[Lung transplantation. Indications, long-term results and special impact of follow-up care]

Aktueller Stand der Transplantationsmedizin im Bereich Herz- und Lungentransplantation

Die Transplantationsmedizin in Deutschland ist klar strukturiert und verbindlich geregelt. Zur Stärkung der Organspende wurden die rechtlichen Rahmenbedingungen in den letzten Jahren mehrfach angepasst. Dennoch bleibt die eingeschränkte Organverfügbarkeit die Hauptlimitation dieser Therapie, auch im Bereich der Herz- und Lungentransplantation. Beide Verfahren sind mittlerweile etablierte Therapieoptionen für selektierte Patienten mit terminalem Organversagen. Ziel ist die Verbesserung der Lebensqualität und des Überlebens. Der Erfolg der Therapie hängt maßgeblich von der Selektion geeigneter Empfänger sowie dem optimalen peri- und postoperativen Management ab, einschließlich einer lebenslangen spezialisierten Nachsorge. Die Komplexität der Therapie erfordert ein hohes Maß an speziellen Kenntnissen und Fertigkeiten. Der vorliegende Beitrag fasst den aktuellen Stand der Transplantationsmedizin thorakaler Organe mit dem Fokus auf den Inhalt der neuen Zusatzweiterbildung Transplantationsmedizin zusammen.

Airway remodelling in the transplanted lung

Following lung transplantation, fibrotic remodelling of the small airways has been recognized for almost 5 decades as the main correlate of chronic graft failure and a major obstacle to long-term survival. Mainly due to airway fibrosis, pulmonary allografts currently show the highest attrition rate of all solid organ transplants, with a 5-year survival rate of 58 % on a worldwide scale. The observation that these morphological changes are not just the hallmark of chronic rejection but rather represent a manifestation of a multitude of alloimmune-dependent and -independent injuries was made more recently, as was the discovery that chronic lung allograft dysfunction manifests in different clinical phenotypes of respiratory impairment and corresponding morphological subentities. Although recent years have seen considerable advances in identifying and categorizing these subgroups on the basis of clinical, functional and histomorphological changes, as well as susceptibility to medicinal treatment, this process is far from over. Since the actual pathophysiological mechanisms governing airway remodelling are still only poorly understood, diagnosis and therapy of chronic lung allograft dysfunction presents a major challenge to clinicians, radiologists and pathologists alike. Here, we review and discuss the current state of the literature on chronic lung allograft dysfunction and shed light on classification systems, corresponding clinical and morphological changes, key cellular players and underlying molecular pathways, as well as on emerging diagnostic and therapeutic approaches.

Employment after lung transplantation--a single-center cross-sectional study

BACKGROUND

359 lung transplantations were performed in Germany in 2013. The main goals of lung transplantation are to prolong survival and improve the quality of life. Both of these goals can be reflected in a return to employment. We report the first study of employment after lung transplantation in Germany.

METHODS

We evaluated the findings of a single-center, questionnaire-based cross-sectional investigation of the social and economic situation of 531 patients (September 2009 to March 2010) and obtained 5-year follow-up data in December 2014.

RESULTS

38% of the patients were employed after lung transplantation. They took a mean of ten sick days off from work each year; they did not have infections or organ rejection any more frequently than other patients. The fiveyear follow-up data showed no difference in the overall survival rate of employed and unemployed patients. Employment was associated with a better quality of life (80% [interquartiles: 70%, 95%]) versus 75% [interquartiles: 50%, 85%], p = 0.001). Factors associated with a return to employment included a higher educational level (odds ratio [OR] 2.6, 95%confidence interval [CI] 1.7-4, p = 0.001) and better physical fitness (OR 2, 95%CI 1.3-3.2, p = 0.001).

CONCLUSION

The rate of return to work after lung transplantation in Germany is similar to the rates observed in other countries. The findings of this study imply that employment improves the quality of life and does not endanger health. Thus, patients who have received lung transplants should be advised to return to work if possible.

Lung transplantation: a treatment option in end-stage lung disease

BACKGROUND

Lung transplantation is the final treatment option in the end stage of certain lung diseases, once all possible conservative treatments have been exhausted. Depending on the indication for which lung transplantation is performed, it can improve the patient's quality of life (e.g., in emphysema) and/ or prolong life expectancy (e.g., in cystic fibrosis, pulmonary fibrosis, and pulmonary arterial hypertension). The main selection criteria for transplant candidates, aside from the underlying pulmonary or cardiopulmonary disease, are age, degree of mobility, nutritional and muscular condition, and concurrent extrapulmonary disease. The pool of willing organ donors is shrinking, and every sixth candidate for lung transplantation now dies while on the waiting list.

METHOD

We reviewed pertinent articles (up to October 2013) retrieved by a selective search in Medline and other German and international databases, including those of the International Society for Heart and Lung Transplantation (ISHLT), Eurotransplant, the German Institute for Applied Quality Promotion and Research in Health-Care (Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen, AQUA-Institut), and the German Foundation for Organ Transplantation (Deutsche Stiftung Organtransplantation, DSO).

RESULTS

The short- and long-term results have markedly improved in recent years: the 1-year survival rate has risen from 70.9% to 82.9%, and the 5-year survival rate from 46.9% to 59.6%. The 90-day mortality is 10.0%. The postoperative complications include acute (3.4%) and chronic (29.0%) transplant rejection, infections (38.0%), transplant failure (24.7%), airway complications (15.0%), malignant tumors (15.0%), cardiovascular events (10.9%), and other secondary extrapulmonary diseases (29.8%). Bilateral lung transplantation is superior to unilateral transplantation (5-year survival rate 57.3% versus 47.4%).

CONCLUSION

Seamless integration of the various components of treatment will be essential for further improvements in outcome. In particular, the follow-up care of transplant recipients should always be provided in close cooperation with the transplant center.

Anesthetic considerations for nontransplant procedures in lung transplant patients

Lung transplantation has become an accepted option for many patients with end-stage pulmonary diseases. Anesthesia and surgery following lung transplantation may be required for various diseases that may affect both systemic organs and the transplanted graft. When a patient with a lung transplant undergoes surgery, there is the potential for interference with lung function, depending on the type of intervention and its anatomical site. Accurate preoperative evaluation, an understanding of the physiology of the transplanted lung, proper airway instrumentation, individualized management of intraoperative ventilation, and fluid balance are essential for a positive perioperative outcome.

Vibration response imaging (VRI) in lung transplant recipients

BACKGROUND

In the first 6 months following lung transplantation, the most frequently occurring complications are infection, acute rejection and anastomotic dysfunction. The utility of vibration response imaging (VRI) lung images in assisting with the detection of these complications was evaluated.

OBJECTIVES

The study aimed to evaluate if VRI is a good, non-invasive method of detecting clinical problems in lung transplant (LTx) recipients during early follow-up.

METHODS

Between 06/2006 and 03/2007 all LTx patients who received transplants during the preceding 6 months at the Hannover Medical School received baseline VRI at enrollment with subsequent reassessment in combination with standard follow-up at 1, 3 and 6 months thereafter. The resulting images were analysed by two blinded reviewers.

RESULTS

Fifty-five lung transplant recipients were enrolled in the study, with 49 patients successfully completing follow-up. Device operability and patient participation occurred without significant problems. High numbers of abnormal scans were detected. According to the clinical diagnosis, 29 patients (59.2 %) were stable at all four visits. Twenty clinical problems occurred (e.g., infections, rejections, obstructions, unknown deterioration). Agreement with clinical interpretation of rejections and infections was poor. Central airway obstruction (CAO) was detected in 80% by both reviewers. Accuracy in detecting obstructions was 89%; positive predicted value and negative predicted value were 80% and 90%, respectively.

CONCLUSION

The VRI system is a non-invasive easy-to-use method with technical success and good image quality. The high number of abnormal scans makes interpretation following LTx difficult. VRI was unable to detect deterioration in graft function with the exception of ventilation disorders like central airway complications.