Lung transplantation

Lung transplantation ( Lutx ) is a form of treatment for advanced lung disease and is the transplantation of a lung (single lung transplantation), both lungs (bilateral lung transplantation ), or only one or more lobes of the lungs from an organ donor to a recipient. The heart - lung transplantation, that is, the transplantation of both lungs together with the heart, is now rarely, mainly performed in patients with heart defects. For several years, is also mainly for consumptive children the possibility of a so-called live - lung transplantation (English living -related transplant treatment ), ie transplanting each one lobe of two living donors to a mostly very young recipients.

History

Since the 80s, the lung transplantation of an experimental technique developed to established treatment potential for serious diseases of the lungs and the pulmonary circulation. This progress has mainly attributable to improved surgical technique and Organpräservation, the more accurate selection criteria as well as a more refined diagnosis, prophylaxis and treatment of graft rejection and infection possible. The goal of all efforts, however, continues to be the reduction of morbidity and mortality due to the so-called bronchiolitis obliterans syndrome - (BOS ), which continues to diminish the long-term results of lung transplantation most.

In the 1940s, the Russian surgeon Vladimir Demichow caused death in dogs over 100 experimental heart - lung transplants without a heart -lung machine or immunosuppression. He was able to show that these transplanted organs, the animals were alive at least for a short time. These results were confirmed by Dominique METRAS 1950 in France and Hardin 1954 in the USA. As a result - in particular thanks to the introduction of the heart -lung machine by Webb - succeeded James D. Hardy 1963, the first unilateral lung transplantation in humans. However, the patient survived only 18 days. Until 1980, a total of 3 heart-lung and 38 single lung transplants were performed in humans. With the exception of one patient who survived 10 months, all died within three months. With the introduction of cyclosporin in 1981 a new era of transplantation surgery including LTPL began. In March 1981, Bruce Reitz succeeded in Stanford, the first long-term successful heart - lung transplantation. Further technical developments of the isolated lung transplantation were mainly influenced by the work of Joel Cooper and colleagues in Toronto and later in St. Louis. This group conducted in 1983 by the first single - lung transplantation, 1986, the first en bloc double - lung transplantation and 1989, the first sequential bilateral lung transplantation.

In 1993 it was Vaughn Starnes from Stanford Medical Center, who performed the first lung transplant surgeon a among living relatives. He took each one lung of the father and mother and transplanted them to the 12 - year-old daughter.

By mid-2005 about 18 000 lung transplants worldwide, about half of single transplants performed. The average one- or five-year survival rate is 70 % and 50 % worldwide. Individual centers reach but now a five-year survival of about 80 %. There are several cases of second, third and even fourth lung transplants in Germany, where patients are instructed on average every five years to a new lung donor.

Lung transplant centers

In Germany, only a few hospitals can transplant lungs. Most lung transplants are performed at the Hospital of Hannover Medical School; Second place is for the University of Munich.

In Switzerland there are two malls: the one for the German Switzerland at the University Hospital Zurich (USZ ) and the Centre Romandie as cooperation between the two Unispitäler in Lausanne ( CHUV) and Geneva ( HUG).

Indications

The indication for LTPL occurs in the advanced stage of a disease of the lungs or of the pulmonary circulation after all conservative treatment options have been maximized. In this phase, the patient already suffering on the slightest exertion, sometimes even at rest under shortness of breath (dyspnea ) ( NYHA class III -IV). The assumed life expectancy without transplantation is then often only about 6 to 18 months. This estimate is in the individual case, of course, very difficult, and depends above all on the underlying disease. These are mainly the following:

• Chronic obstructive pulmonary disease ( COPD) including pulmonary emphysema in alpha 1- antitrypsin deficiency

• Including bilateral bronchiectasis

• Idiopathic form, in the context of heart disease ( Eisenmenger's syndrome)

We know based on studies that in COPD life expectancy according to indication for long-term oxygen therapy, that is, at an oxygen partial pressure <55 mmHg (< 7.3 kPa), and a pulmonary function with an FEV1 of 30 to 40 %, the 2-year survival rate is still about 80 is %. Quite different but it looks in cystic fibrosis, because it has to be considered in these patients at the same above-mentioned values, a LTPL necessarily considered. It is also difficult indication for pulmonary hypertension, where, for example, the pressure values ​​measured in the pulmonary circulation for the indication for LTPL not play a decisive role.

A simple but important test to assess general physical limitation, the 6 - or 12 - minute walk test, in which transplant candidates can usually cover much less than 400 or 600 meters.

The upper age limit for lung transplantation is currently about 65 years. More important than the chronological age but is the biological age for decision-making, that is, the general health and nutritional status, the absence of interference to other organ systems as well as a stable psychosocial situation. The ideal time for transplanting is therefore often difficult to determine and depends above all on the individual course of the disease. In particular, it is important to seize the moment in which the condition of the patient rapidly begins to deteriorate. Important notes for this are a rapid decline in lung function values ​​, an increasing oxygen use, Rechtsherzdekompensationen repeated, frequent exacerbations and hospitalizations, threatening bedridden and in particular the onset of weight loss despite optimal diet.

The coined by the Stanford group term " transplant window " illustrates very well the importance of these considerations in view of the fact that the patient is not pulled too early, nor too late for a possible lung transplant into consideration. In many patients, is for the decision to transplant especially difficult reduced quality of life that makes life not worth living, decisive.

Contraindications

Absolute contraindications for LTPL have become rare with medical advances in recent years. These are especially severe systemic diseases such as sepsis, intractable bleeding disorders, severe general arteriosclerosis or tumors that are not dealt with more than 5 years successfully. Dysfunction of other organs such as chronic renal failure, liver failure or heart failure today are relative contraindications because in such patients, in selected cases, a combined transplantation, so for example the lungs and kidneys, comes into question. As a highly problematic, however, applies a transplant for severe diseases of the nervous system, with serious psychiatric illness or abuse of drugs, alcohol or nicotine. Unlike in the past today lead most centers a LTPL even in cases of have been those in which earlier operations on the thorax performed or have severe adhesions in the chest cavity.

Technique of LTPL

The nature of the transplantation depends on the underlying illness. Lung disease associated with chronic infections such as cystic fibrosis or bronchiectasis require a two-sided LTPL. For all other lung diseases is in theory a single LTPL in question. She stood until recently the method of choice for pulmonary fibrosis or emphysema dar. in recent years has shown, however, that in the transplantation of only one lung often problems with the other remaining diseased lung arise such as serious infections. Therefore, today a bilateral LTPL is often performed in these cases. This also has the advantage that the pulmonary function after transplantation, is significantly better. The disadvantage is, however, that from an organ donor instead of two only one patient can be transplanted. A heart - lung transplantation is now only necessary for non- correctable heart defect with Eisenmenger reaction. This is based on the experiences of the last few years, finding that this within a few days to weeks fully recovered even with heavy failure of the right heart in pulmonary hypertension itself. The technique of LTPL today is largely standardized. The opening of the chest is nowadays mostly by a lateral section of approximately 8 to 9 ribs. After removal of the diseased lung, the pulmonary artery of the donor lungs with the corresponding structures in the receiver, first the bronchi, and then the pulmonary veins with a piece of the auricle, and the end joined by a seam. In the two-sided LTPL is equal then the other transplanted after transplantation of a lung using the same technique. Often can even be operated without a heart - lung machine, as the patient can be powered by ventilation, the other remaining diseased lung enough oxygen during transplantation of the first lung, and then during the replacement of the second lung ventilation then already on the "new can be "donor lungs. Patients are at no complications weaned usually within a few hours from the ventilator and transferred to two to three days from the ICU to the normal ward. This is followed by a rapid mobilization with intensive physiotherapy care. All hospital treatment takes about 3 weeks. The course is delayed especially in patients with pulmonary hypertension something, and in 10-20 % there will be complications which require a significantly longer stay in the ICU and a longer hospital treatment is necessary.

Complications after LTPL

In the first weeks after LTPL show surgical problems such as bleeding, paralysis of the diaphragm, divergence or strictures of the interface to the bronchi and pulmonary vessels, acute lung or heart failure as well as infections, the most common complications dar. After the first it is up to the sixth month, especially acute rejection, and infection with bacteria, viruses and fungi. In the long-term course, that is after the sixth month after LTPL, is probably primarily due to a chronic rejection reaction based bronchiolitis obliterans, bronchiolitis obliterans or the syndrome ( BOS), the most serious complication. The acute rejection following LTPL has become rare due to improved immunosuppression today. It is observed in approximately one third of patients, and some make two or more such episodes by. Acute rejection is based on a defense mechanism of the body against the foreign organ. Microscopically in the tissue accumulation of inflammatory cells around the small pulmonary vessels. While in the first 3-4 weeks while the patients have often fever, shortness of breath or changes in the chest x-ray, the acute rejection reaction proceeds in the course usually without symptoms and can only be due to daily control of lung function and regular transbronchial lung biopsies, that is a Gewebsprobenentnahme by means of bronchoscopy detected. The acute rejection reaction can always be well treated with high-dose cortisone, but is one of the major risk factors for the later development of BOS dar. infections after LTPL manifest itself most as pneumonia. However, sepsis, infections of the gastrointestinal tract, the kidneys and urinary tract, or the nervous system occur. The most common cause are various bacteria, viruses (especially cytomegalovirus ) and fungi ( Aspergillus fumigatus, Pneumocystis jirovecii ). By having a good prophylaxis, these infections usually prevented or their severity can be reduced.

Bronchiolitis obliterans - syndrome ( BOS)

Without a doubt, the BOS is the most important and serious complication after LTPL. It occurs over the years in up to half of patients and is a disease that is characterized by a generally slow beginning, but unfortunately in many cases inexorably progressive deterioration of lung function. Histologically, the BOS manifested by scarring and ultimately destruction of the bronchioles and Pfröpfen of tissue in the small airways and alveoli. However, since the transbronchial lung biopsy is often unproductive, the diagnosis is made because of lung function. At BOS, there is a deterioration in FEV1 compared to the average of the two best post-operatively measured values. The following stages of BOS can be distinguished:

• Stage 0 FEV1 > 90 % of baseline
• Stage 0 -p FEV1 81-90 % of baseline
• Stage 1 FEV1 66-80 % of baseline
• Stage 2 FEV1 51-65 % of baseline
• Stage 3 FEV1 <50 % of baseline

The cause of the BOS is not fully understood. Most authors are of the opinion that this is a form of chronic rejection, which is possibly a result of missed or not treated acute rejection. Today it is but believes that many other factors such as repeated infections or unrecognized nocturnal aspiration of gastric juice ( gastroesophageal reflux ) play an important role. A connection with cytomegalovirus is discussed again and again, but so far could not be clearly demonstrated. Most often, the BOS occurs 1-2 years after LTPL. Starts later, is arguably the most common cause of poor patient compliance, that is an unreliable taking the medication.

The prophylaxis of BOS is mainly in the early diagnosis and treatment of acute rejection, in the systematic prevention and treatment of infections, in action against gastroesophageal reflux, and the intensive supervision and motivation of patients to improve medication compliance. The treatment of an existing BOS is difficult. Approximately 1/3 of the cases can be achieved by increased immunosuppression improvement. A third of the patients showing a stationary curve. However, in another third, there is a persistent, uncontrollable deterioration of lung function, so that finally only a re- transplantation is in question.

Film

• A new lung for Manja. 60 min Documentary, Germany 2006, First broadcast. Director: Till Lehmann ( story of a 31- year-old mother and her husband, baker - at times their carers, from Mecklenburg- Vorpommern).