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Lung Transplantation2020Tahuanty Peña, MD, MSDivision of Pulmonary, Critical Care andOccupational Medicine1Relevant Financial Relationship Disclosure StatementI will not discuss off label use and/or investigational use of the followingdrugs/devices.NO relevant financial relationships exist related to this presentation.21

Objectives Overview of Lung Transplantation Lung Transplant at UIHC Case Studies3Objectives Overview of Lung Transplantation Lung Transplant at UIHC Case Studies42

Who needs a transplant? Severe end stage lung disease Ineffective/maximal medical therapy Limited life expectancy ( 2 yrs) Capable of full rehabilitation post transplantation Adequate psychosocial profile5Recipient Selection Diseases Obstructive: Emphysema, Alpha 1 anti-trypsin, COPD Suppurative: Cystic fibrosis, bronchiectasis Restrictive: interstitial lung diseases Vascular: Pulmonary hypertension63

Lung function after 390FEF 25-75%0.103.344122FEF 25-75% %Predicted7Recipient Selection Absolute Contraindications Recent history of Malignancy. Untreatable significant organ system dysfunction (heart, liver,kidney, brain) Combined transplantation. CAD non amenable to revascularization. Acute Medical instability (non-pulmonary). Uncorrectable bleeding diathesis. Chronic infection with highly virulent/resistant microbes.J Heart Lung Transplant. 2015 Jan;34(1):1-15. doi: 10.1016/j.healun.2014.06.014. Epub 2014 Jun 2684

Recipient Selection Absolute Contraindications Class II or III obesity (BMI 35).Non-adherence to medical therapy.Uncontrolled Psychiatric/Psychological conditions.Absence of reliable social support.Poor rehabilitation potential.Substance abuse or dependence.J Heart Lung Transplant. 2015 Jan;34(1):1-15. doi: 10.1016/j.healun.2014.06.014. Epub 2014 Jun 269Recipient Selection Relative Contraindications Age 65Class I obesity (BMI 30-35)Malnutrition, OsteoporosisPrior chest surgeryMechanical Ventilation or ECLSInfections Hepatitis B or CHIVB. CepaciaM. AbscessusJ Heart Lung Transplant. 2015 Jan;34(1):1-15. doi: 10.1016/j.healun.2014.06.014. Epub 2014 Jun 26105

Surgical ChoicesBilateral TransplantSingle Transplant Mandatory forsuppurative lungdisease Preferred forpulmonary HTN Better choice foryounger patients. Extends a limited donorpool Shorter operation withfewer peri operativecomplications11Lung Allocation Score Replaced prior time-based system. Active as of May 2005. Intended to facilitate allocation of available donors (shortsupply) to individuals with more urgent need. Patients 12 years of age. Has reduced waitlist mortality in IPF, COPD, CF.126

Lung Allocation Score FVC Pulmonary Hemodynamics O2 at rest Age BMI DM Functional status 6MW distance Assisted ventilation Creatinine Diagnosis PCO2 Bilirubin13Lung Allocation Score Score from 0 to 100. Tries to balance severity of illness (risk of mortality) andchances of success following transplant (survival probability). Provides a rank on waitlist based on blood group.147

Lung Allocation Score15Lung Allocation Score Donor identified family consents for donation. Organ offered to programs in a 250 nautical miles radius(Zone A). 1 Offered to patients listed in Zone A, ABO identical. 2 Offered to patients listed in Zone A, ABO compatible. 3 Zone B, ABO identical. 4 Zone B, ABO compatible. Etc 168

Lung Allocation Score17189

Surgery192010

212211

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Adult and Pediatric Lung TransplantsNumber of Transplants by Year and Location5000OtherNumber of transplants4500North OTE: This figure includes only the lung transplants that arereported to the ISHLT Transplant Registry. As such, thisshould not be construed as representing changes in the numberof lung transplants performed worldwide.JHLT. 2018 Oct; 37(10): 1155-120625Adult and Pediatric Lung TransplantsNumber of Transplants by Year and Procedure TypeNumber of Transplants500046614500Bilateral/Double Lung4000Single 83300025002228197920181785170815681512155013921213 1391110520001500923100070940850005735 741672018NOTE: This figure includes only the lung transplants that arereported to the ISHLT Transplant Registry. As such, thisshould not be construed as representing changes in the numberof lung transplants performed worldwide.JHLT. 2018 Oct; 37(10): 1155-12062613

Adult and Pediatric Lung TransplantsAverage Center Volume(Transplants: January 2004 – June 2017)Percentage of transplants60365030402430184542201230281019101506% of Transplants (red line)Number of CentersNumber of centers01-45-910-1920-2930-3940-4950 Average number of lung transplants per year2018JHLT. 2018 Oct; 37(10): 1155-120627Adult Lung TransplantsMajor Diagnoses by Year (Number)4,000COPDA1ATDCFIIPILD-not IIPRetransplantNumber of plant Year2018JHLT. 2018 Oct; 37(10): 1155-12062814

Adult Lung TransplantsDiagnosis Distribution by Location(Transplants: January 2004 – June 2017)100%OtherSarcoidosis% of Transplants80%RetransplantNon CF-bronchiectasis60%IPAHILD-not IIP40%IIPCOPD20%CFA1ATD0%EuropeNorth AmericaOther2018JHLT. 2018 Oct; 37(10): 1155-120629Objectives Overview of Lung Transplantation Lung Transplant at UIHC Case Studies3015

Lung Transplantation at theUniversity of Iowa First and only lung transplant program inIowa Originally active 1988-1996 Reactivated May 2007 198 lung transplants and counting 31UNOS Zones73 centers doing adult lung transplants3216

Multidisciplinary Approach toTransplantation Pulmonary Medicine Thoracic Surgery Pharmacy Nursing Respiratory Therapy Pulmonary Rehabilitation Social Work Nutrition Transplant Financial33University of Iowa LungTransplantation ProgramThoracic SurgeryTransplant Social WorkKalpaj Parekh, Surgical DirectorJohn KeechEvgeny ArshavaEmily MathewsStephanie RauckhorstPulmonary MedicineJulia Klesney-Tait, Medical DirectorMichael EberleinTahuanty PeñaLakshmi DurairajLung Transplant CoordinatorsAbigail MackRebecca HoranDani SlaughterTransplant PharmacySarah MinnerHeather Bream-RouwenhorstPulmonary RehabilitationCarol McCaffertyKim EppenJane GreinerJulie WieboldTransplant OfficeDebbie HunterKent BeckerRob HuberOrgan Transplant CenterHeart and Vascular Center3417

Program Highlights Kalpaj Parekh, MD hired in August 2006 Julia Klesney-Tait, MD hired in January 2007 First transplant May 1, 2007 198 patients transplanted Medicare approved on April 2, 2009 Only program in Iowa Catchment areaTransplants252015ooooooIowaNebraskaSouth DakotaWestern IllinoisNorthern MissouriSouthern 019— 35 —35UIOWA Survival3618

Adult Lung TransplantsKaplan-Meier Survival by Procedure Type for Primary(Transplants: January 1992 – June 2017)Transplant Recipients100Median survival (years):Double Lung 7.8; Conditional 10.2Single Lung 4.8; Conditional 6.5Survival (%)75p 0.00015025Bilateral/Double Lung (N 40,623)Single Lung (N 20,034)00123456789 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24Years2019citation37Adult Lung TransplantsFunctional Status of Surviving Recipients byKarnofsky Score(Follow-ups: January 2010 – June 2018)100%Moribund, fatal processes progressingrapidlyVery sick, hospitalization necessary:active treatment necessary80%Severely disabled: hospitalization isindicated, death not imminentDisabled: requires special care andassistance60%Requires considerable assistance andfrequent medical care40%Requires occasional assistance but isable to care for needsCares for self: unable to carry on normalactivity or active work20%Normal activity with effort: somesymptoms of diseaseAble to carry on normal activity: minorsymptoms of disease0%1 Year(N 13,896)2 Year(N 11,520)3 Year(N 9,510)Normal, no complaints, no evidence ofdisease2019citation3819

Objectives Overview of Lung Transplantation Lung Transplant at UIHC Case Studies39IPF 71 y/o male Diagnosed with IPF in 2016. First transplant clinic 3/2017. Declined for transplant at 2other centers in the region. O2: 4lpm at rest, 10lpm withactivity. BMI 34 CAD: 50% LAD, 50% RCA.4020

IPF Decision to list for a SLT. Weight loss to a BMI 30. Listed 8/2017, Txp 9/201741CF 32 y/o male with CF (2008) BMI 20 Multiple exacerbations per year 2lpm at rest, 4lpm with activity Listed for BLT Transplanted on Jan/20084221

CF43COPD 54 y/o female with COPD FEV1 0.56L PCO2 – 62 4lpm at rest, 6lpm with activity CAD: 80% occlusion of LAD,stent placed. Hepatitis C positive,underwent treatment. Listed for txp on 4/2014,transplanted on 8/2015.4422

LAM 28 y/o female withLymphangiomyomatosis Dx while pregnant in 2008 Rapid decline after stoppingsirolimus for txp. 6lpm at rest, 15lpm withactivity. Listed on Jan/2011,transplanted on May/2011 Waited for Txp in thehospital, 4 chest tubes,10lpm at rest.45LAM4623

Melanie P. Lung Transplant 201147Andrea S. Lung Transplant 2011Lance S. Lung Transplant 2014Andrea S. Lung Transplant 2011Lance S. Lung Transplant 20144824

Don R. Lung Transplant 201349Destiny R. Lung Transplant 20095025

2016 Annual Picnic- Lung recipients515226

Thank You5327

Kaplan-Meier Survival by Procedure Type for Primary Transplant Recipients Median survival (years): Double Lung 7.8; Conditional 10.2 Single Lung 4.8; Conditional 6.5 p 0.0001 (Transplants: January 1992 - June 2017) 2019 citation 2019 citation Adult Lung Transplants Functional Status of Surviving Recipients by Karnofsky Score