Lung and Heart-Lung Transplantation



Lung and Heart-Lung Transplantation


Kevin C. Carney, MSN, CRNP, CCTC

J. Eric Hobson, MSN, CRNP

Vicki McCalmont, RN, MS, ANP-BC, CNS, CCTC



I. INTRODUCTION

A. Lung transplantation has evolved into a treatment option for patients with end-stage pulmonary disease.



  • It has been over 50 years since the first human lung transplant was performed by Hardy and colleagues at the University of Mississippi in 1963.1



    • The donor died from a myocardial infarction and the donation after cardiac death (DCD) lungs were transplanted into the recipient who succumbed 18 days later of renal failure. Similar to the experiences of other solid organ transplant pioneers, dismal outcomes resulted in slow progress.2,3


    • It took another 20 years before the Stanford group performed the first successful heart-lung transplant in 1981.4


    • Subsequently in 1983, the Toronto Lung Transplant Group reported the first successful single-lung transplant.5


    • In 1993, the University of Wisconsin team reported the first successful lung transplant using a DCD lung.6


    • These noteworthy events led to a series of clinical advances in the area of lung transplantation, including improved selection criteria, implementation of the lung allocation score (LAS), refined surgical techniques, advancements in immunosuppression, and avoidance of steroids immediately postoperatively.7,8,9,10,11


  • Three decades later, lung transplantation has become an established treatment of choice for selected patients with a variety of end-stage lung diseases, leading to increased survival and improvement in quality of life.



    • Remarkable progress continues to evolve with improved understanding of transplant immunology, microbiology, and pathology. Surgeons continue to explore opportunities to improve techniques such as the omentopexy, bronchial wrap, or telescoping or end-to-end anastomosis, which result in fewer airway-related complications.12







      FIGURE 11-1 Adult lung transplant survival (Transplants: January 1990-June 2012). These survivals are estimates as some patients were lost to follow-up. (Data retrieved from ISHLT registry. Yusen RD, Edwards LB, Kucheryavaya AY, et al. The registry of the international society for heart and lung transplantation: thirty-first adult lung and heart-lung transplant report—2014; focus theme: retransplantation. J Heart Lung Transplant. 2014;33(10):1009-1024.)


    • For adults, recent unadjusted survival rates are 80% and 53% at 1 and 5 years, respectively. Median survival is 5.6 years (Figure 11-1).13


    • Despite these improvements in short- and intermediate-term survival, long-term survival of lung transplant recipients is less than that of other solid organ transplant recipients. Survival is limited by the prevalence of chronic allograft rejection, known as bronchiolitis obliterans syndrome (BOS), and by the worldwide shortage of donor organs, which leads to mortality rates on the waiting list of approximately 8% to 10%.13,14


II. INDICATIONS AND CONTRAINDICATIONS FOR LUNG TRANSPLANT

A. Indications for lung transplantation15,16,17



  • Patients with chronic, end-stage lung disease and who meet all of the following criteria should be considered for lung transplantation per 2014 International Society for Heart and Lung Transplant (ISHLT) consensus guidelines.15



    • High (>50%) risk of death from lung disease within 2 years if lung transplant is not performed.


    • High (>80%) likelihood of surviving at least 90 days after lung transplantation.


    • High (>80%) likelihood of 5-year posttransplant survival from a general medical perspective, provided that there is adequate graft function.


  • Diseases currently accepted as indications for lung transplantation (single or bilateral) or a combined heart and lung transplant (HLT) are listed in Table 11-1.13,15









    TABLE 11-1 Diseases Treated by Lung Transplantation


























































































    Diagnosis


    SLT (N = 15,321)


    BLT (N = 26,579)


    HLT (N = 3,255)


    COPD/emphysema


    6,594 (43.0%)


    7,078 (26.6%)


    141 (4.3%)


    Idiopathic pulmonary fibrosis


    5,354 (34.9%)


    4,825 (18.2%)


    121 (3.7%)


    Cystic fibrosis


    234 (1.5%)


    6,628 (24.9%)


    459 (13.9%)


    Alpha-1


    771 (5.0%)


    1,572 (5.9%)


    62 (1.9%)


    Idiopathic pulmonary arterial hypertension


    92 (0.6%)


    1,158 (4.4%)


    907 (27.4%)


    Pulmonary fibrosis, others


    677 (4.4%)


    970 (3.6%)


    121 (3.7%)


    Bronchiectasis


    62 (0.4%)


    1,069 (4.0%)


    30 (0.9%)


    Sarcoidosis


    280 (1.8%)


    776 (2.9%)


    54 (1.6%)


    Retransplant: obliterative bronchiolitis


    312 (2.0%)


    379 (1.4%)


    24 (0.7%)


    Connective tissue disease


    177 (1.2%)


    409 (1.5%)


    n/a


    Obliterative bronchiolitis (not retransplant)


    105 (0.7%)


    351 (1.3%)


    25 (0.8%)


    LAM disease


    138 (0.9%)


    302 (1.1%)


    n/a


    Retransplant: not obliterative bronchiolitis


    205 (1.3%)


    227 (0.9%)


    32 (1%)


    Congenital heart disease


    58 (0.4%)


    291 (1.1%)


    1,178 (35.5%)


    Cancer


    7 (0.0%)


    29 (0.1%)


    n/a


    Others


    255 (1.7%)


    515 (1.9%)


    101 (3%)


    Data collected from ISHLT registry: 1995-2013.


    Adapted from Yusen RD, Edwards LB, Kucheryavaya AY, et al. The registry of the international society for heart and lung transplantation: thirty-first adult lung and heart-lung transplant report—2014; focus theme: retransplantation. J Heart Lung Transplant. 2014;33(10):1009-1024.




    • The most common indications for lung transplantation are13,14,15



      • Chronic obstructive pulmonary disease (COPD); approximately 33% of patients


      • Idiopathic pulmonary fibrosis (IPF); approximately 24% of patients


      • Cystic fibrosis (CF); approximately 16% of patients13


    • The number of combined HLTs continues to decline.13



      • The highest number of HLTs was approximately 170 cases in 1994 and 1995, out of a total of approximately 1,200 lung and heart-lung transplant procedures worldwide.


      • Since 1999, the number of HLTs has declined overall; however, since 2003, the number appears to have stabilized between 62 and 94 procedures per year.


      • As of 2012, only 75 HLTs out of a total of approximately 3,000 lung and heart-lung transplant procedures were performed worldwide.


      • Congenital heart disease (CHD), pulmonary arterial hypertension (PAH), and CF remain the most common indications (see Table 11-1).


  • Contraindications to lung transplantation:



    • In 2014, selection criteria were updated by the ISHLT to standardize the selection process and to provide evidence-based guidelines.15


    • See Tables 11-2 and 11-315,16 for detailed criteria concerning medical conditions that may have an impact on transplant selection eligibility for and contraindications to lung transplantation.









      TABLE 11-2 Medical Conditions Impacting Lung Transplantation Eligibility









      • Colonization of respiratory tract with fungi or atypical mycobacterium



      • Requirement of mechanical ventilation



      • Previous thoracotomy, sternotomy, pneumonectomy, or extensive pleural scarring



      • Active infection/sepsis



      • Active or recent malignancy/cancer



      • Substance abuse or addiction



      • Cigarette smoking within 4-6 mo of activation on the waiting list



      • Irreversible left heart failure



      • Severe osteoporosis (e.g., symptomatic compression fractures)



      • Severe musculoskeletal disease



      • Malnutrition: <70% or >130% of ideal body weight



      • Psychosocial problems that place patient at high risk of poor outcome



      • Severe, untreated psychiatric disease


      Data from Weill D, Benden C, Corris P, et al. A consensus document for the selection of lung transplant candidates: 2014 an update from the pulmonary transplantation council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2015;34(1):1-15; Kreider M, Hadjiliadis D, Kotloff RM. Candidate selection, timing of listing, and choice of procedure for lung transplantation. Clin Chest Med. 2011;32(2):199-211.



    • Despite these selection criteria, controversies persist regarding11,15,16,17,18:



      • Upper age limits for lung or heart-lung transplantation


      • Selection of patients colonized or infected with antibiotic-resistant organisms


      • Selection of patients with a history of nonadherence or with limitations due to physical conditions


      • Lack of reliable social support








TABLE 11-3 Absolute Contraindications to Lung Transplantation













  • Malignant disease—patients should be tumor-free for at least 5 y prior to consideration for transplantation. A 2-year disease-free interval may be reasonable for localized, nonmelanoma skin cancer that has been appropriately treated.



  • Irreversible end-stage organ disease in another organ (other than in the setting of a combined organ transplant)



  • Atherosclerotic disease with end-organ ischemia that is not able to be revascularized.



  • Acute medical instability (e.g., sepsis, myocardial infarction, and liver failure)



  • Bleeding diathesis that cannot be corrected



  • Chronic infection with resistant microbes that are poorly controlled prior to transplant



  • Active tuberculosis infection



  • Significant spinal or chest wall deformity that may limit allograft expansion



  • Class II or III obesity: body mass index > 35 kg/m2



  • Current, prior, repeated, or prolonged nonadherence to medical regimen that would increase the risk of posttransplant nonadherence



  • Psychiatric or psychologic conditions that preclude ability to cooperate with the interdisciplinary transplant team or adhere to the therapeutic regimen



  • Lack of an adequate and dependable social support system



  • Functional status that is severely limited and not amenable to rehabilitation



  • Alcohol, tobacco, or other illicit substance abuse or dependence


    – Note: Long-term participation in therapy and periodic blood and urine testing should be required before transplantation is considered.


Relative Contraindications to Lung Transplantation15




  • Age > 65



  • Class I obesity (body mass index 30.0-34.9 kg/m2)



  • Malnutrition that is progressive or severe



  • Osteoporosis that is severe and/or symptomatic



  • Prior extensive lung resection surgery



  • Mechanical ventilation, extracorporeal life support



  • Chronic infection with resistant microbes that are poorly controlled prior to transplant



  • Hepatitis B or C virus infection


    – Consider transplantation* for stable patients on appropriate therapy if there are no clinical, radiological, or biochemical evidence of cirrhosis or portal hypertension.



  • Human immunodeficiency virus (HIV)


    – Consider transplantation* for patients who are compliant with antiretroviral therapy in the setting of controlled disease, undetectable HIV-RNA



  • Other infections* (e.g., multidrug-resistant mycobacterium abscesses); infections caused by certain types of organisms (e.g., Burkholderia species)



  • Atherosclerotic disease that would increase the patient’s risk for posttransplant end-organ disease



  • Note: Treatment for other diseases that have not yet caused end-organ damage should be optimized before transplantation (e.g., diabetes mellitus)


* In transplant centers with expertise in this condition.


Data from Weill D, Benden C, Corris P, et al. A consensus document for the selection of lung transplant candidates: 2014 an update from the pulmonary transplantation council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2015;34(1):1-15.; Kreider M, Hadjiliadis D, Kotloff RM. Candidate selection, timing of listing, and choice of procedure for lung transplantation. Clin Chest Med. 2011;32(2):199-211.




III. PATIENT REFERRAL AND EVALUATION OF POTENTIAL CANDIDATES

A. Patients are typically referred to the lung transplant program by their local pulmonologist or primary care physician.



  • Medical information is sent to the transplant center for review.


  • The patient is then scheduled for a clinic visit to determine



    • Whether the patient does indeed have end-stage disease


    • If the patient has any conditions that may preclude lung transplantation


  • Timing of the referral is one of the most important aspects in lung transplantation.



    • Referrals that are late in the disease process may result in the patient being too sick for transplantation.


    • Careful consideration of the natural history and prognosis of the underlying primary disease is crucial in this decision process.16,19


    • Measures of quality of life with and without transplant must be weighed.11,20,21


    • Attention should be given to



      • The patient’s age at time of referral


      • Associated consequences of the lung disease on other organ systems


      • Current physical condition



    • Waiting time on the list for donor lungs or combined heart-lungs must be factored into the decision regarding the timing of referral.



      • Per 2012 Organ Procurement and Transplantation Network (OPTN) data, 12.7% of patients waiting had an LAS of 50% to 100%, and 65% of patients were transplanted within 1 year of listing.22 Data accessed on October 1, 15 from www.optn.transplant.hrsa.gov/.


      • Per Scientific Registry of Transplant Recipients (SRTR) data, 2014 waitlist mortality was 13.3%.23


    • Referring a patient late in the disease process state or at an older age may prevent the patient from being listed for transplantation. Older adults have difficulty enduring prolonged wait times, and this may lead to an increased waitlist mortality or removal from the list due to a deterioration in health if they become “too sick to transplant.” Blood type and HLA reactivity may also lead to prolonged wait times and higher waitlist mortalities.16


    • Patient referrals can also come from another transplant center when dual listing is advantageous to the patient. The United Network for Organ Sharing (UNOS) mandates that patients are informed of the right to be dual listed, as this may provide more opportunities for organ offers and expedite transplantation. Potential dual listing may be recommended for patients with



      • Elevated HLA antibodies


      • Worsening disease progression


      • Uncommon size


      • Adequate health care insurance



        • Prior approval from insurance company is typically required.


IV. TRANSPLANT EVALUATION

A. Patients referred for lung transplantation undergo a thorough evaluation, which includes a medical history and physical and consultations with specialists and interdisciplinary team members (social workers, dieticians, pharmacists, etc.; lab and diagnostic testing). This evaluation process is detailed in Table 11-4.15,16,17



  • Tests are tailored to the patient’s specific lung disease.


  • The purpose of this evaluation is to



    • Ensure that the individual meets medical and psychosocial eligibility criteria for transplantation


    • Minimize the risk associated with the transplant surgery


  • The evaluation is typically done as an outpatient and takes 3 to 5 days to complete. It consists of



    • Objective measures of end-stage organ failure



    • Psychosocial assessment, including, but not limited to



      • Cognitive functioning


      • Psychiatric disorders


      • Substance abuse


      • Social support24,25


    • Informed consent is obtained from the patient to proceed with the evaluation after comprehensive patient education is provided regarding the nature and rationale for all tests, procedures, and consults. Refer to the Patient Education chapter for additional information.










      TABLE 11-4 Evaluation Protocol for Lung Transplantation



































      General




      • Vital signs



      • Height, weight, body mass index



      • Functional level


      Lab tests/blood chemistries




      • Liver function tests (bilirubin, aspartate aminotransferase; alanine transaminase, and alkaline phosphatase)



      • Blood urea nitrogen, creatinine, and estimated glomerular filtration rate



      • Calcium



      • Phosphorus



      • Magnesium



      • Serum electrolytes



      • Fasting lipid profile



      • Stool for heme (×3), or recent colonoscopy



      • Prostate-specific antigen (males)*



      • Beta-hCG (females)


      Hematology and coagulation profile




      • Complete blood cell count with differential and platelet count



      • Prothrombin time (or international normalized ratio) and partial thromboplastin time


      Urine tests




      • Urinalysis



      • 24-Hour urine for creatinine clearance



      • 24-Hour urine for protein if diabetic or if urinalysis positive for protein*


      Scans




      • Ventilation-perfusion scan (V-Q scan)*



      • Computed tomography scan with high resolution to chest


      Radiology and ultrasound




      • Mammography*



      • Sinus films*



      • Chest radiograph



      • Abdominal ultrasound study (liver, pancreas, gallbladder, and kidney evaluation)



      • Carotid ultrasound*


      Consultations and evaluations




      • Complete history and physical examination



      • Respiratory therapist



      • Pulmonologist



      • Cardiologist*



      • Transplant coordinator



      • Surgeon



      • Infectious disease specialist



      • Dietician



      • Social worker



      • Psychiatric evaluation*



      • Neuropsychiatric evaluation (neurocognitive evaluation)*



      • Dental evaluation


      Pulmonary




      • Pulmonary function testing with arterial blood gases



      • Six-minute walk (at most centers)



      • Cardiopulmonary exercise test (CPET)* optional test


        – Measure as oxygen uptake and abbreviated as VO2


        – VO2 ≤ 8.3 mL/kg/min is associated with increased mortality risk


      Cardiovascular




      • Electrocardiogram



      • Two-dimensional echocardiogram with Doppler study



      • Right heart catheterization with detailed hemodynamic evaluation



      • Left heart catheterization with coronary angiography*


      Immunology




      • ABO blood type and antibody screen



      • Panel-reactive antibody screen



      • Human leukocyte antigen typing (if listed for transplantation)


      Digestion and gastrointestinal




      • Barium swallow or esophagram



      • pH probe testing and manometry



      • Gastric emptying study


      Infectious disease screening Serologies for:




      • Hepatitis virus A, B, and C



      • Herpes simplex virus



      • Human immunodeficiency virus



      • Cytomegalovirus (CMV)



      • Toxoplasmosis



      • Varicella virus



      • Rubella



      • Epstein-Barr virus



      • Venereal disease research laboratory



      • Lyme titers*



      • Histoplasmosis


      Cultures




      • Throat swab for viral cultures (CMV, adenovirus, and herpes simplex virus)*



      • Urine culture and sensitivity*



      • Sputum for bacterial, fungal, and mycobacterial cultures*


      Skin test




      • Purified protein derivative skin test with controls (i.e., mumps, dermatophytin, histoplasmosis, and coccidioidomycosis) or QuantiFERON Gold, a blood test to screen for exposure to tuberculosis


      Vaccinations




      • Hepatitis A and B series



      • Pneumovax every 5 y



      • Influenza vaccine each fall



      • Consider shingles vaccine and measles, mumps, and rubella for age-appropriate, nonimmunocompromised candidates.


      * Only performed if appropriate or indicated.


      From Weill D, Benden C, Corris P, et al. A consensus document for the selection of lung transplant candidates: 2014 an update from the pulmonary transplantation council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2015;34(1):1-15; Kreider M, Hadjiliadis D, Kotloff RM. Candidate selection, timing of listing, and choice of procedure for lung transplantation. Clin Chest Med. 2011;32(2):199-211; Dudley KA, El-Chemaly S. Cardiopulmonary exercise testing in lung transplantation: a review. Pulm Med. 2012;2012:237852.










      TABLE 11-5 Objective Measures of Deteriorating Medical Condition, Guidelines for Selection


























      Primary Disease


      Clinical Criteria


      COPD/emphysema


      BODE index of 7-10 or at least 1 of the following:




      • History of hospitalization for lung exacerbation associated with hypercapnia (pCO2 > 50 mm Hg)



      • pO2 < 50 mm Hg (rest)



      • Pulmonary hypertension or cor pulmonale or both despite O2 therapy



      • FEV1 <25% and either DLCO <20% or homogeneous distribution of emphysema without reversibility


      Cystic fibrosis




      • FEV1 < 30 % predicted



      • pCO2 > 50 mm Hg



      • pO2 < 50 mm Hg (rest)



      • Rapid decline in FEV1, particularly if female (*list urgently)



      • Increased antibiotic resistance and/or incomplete recovery from exacerbations.



      • Frequent hospitalization, use of noninvasive ventilation



      • Recurring hemoptysis



      • Pneumothoraces, loss of body weight



      • Pulmonary hypertension


      Pulmonary fibrosis


      Histologic or radiologic evidence of usual interstitial pneumonia




      • FVC < 60%-80% predicted or ≥ 10% decrease in FVC during 6-month follow-up



      • DLCO < 40% predicted



      • PAPm > 25 mm Hg



      • ANY O2 requirement.



      • Honeycombing on high-resolution CT scan (fibrosis score > 2)



      • Symptomatic, progressive disease with failure to maintain lung function despite steroids and good medical therapy


      Pulmonary hypertension




      • NYHA class III or IV despite combination medical therapy including prostanoids.



      • Low or declining 6 MWT (350 m)



      • Right arterial pressure > 15 mm Hg



      • Pulmonary arterial pressure > 50 mm Hg



      • Cardiac index < 2 L/min/m2



      • Uncontrolled syncope, hemoptysis, pericardial effusions, or progressive right heart failure



      • Right arterial pressure >15 mm Hg


      Sarcoidosis




      • NYHA functional class III or IV and any of the following:



      • Hypoxemia at rest



      • Pulmonary hypertension



      • Elevated right atrial pressure > 15 mm Hg


      Lymphangioleiomyomatosis (LAM)




      • VO2 max < 50% predicted (severe impairment in exercise and lung function)



      • Hypoxemia at rest


      * Special circumstances.


      BODE index, body mass index, airflow obstruction, dyspnea, exercise. Scores range from 0 to 10 and provide mortality risks based on data entered. CT, computed tomography; FEV1, forced expiratory volume in 1 second; MWT, minute walk test; pCO2, carbon dioxide tension; PAPm, pulmonary arterial pressure by mean; VC, vital capacity; DLCO, diffusing capacity of carbon monoxide; oxygen, O2; NYHA, New York Heart Association.


      Adapted from Hook J, Lederer D. Selecting lung transplant candidates: where do current guideline fall short? Expert Rev Respir Med. 2012;6(1):51-61; Weill D, Benden C, Corris P, et al. A consensus document for the selection of lung transplant candidates: 2014 an update from the pulmonary transplantation council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2015;34(1):1-15; Kreider M, Hadjiliadis D, Kotloff RM. Candidate selection, timing of listing, and choice of procedure for lung transplantation. Clin Chest Med. 2011;32(2):199-211.




    • If the patient is acutely ill, an expedited inpatient evaluation can be done. This type of evaluation has limitations as it does not



      • Provide the most accurate assessment of the patient’s functional status, compliance, and social support


      • Allow for a demonstration of commitment by the patient and his/her support system


  • The evaluation process can be a very stressful time for the patient and family.



    • Many patients experience feelings of anxiety, ambivalence, and hopelessness during this process.


    • The needs of the patient should be addressed by providing educational and emotional support to the patient and family.24,25,26


    • Members of the patient’s support system are evaluated for their willingness and ability to provide care for the patient long term, as caregiver burden can become problematic with prolonged illness.25,26,27


    • Please see chapters on the Evaluation of Transplant Patients and Psychosocial Issues in Transplantation for additional information.


V. LISTING PATIENTS FOR LUNG TRANSPLANTATION

A. Patients considered for transplant are presented to the interdisciplinary transplant selection committee after the evaluation process is complete. All information is compiled prior to the meeting and formally presented for discussion by the team. Members of the transplant team requested to participate in the transplant evaluation and selection meeting include



  • Pulmonologists


  • Cardiothoracic surgeons


  • Cardiologists, for patients who may require combined HLT


  • Respiratory, speech, and physical therapists


  • Dietitians


  • Nurse coordinators


  • Social workers


  • Psychiatrists or psychologists


  • Pharmacists


  • Ethicists


  • Research staff


  • Financial counselor/coordinator

B. After a comprehensive discussion, the transplant selection team may



  • Determine that the patient meets disease-specific criteria for lung transplantation (see Table 11-5).11,14,15,16



    • If candidate meets medical criteria to be placed on the transplant waiting list, the timing of listing must be determined.



      • Is the patient ready to list?


      • Is the patient above the functional threshold for listing, in which case the patient is monitored for disease progression and functional decline (Figure 11-2) as indicated by



        • Decline in FVC ≥10% during 6 months of follow-up


        • Decline in DLCO ≥ 15% during 6 months of follow-up


        • Desaturation to <88% or walking <250 m on 6-minute walk test over a 6-month follow-up period







          FIGURE 11-2 The order of tests to determine the cardiopulmonary status of the patient and the extent of lung resection that would be tolerated. A. The whole-lung function test is a basic screening test. B. The split-lung function tests are regional tests to determine the involvement of the diseased lung to be removed. ABG, arterial blood gas; FVC, forced vital capacity; FEV1, forced expiratory volume in 1 second; VC, vital capacity; MVV, maximum voluntary ventilation; RV/TLC, residual volume/total lung capacity; DLT, double-lumen tube. DLCO, diffusing capacity for carbon monoxide. (Adapted from Neustein SM, Cohen E. Preoperative evaluation of thoracic surgical patients. In: Cohen E, ed. The Practice of Thoracic Anesthesia. Philadelphia, PA: JB Lippincott; 1995:187, with permission.)


        • Pulmonary hypertension on right heart catheterization


        • Acute hospitalization for respiratory failure, pneumothorax, or disease exacerbation28,29


  • Decide that the patient does not meet medical or psychosocial transplant eligibility criteria at this time and determine whether or not



    • The issue can be corrected or resolved over time, with recognition of current medical status and if feasible and realistic


    • The patient should consider alternative centers for listing if the contraindications are center specific and not universal


    • The patient should be reassessed after current medical and/or psychosocial concerns are resolved and reconsidered for listing


  • If all viable treatment options are exhausted and a decision is made to offer transplant listing to the patient, the patient must then decide if he/she wants to be placed on the waiting list for a donor organ.

C. Candidates for lung transplantation are listed on a national computerized waiting list maintained by UNOS, a private, nonprofit organization contracted by the US Department of Health and Human Services to allocate organs according to OPTN policies.15



  • Listing information is outlined in Table 11-6 per UNOS guidelines.









    TABLE 11-6 UNOS Listing Information









    Listing information consists of




    1. Social security number



    2. Organ—heart-lung or lung



    3. Age group—adult or pediatric



    4. Patient name



    5. Locality



    6. Date of birth



    7. Race



    8. Diagnosis and blood group



    9. Height and weight



    10. Forced expiratory volume in 1 sec (FEV1) and forced vital capacity (FVC)



    11. Right heart catheterization pressures



    12. 6-Minute walk test distance



    13. Acceptable smoking history for a donor >20 pack years



    14. Acceptable donor serologies (human immunodeficiency virus, hepatitis B virus, and hepatitis C virus)



    15. Acceptable donor height range and age range



    16. A maximum distance the organ recovery team is willing to travel



    17. Whether a donor-specific crossmatch will be needed at the time of transplant


    Adapted in part from United Network of Organ Sharing (UNOS). Available at www.unos.org/wp-content/uploads/unos/Lung_Professional.pdf?b2d5de. Accessed October 12, 2015 and personal experience.



  • The patient’s LAS is calculated using a series of data factors that determine the probability of a patient surviving the next year without a transplant (urgent need) and the projected survival with a transplant (long-term benefit).15,28,29,30



    • Data for clinical variables are entered into the LAS calculator and the LAS score is calculated (see Table 11-7).15,28,29,30


    • The LAS ranges from 0 to 100 with a higher score suggestive of a higher severity of illness/increased urgency for transplantation and a higher probability of success following transplant.



      • The LAS is used to prioritize patients on the lung transplant waiting list.


      • The score is typically provided to the patient at the time of official listing notification.


  • Candidates are typically required to reside or establish temporary residency within a 2-hour distance to the transplant center (by ground or air transportation).



    • When distance precludes arrival at the transplant center via ground transportation within the 2-hour time limit, some transplant centers assist patients and families with alternate air transportation arrangements when a donor organ becomes available. Such arrangements



      • Afford patients the opportunity to wait for their transplant in their own home, which is an important consideration in areas of the country where there are few lung transplant programs (e.g., rural communities). This allows patients to remain close to family and friends for support.


      • Attempt to maintain equity of organ allocation and distribution


    • Other centers will allow for long-distance travel by notifying patients of organ offers earlier in the process and thus for car travel at the time of donor organ offers.



      • Patients are notified that there is a risk that the organ offer may not be accepted as additional clinical information regarding the donor is obtained while the patient is en route.









TABLE 11-7 Lung Allocation Score (LAS)







Lung Allocation Score Data




  • Diagnosis



  • Date of birth



  • Height



  • Weight



  • Forced vital capacity



  • Supplemental oxygen—(amount of FiO2 in liters or %):


    – At rest


    – At night


    – With exercise


    – Not needed



  • Need for mechanical ventilation and type



  • Arterial blood gases (need pCO2’s—current, highest, and lowest)



  • 6-Minute walk (feet)/functional status



  • Serum creatinine



  • Right heart catheterization pressures (right atrial pressure, pulmonary artery pressures, and cardiac index)



  • Presence or absence of diabetes mellitus (with/without Insulin use)


From Weill D, Benden C, Corris P, et al. A consensus document for the selection of lung transplant candidates: 2014 an update from the pulmonary transplantation council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2015;34(1):1-15; Smits JM, Nossent GD, Vries ED, et al. Evaluation of the lung allocation score in highly urgent and urgent lung transplant candidates in Eurotransplant. J Heart Lung Transplant. 2011;30(1):22-28; Braun AT, Dasenbrook EC, Shah AS, et al. Impact of lung allocation score on survival in cystic fibrosis lung transplant recipients. J Heart Lung Transplant. 2015;34(11):1436-1441. doi: 10.1016/j.healun.2015.05.020; Organ Procurement and Transplantation Network. Policy 10: Allocation of Lungs, 134-150. Available at optn.transplant.hrsa.gov/ContentDocuments/OPTN_Policies. Accessed September 29, 2015.



VI. MANAGEMENT OF PATIENTS AWAITING LUNG TRANSPLANTATION

A. During the waiting period, the health status of the lung transplant candidate is monitored regularly. This monitoring differs from center to center.



  • Stable patients are typically followed in an outpatient clinic every 8 to 12 weeks.



    • To maintain a current LAS, certain variables including functional status, diabetic status, assisted ventilation, and oxygen requirements are updated as frequently as every 2 weeks for patients with a LAS > 50 and at least every 6 months when the LAS <50.14,28,29,30


  • Other variables including pulmonary function tests, 6-minute walk, and serum creatinine are updated at least every 6 months.15,28,29,30


  • It is important to impress upon the patient and family that the transplant team must be notified of any hospitalizations, deterioration in pulmonary or general health status, and change in insurance or contact information and must keep all scheduled appointments.


  • Many transplant centers require patients to participate in cardiopulmonary rehabilitation two to three times a week while they are on the waiting list.



VII. INDICATORS OF DETERIORATION

A. Subjective complaints may include the following:



  • Symptoms of increased anxiety and depression.


  • Fear of dying.


  • Increased shortness of breath.


  • Decreased exercise tolerance.


  • Increased dependence on others.


  • Complaints of weight loss despite increase caloric intake.


  • Early satiety or decreased appetite.


  • These factors are multidimensional influences and may be interrelated.

B. Objective findings may include the following11,15:



  • Weight loss.


  • Decline in pulmonary function measurements (↓ forced vital capacity [FVC] or ↓ diffusing capacity of the lung for carbon monoxide [DLCO]).


  • Pulmonary hypertension (elevated right heart pressures).


  • Decline of walk distance on a 6-minute walk test (6 MWT).


  • Increasing supplemental O2 requirements at rest and/or with exertion:



    • 6 MWT O2 requirements may be increased.


  • Respiratory support requirements (continuous positive airway pressure [CPAP], bilevel positive airway pressure [BIPAP], mechanical ventilation).


  • Increased work of breathing.


  • Hospitalization for respiratory distress indicates higher urgency for transplant.


VIII. EDUCATION FOR THE LUNG TRANSPLANT PATIENT ACROSS THE TRANSPLANT CONTINUUM

A. Patient and family/caregiver education is an essential component of solid organ transplantation patient care and aids in managing expectations and optimizing adherence.



  • Education begins at the time the patient is referred for transplant evaluation and continues throughout the transplant continuum.

B. Pretransplant education for critically ill patients and their families requires special attention.



  • Given poor oxygenation and high levels of anxiety and overstimulation, patients may have less ability to concentrate and learn.


  • Small amounts of information shared at each interaction with repetition and gradual expansion of concepts optimizes retention.

C. Topics that should be covered while the patient is in the pretransplant phase of care could include, but are not limited to, the following:



  • The evaluation process:



    • Expected time line from beginning of evaluation to completion (scheduling testing and consultations, follow-up appointments, review of results, and recommendations from the selection team)


    • Evaluation tests (see Table 11-4)15,16,17:



      • These vary from transplant program to transplant program.


    • Consultation with interdisciplinary team members




      • Note: the Centers for Medicare and Medicaid (CMS) requires the following:



        • All patients must be evaluated using an interdisciplinary team approach.


        • Notes from each discipline must be documented in the patient record for CMS review.


        • If the patient does not have a need for a specific interdisciplinary team assessment, this must be documented in lieu of the consult note.


        • Interdisciplinary team assessments from a social worker, dietician, and pharmacist must occur prior to listing, immediately after transplantation, and prior to discharge.


      • In addition to patient education, discipline-specific consults may include the following assessments:



        • Social worker:



          • Emotional status and coping skill


          • Support system and resources


          • Existing stressors and prior mental health support


          • History of adherence to medical regimen


          • See chapter on Psychosocial Issues in Transplantation for additional information


        • Dietician:



          • Body habitus


          • Nutritional status


          • Bone health indicators and osteoporosis status


        • Pharmacist:



          • Current medications and tolerance


          • Medication allergies


          • Potential problems with posttransplant immunosuppression regimen


        • Financial coordinator:



          • Current health care insurance, including medication benefits


          • Disability status


        • Transplant coordinator:



          • Overall patient and family awareness of health status and disease state


          • Current status of routine health screening (e.g., mammography, prostate-specific antigen tests, dental examinations)


  • Waiting for a transplant



    • Self-care


    • Follow-up care with the transplant center; periodic labs and other tests


    • Exercise program


    • Nutrition and weight management:



      • Cachectic patients may require nutritional supplements to achieve a body mass index (BMI) > 18.


      • Obese patients may be required to lose weight to achieve a BMI < 30.


    • Support groups


    • Communication with the transplant center reporting:



      • Admission to other hospitals during the waiting period


      • Deterioration of condition and change in O2 requirement


      • Signs and symptoms of infection


      • Change of insurance, address, or phone number



  • Optimal donor:



    • Donor evaluation, matching, and selection31


  • Immediate preoperative period:



    • When the donor offer comes31,32,33:



      • Offer reviewed by surgeon and accepted if



        • The donor/recipient are ABO compatible


        • The size of the donor is appropriate for the size of the patient


        • The donor organ is deemed suitable for transplant


      • Patient notification of donor offer and admission to hospital:



        • Appropriate hospital entry to use


      • Estimated time line of events; potential for delays


    • Testing on admission:



      • Lab work


      • Chest radiograph (CXR)


      • Electrocardiogram (ECG)


      • Preoperative shower/scrub preparation


    • Placement of lines and catheters


    • Holding area


    • Family waiting area


  • Surgical procedure34,35:



    • Consent


    • Completion of central lines and arterial line placement


    • Initiation of anesthesia


    • Type of incision


    • Duration of surgical procedure


    • Updating family during surgical procedure


    • Transfer from the operating room directly to the intensive care unit (ICU). Postanesthesia management and recovery occur in the critical care unit, rather than in a postanesthesia care unit (PACU). Anesthesia is nearby if needed.


  • Immediate postoperative course:



    • Length of stay in the ICU and intermediate care unit


    • Lines, tubes, and devices insertion, maintenance, and removal


    • Ventilator and ventilator weaning protocol


    • Bronchoscopy for airway inspection and culture collection


    • Supplemental O2


    • Pain management


    • Medications:



      • Tolerance and safety for oral administration of medications


      • Weaning of intravenous (IV) inotropic and vasopressor support


      • Weaning of inhaled medications


      • Immune suppression:



        • In addition, antifungal medications interact with immunosuppression and complicate management.



          • Precautions vary from center to center and even provider to provider.


    • Postoperative routines:



      • Frequent vital sign/hemodynamic assessments


      • Diet progression


      • Ambulation (progressive increase in activity and physical therapy)


      • Use of incentive spirometer


      • Wound care and dressing changes


    • Visitation by family and significant others



  • Long-term follow-up care posttransplantation:



    • Adherence with the medical regimen.


    • Posttransplant clinic appointments.


    • Strategies to prevent infections, for example:



      • Wearing a mask for a specified time after surgery (per transplant program protocol). May include use when the patient is



        • Exposed to crowds during the first 3 months following transplant


        • Around sick people during the cold/flu season


        • Returning to the hospital or physician’s office where exposure to sick people is possible


      • Good hand hygiene.


      • Patients should not accompany others to physician office appointments.


      • Patients should not visit other patients in the hospital within 3 months posttransplant.


      • Patients should avoid crowded times at restaurants, movie theaters, banks, grocery stores, shopping malls, and indoor sporting events.


      • Limit hand contact with contaminated surfaces such as handrails, doorknobs, and countertops.


      • Proper food preparation and food handling and preparation surface maintenance and cleaning.


      • Pet care:



        • Patients should not have contact with domestic birds (risk for psittacosis, histoplasmosis, and other diseases).


        • Patients should not have contact with cat litter boxes due to risk of toxoplasmosis exposure.


        • Obtaining a new pet is typically discouraged during the first year posttransplant.


      • Home construction or gardening can be hazardous due to risk of dust/spore inhalation.


      • Dust inhaled related to these activities may often contain mold spores and can lead to fungal infections, which are difficult to treat.


    • Some are more conservative and instruct patients to avoid all of the above activities at all costs, while others allow patients to participate, but instruct patients to use protective masks of varying quality.



      • Wearing masks will reduce, but not completely eliminate, the risk.


      • In general, programs typically advise recipients to avoid the following activities:



        • Pulling up carpets


        • Repairing or replacing walls/ceilings


        • Gardening and yard work involving digging, fertilizing, and leaf raking


    • Daily use of a home spirometry device to monitor the lung function.


    • Immunosuppressants and other medications:



      • Purpose


      • Adherence regarding timing, exact dosing, and intervals


      • Potential side effects



      • Potential drug interactions:



        • Prescription drugs


        • Over-the-counter medications


      • Food/drug interactions such as those with grapefruit and/or grapefruit juice


      • Supplements and herbal remedies (avoid Echinacea, probiotics, and other remedies that are contraindicated posttransplant)


      • Monitoring medication supply, availability, and trough levels


    • Management of symptom distress:



      • When to call the transplant center or coordinator on call


      • Quality of life and realistic expectations


    • Posttransplant health care costs:



      • Coverage of health care costs for the posttransplant treatment and potentially expensive immunosuppressant medications can be one of the greatest concerns for patients and health care professionals.


      • Without prescription drug, transplant recipients face a significant financial challenge.


      • Patients should be referred to a social worker, pharmacist, and/or transplant financial coordinator who can



        • Identify potential financial resources.


        • Help the patient apply for pharmacy assistance programs or grants or engage in fundraising to defray future costs.


        • Patients should not share medications with one another as this is illegal.


    • Returning to work after lung transplantation should be encouraged.



      • The social worker may assist patients and families with return to work issues, including, but not limited to



        • Insurance coverage concerns


        • Potential loss of Medicare or other public insurance benefits

D. See chapter on Education for the Transplant Patient for additional information.


IX. DONOR SELECTION

A. Successful lung transplantation is dependent on optimal donor selection.30,31,32

B. Guidelines for the identification and management of potential lung donors have been established by UNOS.

C. Characteristics of optimal lung donor31,32,33:



  • Usually younger than 55 years of age.


  • Chest radiograph: clear:



    • Ventilator recruitment maneuvers may clear areas of atelectasis.


  • Arterial blood gas (ABG) with normal gas exchange and PaO2 > 300 mm Hg on 100% FiO2, 5 cm positive end-expiratory pressure (PEEP) for 5 minutes (Figure 11-3).


  • No previous thoracic surgery, pulmonary contusions, or chest trauma.


  • No evidence of aspiration.







    FIGURE 11-3 Acid-base nomogram NB. If ABG not available, can use VBG, but note that pH ˜0.04 ↓, PaCO2 ˜8 mm Hg ↑, and HCO3 ˜2 mEq ↑. (Adapted from Brenner BM, ed. Brenner & Rector’s The Kidney. 8th ed. Philadelphia, PA: Elsevier; 2007; Ferri F, ed. Practical Guide to The Care of the Medical Patient. 7th ed. Philadelphia, PA: Elsevier; 2007.)


  • Bronchoscopy should demonstrate clear airways:



    • Free of purulent or aspirated material.


    • Cultures should be negative, no lung infection.


  • Tobacco history < 20 pack/years.


  • Absence of any transmittable diseases.


  • If considering DCD lungs, follow above criteria and use direct visualization of lungs in the operating room.


  • Some programs will consider extended criteria lung donors (ECLD). These donors may be above age 55 and have an abnormal CXR or infiltrate, smoking history >20 pack/years, positive sputum cultures, and heavy secretions upon bronchoscopy.

D. Donor and recipient size match is also an important factor considered during the selection process.


Oct 27, 2018 | Posted by in NURSING | Comments Off on Lung and Heart-Lung Transplantation
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