Chapter 42 - Transplantation medicine

Summary

Solid organ transplantation

The field of organ transplantation has been revolutionized over the past decades. Major advances have been made in surgical technique, immunosuppressive management, prevention and treatment of the infections that occur in the immunocompromised host, as well as in the screening and selection of candidates for transplantation. These advances have translated into a steady improvement in organ and patient survival, and have allowed transplantation to be made available to an increasing number of patients. This chapter will review lung, liver, kidney, and pancreas transplantation with a special emphasis on perioperative medical care.

Lung transplantation

Introduction

Lung transplantation (LTx) is the standard of care for end-stage lung diseases that do not respond to conventional medical or surgical treatments. The annual number of lung transplants has significantly increased to approximately 2,800 worldwide due to consistent growth in the number of bilateral lung transplants (BLTx) during the past 15 years [1,2]. Of the 28,664 solid organ transplants performed in the USA in 2010, 1,770 were adult lung transplants [3].

For end-stage lung diseases, LTx offers better survival and quality of life. As the technical difficulties with surgery have been addressed and critical care management improved, the first-month mortality has declined to 5–7% resulting in 3 month-, 1-, 5-, and 10-year survivals of 92.6%, 84%, 53.5%, and 27% respectively [2]. Long-term survival continues to be limited due to chronic rejection (bronchiolitis obliterans syndrome) and ensuing recurrent infections [4].

Candidates should have end-stage lung disease with limited life expectancy of 12–24 months despite optimal medical therapy. Disease-specific selection guidelines can be found in the literature [5]. Since 2005, a new lung allocation algorithm was initiated in the USA based on the diagnosis, severity of illness, and net transplant benefit within 1 year. Diagnostic groups are summarized in Table 42.1. Median time to transplant varies and is less than 35 days for those in the highest quartile [6].