Organ Transplantation

Rosa Malo de Molina Ruiz , MD Pulmonary Department University

Hospital Puerta de Hierro

Alpha 1-antitrypsin deficiency

EMPHYSEMA

Normal Lung

Emphysematic Lung

PROGRESS / DISABILITY / MORTALITY

TRASNFER TO

TRANSPLANT

CENTER

INCLUSION IN WAITING

LIST

PRIORITIZATION IN

TRANSPLANTATION

WAITING LIST

Lung transplant

Lung transplant

• The process of assessing lung transplantation in a specific patient aims to answer three fundamental questions:

It is necessary? It can be done? Does the patient want it?

TRASNFER TO

TRANSPLANT

CENTER

Lung Trasplant

Indication

No contraindication

• Recent tumor history (> 5 years disease free) • Dysfunction of another major organ • Coronary Disease with no possibility of

revascularization • Hemorrhagic diathesis • Deformities of the thoracic wall • Morbid obesity • Infection by TBC or by highly resistant germs • Altered functional status w/o rehabilitation

possibility • Psychiatric disorders, lack of social support • Non-adherence

It can be done? Absolute contraindication

J Heart Lung Transplant. 2015;34(1):1-15.

• Age> 65 years • Obesity (BMI 30-34.9) or severe malnutrition • Severe symptomatic osteoporosis • Anterior thoracic surgery with pulmonary

resection • Extracorporeal support or mechanical

ventilation • B or C virus infection with evidence of

significant hepatic injury and / or portal hypertension

• HIV Infection • Infection by multiresistant germs.

J Heart Lung Transplant. 2015;34(1):1-15.

It can be done?: Relative contraindications

Transplant window

TRASNFER TO

TRANSPLANT

CENTE

“Primum non nocere” Hipocrates

Test

Distance walked in 6 minutes

Celli B; N Engl J Med .2004;350:1005-12

• BMI (weight and hight) • Dyspnea

The BODE Index For COPD

Ecocardiography

COPD: Criteria for transfer to a transplant

center

Progressive disease despite treatment Non suitable for LVRS or ELVR BODE 5-7 FEV 1

COPD: Inclusion waiting list

• BODE index ≥7 • FEV1

Survival BODE Transplant: ISHLT

B. Celli. N Engl J Med. 2004 Mar 4;350(10):1005-12 www. ISHLT

ADULT LUNG TRANSPLANTATION: Indications for Single Lung Transplants (Transplants: January 1995 - June 2010)

*Other includes: Pulmonary Fibrosis, Other: 3.4%

Sarcoidosis: 1.9%

Bronchiectasis: 0.4%

Congenital Heart Disease: 0.3%

LAM: 0.8%

Connective Tissue Disease: 1.0%

OB (non-ReTx): 0.6%

Miscellaneous: 0.9%

ISHLT 2011 ISHLT

J Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132

Gráfico1

Alpha-1Alpha-1Alpha-1Alpha-1Alpha-1Alpha-1

COPDCOPDCOPDCOPDCOPDCOPD

CFCFCFCFCFCF

IPFIPFIPFIPFIPFIPF

IPAHIPAHIPAHIPAHIPAHIPAH

Re-TxRe-TxRe-TxRe-TxRe-TxRe-Tx

Other*Other*Other*Other*Other*Other*

Single

0.059

0.4675

0.0173

0.3238

0.0063

0.0308

0.0952

Sheet1

Single

Alpha-15.90%

COPD46.75%

CF1.73%

IPF32.38%

IPAH0.63%

Re-Tx3.08%

Other*9.52%

ADULT LUNG TRANSPLANTATION: Indications for Bilateral/Double Lung Transplants (Transplants: January 1995 - June 2010)

26%

16%

17%

7%

27%

5% 2%

Alpha-1 COPD CF IPF IPAH Re-Tx Other*

*Other includes:

Pulmonary Fibrosis, Other: 2.9%

Sarcoidosis: 3.0%

Bronchiectasis: 4.4%

Congenital Heart Disease: 1.2%

LAM: 1.1%

Connective Tissue Disease: 1.3%

OB (non-ReTx): 1.3%

Miscellaneous: 1.7%

ISHLT 2011 ISHLT J Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132

Lung transplant

• The process of assessing lung transplantation in a specific patient aims to answer three fundamental questions:

It is necessary? It can be done? Does the patient want it?

Lung transplant: Disadvantages

• It is not a curative treatment • Limited duration • Accurate self-care • Immunosuppressive therapy

indefinite • Adverse effects • Permanent risk of rejection

and / or infection

Pre-transplant follow-up

• Vaccinations • Dietary Tips • Treatment exacerbations • Deactivate / Activate in

waiting list • Rehabilitation • Exercise

“From fighting for my live, to lifting for my live”

www.alpha-1-1-athlete.com

Surgery and perioperative care

Cause of death after transplant ISHLT Registry (1992 – 2013)

Yusen J Heart Lung Transplant 2014 Oct; 33(10): 1009-1024

Gráfico1

0-30 Days (N=2,905)0-30 Days (N=2,905)0-30 Days (N=2,905)0-30 Days (N=2,905)0-30 Days (N=2,905)

31 Days – 1 Year (N=5,098)31 Days – 1 Year (N=5,098)31 Days – 1 Year (N=5,098)31 Days – 1 Year (N=5,098)31 Days – 1 Year (N=5,098)

>1 Year – 3 Years (N=4,797)>1 Year – 3 Years (N=4,797)>1 Year – 3 Years (N=4,797)>1 Year – 3 Years (N=4,797)>1 Year – 3 Years (N=4,797)

>3 Years – 5 Years (N=2,746)>3 Years – 5 Years (N=2,746)>3 Years – 5 Years (N=2,746)>3 Years – 5 Years (N=2,746)>3 Years – 5 Years (N=2,746)

>5 Years – 10 Years (N=3,263)>5 Years – 10 Years (N=3,263)>5 Years – 10 Years (N=3,263)>5 Years – 10 Years (N=3,263)>5 Years – 10 Years (N=3,263)

>10 Years (N=1,092)>10 Years (N=1,092)>10 Years (N=1,092)>10 Years (N=1,092)>10 Years (N=1,092)

Bronchiolitis

Malignancy (non-Lymph/PTLD)

Infection (non-CMV)

Graft Failure

Cardiovascular

% of Deaths

0.3

0.2

18.9

24.2

11.3

4.6

2.8

35.4

16.6

5

25.6

7.9

21.7

18.9

4.4

29.3

10.9

18.4

18

5

24.7

13.7

18

17.1

5.6

20.1

12.4

16.7

16.6

7.6

Sheet1

Time0-30 Days (N=2,905)31 Days – 1 Year (N=5,098)>1 Year – 3 Years (N=4,797)>3 Years – 5 Years (N=2,746)>5 Years – 10 Years (N=3,263)>10 Years (N=1,092)

Bronchiolitis0.34.625.629.324.720.1

Malignancy (non-Lymph/PTLD)0.22.87.910.913.712.4

Infection (non-CMV)18.935.421.718.41816.7

Graft Failure24.216.618.91817.116.6

Cardiovascular11.354.455.67.6

Normal results • Adequate lung function • Improved quality of life • Lack of infection and rejection • Increased exercise capacity

What is the job of a transplanted patient?

• Periodic controls to detect early • Active participation • Good adhesion to treatment

Nebulized treatment

It is recommended , as soon as possible to include the physical exercise in the daily routine that will progressively increase

Graft Failure Adverse event

due to treatment

Inmunosupresive Equilibrium

New techniques in lung transplantation

Selection criteria Standard Extended AB0 compatibility Identical Compatible Age < 55 years > 55 years Smoking < 20 pack-years > 20 pack-years acceptable

Thoracic trauma Abscense Localized Intubation time < 7 days > 7 days acceptable Asthma No Yes acceptable Cancer No (except for skin) Primary central nervous

system tumour

Secretion culture Negative Positive acceptable (with prophylaxis

PaO2/FiO2 ratio > 300 < 300 acceptable Chest X-ray Normal Focal or unilateral

abnormality

Bronchoscopy Normal Secretion in principal airway acceptable

Cardiothoracic surgery Absent Occasionally acceptable

Serological test Negative Cytomegalovirus and toxoplasmosis tolerated

Expanding donor criteria

Ex vivo lung perfussion

Living-donor lung transplantation

Inclusion bodys in the liver

Alpha-1 deficiency, uncommon indication for Liver Transplantation

73/5246

1.4%

History of liver disease

• Chronic

liver disease

Compensated cirrhosis

Development of complications:

Variceal hemorrhage

Ascites Encephalopathy

Jaundice

Deconmpensate

Cirrosis Death

Goals

• Provides maximum benefit to patients with liver failure who have no other option

• Likely prolongs life

• Restores patient to normal or near normal functional status

Contraindications to Liver Transplant

ABSOLUTE Active infection Spontaneus Bacterial

Peritonitis Pulmonary HTN Extrahepatic

malignancy Active alcoholism Substance abuse Non compliance

RELATIVE CRF Advanced cachexia Large Hepatocelular

carcinoma Multisystem organ

failure states HIV ?

Pre-transplant Work-up Liver function tests, total protein,

albumin

Hepatitis screen (A, B, C)

Serologies - Cytomegalovirus (CMV), herpes simplex virus (HSV),

Epstein-Barr virus (EBV), HIV Tumor markers Alpha-fetoprotein, cholinesterase Arterial blood gases Others (selective) - Carbohydrate

antigen 19-9, cancer antigen 125

CT scan whole body Colonoscopy Cardiopulmonary clearance Psychiatrist and social worker

consultations

MELD SCORE MELD score based on 3

biochemical variables, (1) serum bilirubin, (2) serum creatinine, and (3) INR

Highly predictive 3-month

mortality of patients with ESLD

Minimum score for LT: 15

points Maximum score: 40 points

Living Donor Living-donor Liver

Transplant: part of the liver from a living donor is resected and transplanted into a recipient

Complications liver transplant

Acute rejection (up to 40 % in first 3 months) Chronic rejection: ductopenia, fibrosis Primary graft failure ( up to 7 %) Biliary complications (strictures) Hepatic Artery Thrombosis Infections (viral and fungal) Post transplantation lymphoproliferative

disorder (PTLD): EBV

Thank you!!!

Organ Transplantation Slide Number 2Slide Number 3Lung transplantSlide Number 5It can be done? �Absolute contraindication �It can be done?: Relative contraindicationsSlide Number 8Slide Number 9Slide Number 10Slide Number 11Slide Number 12The BODE Index For COPDSlide Number 14Slide Number 15EcocardiographyCOPD:�Criteria for transfer to a transplant center COPD:�Inclusion waiting listSurvival�ADULT LUNG TRANSPLANTATION: Indications for Single Lung Transplants (Transplants: January 1995 - June 2010)ADULT LUNG TRANSPLANTATION: Indications for Bilateral/Double Lung Transplants (Transplants: January 1995 - June 2010)Lung transplantLung transplant:� DisadvantagesPre-transplant follow-up“From fighting for my live, to lifting for my live”Surgery and perioperative careCause of death after transplant�ISHLT Registry (1992 – 2013)Normal resultsWhat is the job of a transplanted patient?�Nebulized treatmentSlide Number 31Slide Number 32Slide Number 33Slide Number 34Slide Number 35Slide Number 36New techniques in lung transplantationExpanding donor criteriaEx vivo lung perfussionLiving-donor lung transplantation�Slide Number 41Inclusion bodys in the liverAlpha-1 deficiency, uncommon indication for �Liver TransplantationHistory of liver diseaseGoalsContraindications to Liver TransplantPre-transplant Work-upLiving DonorComplications liver transplantSlide Number 50Slide Number 51