20
30
40
50
60
70
80
90
100
LTX/107
Wait time (weeks)
survival on wait list
1 year survival
3 year survival
% lung used
ABM
SwissTX
UNOS
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In conclusion
• BPCO, Mucoviscidose et Fibrose sont les principales indications à la TX pulmonaire
• Les critères pour adresser le patient à un centre de TX diffèrent selon les pathologies
• La TX pulmonaire est une forme de traitement avec un rationnement explicite
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Equations de prédiction de survie (préTX)
Maladie Nom/paramètre Auteurs Validation prospective
COPD BODE Celli 2004 oui
Mucoviscidose Âge, sexe, FEV1, pancréas, infections
Liou 2001 Oui (ped + adulte)
Hypert. Art. Pulm. mPAP, OD, CI Thenapan 2010 non
IPF Composite physiologicalindexPath, DLCO, FEV1,FVC
Wells 2003 non
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BPCO:BODE > 5
Évolution progressive malgré tttPaCO2>50 mmHgPaO2<60 mmHgVEMS<25% de la VPPas de réduction de vol
Mucoviscidose:VEMS< 30% ou ↘rapide du VEMS NTM, B Cepacia Complex et/ou avec diabèteAugmentation des exacerbations/hosp:AB+R Pneumothorax/Hémoptysies6’:<400mHTAPVNI
Pneumopath interst.Evidence Rx ou histol NSIP/UIPCVF< 80% de la VP ou DLCO<40% de la VPDyspnée ou limitation fct liée à la maladie interstitielleO2
répondant pas au ttt
Maladies vasc pulm:NYHA III-IV Maladie progressant rapidementTtt ivSusp- maladie veino occlusiveHémangiomatose capillaire
Référer à centre
de Tx
NSIP:
Evidence histologique de
fibrose sur NSIP