Longtransplantatie bij COPD. Drs. Diana van Kessel, longarts Heleen Froon, diëtist

Transcriptie

1 Longtransplantatie bij COPD Drs. Diana van Kessel, longarts Heleen Froon, diëtist 8 oktober 2012

2 historie 1963 eerste longtransplantatie bij de mens 1986 Toronto lung transplant group 1989 eerste enkelzijdige longtransplantatie in Ned 1990 eerste dubbelzijdige longtransplantatie in Ned 1992 stop longtransplantatie St. Antonius Ziekenhuis begin UMCG 1993 start ontwikkelingsgeneeskunde 1997 longtransplantatie in ziekenfondspakket e centrum voor longtransplantatie aan HLCU en EMCR

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4 St. Antonius Ziekenhuis: de eerste procedure

5 fasen aanmelding wachtlijst screening transplantatie posttransplantatie

6 ADULT LUNG TRANSPLANTATION Major Indications By Year (Number) Number of Transplants CF IPF COPD Alpha-1 IPAH Re-Tx Myopathy ISHLT Transplant Year 2010 J Heart Lung Transplant Oct; 29 (10):

7 Number of Transplants NUMBER OF LUNG TRANSPLANTS REPORTED BY YEAR AND PROCEDURE TYPE ISHLT Bilateral/Double Lung Single Lung J Heart Lung Transplant Oct; 29 (10): NOTE: This figure includes only the lung transplants that are reported to the ISHLT Transplant Registry. As such, this should not be construed as representing changes in the number of lung transplants performed worldwide.

8 timing verwijzing 50% kans levensverwachting 2-3 jaar overweeg: survival per ziektebeeld lengte wachtlijst opnames/ IC zuurstofafhankelijkheid gewichtsverlies bloedgroep IC-opname snelheid progressie Orens et al, J Heat Lung Transplant 2006;25:

9 longemfyseem verwijzing: BODE index > 5 transplantatie: BODE-index 7-10 opname ivm exacerbatie met hypercapnie (PaCO2 7.4 kpa) pulmonale hypertensie en/of cor pulmonale ondanks zuurstof FEV1< 20 % /DLCO< 20 % of homogene distributie bulleuze afwijkingen Orens et al, J Heart Lung Transplant 2006;25:

10 BODE index Table 2. Variables and Point Values Used for the Computation of the Body Mass Index, Degree of Airflow Obstruction and Dyspnea, and Exercise Capacity (BODE) Index.* Variable Points on BODE Index FEV 1 (% of predicted) Distance walked in 6 min (m) MMRC dyspnea scale Body-mass Index >21 21 Celli et al. N Engl J Med 2004;

11 BODE-index quartile: 1 = = = = 7-10 Celli et al. N Engl J Med 2004;

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13 contra-indicaties: absoluut maligniteit in de laatste 2 jaar 5-jaar ziektevrij interval onbehandelbare dysfunctie ander orgaansysteem (hart, lever,nier) onbehandelbare extrapulmonale infectie gedeformeerde borstkas therapie-ontrouw onbehandelbare psychiatrische aandoening geen sociale ondersteuning verslaving laatste 6 maanden Orens et al, J Heat Lung Transplant 2006;25:

14 contra-indicaties: relatief ouder dan 65 jaar klinisch instabiel: beademing/shock kolonisatie zeer resistente micro-organismen BMI>30 symptomatische osteoporose aandoeningen zonder irreversibele beschadiging: diabetes mellitus, coronarialijden na CABG/PTCA Orens et al, J Heat Lung Transplant 2006;25:

15 fasen aanmelding screening wachtlijst transplantatie posttransplantatie

16 Am J Respir Crit Care Med November 1; 180(9): Published online 2009 July 16. doi: /rccm OC

17 Am J Respir Crit Care Med November 1; 180(9): Published online 2009 July 16. doi: /rccm OC

18 Continuous relationships of body mass index and the risk of death (A) at 1 year and (B) at 5 years conditional on 1-year survival after lung transplantation. Thick dotted lines = smoothed regression lines adjusted for the model 4 covariates listed in the footnote to Thin solid lines = 95% confidence intervals. In (A), both nonlinear (P = 0.02) and linear (P = 0.02) relationships were statistically significant. In (B), the nonlinear (P = 0.04), but not the linear (P = 0.35), relationship was statistically significant. The significant P values for the smoothed (nonlinear) curves suggest that the relationship between body mass index and the risk of death after lung transplantation is nonlinear, with higher early and late mortality rates for both underweight and obese recipients. The wide confidence intervals at the extremes of body mass index are due to smaller numbers of transplant recipients with these value Am J Respir Crit Care Med November 1; 180(9): Published online 2009 July 16. doi: /rccm OC

19 Multivariable-adjusted survival curves for underweight, normal weight, overweight and obese lung transplant recipients. Am J Respir Crit Care Med November 1; 180(9): Published online 2009 July 16. doi: /rccm OC

20 Primary graft dysfunction defined as the occurrence of acute lung injury (ALI) in the allograft within 72 hours of transplantation leading cause of death early after lung transplantation risk factor for chronic allograft rejection due to ischemia-reperfusion injury of the allograft, systemic inflammation plays a critical role The Journal of Thoracic and Cardiovascular Surgery Volume 131, Issue 1, January 2006, Pages 73-80

21 Continuous association between body mass index and grade 3 primary graft dysfunction adjusted for diagnosis, cardiopulmonary bypass, and transplant procedure type. Dark dotted line =effect estimate. Thin lines = 95% confidence bands. The p-value is for the association between body mass index and PGD. Obesity and Primary Graft Dysfunction after Lung Transplantation: The LTOG Obesity Study. Lederer DJ, Kawut SM, Wickersham N, Winterbottom C, Bhorade S, Palmer SM, Lee J, Diamond JM, Wille KM, Weinacker A, Lama VN, Crespo M, Orens JB, Sonett JR, Arcasoy SM, Ware LB, Christie JD; for the Lung Transplant Outcomes Group Am J Respir Crit Care Med Jul

22 ADULT LUNG TRANSPLANTATION: Indications for Single Lung Transplants (Transplants: January June 2009) Alpha-1 COPD CF IPF IPAH Re-Tx Other* 31% 2% 1% 3% *Other includes: 9% Sarcoidosis: 2.0% Bronchiectasis: 0.4% Congenital Heart Disease: 0.3% LAM: 0.9% OB (non-retx): 0.5% 6% Miscellaneous: 5.3% 48% ISHLT 2010 J Heart Lung Transplant Oct; 29 (10):

23 ADULT LUNG TRANSPLANTATION: Indications for Bilateral/Double Lung Transplants (Transplants: January June 2009) Alpha-1 COPD CF IPF IPAH Re-Tx Other* 16% 5% 2% 26% 17% 7% *Other includes: Sarcoidosis: 3.0% Bronchiectasis: 4.4% Congenital Heart Disease: 1.3% LAM: 1.2% OB (non-retx): 1.2% Miscellaneous: 5.8% ISHLT 26% 2010 J Heart Lung Transplant Oct; 29 (10):

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26 longtransplantatie longtransplantaties in nederland Number Total Year

27 longtransplantatie Number Bilateral Single Year

28 Survival (%) ADULT LUNG TRANSPLANTATION Kaplan-Meier Survival by Era (Transplants: January 1988 June 2008) (N=4,318) (N=6,558) /2008 (N=17,227) Survival comparisons by era vs : p = : vs /08: p < vs /08: p < N at risk = : 1/2-life = 4.0 Years; Conditional 1/2-life = 7.0 Years : 1/2-life = 4.6 Years; Conditional 1/2-life = 7.3 Years /2008: 1/2-life = 5.7 Years; Conditional 1/2-life = 7.9 Years N at risk = 406 N at risk = Years ISHLT 2010 J Heart Lung Transplant Oct; 29 (10):

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30 ADULT LUNG TRANSPLANTATION Kaplan-Meier Survival by Gender (Transplants: January 1990 June 2008) 100 Male (N=14,799) 75 Female (N=13,050) Survival (%) 50 p = N at risk at 10 years= HALF-LIFE Male: 5.0 years; Female: 5.4 Years ISHLT N at risk at 10 years= Years J Heart Lung Transplant Oct; 29 (10): N at risk = 154 N at risk = 127

31 ADULT LUNG TRANSPLANTATION Kaplan-Meier Survival by Age Group (Transplants: January 1990 June 2008) 100 HALF-LIFE 18-34: 5.9 Years; 35-49: 6.3 Years; 50-59: 5.1 Years; 60-65: 4.3 Years; 66+: 3.3 Years Survival (%) (N = 4,819) (N = 7,127) (N = 10,069) (N = 4,929) 66+ (N = 907) Survival comparisons All p-values significant at p < except vs : p =0.4955; vs. 66+: p = ISHLT 2010 Years J Heart Lung Transplant Oct; 29 (10):

32 ADULT LUNG TRANSPLANTATION Kaplan-Meier Survival By Diagnosis (Transplants: January 1990 June 2008) 100 Alpha-1 (N=2,187) CF (N=4,144) COPD (N=9,616) IPF (N=5,459) IPAH (N=1,123) Sarcoidosis (N=660) Survival (%) Survival comparisons All comparisons with Alpha-1 and CF are statistically significant at 0.01 IPAH vs. IPF: p = COPD vs. IPF: p < HALF-LIFE Alpha-1: 6.1 Years; CF: 7.1 Years; COPD: 5.2 Years; IPF: 4.3 Years; IPAH: 4.9 Years; Sarcoidosis: 5.1 Years Years ISHLT 2010 J Heart Lung Transplant Oct; 29 (10):

33 100 ADULT LUNG TRANSPLANTATION Kaplan-Meier Survival by Procedure Type (Transplants: January 1990 June 2008) Diagnosis: Emphysema/COPD P < Survival (%) N at risk at 5 years = 1,970 COPD/Single lung (N=5,959) N at risk at 5 years = 878 N=51 COPD/Double lung (N=3,653) N= ISHLT Years 2010 J Heart Lung Transplant Oct; 29 (10):

34 100 ADULT LUNG TRANSPLANTATION Kaplan-Meier Survival by Procedure Type and Age (Transplants: January 1990 June 2008) Diagnosis: Emphysema/COPD P < Survival (%) <50/Single lung (N=724) <50/Double lung (N=823) 50+/Single lung (N=5,235) 50+/Double lung (N=2,830) N=34 N= ISHLT 2010 Years J Heart Lung Transplant Oct; 29 (10): N=22 N=29

35 Relative Risk of 1 Year Mortality ADULT LUNG TRANSPLANTS (1/1996-6/2008) Risk Factors for 1 Year Mortality Recipient Age 2 1,5 1 0,5 p < ISHLT Recipient Age 2010 J Heart Lung Transplant Oct; 29 (10):

36 LONGTRANSPLANTATIE

37 (no value) LAS calculator Date of birth dd-mm-yyyy Height cm Weight kg Lung Diagnosis Code Assistance level Diabetes Assisted Ventilation Supplemental Oxygen Amount of oxygen FVC predicted % Pulmonary Artery Systolic Pressure mmhg Mean Pulmonary Artery Pressure mmhg Pulmonary Capillary Wedge Mean mmhg Current PCO 2 mmhg Highest PCO 2 mmhg Lowest PCO 2 mmhg Change in PCO 2 % Six minute walk distance m Serum Creatinine mg/ dl

38 wachtlijst versus longtransplantatie

39 toekomst donoren non-heart beating donoren levende familie-donoren niet meer boven de zestig? behandeling donoren meer marginale donoren nieuw donorsysteem, meer donoren?

40 toekomst betere bewaartechnieken donorlong UMCG meer enkelzijdig? kunstlong? xenotransplantatie stamcel

41 toekomst na de transplantatie betere medicijnen tegen afstoting,minder bijwerkingen snellere diagnose afstoting ontwikkeling medicatie voor tolerantie

42 toekomst onderzoek chronische afstoting voorspelbaar? verfijning diagnostiek/ soorten? waarom bij wie en wanneer? op zoek naar biomarkers die vroeg detecteren

43 Voeding rondom LOTX Wat is de rol van de diëtist in het transplantatieteam Screening Wachtlijst Transplantatie Na de transplantatie 43

44 Screening Tijdens opname in ziekenhuis (2 weken) Doel: beoordelen voedingstoestand Patiënten in kaart brengen Knelpunten opsporen Wanneer is de operatie?? 44

45 Screening Antropometrie Gewicht, BMI Contra-indicatie: BMI < 17 BMI > 30 Gewichtsverloop, VVM-index Beoordeling voedselinname inname voedingsstoffen versus behoefte Gebruik aanvullende voedingssupplementen Voedingsgerelateerde klachten Algemeen Dieetgeschiedenis Bekend bij dietist Dieet na LOTX 45

46 Screening Gegevens verzamelen Conclusie, enige harde eis : BMI Indien verdere dieetbegeleiding nodig is: samen met patient kijken waar dit kan plaatsvinden 46

47 Screening Grootste knelpunt Gewicht BMI> 30 Zeer gemotiveerde/gedreven groep Gewicht beïnvloedbaar Weinig mobiliseren Jojo-effect 47

48 Wachtlijst Poliklinisch/1 e lijn/eigen ziekenhuis BMI Optimaliseren of behouden van de voedingstoestand Inname van voldoende energie en eiwit voor behoud of verbetering van de vetvrije massa Streven naar optimale training samen met juiste dieetadvies 48

49 Transplantatie Tijdens opname Evalueren en optimaliseren van de benodige voedselinname Afstemming voedings- en trainingsadviezen voor optimaliseren van de voedingstoestand Uitleg over hygienische voedingsrichtlijnen ter voorkoming voedselinfectie bij verminderde weerstand 49

50 Na transplantatie Poliklinisch 1 e jaar na LOTX: 4 x naar dietist Daarna 1-2 keer per jaar Zo nodig vaker Vragen m.b.t hygiënische voedingsrichtlijnen Herstel en behoud van een gezond gewicht Dieetbegeleiding bij complicaties (DM, overgewicht, nierfunctiestoornissen) 50

51 Hygienische voedingsrichtlijnen Nodig ivm gebruik immuunsuppresiva (Prograft, Cellcept) Adviezen m.b.t Inkoop Bereiding Bewaren Vanaf nu altijd deze richtlijnen 51

52 Hygiënische voedingsrichtlijnen Nieuwe richtlijnen sinds november 2011 i.s.m UMCU en Erasmus MC. Waarom nieuwe richtlijnen? Behoefte aan landelijke richtlijn, eenduidige informatie voor de patiënt Nieuwe inzichten in hygiene romdom voeding icm Voedingscentrum, Medisch microbiologen en RIVM Lastig door: verschil in inzichten/ ontbreken evidence

53 Wat mag niet/niet toegestaan? rauwe (ongepasteuriseerde) melk en rauwmelkse kazen probiotica zoals in oa. Vifit, Yakult en Actimel Rauw vlees en vleeswaren zoals fricandeau, ossenworst Rauwe vis zoals in sushi Rauwe schaal- en schelpdieren zoals oesters Zachtgekookt of rauw ei Warm gehouden vlees, vis, kip- en rijstproducten (> 1 uur) Niet zelf peper strooien Noten zelf pellen en/of onverhit consumeren Voorverpakte koudgerookte vis zoals zalm, paling en makreel 53

54 Wat mag wel/is toegestaan? Schaal- en schelpdieren indien gekookt/gebakken Haring (dagvers!) Geitenkaas, schimmelkaas en buitenlandse kaassoorten mits gepasteuriseerd (bijvoorbeeld Brie,Gorgonzola, Boursin) Milkshake, soft- en schepijs uit ijskraam of restaurant Snacks/Maaltijden uit afhaal- of bezorgrestaurants mits korter dan 1 uur warmgehouden Rauwe (kiem)groente mits goed gewassen

55 Hygienische voedingsrichtlijnen Immuunsuppresieva worden rest van het leven gebruikt = Rest van het leven slechte weerstand = Rest van het deze voedingsrichtlijnen 55

56 Film De patient aan het woord.. 56

57 Vragen?

58 TABLE 1. Definitions of primary graft dysfunction grade Definitions of primary graft dysfunction grade ISHLT PGD definition Modified ISHLT PGD definition Grade 0 P/F ratio >300 CXR clear NA Grade 1 P/F ratio >300 CXR infiltrate P/F ratio >300 Grade 2 P/F ratio P/F ratio Grade 3 P/F ratio <200 P/F ratio <200 Time points T0, T12, T24, T48, T72 T0, T12, T24, T48 Worst grade T(0-48) T(0-72)T(0-48) ISHLT, International Society for Heart and Lung Transplantation; PGD, primary graft dysfunction; P/F, partial pressure of arterial oxygen/fraction of inhaled oxygen concentration ratio; CXR, chest radiograph; NA, not applicable

59 Long-term survival stratified by modified primary graft dysfunction grade. The Journal of Thoracic and Cardiovascular Surgery Volume 131, Issue 1, January 2006, Pages 73-80

60 ADULT LUNG TRANSPLANTS (1996-6/2004) Risk Factors for 5 Year Mortality DONOR CHARACTERISTICS N Relative Risk P-value 95% Confidence Interval Donor history of diabetes Donor cause of death = anoxia RECIPIENT CHARACTERISTICS IV inotropes < Recipient on dialysis Prior sternotomy Hospitalized (including ICU) Recipient history of diabetes Chronic steroid use 3, ISHLT (N=7,609) 2010 J Heart Lung Transplant Oct; 29 (10):

61 ADULT LUNG TRANSPLANTS (1/1996-6/2004) Risk Factors for 5 Year Mortality Recipient Age Relative Risk of 5 Year Mortality 2 1,5 1 0,5 p < ISHLT Recipient Age 2010 J Heart Lung Transplant Oct; 29 (10):

62 ADULT LUNG TRANSPLANTS (1/1996-6/2004) Risk Factors for 5 Year Mortality Donor Age Relative Risk of 5 Year Mortality 2 1,5 1 0,5 p = Donor Age ISHLT 2010 J Heart Lung Transplant Oct; 29 (10):

63 ADULT LUNG TRANSPLANTS (1/1996-6/2004) Risk Factors for 5 Year Mortality Recipient age Continuous Factors (see figures) Recipient oxygen required at rest Transplant center volume Cardiac output Bilirubin Donor age Recipient FEV1 % predicted Recipient height (borderline) ISHLT 2010 J Heart Lung Transplant Oct; 29 (10):

64 ADULT LUNG TRANSPLANTS (1/1996-6/2004) Risk Factors for 5 Year Mortality Conditional on Survival to 1 Year Continuous Factors (see figures) Recipient age Transplant center volume Cardiac output (borderline) Height difference Donor age (borderline) Recipient Height (borderline) Recipient FEV1 % predicted (borderline) ISHLT 2010 J Heart Lung Transplant Oct; 29 (10):

65 ADULT LUNG TRANSPLANTS (1996-6/2004) Risk Factors for 5 Year Mortality DONOR CHARACTERISTICS N Relative Risk P-value 95% Confidence Interval Donor history of diabetes Donor cause of death = anoxia RECIPIENT CHARACTERISTICS IV inotropes < Recipient on dialysis Prior sternotomy Hospitalized (including ICU) Recipient history of diabetes Chronic steroid use 3, ISHLT (N=7,609) 2010 J Heart Lung Transplant Oct; 29 (10):

66 ADULT LUNG TRANSPLANTS (1/1996-6/2004) Risk Factors for 5 Year Mortality Recipient Age Relative Risk of 5 Year Mortality 2 1,5 1 0,5 p < ISHLT Recipient Age 2010 J Heart Lung Transplant Oct; 29 (10):

67 ADULT LUNG TRANSPLANTS (1/1996-6/2004) Risk Factors for 5 Year Mortality Donor Age Relative Risk of 5 Year Mortality 2 1,5 1 0,5 p = Donor Age ISHLT 2010 J Heart Lung Transplant Oct; 29 (10):

68 ADULT LUNG TRANSPLANTS (1/1996-6/2004) Risk Factors for 5 Year Mortality Recipient age Continuous Factors (see figures) Recipient oxygen required at rest Transplant center volume Cardiac output Bilirubin Donor age Recipient FEV1 % predicted Recipient height (borderline) ISHLT 2010 J Heart Lung Transplant Oct; 29 (10):

69 ADULT LUNG TRANSPLANTS (1/1996-6/2004) Risk Factors for 5 Year Mortality Conditional on Survival to 1 Year Continuous Factors (see figures) Recipient age Transplant center volume Cardiac output (borderline) Height difference Donor age (borderline) Recipient Height (borderline) Recipient FEV1 % predicted (borderline) ISHLT 2010 J Heart Lung Transplant Oct; 29 (10):