lung transplant

Overview

• Indications: end stage, progressive decline despite max medical Rx, <2-y life expectancy; COPD, ILD (IPF), pulmonary HTN, cystic fibrosis, alpha 1-antitrypsin
• Contraindic: age >70, uncontrolled/unRx’d infxn, malig in prior 5 yrs, severe non-pulm dis., BMI ≥35 or <16, active smoking, EtOH/drug depend., med nonadherence, psychosocial

Posttransplant care

• Immunosuppression: no single best regimen. Calcineurin inhibitor (tacro >cyclosporine, ↓ incidence of graft failure (JHLT 2021;40:S165) + steroids + MMF or AZA
• Monitoring: clinic visits, serial PFTs, chest X-ray, bronchoscopy w/ transbronchial biopsy

Complications

• Primary graft dysfunction (PGD): acute lung injury following txp; assoc w/ early mortality
• Anastomotic: vascular (stenosis, thrombosis) and airway (infection, necrosis, dehiscence, granulation tissue, tracheobronchomalacia, stenosis, fistula)
• Acute rejection: ↓ lung fxn, cough, SOB, fever; Dx w/ trans-bronch bx; Rx immunosupp
• Chronic rejection: bronchiolitis obliterans w/ obstruction; Dx w/ PFTs, trans-bronch bx; Rx limited (azithromycin, montelukast, Δ immunosuppressives)
• Infection: ↑ bacterial, fungal, viral pneumonia, systemic infections, CMV, OI
• Malignancy: 2× ↑ risk overall. 5.5× ↑ risk lung cancer. PTLD (assoc w/ EBV) common.
• Misc: GVHD, CKD, DM, CAD, CHF, stroke, encephalopathy, drug toxicity