Bonus Material-20_2025 FINAL FINAL TXDlevine transplant board review

Pdf Summary

This comprehensive review on lung transplantation (LT), presented by Dr. Deborah Jo Levine, covers current practices, outcomes, indications, complications, and management strategies in LT as of 2025.<br /><br />LT has evolved over six decades and is indicated for select patients with end-stage lung diseases like idiopathic pulmonary fibrosis (IPF), chronic obstructive pulmonary disease (COPD), cystic fibrosis, bronchiectasis, and pulmonary arterial hypertension (PAH) who have exhausted other therapies. Annually, over 3,000 adult lung transplants are performed in the US, with 1-year survival at 88.5%, 5-year survival around 54-61%, and a median survival of 6.7 years. Heart-lung transplants are less common, mostly reserved for combined irreversible cardiac and lung diseases.<br /><br />Candidate selection relies on multidisciplinary evaluation, targeting patients with a high risk of death without transplant and a good likelihood of 5-year post-transplant survival. Timing is critical for referral and listing to optimize outcomes.<br /><br />Post-transplant monitoring involves regular clinical assessment, pulmonary function tests, bronchoscopy with biopsies, imaging, and laboratory surveillance to detect rejection or infection early. Complications include:<br /><br />- Acute cellular rejection (ACR), common in first 2 years, diagnosed by histopathology showing perivascular lymphocytic infiltrates and treated mainly with high-dose steroids.<br />- Antibody mediated rejection (AMR), associated with donor-specific antibodies and managed by plasma exchange, IVIG, and rituximab.<br />- Chronic lung allograft dysfunction (CLAD), the leading cause of graft failure after 1 year, diagnosed by persistent >20% decline in FEV1 over 3 months. Phenotypes include bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS).<br />- Infections (bacterial, viral including CMV, fungal) remain a major morbidity driver.<br />- Other complications include primary graft dysfunction, airway complications, malignancy (e.g., post-transplant lymphoproliferative disorder), and side effects of immunosuppression (renal dysfunction, cytopenias).<br /><br />Immunosuppressive regimens use calcineurin inhibitors (tacrolimus, cyclosporine), corticosteroids, and DNA synthesis inhibitors. Drug interactions notably affect calcineurin inhibitor levels.<br /><br />Lung allocation in the US now employs a Composite Allocation Score to prioritize candidates. Research is ongoing into donor organ evaluation, ex vivo lung perfusion, and tolerance induction.<br /><br />In summary, lung transplantation is a complex, multidisciplinary process with improving survival, yet long-term graft dysfunction and complications require vigilant monitoring and tailored management to optimize outcomes.

Meta Tag

Concept Lung Transplantation

Concept Chronic Lung Allograft Dysfunction

Concept Acute Cellular Rejection

Concept Antibody-Mediated Rejection

Concept Transplant Indications

Keywords

lung transplantation

idiopathic pulmonary fibrosis

chronic obstructive pulmonary disease

COPD

cystic fibrosis

CF

pulmonary arterial hypertension

PAH

acute cellular rejection

antibody mediated rejection

chronic lung allograft dysfunction

immunosuppression

Composite Allocation Score

Lung Transplantation

Chronic Lung Allograft Dysfunction

Acute Cellular Rejection

Antibody-Mediated Rejection

Transplant Indications