20/03/15 Sidonnaisuuteni kaupalliseen yritykseen (ky) viimeisten 2 v aikana Keuhkonsiirto PAH ja sidekudossairauspotilailla Maija Halme HYKS / Keuhkosairauksien klinikka 20.3.2015 SKLY / Kuopio ISHLT: A consensus document for the selection of lung transplant candidates: 2014 update Absolute contraindications • recent history of malignancy • untreatable significant dysfunction of another major organ (e.g heart, liver, kidney or brain) unless combined organ tx can be performed • uncorrected atherosclerotic disease with suspected or confirmed end–organ ischemia or dysfunction and / or coronary artery disease not amenable to revascularization • acute medical instability, including, but not limited to, acute sepsis, myocardial infarction, and liver failure • uncorrectable bleeding diathesis • chronic infection with highly virulent and / or resistant microbes that are poorly controlled pre-tx • evidence of active M. tuberculosis infection ISHLT: A consensus document for the selection of lung transplant candidates: 2014 update Sidonnaisuuden laatu Ky 1 Ky 2 Saanut ky:lta apurahan - - Omistan ky:n osakkeita - - Saanut ky:lta palkkaa/palkkion - - Suunnitellut koulutustilaisuuden ja saanut ky:lta palkkion Bayer, BI, GSK, Intermune, MSD Osallistunut kongressiin ky:n osittain tai kokonaan maksamana Bayer, GSK, NordicInfu Care, Olympus, Pfizer, Takeda Osallistunut ky:n hallintoelinten toimintaan - - Olen työsuhteessa ky:een - - Vastaanottanut muuta tukea ky:lta - - ISHLT: A consensus document for the selection of lung transplant candidates: 2014 update Absolute contraindications, cont. • significant chest wall or spinal deformity expected to cause severe restriction after tx • class II or III obesity (BMI > 35.0 kg/m2) • current non-adherence or a history of repeated or prolonged episodes of non-adherence to medical therapy • psychiatric or psychologic conditions associated with inability to cooperate • absence of an adequate or reliable social support system • severily limited functional status with poor rehabilitation potential • substance abuse or dependance (e.g alcohol, tobacco, marijuana, or other illicit substances) ISHLT: A consensus document for the selection of lung transplant candidates: 2014 update Relative contraindications Relative contraindications, cont. • age > 65 years in association with low physiologic reserve and or other relative contraindications • class I obesity (BMI 30.0-34.9 kg/m2), particularly truncal obesity • progressive or severe malnutrition • severe, symptomatic osteoporosis • extensive prior chest surgery with lung resection • mechanical ventilation and / or extracorporeal life support • colonization or infection with highly resistant or virulent bacteria, fungi, and certain strains of mycobacteria • lung tx in candidates with hepatitis B or C should be performed in centers with experienced hepatology units • lung tx in HIV-positive candidates (controlled disease with undetectable HIV-RNA, and compliant on combined anti-retroviral therapy) should be performed in centers with expertise • patients infected with Burkholderia cenocepacia / gladioli and multidrug resistant M abscessus should be evaluated by centers with significant experience • atherosclerotic disease burden sufficient to put the candidate at risk for end-organ disease after lung tx • diabetes, systemic hypertension, epilepsy, central venous obstruction, peptic ulcer disease, gastroesophageal reflux should be optimally treated before tx 1 20/03/15 ISHLT: A consensus document for the selection of lung transplant candidates: 2014 update ISHLT: A consensus document for the selection of lung transplant candidates: 2014 update Pulmonary vascular disease: Timing of transplant listing Pulmonary vascular disease: Timing of referral • NYHA functional class III or IV symptoms during escalating therapy • rapidly progressive disease (assuming weight and rehabilitation concerns not present) • use of parenteral targeted PAH therapy regardless of symptoms or NYHA functional class • known or suspected pulmonary veno-occlusive disease (PVOD) or pulmonary capillary hemangiomatosis • NYHA functional class III or IV despite a trial of at least 3 months of combination therapy including prostanoids • cardiac index of < 2 l/min/m2 • mean right atrial pressure of > 15 mmHg • 6-minute walk test of < 350 m • development of significant hemoptysis, pericardial effusion, or signs of progressive right heart failure (renal insufficiency, increasing bilirubin, BNP, or recurrent ascites) ISHLT: A consensus document for the selection of lung transplant candidates: 2014 update ISHLT: A consensus document for the selection of lung transplant candidates: 2014 update Interstitial lung disease: Timing of referral Interstitial lung disease : Timing of transplant listing • histopathologic or radiographic evidence of UIP or fibrosing NSIP, regardless of lung function • abnormal lung function: FVC < 80% predicted or diffusion capacity (DLCO) < 40 % predicted • any dyspnea or functional limitation attributable to lung disease • any oxygen requirement, even if only during exertion • for inflammatory interstitial lung disease (ILD), failure to improve dyspnea, oxygen requirement, and / or lung function after a clinically indicated trial of medical therapy • decline in FVC > 10% during 6 months of follow-up • decline in DLCO > 15% during 6 months of follow-up • desaturation to < 88% or distance < 250 m on 6MWT or > 50 m decline in 6MWT over 6-month period • PH on right heart catheterization or 2-dimensional echocardiography • hospitalization because of respiratory decline, pneumothorax, or acute exacerbation Does the presence of CTD modify survival in patients with pulmonary fibrosis? Interstitial lung disease: special considerations 324 cases of CTD-ILD and 2209 cases of IPF (follow-up 2.3 y) ILD severe enough to warrant consideration to lung tx may be associated with collagen vascular diseases such as scleroderma and rheumatoid arthritis. Data regarding specific predictors of prognosis in this setting is limited. If the lung disease has not responded to appropriate treatment and there are no extrapulmonary contraindications to tx, it is reasonable to use similar guidelines to those proposed for idiopathic ILD. ISHLT 2015 RA (65%) SSc (14%) misc. (19%) median surv. 6.6 y 8.8 y 5.6 y IPF 3.1 y Navaratham V et al Resp Med 2011 2 20/03/15 Survival and quality of life in rheumatoid arthritis– associated interstitial lung disease after lung transplantation NON-IPF ILD and lung tx Patients with non-IPF ILD (including sarcoidosis and scleroderma) should be evaluated for lung tx if disease progression occurs in the context of advanced patients with FVCs less than 50% or those with hypoxemia (pO2 < 55 mmHg) at rest and/or ”out of proportion” pulmonary hypertension (mPAP > 35 mmHg or mPAP > 25 mmHg + CI < 2.0 l/min/m2) Gottlieb J ERS Monograph 2011 pp 332-340 In scleroderma, significant extrapulmonary disease (especially kidney and esophageal) should also be excluded Gottlies J Curr Opin Pulm Med 2014; 20: 457-462 Figure 1 Kaplan – Meier survival curves 1 year after lung transplantation. RA-ILD, rheumatoid arthritis – associated interstitial lung disease; SScILD, scleroderma-associated interstitial lung disease; IPF, idiopathic pulmonary fibrosis. ”In RA-ILD patients, lung tx appears to result in a significant improvement in QoL with regard to respiratory symptoms” (SF-36, SGRQ) n=10 n= 17 n= 53 Yazdani A et al: The Journal of Heart and Lung Transplantation, Volume 33, Issue 5, 2014, 514 - 520 Indications for lung and heart-lung transplantations in Finland Adult Lung Transplants Major Indications by Year (Number) 2014 JHLT. 2014 Oct; 33(10): 1009-1024 For some retransplants, diagnosis other than retransplant was reported, so the total number of retransplants may be greater. Indication SL DL HL Total Fibrosis 11 72 (+5) 1 84 (+5) Emphysema (α1AT) 4 (+2) 32 0 36 (+2) COPD 3 27 2 32 CHD 1 1 19 21 PAH 2 8 (+1) 9 19 (+1) CTEPH 3 1 3 7 Cystic fibrosis 0 13 (+1) +1 lobar 0 14 (+1) Bronchiectasis 0 4 0 4 LAM 0 6 0 6 Cardiomyopathy 0 0 4 4 PVOD 0 4 (+3) 0 4 (+3) ARDS / DAD 0 5 (+1) +1 lobar 0 6 (+1) Occupational 0 2 0 2 Bronchiolitis (obstr./constr.) 0 2 + 1 lobar 0 3 24 (+2) 177 (+11) +3 lobar 38 242 (+13) 31.12.2014 Indications for lung and heart-lung transplantations in Finland Indication SL DL HL Total Fibrosis 11 72 (+5) 1 84 (+5) Emphysema (α1AT) 4 (+2) 32 0 36 (+2) COPD 3 27 2 32 CHD 1 1 19 21 PAH 2 8 (+1) 9 19 (+1) CTEPH 3 1 3 7 Cystic fibrosis 0 13 (+1) +1 lobar 0 14 (+1) Bronchiectasis 0 4 0 4 LAM 0 6 0 6 Cardiomyopathy 0 0 4 4 PVOD 0 4 (+3) 0 4 (+3) 0 5 (+1) +1 lobar 0 6 (+1) Occupational 0 2 0 2 Bronchiolitis (obstr./constr.) 0 2 + 1 lobar 0 3 24 (+2) 177 (+11) +3 lobar 38 30 lobar 25 3 HL 38 15 DL 188 10 SL 26 20 5 0 14 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 2099 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 19 ARDS / DAD Lung and heart-lung transplantations in Finland 1988 – 2014 (n = 255) year 242 (+13) 31.12.2014 3 20/03/15 IPF (73) ja sidekudossairauteen liittyvä ILD (11) keuhkon- ja sydänkeuhkosiirtojen indikaationa Suomessa 30 25 ILD: polymyosiitti (1) nivelreuma (2) MCTD (2) skleroderma (2) SLE (4) 20 15 10 5 0 14 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 2099 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 19 Nathan S Chest 2015 PAH & survival Pulmonaaliarteriahypertension ( = PAH) yleisimmät etiologiat • Idiopaattinen PAH (IPAH) 39-61% • Sidekudossairauksiin liittyvä PAH 11-28% • Synnynnäiseen sydänvikaan liittyvä PAH 10-20% • Portopulmonaalinen PAH 5-10% Hoeper & Gibbs 2014 Pulmonary hypertension and transplantation ESC/ERJ guidelines 2009 The worst prognosis is seen in patients with PVOD and pulmonary capillary haemangiomatosis (PCH) because of the lack of effective medical treatments. Those patients should be listed for transplantation at diagnosis. McLaughlin et al 2006 Factors associated with increased mortality (US Registry to EValuate EArly and Longterm PAH disease management, REVEAL) • • • • • functional class NYHA IV male gender with age > 60 years increased PVR PAH associated with portal hypertension family history of PAH 4 20/03/15 Additional factors associated with increased mortality (REVEAL) • functional class NYHA III • increased mean right atrial pressure • decreased resting systolic blood pressure or an elevated heart rate • decreased 6MWT • increased BNP • PAH associated with connective tissue disease (CTD) • renal insufficiency • presence of pericardial effusion • decreased DLCO Matala diffuusiokapasiteetti PAH-potilaalla Muista! • veno-oklusiivinen tauti (PVOD) • emfyseeman ja keuhkofibroosin kombinaatio • systeemiseen skleroosiin liittyvä PAH Huonompi prognoosi kuin IPAH-potilailla Diffuusiokapasiteetti • PAH potilailla alentunut • sidekudostautia sairastavilla PAH-potilailla matalampi kuin esim. synnynnäiseen sydänvikaan liittyvässä PAH:ssa • matala DLCO – itsenäinen riskitekijä mortaliteettiriskianalyyseissä A subgroup of patients presenting with a DLCO arbitrarily defined as < 45% predicted who have significantly poorer survival compared with patients with DLCO > 45% predicted • older than general PAH population • more likely to have history of smoking • significantly higher mortality features just linked to age or different type of pulmonary vasculopathy? Trip P et al ERJ 2013 Updated Treatment Algorithm of Pulmonary Arterial Hypertension HYKS: spesifistä lääkehoitoa saavat potilaat (2000 - ) 100% APAH 90% IPAH 80% CTEPH n = 25 (11) n = 24 (12) n = 23 (9) 70% 60% 50% 40% 30% 20% 10% 0% 0 Galiè N et al JACC 2013 1 68% 2 3 48% 4 5 34% 6 NIH (Alonzo 1991) 5 20/03/15 PAH ja keuhkonsiirto • Leikkaustyyppi – sydänkeuhkosiirto (HL): nykyään vain tietyt synnynnäistä sydänvikaa sairastavat potilaat – yhden keuhkon siirto (SL) – kahden keuhkon siirto (DL) • yleisin leikkaustyyppi nykyään • vähemmän välittömän postop.vaiheen riskitilanteita SL verrattuna • parhaimmat pitkäaikaistulokset Galie N et al JACC 2013 • Suurentunut riski kuolla leikkausjonossa (vrt LAS) →”siltana” keuhkonsiirtoon tarvittaessa – ECMO tai eteisseptostomia Indications for lung and heart-lung transplantations in Finland PAH ja keuhkonsiirto, tulokset • hemodynamiikka / sydämen oikean puolen dysfunktio korjautuu nopeasti leikkauksen jälkeen • käytössä ollut spesifinen vasodilatoiva hoito pystytään yleensä lopettamaan leikkauksen yhteydessä • riski suurentunut primaarille graftin dysfunktiolle ja (BOS:lle) Indication SL DL HL Total Fibrosis 11 72 (+5) 1 84 (+5) Emphysema (α1AT) 4 (+2) 32 0 36 (+2) COPD 3 27 2 32 CHD 1 1 19 21 PAH 2 8 (+1) 9 19 (+1) CTEPH 3 1 3 7 Cystic fibrosis 0 13 (+1) +1 lobar 0 14 (+1) Bronchiectasis 0 4 0 4 LAM 0 6 0 6 Cardiomyopathy 0 0 4 4 PVOD 0 4 (+3) 0 4 (+3) ARDS / DAD 0 5 (+1) +1 lobar 0 6 (+1) Occupational 0 2 0 2 Bronchiolitis (obstr./constr.) 0 2 + 1 lobar 0 3 24 (+2) 177 (+11) +3 lobar 38 242 (+13) 31.12.2014 IPAH, PVOD ja CTEPH keuhkon- ja sydänkeuhkosiirtojen indikaationa Suomessa www.ISHLT.org/ registries 30 25 ”In 1991 11.8% of all lung transplants were for idiopathic PAH vs only 2.7% in 2011” 20 15 10 5 0 14 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 2099 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 19 iloprosti inh. sildenafiili bosentaani treprostiniili ambrisentaani riosikvaatti masitentaani 6 20/03/15 Adult Lung Transplants DL Gra' survival by diagnosis Kaplan-Meier Survival by Diagnosis (Transplants: January 1990 – June 2012) 100% 90% 80% 70% 60% 50% IPF (n=76) 40% A1A (n=30) 30% COPD (n=26) 20% PAH (n=8) 10% CF (n=14) All pair-wise comparisons with CF were significant at p < 0.0001 Alpha-1 vs. COPD: p < 0.0001 Alpha-1 vs. IPF: p < 0.0001 COPD vs. IPF: p < 0.001 IPF vs. IPAH: p = 0.0362 0% 0 2 4 6 8 10 Years 2014 JHLT. 2014 Oct; 33(10): 1009-1024 Systeemisessä skleroosissa United Network for Organ Sharing Registry (UNOS) • of the 20 135 patients transplanted between 1987 and 2011, 142 had the diagnosis of scleroderma • PAH:n prevalenssi 5-10% • ILD:n prevalenssi ~ 40% • the outcome of patients with scleroderma were similar to that of other patients Launay D et al 2014 DePasquale E et al JHLT 2014 Proposed systemic sclerosis contraindications Proposed systemic sclerosis contraindications Working group on heart/lung tx in systemic sclerosis of the French network on PH Working group on heart/lung tx in systemic sclerosis of the French network on PH • Uncontrolled active inflammatory myopathy; progressive myopathy; myopathy with diaphragm involvement • Digital ulcers: – > 1 severe episode / year despite optimal treatment – active digital ulcer: temporary contraindication • Gastrointestinal: – oesophageal stricture – active and severe upper gastrointestinal ulcerations despite optimal treatment, including proton pump inhibitors and prokinetics – high grade dysplasia in a Barett´s esophagus – gastroparesis [abnormal gastric emptying (< 25% clearance at 90 min postingestion)] despite medical treatment – chronic gastrointestinal bleeding with or without anaemia – symptomatic involvement of the small intestine, such as malabsorption and pseudo-obstruction – colorectal involvement with pseudo-obstruction, and/or diverticulitis and/ Launay D et al or perforation Presse Med 2014 • Heart: – conduction abnormalities and/or rhythm disturbances (symptomatic bradycardia, ventricular and atrial tachycardia): these must be managed prior to lung tx (implantation of a pacemaker, where appropriate) but are not a contraindication if heart tx is considered • Kidney – renal function should have been stable for 3 months except in the case of acute functional renal failure related to right ventricle dysfunction – interval < 3 years between systemic sclerosis renal crisis and heart / lung tx – increased risk of scleroderma renal crisis a. diffuse systemic sclerosis evolving for less than 3 years since the first non-Raynaud sign / symptom b. rapidly progressive and severe cutaneous involvement: progression of the cutaneous involvement characterised by an increase of more than 25% in Rodnan score within 6 to 12 months Launay D et al c. corticosteroids > 15 mg prednisone (or equivalent) /day Presse Med 2014 7 20/03/15 J Heart Lung Transplant 2015; 34: 1-15 8
© Copyright 2024