Il trapianto polmonare. Indicazioni, criticit ed esperienza del - - PowerPoint PPT Presentation

Il trapianto polmonare. Indicazioni, criticità ed esperienza del Centro di Riferimento di Siena

Dott.ssa Laura Franceschini

Scuola di specializzazione in Allergologia e Immunologia clinica U.O.C Medicina Interna 2, Le Scotte-Siena

www.eurotransplant.org

TRANSPLANTATION TIMELINE

1963- Dr. James Hardy

single lung tx in male patient, 58 y.o., life sentence in prison, with bronchogenic CA and severe BPCO immunosuppression: AZA, prednisone, cobalt irradiation survived 18 days (renal failure; an autopsy showed no evidence of rejection) early 2000's: double lung transplant more common

… IL POLMONE E’ DIVERSO

http://www.ctstransplant.org

! maggiore rischio di danno da riperfusione

(ampia area endoteliale)

! contatto con l’ambiente esterno !

ridotti meccanismi di difesa:

• rgano denervato no riflesso tussigeno

INDICAZIONI CONTROINDICAZIONI

INDICAZIONI

a chronic, end-stage lung disease who meet all the following general criteria:

• 1. High (>50%) risk of death from lung disease within 2 years

if lung transplantation is not performed.

• 2. High (>80%) likelihood of surviving at least 90 days after lung transplantation.
• 3. High (>80%) likelihood of 5-year post-transplant survival from a general

medical perspective provided that there is adequate graft function

• JHJHLT. 2017 Oct; 36(10): 1037-1079

J Heart Lung Transplant 2015 Jan;34(1):1-15. Epub 2014 Jun 26.

Adult Lung Transplants

Major Indications by Year (Number)

• JHJHLT. 2017 Oct; 36(10): 1037-1079

2017

Adapted by J Heart Lung Transplant 2015 Jan;34(1):1-15. Epub 2014 Jun 26.

25 50 75 100 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Survival (%) Years

A1ATD (N=3,117) CF (N=8,381) COPD (N=17,098) IIP (N=12,710) ILD-not IIP (N=2,730) Retransplant (N=2,226)

2017

• JHLT. 2017 Oct; 36(10): 1037-1079

Adult Lung Transplants

Kaplan-Meier Survival by Diagnosis

All pair-wise comparisons were significant at p < 0.05 except A1ATD vs. ILD-non IIP and COPD

• vs. ILD-non IIP

Median survival (years): A1ATD: 6.7; CF: 9.2; COPD: 5.8; IIP: 4.9; ILD- not IIP: 6.0; Retransplant: 2.9

(Transplants: January 1990 – June 2015)

CONTROINDICAZIONI

ABSOLUTE CONTRAINDICATIONS

• malignancy within prior 2 years
• another major organ failure (heart, liver, kidney)
• chronic infection with highly virulent and/or resistant microbes that

are poorly controlled pre-transplant

• substance abuse or dependence (alcohol, tobacco, marijuana, ...)
• no compliance / psychiatric conditions associated with the inability to cooperate
• acute medical instability (acute sepsis, myocardial infarction, liver failure, ...)
• uncorrectable bleeding diathesis
• BMI ≥ 35
• absence of an adequate social support system

RELATIVE CONTRAINDICATIONS

• age >65 years
• mechanical support (mechanical ventilation and/or ECLS), but...
• chronic colonization or infection with highly resistant or highly

virulent bacteria, fungi, and certain strains of mycobacteria

hepatitis B and/or C, HIV+

Burkholderia cenocepacia, Burkholderia gladioli multi-drug-resistant Mycobacterium abscessus

• other medical conditions with not end-stage organ damage

(diabetes mellitus, systemic hypertension, epilepsy, UP, GERD) should be optimally treated before transplantation

• BMI 30-34 or <17
• severe, symptomatic osteoporosis
• extensive prior chest surgery with lung resection

CRITICITA’

. THE TRANSPLANT WINDOW . WAITING LIST / REMOVAL FROM WAITING LIST . SPECIAL TRANSPLANT CIRCUMSTANCES . SINGLE or DOUBLE ? . COMPLICATIONS . SUPPLY AND DEMAND

THE TRANSPLANT WINDOW

Quezada W, Make B. Chronic Obstr Pulm Dis. 2016; 3(1): 446-453

• L. Franceschini

MANAGEMENT OF THE WAITING LIST

“…It is imperative that all wait-listed patients be regularly evaluated...ensuring that candidate selection is not simply a one-time static determination but rather a continuous

• process. “

REMOVAL FROM THE WAITING LIST

either temporarily or permanently

NEGATIVE DEVELOPMENT Development of any of the above-discussed absolute or relative contraindications: changes in weight or rehabilitation status, renal failure, demonstrable medical non-compliance, or patient ambivalence toward transplantation Patients bridged by mechanical ventilation and/or ECLS, who more frequently develop changes in clinical status that would preclude the likelihood of an acceptable transplant outcome. POSITIVE DEVELOPMENTS Response to medical therapy ( > APH) Improvement in quality of life status that would alter the risk/benefit equation away from transplantation at the current time should prompt a reevaluation of a patient’s transplant candidacy

Weill et al, J. Heart Lung Transplant. 2015; 34: 1–15.

en bloc double-lung procedure bilateral sequential single-lung

(< incidence of anastomotic complications)

SLT BLT SINGLE or DOUBLE ?

Varun Puri, Thorac Surg Clin. 2015; 25(1):47-54

Adult Lung Transplants

Indications for Single vs Double Lung Transplants

(Transplants: January 1995 – June 2012)

• JHLT. 2013 Oct; 32(10): 965-

978

2013

SLT BLT

*Other includes: Pulmonary Fibrosis, Other: 3.5% Bronchiectasis: 4.1% Sarcoidosis: 2.9% Connective Tissue Disease: 1.4% OB (non-ReTx): 1.3% LAM: 1.1% Congenital Heart Disease: 1.2% Miscellaneous: 1.8% *Other includes: Pulmonary Fibrosis, Other: 4.0% Bronchiectasis: 0.4% Sarcoidosis: 1.9% Connective Tissue Disease: 1.1% OB (non-ReTx): 0.7% LAM: 1.0% Congenital Heart Disease: 0.4% Miscellaneous:

1.1%

SPECIAL TRANSPLANT CIRCUMSTANCES

Lung retransplantation

• BILATERAL >> SINGLE TX

Ipsilateral single-lung retransplantation has been associated with a higher acute risk of death compared with contralateral single-lung retransplantation

• Of the 55.795 reported adult lung transplants that were performed through June 2015:

2.187 (3.9%) had a first retransplantation and 86 (0.2%) had a second retransplantation.

• patients who are >2 years out from initial transplantation fare better than patients

retransplanted earlier.

Weill et al, J. Heart Lung Transplant. 2015; 34: 1–15.

2016

• JHLT. 2016 Oct; 35(10): 1149-1205

Adult Lung Transplants

Transplant Type Distribution by Recipient Age Group (Transplants: January 1990 – June 2015)

Cancer

Weill et al, J. Heart Lung Transplant. 2015; 34: 1–15.

COMPLICANZE

IATROGENE RIGETTO iperacuto acuto cronico INFEZIONE batterica virale fungina ALTRE:

PGD K Versamento pleurico Stenosi bronchiali Ricorrenza malattia primaria Complicanze naturali del polmone

CHEST 2011 139, 402-411 DOI: (10.1378/chest.10-1048)

CHEST 2011 139, 402-411DOI: (10.1378/chest.10-1048)

RIGETTO CRONICO

OB:

• bliterative bronchiolitis

BOS/OB: bronchiolitis obliterans syndrome (BOS) dal 2008 RAS: restrictive allograft syndrome CLAD: chronic lung allograft dysfunction ALAD: acute lung allograft dysfunction

INCREMENTO DEL POOL DELLE DONAZIONI

2008: EVLP ex-vivo lung perfusion

TORINO - OSP. S. GIOV. BATTISTA-MOLINETTE MILANO - PRESIDIO OSP. MAGGIORE POLICLINICO MILANO - OSPEDALE CA' GRANDA MILANO - OSPEDALE NIGUARDA BERGAMO - OSPEDALI RIUNITI PAVIA - OSPEDALE POLICLINICO S. MATTEO UDINE – S. MARIA DELLA MISERICORDIA BOLOGNA - S. ORSOLA-MALPIGHI

_________________________________

SIENA - AOU S. MARIA ALLE SCOTTE ROMA - POLICLINICO UMBERTO I ROMA - OSPEDALE PEDIATRICO BAMBINO GESU’

________________________________

PALERMO - Is.mE.T

… in ITALIA: 12 CENTRI AUTORIZZATI

2 4 6 8 10 12 14 16 a 2001 a 2002 a 2003 a 2004 a 2005 a 2006 a 2007 a 2008 a 2009 a 2010 a 2011 a 2012 a 2013 a 2014 a 2015 a 2016

REDO-LTX OTHER COPD CF IPF

IL TRAPIANTO DI POLMONE A SIENA

> 140 TX

pneumologi immunologi infettivologi fisioterapisti anestesisti Chirurghi toracici psicologi

team

IL TRAPIANTO DI POLMONE A SIENA

KEY POINTS

• il trapianto polmonare è diventato un mezzo efficace e

affidabile per migliorare la sopravvivenza e la qualità della vita in pazienti accuratamente selezionati con malattia polmonare end-stage

• Il successo attuale nel trapianto è attribuito ad un timing

corretto di rinvio ed inserimento in lista d’attesa, alla presenza di un team multidisciplinare, al miglioramento della gestione dei donatori e all’attento follow-up dei trapiantati