When shown a lung transplant?
Lung transplantation (TP) is a therapeutic option for patients with respiratory failure from any cause, in the absence of alternative treatments and no evidence of contraindications.
The TP was developed with a thoracic surgeon, Dr Cooper, who won the first successful lung transplant in unilateral idiopathic pulmonary fibrosis patients in Toronto in 1983. Three years later he performed bilateral sequential lung transplantation for patients with chronic obstructive pulmonary disease (COPD).
The transplant activity has increased in the 90’s, at the present time are made over a thousand lung transplants worldwide. Patients with COPD are the most candidates in the International Transplant Registry.
Lung transplantation or heart-lung covers the entire spectrum of lung diseases, but the most frequent diagnoses of COPD, idiopathic pulmonary fibrosis (IPF), cystic fibrosis (CF), primary pulmonary hypertension (PPH) and Eisenmenger syndrome. Other indications are less frequent in patients with bronchiectasis, sarcoidosis, among others.
Who are the candidates?
The recipient selection is one of the key points in the results of this technique. Each hospital has its own protocol for selection of candidates taking a few general guidelines to their own experience and its waiting list.
Table I shows the general guidelines for selecting recipients.
SELECTION OF RECIPIENTS
Severe functional and clinical pathology in the absence of other treatment option with a life expectancy of less than 1 or 2 years.
Absence of active infection, including HIV.
Absence of irreversible damage to other organs (heart, liver, kidney, and CNS) or active systemic disease.
Absence of toxic habits (snuff, alcohol, drugs) at least 6 months prior to its inclusion on the waiting list.
Walking situation with the potential to go to rehab.
Psychosocial situation acceptable.
Good nutritional status between 80-120% of ideal weight
Table I. – Selection of Recipients
According to the diagnosis that motivates the TP there are a number of recommendations proposed by scientific societies. So, are candidates for lung transplant patients presenting with respiratory failure from any cause in which life expectancy is less than 1 or 2 years, once they have exhausted all available treatment resources. One of the requirements is the absence of injury to other organs such as heart, liver, kidney and central nervous system and absence of systemic disease activity.
Generally excluded patients with cancer and HIV-infected patients. B virus infection or hepatitis C virus is a subject open to debate. Most centers exclude patients or require the absence of severe histologic injury to accept them. When there are any active infection data exclude the possibility of TP until it is resolved.
Transplant Patient Care
On the other hand, patients should be able to understand, engage and meet the requirements to use diagnostic or therapeutic measures before, during and after transplantation with acceptable psychosocial profile. They should not have harmful habits, alcohol, snuff or drugs, with a strong emphasis on smoking cessation for at least 6 months before entering the active waiting list. It requires that your physical condition is acceptable enough to go to the hospital and begin a rehabilitation program and to maintain adequate nutritional status, weighing between 70 and 130% of ideal weight.
After the transplant, the patient undergoes a triple immunosuppressive therapy and prophylaxis to prevent various infections. During this time, you may work with a professional from a respiratory therapist school. The occurrence of at least one episode of acute rejection is the norm, with good overall response to treatment with high doses of methylprednisolone and intensification of inmusupresión.
Acute rejection is most common during the first three months, but can appear at any subsequent time. Chronic rejection manifested as bronchiolitis obliterans. Clinically, it corresponds to a deterioration of lung function and eventual development of respiratory failure. None of the available therapeutic options are really adequate to control it. It is the biggest problem of transplantation up to 50% of patients alive at 5 years after transplantation.
Evolution is different depending on each patient, either by falling on steps or a rapidly progressive deterioration. The risk of such potent immunosuppression is the development of bacterial, viral and fungal infections that affect a significant morbidity and mortality
There are specific issues that deserve comment transplant patients because of the importance or the frequency in which they appear. Osteoporosis is one of the most important because it limits the quality of life after lung transplantation. The incidence of one in this group of patients is elevated by prior corticosteroid use and immobility among other causes. After transplantation is aggravated by the use of corticosteroids and cyclosporine with increased incidence of fractures that can greatly interfere with mobility and functional recovery of these patients. Osteoporosis is therefore a relative contraindication to be properly assessed individually.
In patients with cystic fibrosis or bronchiectasis that are often colonized by bacteria different severity of post-transplant infections and mortality associated with them is greater. In these cases, each school adopts a policy on these issues, based on their experience and results.
Patients receiving mechanical ventilation have been excluded in most programs. Mortality is high even when they have been successful. If we add the waiting list and ethical considerations in this regard, many centers prefer not to accept these cases, unless the patient was previously included on the waiting list and require ventilation functional impairment, no evidence of active infection.
Limitations to transplantation
The age limit for transplant candidate transplant depends on the type proposed, as well as biological age of the candidate. In the case of unilateral transplant is considered to be between 60-65 years, bilateral and 55 heart-lung 50 years. Survival is slightly lower in patients older than 60 years in the International Registry data transplantation.
Cardio-thoracic surgery prior surgery increases the risk of transplantation, but each case is settled individually.
Patients sensitized to human leukocyte antigen (HLA) can be a problem, given the risk of hyperacute rejection. This sensitization may occur after transfusions, pregnancies or previous transplants. In these cases, finding a compatible donor can be difficult to transplant.
Where does a lung transplant?
Treatment should be performed in accredited centers have the expertise to address all possible treatment options, ie it can offer the following alternative and Surgical lung transplantation (TP).
The results of transplantation can be considered from several perspectives: survival, quality of life and lung function. Actuarial survival from the International Register of St. Louis, is 80% the first year and 56% the third. The improvement in the quality of life is clear with what is necessary to know who can benefit as they should be offered lung transplantation as a treatment option.