Transplantation – Lung | Links Medicus Content Curation & Alerts in Medicine

Review: Lung Transplantation

16 Nov, 2024 | 13:33h | UTC

Introduction: Lung transplantation has progressed from experimental to standard therapy for life-threatening lung diseases, offering improved survival and quality of life. Challenges include primary graft dysfunction, chronic lung allograft dysfunction (CLAD), infections, and long-term immunosuppression effects. This review highlights current practices, developments, and opportunities to enhance this transformative therapy.

Key Recommendations

Candidate Selection: Selection criteria have shifted from strict contraindications to a holistic approach emphasizing physiologic age, frailty, and recoverability. Early referral and multidisciplinary assessment are recommended to address barriers and optimize outcomes.
Donor-Lung Utilization: Extended-criteria donors, including older donors and those with smoking histories, are increasingly used. Ex vivo lung perfusion allows detailed lung assessment and reconditioning, while antiviral therapies enable transplantation of lungs from hepatitis C-positive donors.
Lung Allocation: Urgency-weighted scores prioritize factors like medical urgency and post-transplant survival. Recent updates include biologic disadvantages, patient access, and logistical efficiency to improve fairness and outcomes.
Surgical Techniques: Bilateral sequential lung transplantation is standard, with ECMO replacing cardiopulmonary bypass in many cases. Surgical approaches are tailored to individual needs, with options like volume reduction or lobectomy for size mismatches.
Postoperative Management: Primary graft dysfunction affects up to 25% of recipients and is a major early complication. Preventive strategies, ECMO support, and infection management are critical. Attention to airway complications and acute kidney injury further improves recovery.
Immunosuppression: Maintenance therapy typically includes a calcineurin inhibitor, glucocorticoid, and cell-cycle inhibitor. Induction therapy is individualized. Ongoing studies are exploring adjunct therapies like mTOR inhibitors and inhaled immunosuppressants to prevent CLAD.
Management of ALAD and CLAD: Early detection and treatment of acute lung allograft dysfunction are essential. CLAD, affecting half of recipients within 5 years, remains a major challenge. Current therapies slow progression, but further research is needed for targeted prevention and treatment.
Infections: Infections remain a leading cause of morbidity and mortality. Prophylaxis against cytomegalovirus, fungal pathogens, and community-acquired viruses is essential to minimize complications and reduce CLAD risk.
Cancer Risk: Post-transplant cancer risk is elevated due to immunosuppression. Lung cancer and post-transplant lymphoproliferative disease are the most common malignancies, emphasizing the need for routine surveillance and early intervention.
Long-Term Outcomes: Median survival remains limited at 6.7 years. Efforts focus on improving long-term outcomes by balancing graft function maintenance with minimizing adverse effects of immunosuppression. Collaborative research aims to refine diagnostics, personalize therapies, and address CLAD mechanisms.

Conclusion: Enhanced donor utilization, tailored candidate selection, refined perioperative care, and robust long-term monitoring are pivotal to advancing lung transplantation. Ongoing research and collaboration are critical to overcoming challenges like CLAD, improving survival, and enhancing patient quality of life.

Reference: Christie JD, et al. Lung Transplantation. New England Journal of Medicine. 2024. DOI: http://doi.org/10.1056/NEJMra2401039

Extracorporeal CPR dissemination and integration with organ preservation in the USA: ethical and logistical considerations

28 Apr, 2023 | 12:47h | UTC

Extracorporeal cardiopulmonary resuscitation dissemination and integration with organ preservation in the USA: ethical and logistical considerations – Critical Care

Cold static preservation at 10°C shows promising results for safely extending lung transplantation timeframes

24 Apr, 2023 | 13:38h | UTC

Extension of Cold Static Donor Lung Preservation at 10°C – NEJM Evidence

Commentary on Twitter

Donor lungs for transplantation are stored on ice and transplanted as rapidly as possible. In an advance that may ease transplant logistics, Ali et al. now report that prolonged storage of donor lungs at 10°C may lead to equivalent outcomes.

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— NEJM Evidence (@NEJMEvidence) April 22, 2023

Expanding Organ Usage: UK study finds organs from patients with a primary brain tumor are a viable option

27 Mar, 2023 | 13:27h | UTC

Summary: A national cohort study in the UK investigated the risk of cancer transmission from deceased donors with primary brain tumors to organ recipients. The study found no cases of brain tumor transmission among 778 transplants from 282 donors with primary brain tumors, including 262 from donors with high-grade tumors. Organ transplant survival was equivalent to that in matched controls, and some organs from donors with high-grade tumors were less likely to be transplanted.

The results suggest that the risk of cancer transmission in transplants from deceased donors with primary brain tumors is lower than previously thought. Furthermore, the study indicated that donors with brain tumors provided good-quality organs with favorable risk markers and excellent transplant outcomes. Some organs from donors with high-grade tumors were underutilized, indicating a possible aversion by transplant clinicians or patients to use these organs.

These findings imply that it may be possible to safely expand organ usage from donors with primary brain tumors without negatively impacting outcomes, potentially benefiting many patients waiting for a transplant. Although this might lead to a slight rise in transplant numbers in the UK, the findings may hold particular significance for nations with stricter guidelines, such as the United States. The study’s findings can help transplant clinicians discuss the risks and benefits of accepting organ offers from such donors.

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