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Recipient Age and Lung Transplant PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Recipient age and lung transplant" by Kevin Conroy and Matt Dickson.
This medical PowerPoint presentation talks about lung transplant and age consideration of the recipients.
Age is an important factor to consider when it comes to lung transplant. While there is no set age limit for lung transplantation, older recipients may face greater risks during the procedure and in the post-operative period.

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Published on : Mar 19, 2023 | Views : 625 | Downloads : 0

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Slide 1-

Recipient age and lung transplant Kevin Conroy ST4 Matt Dickson ST3
Slide 2-

Introduction Criteria for lung transplantation Assessment process Ethical considerations Arguments for age limitation Arguments against age limitation
Slide 3-

ISHLT Guidance for Lung Transplant Should be considered for patients with chronic, end-stage lung disease who meet following general criteria: High (>50%) risk of death from lung disease within 2 years if lung transplantation is not performed. High (>80%) likelihood of surviving at least 90 days after lung transplantation. High (>80%) likelihood of 5-year post-transplant survival from a general medical perspective provided that there is adequate graft function.
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Contraindications Absolute: Recent history of malignancy Untreatable significant dysfunction of other major organ Uncorrected/untreatable atherosclerotic disease with end-organ ischaemia/dysfunction Acute medical instability Uncorrected hypocoagulopathy Chronic infection with highly virulent/pan-resistant organisms Significant chest wall/spinal deformity BMI >35 Poor compliance to medical therapy Untreated psychiatric/psychological conditions Absence of adequate/reliable social support system Substance abuse or dependence
Slide 5-

Contraindications Relative: Age >65 years for single lung transplant, >60 for bilateral BMI <18 or >30 Severely deconditioned with poor rehab potential Colonisation with certain pathogens HIV, Hepatitis B and C Severe, symptomatic osteoporosis Extensive prior chest surgery/lung resection Mechanical ventilation and/or extracorporeal life support Significant atherosclerotic disease
Slide 6-

Assessment Process Height, weight and BMI >17, <30 Bloods – FBC, Creatinine clearance, LFT, tissue typing and antibody screen Virology – HIV, Hep B, Hep C, CMV Sputum MCS Urine MSU
Slide 7-

Assessment Imaging CXR Latest Images DEXA Perfusion (Q) scan Echocardiogram ECG Angiogram / CT angiogram Ultrasound abdomen/ liver
Slide 8-

Assessment PFTS - spirometry, TLC, DLCO 6MWT – assess exercise capacity Social work / family support
Slide 9-

Common issues Lack of recent imaging Deconditioning BMI outside tolerance Outstanding coronary artery assessment
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Ethical considerations in organ transplants Medical ethics: Beneficence, non-maleficence, autonomy and justice Distributive justice: Only becomes an issue when scarce resources Thinks about group ethic rather than patient-centred ethic Equal access Distribution free of bias Maximum benefit Maximise successful transplants
Slide 11-

Controversy surrounding Age Criteria <60 for bilateral lung transplant <65 for single lung transplant Age has been revisited periodically Contradictory evidence Increased complication rates and decreased survival rates among older vs possibility of benefiting younger persons with better outcomes Other studies show equivocal outcomes Chronological age vs. Physiological age
Slide 12-

Arguments for Age Criteria
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ISHLT Registry Report 2015 International heart and lung transplant registry collecting data since 1983 Tracks morbidity and mortality post-transplant ISHLT registry report 2015 summarised data from 51,440 adult lung transplants 242 Lung transplant centres and 174 Heart-Lung transplant centres provided Report encompassed data up to June 30th 2014
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Findings of the 2015 report 45,542 adults underwent primary lung transplantation between 1990 and June 2013 Median survival of 5.7 years Survival rates of 89% at 3 months, 80% at 1 year, 65% at 3 years, 54% at 5 years and 31% at 10 years Those surviving at 1 year had median survival of 7.9 years Better survival in bilateral lung transplants (7.1 years vs 4.5 for single) Better survival in latest era (i.e. between 2009-2013) Survival also varied for different indications, sex as well as age The Registry of the International Society for Heart and Lung Transplantation: Thirty-second Official Adult Lung and Heart-Lung Transplantation Report--2015; Focus Theme: Early Graft Failure. Yusen RD, Edwards LB, Kucheryavaya AY, Benden C, Dipchand AI, Goldfarb SB, Levvey BJ, Lund LH, Meiser B, Rossano JW, Stehlik J. J Heart Lung Transplant. 2015;34(10):1264
Slide 15-

Arguments for current age criteria Multiple risk factors for death identified in 17,755 adult transplants between 2001-2013 Highest hazard ratios were transplant centre volume and recipient age Increased risk of 1 year post-transplant death began at ~55 years Rises exponentially thereafter
Slide 16-

Hazard ratio for mortality within the first post-transplant year for adult lung transplant recipient age and center volume (transplants: January 2001–June 2013). The dashed lines represent 95% confidence intervals.
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ISHLT Registry Report 2013 – focus theme: age 66% of recipients for lung transplant were between ages of 45-65 Since 1985, median age of recipient increased from 45 to 55 2006-2012, 10% aged >65, 3% >70 compared with 3% and 0.3% respectively between 2000-20052 Mortality rates differed depending on era (most recent, better survival) Increased age of recipient mainly in ILD and COPD (excluding A1ATD) Older sub-groups generally had lower long-term survival and higher long-term complication rates than younger sub-groups Yusen RD, Christie JD, Edwards LB, et al. for the International Society of Heart and Lung Transplantation. Registry of the International Society for Heart and Lung Transplantation: 30th adult lung and heart-lung transplant report–2013; focus theme: age. J Heart Lung Transplant 2013;32:965-78
Slide 18-

ISHLT Registry Report 2013 – focus theme: age Mortality also dependent on indication for transplant: 3 month mortality rates highest in IPAH (22%), lowest in non-A1ATD COPD (9%) Median survival for those surviving to 1 year highest for CF (10.5), IPAH (10) and lowest for ILD (7.0) and non-A1ATD COPD (6.9) Median survival for transplants between 1990 and 2011: >65 years - 3.6 years 60-65 years - 4.5 years 50-59 years - 5.3 years 35-49 years - 6.7 years 18-34 years - 6.5 years
Slide 19-

ISHLT Registry Report 2013 – focus theme: age Five year survival rates: >65 years – 38% 60-65 years – 46% 50-59 years – 52% 35-49 years – 57% 18-34 years – 55% Interaction between age and indication for transplant Older recipients within each diagnostic group had worse survival Non-A1ATD COPD had better overall survival compared to ILD 18-49: 6.4 years vs 5.7 years 50-65: 5.4 years vs 4.3 years >65: 3.7 vs 3.8 years
Slide 20-

Why does increased age lead to poorer outcomes? Chronic kidney disease Diabetes Cardiovascular complications Thromboembolic disease Malignancy
Slide 21-

Arguments against Age Criteria
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Age isn’t a barrier Distributive justice of finite resource Aging population Shrinking health budget Improving health in older age Delaying pension / working longer Feasibility and better outcomes
Slide 23-

Age isn’t a barrier ISHLT guidance suggests ‘physiological’ age of <65 single lung, <60 double lung tx. No absolute age limit ISHLT registry – cumulative – doesn’t reflect newer data Personalized care
Slide 24-

Age isn’t an Barrier Delayed pension Societal roles Increased expectation Equality The aim of transplant
Slide 25-

Age isn’t a barrier Mahidhara, Bastani et al 2008 No significant difference in survival at 3 years <65 vs >65 Reduced (p=0.16) survival 1-12 month period – infection Immunosenescence of age – tx not tailored to older age Freedom from BOS lower at 12/12 but not significant overall But >65 76% SLTx Basiliximab induction c.f ATG Non standardized donor organs Mahidhara et al. Lung transplantation in older patients? Journal of thoracic and cardiovascular surgery 2008
Slide 26-

Age isn’t a barrier 182 - 52 >60 years old No significant difference in survival over 5 years (p=0.61) Mortality slightly worse before 30 days for >60 – probability curves taken from beyond 30 days. In hospital mortality 12% c.f 7% in under 60. All over 65 had SLT Smith et al. Lung transplantation in over 60 years and older: results, complications and outcomes. Journal of the society of thoracic surgeons. 2006
Slide 27-

Age isn’t a barrier 2 year period 268 lung tx, 47% aged over 60 No significant difference in survival at 1, 12 and 36 months <60, 60-65, >65. Similar rates of significant bacterial infecgtion Malignancy and drug toxicity more likely in >65 (p=0.004), (0.03) than 60-65 Rejection more common 60-65 group c.f >65 Vadnerkar et al Age-specific complications among lung transplant recipients 60 years and older. JHLT 2011
Slide 28-

Age isn’t a barrier Improving experience Aging population Social responsibility Acceptable outcomes in transplant Careful patient selection
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Any Questions?