LUNG TRANSPLANTATION

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1. INTRODUCTION The purpose of this syllabus is to review the management guidelines for recipients of, single lung and bilateral single lung transplants. Concepts contained herein derive predominantly from the experience at the Toronto lung program, Stanford University Medical Centre, the international transplantation experience, and the input of the recent literature. The enclosed protocols for patient assessment and management represent our own view on the current state-of-the-art assessment and management principles. 1
2. CURRENT STATUS Lung transplantation are currently indicated for patients with advanced forms of lung disease, in whom no realistic hope for extension of life or palliation exists with ordinary forms of medical or surgical intervention. Since, the introduction of Cyclosporine in December, 1980, and further refinements in management strategies have moved biologic lung transplantation from an experimental study to a truly therapeutic procedure with a one year survival rate of 75% to 80% and an expected five year survival rate of 45% to 55% in the best centres. As of 2003, the most recent data from the International Heart Transplant Registry indicates that more than 15000 lung transplants, were performed worldwide. 2.1 Indications a. Single Lung Transplantation - emphysema (44%), idiopathic pulmonary fibrosis (17.9%), alpha 1 anti-trypsin deficiency (12.8%), primary pulmonary hypertension (7.5%), re-transplant (3.3%), cystic fibrosis (1.6%), miscellaneous (12.9%). b. Bilateral/Double Lung Transplantation - cystic fibrosis (37.5%), emphysema (15.6%), alpha 1 anti-trypsin deficiency (10.2%), primary pulmonary hypertension (11%), idiopathic pulmonary fibrosis (5.8%), retransplant (3.6%), miscellaneous (16.3%). 2.2 Outcomes Lung actuarial survival for single lung at 1year is approximately 75%, 5 years is approximately 45-55%. Bilateral or double lung transplantation survival is similar. Better results may be achieved with emphysema and alpha I anti-trypsin deficiency with 1year and 2 year survival rates in the order of 77% and 70% respectively compared to idiopathic pulmonary fibrosis and primary pulmonary hypertension with 1 and 2 year survival rates of 65% and 57% respectively. Comparable results have been achieved with double lung transplantation in this same era. Of interest, single lung transplantation and has a one year survival rate for patients with emphysema of 80% at 1year as opposed to bilateral or double lung transplantation for which the 1 year survival rate has been 60%. For primary pulmonary hypertension, the 18-month survival rate for single lung and bilateral double lung transplantation is approximately 64% and for heart/lung transplantation approximately 55%. 2
Page 1 and 2: LUNG TRANSPLANTATION PROTOCOL Iskan
Page 3: 11. TREATMENT OF REJECTION 11.1 Rej
Page 7 and 8: 3. PREOPERATIVE EVALUATION OF LUNG
Page 9 and 10: information and all relevant medica
Page 11 and 12: LETTER OF INTRODUCTION TO THE REFER
Page 13 and 14: 3.5 LUNG TRANSPLANTATION REFERRAL G
Page 15 and 16: 4. Has the patient demonstrated the
Page 17 and 18: 3.8 LUNG TRANSPLANTATION WORKSHEET
Page 19 and 20: 15. Serology: HBsAG; Anti-Hepatitis
Page 21 and 22: 4. Studies a. Virology testing: i.
Page 23 and 24: 5. PREOPERATIVE MANAGEMENT OF MULTI
Page 25 and 26: Recognizing that brain death may we
Page 27 and 28: myocardial ischemia and arrhythmias
Page 29 and 30: 5.5 MULTIORGAN DONOR ASSESSMENT AND
Page 32 and 33: Parameters: VITAL SIGNS MEDICATIONS
Page 34 and 35: Organ Clamp on Clamp Off Ischemic T
Page 36 and 37: 5.6 DONOR ORDERS FOR MULTI-ORGAN TR
Page 38 and 39: n) HLA typing and Lymphocytotoxic a
Page 40 and 41: Inform the recipient candidate or c
Page 42 and 43: • On arrival at donor centre, inf
Page 44 and 45: Cardioplegia and pulmonary flush wa
Page 46 and 47: 8. POST-LUNG TRANSPLANT ORDERS AND
Page 48 and 49: Date/Time c. Routine Medication: i.
Page 50 and 51: Date/Time Parameters continued - No
Page 52 and 53: 8.2 Lung Transplantation Transfer O
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D O N O T W R I T E I N T H I S S P
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Date/Tim Studies continued (review
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1.5. Cyclosporine 4 to 5 mg per kg
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2. Monitoring MONITOR COMMENTS AZA
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(iv) Watch for anaphylactic reactio
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10.1 Immune Activation While transb
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11. MANAGEMENT OF REJECTION 11.1 In
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For mild acute rejection (Grade A1
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12. PROPHYLAXIS AND TREATMENT OF IN
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undertaken. Herpes simplex ulcerati
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CMV has been isolated from > .2 spe
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Please note: The efficacy of this r
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vi) Viral cultures if indicated. 12
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3. Children with a communicable ill
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15. RENAL FUNCTION Many transplant
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17. POST-LUNG TRANSPLANT ASSESSMENT
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18.2 3-6 MONTH PROTOCOL GUIDELINES
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18.4 1-2 YEAR PROTOCOL GUIDELINES B
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LUNG TRANSPLANTATION

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