Lung Transplant

Major post-operative considerations include:

Indications

Contraindications

Principles

Donor lungs:

  • Denervated below the bronchial anastomosis
    • Loss of normal cough reflex
    • ↓ Mucociliary clearance

Practice

  • Optimise lung function
    • Rapid respiratory wean
    • Minimise fluid administration
    • Chest physiotherapy
    • Analgesia
  • Close coordination with transplant service

Resuscitation:

Specific therapy:

  • Pharmacological
  • Procedural
  • Physical

Supportive care:

Disposition:

Preventative:

Complications

  • Death
  • B
    • PGD
    • Acute Rejection
    • Pneumonia
    • Bronchial ischaemia
      • Stenosis
        • Bronchomalacia
        • Dehiscence
    • Chronic Rejection
  • C
    • PRES
      Calcineurin-inhibitor toxicity.
  • D
    • Delirium
      • Steroids
      • Calcineurin-inhibitor toxicity
  • F
    • CKD
      • Calcineurin-inhibitor toxicity
    • Haemolytic uraemic syndrome
  • G
    • Distal intestinal obstruction syndrome
      • CF patients
  • I
    • Sepsis

Differential diagnosis of respiratory failure after 72 hours must be include infection or rejection.

Primary Graft Dysfunction

Non-immune mediated respiratory failure that develops within 72 hours of transplantation and:

Grading of Primary Graft Dysfunction
Grade P:F Ratio Infiltrates
0 >300 No
1 >300 No
2 200-300 Yes
3 <200 Yes
  • Does not have an alternative dianogis
  • Consists of:
    • Worsening gas exchange
    • ↓ Lung compliance
    • Radiological infiltrates
      • Alveolar and interstitial
      • Most extensive in perihilar areas
  • Is managed as ARDS
    • Lung protective ventilation
    • ECMO may be considered for lung rest
Risk factors for Primary Graft Dysfunction
Donor Recipient Procedural
  • Age >60
  • Smoking >20 p/y
  • Pneumonia
  • Purulent secretions
  • PGD of other organs
  • Age >60
  • Ventilated
  • Pulmonary fibrosis
  • Pulmonary hypertension
  • Single lung transplant
  • CPB used

Acute Rejection

Acute rejection:

Hyperacute rejection is a form of humoral rejection that occurs:

  • Within 24 hours of transplantation
  • In patients with pre-formed HLA antibodies
    Rare with appropriate screening.
  • Generally anti-body mediated
  • Generally non-specific and similar to infection:
    • Respiratory
      • Dyspnoea
      • Cough
      • ↑ Sputum production
      • ↓ FEV1
      • Alveolar infiltrates
    • Systemic
      • Fever
  • May lead to severe graft dysfunction and ARDS
  • Confirmed with lung biopsy
  • Treated with pulsed steroids

Bronchial Ischaemia

Ischaemia of the bronchial anastomoses is common, although significant complications are rare. Complications can include:

The bronchial arteries supply the conducting zone of the lung and are not anastomosed during a transplant, and so the anastomoses are vulnerable until angiogenesis has occurred.

  • Bronchial stenosis
    • Balloon bronchioplasty
  • Bronchomalacia
    • Stenting
  • Bronchial dehiscence
    • Persistent air leak
    • Mediastinitis

Chronic Rejection

Also known as bronchiolitis obliterans syndrome.

Chronic rejection is a:

  • Sustained ↓ in FEV1 by ⩾20%
  • Major determinant in long-term survival

Management strategies include:

  • Re-transplantation
    Only “cure”.
  • Rotation of immunosuppression
    Not well evidenced.

Prognosis

  • Death
    Survival following lung transplant is improving, although not as good as other solid organ transplants. Survival is generally:
    • 1-year: 80%
    • 5-year: 54%
    • 10-year: 32%
  • B
    • Chronic rejection
      • 5-10 years: 60-80%
  • I
    • Malignancy
      3-4× baseline risk.

Improvement in survival is generally due to ↓ early death, generally due to infection or rejection.

Key Studies

References

  1. Bersten, A. D., & Handy, J. M. (2018). Oh’s Intensive Care Manual. Elsevier Gezondheidszorg.