Lung Transplant Outcomes

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Lung Transplant Outcomes

• Dr Andrew Fisher
• Senior Lecturer in Respiratory Medicine
• Newcastle University

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The Lung Transplant Timeline Current
Outcomes Survival Morbidity Quality of
Life Innovations Challenges for the
Future Questions
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The Lung Transplant Timeline
First Human Lung Transplant
First Successful Double Lung
First Successful Heart-Lung
gt 20,000 Lung Transplants Worldwide
Experimental Lung Transplants
First Successful Single Lung
Single Sequential Lung Lobar Lung Transplant DCD
Lung Donation
1950s
2008
1963
1986
1981
1983
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Worlds First Heart-Lung Transplant at Stanford
1981
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Worldwide Lung Transplant Activity
J Heart Lung Transplant 200726 782-795


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Change in Recipient Age Over Time
J Heart Lung Transplant 200726 782-795


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Survival by Age Group 1990 2005
J Heart Lung Transplant 200726 782-795


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Indications for Single Lung Transplants January
1996 - June 2006
Single Lung Transplant
Bilateral Lung Transplant
J Heart Lung Transplant 200726 782-795


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Adult Lung Transplant Survival
J Heart Lung Transplant 200726 782-795


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Survival By Diagnosis January 1994 June 2003
J Heart Lung Transplant 200524 945-982
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Lung/Heart-Lung Transplant Survival (n662)
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Lung/Heart-Lung Transplant Survival (n505)
Scottish Lung/Heart-Lung Transplants Survival
(n157)
Longest Scottish Survivor 19 years after Single
Lung Transplant (Alive and Well)
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Freeman Hospital Scottish Lung Transplants
Pretransplant diagnosis
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Outcomes in Cystic Fibrosis
n176
Meachery et al, Thorax 2008
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Scottish Referrals
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• 31 of population transplanted 1987-1993
• When population extended to 1997 40
• 66 no or only mild BOS stage 0/1
• Median FEV1 51.5 SLT (30-70)
  73.5 BLT/HLT (20-100)
• Good exercise performance
• median 577m on 6MWD
• 70 working or active

Rutherford et al Am J Transplant 2005
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Employment Status of Surviving Recipients 1994
2006
J Heart Lung Transplant 200726 782-795


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Recipe for Longterm Success
Allograft Rejection
Immunosuppression
Acute Rejection Chronic Graft Dysfunction Bronchi
olitis Obliterans Syndrome
Infection Lymphoproliferative Disease Hypertension
Renal Dysfunction Dyslipidaemia Malignancy Side-e
ffects
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Chronic Graft DysfunctionBronchiolitis
Obliterans Syndrome
3.0
Loss of FEV1 750 mls/year
FEV 1
2.0
1.0
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Months after Lung Transplantation
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Obliterative Bronchiolitis (OB)
Proliferative
Inspiratory
Fibrotic
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Bronchiolitis Obliterans Syndrome Current
Concepts in Pathogenesis

• Alloimmune Mechanisms
• Recurrent Acute Rejection
• Lymphocytic Bronchiolitis

• Non-Alloimmune Mechanisms
• Primary Graft Dysfunction
• Infections
• Viral Respiratory and CMV
• Bacterial - Pseudomonas
• Gastroesophageal Reflux

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p0.83
Never cultured Pseudomonas
Pseudomonas recolonised
Transplantation 2008
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p0.02
Never cultured Pseudomonas
De-novo Pseudomonas colonisation
Transplantation 2008
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Protease and Anti-Protease Balance
Human Neutrophil Elastase
Secretory Leukoprotease Inhibitor
P0.0001
P0.01
Anderson et al, ERJ 2008
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Azithromycin in BOS in Newcastle
Yates et al, Am J Resp Crit Care Med 2005)
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Post Lung Transplant MorbidityApril 1994 - June
2006
J Heart Lung Transplant 200726 782-795


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Mortality Risk of Renal Dysfunction
Cheng et al, Am J Kidney Dis 2008
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Innovations
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UK Donor Utilisation - Lung Activity
Data from UK Transplant
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Ex-vivo Donor Lung Resusitation
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Shetland Islands
Newcastle
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Low Level Air Ambulance Transfer
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Lung Transplantation The Challenges for the
Future

• Improved timing and selection of candidates
• Addressing donor shortfall
• Improved efficacy and side effect profiles of
  immunosuppressive strategies
• Tailoring Immunosuppression to individual
• Novel therapies targeting final common in chronic
  allograft dysfunction

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Questions?