Lung Transplantation Guidelines For Selection Milpark Hospital Transplant Unit Johannesburg, South Africa SATS Controversies Meeting May 2011

Lung Lung TransplantationTransplantation

GuidelinesGuidelines For For SelectionSelection

Milpark Hospital Transplant UnitMilpark Hospital Transplant UnitJohannesburg, South AfricaJohannesburg, South Africa

SATS Controversies MeetingMay 2011

South African Guidelines based onSouth African Guidelines based on::

ATS - International Guidelines for the selection of Lung ATS - International Guidelines for the selection of Lung Transplant Candidates – 1998Transplant Candidates – 1998

ISHLT – Update – 2006ISHLT – Update – 2006

GENERALGENERAL-- Patient should be receiving or have received maximal medicalPatient should be receiving or have received maximal medical

therapy, but nevertheless have declining function, with atherapy, but nevertheless have declining function, with alimited life expectancy ( <50% - 2-3 year survival).limited life expectancy ( <50% - 2-3 year survival).

-- The patient should have ambulatory and rehabilitation potential.The patient should have ambulatory and rehabilitation potential.-- A satisfactory psycho-social profile with support systems isA satisfactory psycho-social profile with support systems is

essential.essential.

AGEAGE-- Older patients have a significantly worse prognosis.Older patients have a significantly worse prognosis.

-- HLTHLT <55 years.<55 years.- - BSLT BSLT <60 years.<60 years.- - SLT SLT <65 years.<65 years.

BMIBMI-- 18 – 30%18 – 30%

Lung Transplantation as the sole Lung Transplantation as the sole form of therapy is potentially form of therapy is potentially indicated in any indicated in any irreversibleirreversible condition, resulting in either one or condition, resulting in either one or both of the following disease both of the following disease entities:entities:

• END STAGE RESPIRATORY FAILURE.END STAGE RESPIRATORY FAILURE.((ICD 10 CODE: J96.1)ICD 10 CODE: J96.1)

• PULMONARY ARTERIAL PULMONARY ARTERIAL HYPERTENSION.HYPERTENSION.

((ICD 10 CODE: I27.0)ICD 10 CODE: I27.0)(ICD 10 CODE: Q20 – 28)(ICD 10 CODE: Q20 – 28)

Refer for Assessment at this Stage and Exclude Refer for Assessment at this Stage and Exclude Unsuitable Recipients following Review of Disease Unsuitable Recipients following Review of Disease

Specific Guidelines Specific Guidelines

A.A. End Stage Respiratory FailureEnd Stage Respiratory Failure

Conditions grouped as follows:Conditions grouped as follows: •• COPD COPD (ICD 10 Code: J40 -J46)(ICD 10 Code: J40 -J46)

-- Acquired.Acquired.-- Congenital (Alpha1 – Antitrypsin def.).Congenital (Alpha1 – Antitrypsin def.).

•• Idiopathic Pulmonary Fibrosis (IPF). Idiopathic Pulmonary Fibrosis (IPF). (ICD 10 Code: J80-(ICD 10 Code: J80-J84)J84)

•• Infective/Inflammatory. Infective/Inflammatory. (ICD 10 Code: J47 .xx, J60-(ICD 10 Code: J47 .xx, J60-J70,J85-J86 J70,J85-J86 E84 & other)E84 & other)

-- Cystic Fibrosis (CF).Cystic Fibrosis (CF). -- Bronchiectasis.Bronchiectasis. -- Sarcoidosis.Sarcoidosis. -- Other e.g. – LAM etc.Other e.g. – LAM etc.

B.B. Pulmonary HypertensionPulmonary Hypertension -- Primary (PPH).Primary (PPH). -- Secondary.Secondary.

Disease Specific CriteriaDisease Specific Criteria

COPDCOPD

•• FEV¹ <25% of predicted.FEV¹ <25% of predicted.•• PaCO² > 55/PHT.PaCO² > 55/PHT.•• Progressive deterioration on Domiciliary Progressive deterioration on Domiciliary

Oxygen.Oxygen.•• Frequent admissions with declining function.Frequent admissions with declining function.•• Patients with a high BODE index.Patients with a high BODE index.•• Patients not better served by LVRS.Patients not better served by LVRS.

Disease Specific Criteria – Disease Specific Criteria – cont.cont.

IPFIPF

•• Symptomatic disease.Symptomatic disease.

•• Exercise desaturation.Exercise desaturation.

•• VC < 60 – 75% predicted.VC < 60 – 75% predicted.

•• DLCO < 50 – 60% predicted.DLCO < 50 – 60% predicted.


Infective/Inflammatory (CF)Infective/Inflammatory (CF)

•• FEV¹ < 30% predicted.FEV¹ < 30% predicted.

•• High Risk Patients:High Risk Patients:

-- Young Females with a rapidly decliningYoung Females with a rapidly declining

FEV¹.FEV¹.

-- Weight Loss.Weight Loss.

-- Frequent Infective Exacerbations.Frequent Infective Exacerbations.

-- Haemoptysis.Haemoptysis.


PPHPPH

•• NYHA Class III/IV on optimal treatment – NYHA Class III/IV on optimal treatment – Epoprostanol/Sildenafil/Bosentan.Epoprostanol/Sildenafil/Bosentan.

•• Declining Functional Capacity.Declining Functional Capacity.


EISENMENGERS SYNDROME EISENMENGERS SYNDROME

(2° PAT)(2° PAT)

•• NYHA Class III/IV and Declining Functional NYHA Class III/IV and Declining Functional Capacity.Capacity.

Contra-indicationsContra-indications

• HIV+ve/AIDS.HIV+ve/AIDS.• Hepatitis B, Ag+ve. Hepatitis B, Ag+ve. • Hepatitis C with biopsy proven liver Hepatitis C with biopsy proven liver

disease. disease. • Active malignancy.Active malignancy.• Dysfunction of one or more major organ. Dysfunction of one or more major organ.

systems other than lungs, e.g. renal systems other than lungs, e.g. renal failure.failure.

Relative Contra-Relative Contra-indicationsindications

In combination – increases risk of TxIn combination – increases risk of Tx• Severe Osteoporosis. Severe Osteoporosis. • Hypertension. Hypertension. • Diabetes Mellitus. Diabetes Mellitus. • Peptic Ulcer Disease. Peptic Ulcer Disease. • Musculo-skeletal Disease eg. Kypho-scoliosisMusculo-skeletal Disease eg. Kypho-scoliosis• Long term, high dose corticosteroids. Long term, high dose corticosteroids. • Poor nutritional status. Poor nutritional status. • Substance abuse. Substance abuse. • Psychological disorders. Psychological disorders. • Mechanical ventilation. Mechanical ventilation. • Microbial colonisation. Microbial colonisation.

• T.B. (untreated).T.B. (untreated).

ConclusionsConclusions

•• Most patients with diagnosis of IPF/UIP Most patients with diagnosis of IPF/UIP SHOULD be considered for EARLY transplant SHOULD be considered for EARLY transplant listing – due to rapid progression of listing – due to rapid progression of disease.disease.

•• Very FEW patients with COPD/Airway Very FEW patients with COPD/Airway obstruction WOULD be considered suitable obstruction WOULD be considered suitable for for listing – advanced age with co-morbid listing – advanced age with co-morbid disease.disease.


•• Worldwide the percentage of patientsWorldwide the percentage of patients

undergoing transplantation with PAH is undergoing transplantation with PAH is DIMINISHING due to improved prognosis DIMINISHING due to improved prognosis with with medical therapy. medical therapy.

•• A large and increasing percentage of A large and increasing percentage of CYSTIC FIBROSIS patients could CYSTIC FIBROSIS patients could potentially potentially qualify for listing, although qualify for listing, although some patients some patients currently elect not to follow currently elect not to follow this route.this route.


•• Meeting disease specific criteria Meeting disease specific criteria generally generally implies transplant implies transplant ASSESSMENTASSESSMENT is indicated. is indicated.

Certain percentage will be excluded by Certain percentage will be excluded by Transplant Panel.Transplant Panel.

•• It is in the interest of the Transplant It is in the interest of the Transplant Team to rigorously accept only ideal Team to rigorously accept only ideal

recipient.recipient.

Documents

Lung Transplantation Guidelines For Selection Milpark Hospital Transplant Unit Johannesburg, South Africa SATS Controversies Meeting May 2011