Makindo Medical Notes

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About

• Lung transplantation involves replacing one or both diseased lungs with healthy lungs from a donor.
• Can be performed as a single or double lung transplant.
• Typically offered to patients under 60 years old, although some exceptions may be made.
• Patients require lifelong immunosuppressive therapy to prevent rejection, including Ciclosporin, Tacrolimus, Steroids, Mycophenolate mofetil, Azathioprine, and anti-lymphocyte globulin.
• High risk for opportunistic infections due to immunosuppressive therapy.

Types

• Single Lung Transplant: One diseased lung is replaced while the other remains. More commonly performed for conditions where infection is not a major concern, such as COPD and idiopathic pulmonary fibrosis.
• Double Lung Transplant: Both lungs are replaced, typically performed as two separate transplants. Indicated for conditions where both lungs are severely affected, such as cystic fibrosis, idiopathic pulmonary fibrosis, and primary pulmonary hypertension.

Indications

• Cystic fibrosis (DOUBLE lung transplant preferred).
• Emphysema and alpha-1 antitrypsin deficiency (SINGLE or DOUBLE).
• Idiopathic pulmonary fibrosis (SINGLE or DOUBLE).
• COPD (SINGLE).
• Pulmonary fibrosis due to connective tissue diseases.
• Chronic hypersensitivity pneumonitis (Chronic allergic alveolitis).
• Advanced pulmonary sarcoidosis.
• Primary pulmonary hypertension (DOUBLE).
• Langerhans cell granulomatosis.
• Lymphangioleiomyomatosis.

Complications

• Infections: High risk, especially for opportunistic pathogens like CMV. The risk is greater when the recipient is seronegative and the donor is seropositive.
• Acute Rejection: Occurs in the first weeks to months post-transplant. Requires prompt adjustment of immunosuppressive therapy.
• Chronic Rejection: Characterized by bronchiolitis obliterans syndrome (BOS), not to be confused with BOOP (Cryptogenic organizing pneumonia). BOS presents as progressive dyspnoea, cough, and airflow limitation on spirometry.
• Renal Impairment: Due to long-term use of calcineurin inhibitors like Tacrolimus or Ciclosporin.
• Malignancy: Increased risk of skin cancers and lymphoproliferative disorders due to immunosuppression.
• Gastrointestinal Issues: GI disturbances due to medications, including nausea, diarrhoea, and increased risk of peptic ulcer disease.

Post-Transplant Care

• Close monitoring of lung function through spirometry and imaging to detect early signs of rejection.
• Regular screening for opportunistic infections like CMV, Aspergillus, and Pneumocystis jiroveci pneumonia (PJP).
• Long-term prophylactic medications, such as trimethoprim-sulfamethoxazole (Bactrim) for PJP, are essential.
• Physical rehabilitation to improve exercise capacity and quality of life.
• Regular monitoring of immunosuppressant drug levels to avoid toxicity and rejection.
• Patient education on the importance of medication adherence and recognizing early signs of infection or rejection.

Prognosis

• Median survival after lung transplantation is around 5-7 years, but many patients survive longer with careful management.
• Outcomes are generally better for younger recipients and those receiving double lung transplants for conditions like cystic fibrosis.
• Chronic rejection (BOS) is the most common cause of death after the first year.
• Early detection and management of complications can significantly improve quality of life and survival.

References

• Management of Lung Transplant Recipients
• Lung Transplantation: Indications, Contraindications, and the Future