akciğer nakli: tarihçe ve genel bakış
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Akciğer Nakli: Tarihçe ve Genel Bakış. Dr. Levent Dalar Yedikule Göğüs Hastalıkları ve Göğüs Cerrahisi Eğitim ve Araştırma Hastanesi. Herhangi bir kişi ya da kurumla çıkar ilişkim ve çatışmam yoktur. Tarihçe. Öncüler İlk nakiller Kırılma noktaları Yenilikler. Genel Bakış. Neler değişti? - PowerPoint PPT PresentationTRANSCRIPT
Akciğer Nakli: Tarihçe Akciğer Nakli: Tarihçe ve Genel Bakışve Genel Bakış
Dr. Levent DalarDr. Levent Dalar
Yedikule Göğüs Hastalıkları ve Yedikule Göğüs Hastalıkları ve Göğüs Cerrahisi Eğitim ve Göğüs Cerrahisi Eğitim ve
Araştırma HastanesiAraştırma Hastanesi
Herhangi bir kişi ya da Herhangi bir kişi ya da kurumla çıkar ilişkim kurumla çıkar ilişkim ve çatışmam yoktur.ve çatışmam yoktur.
TarihçeTarihçe
ÖncülerÖncüler İlk nakillerİlk nakiller Kırılma noktaları Kırılma noktaları YeniliklerYenilikler
Genel BakışGenel Bakış
Neler değişti?Neler değişti?
EndikasyonlarEndikasyonlar
TekniklerTeknikler SonuçlarSonuçlar Sağkalım Sağkalım
Öncüler: 1900’lerÖncüler: 1900’ler
Öncüler: 1950’lerÖncüler: 1950’ler
NeptuneNeptune
Öncüler: 1950’lerÖncüler: 1950’ler
Öncüler: MarcusÖncüler: Marcus
İlk Nakiller: Hardyİlk Nakiller: Hardy
İlk akciğer nakli hastası: İlk akciğer nakli hastası: J.R.J.R.
1963-19781963-1978
Nakil denemeleri devam ediyor, Nakil denemeleri devam ediyor, yapılan 38 nakilin tamamı yapılan 38 nakilin tamamı kaybediliyor. Sadece;kaybediliyor. Sadece;
1969 Fritz Derom’un sağ AC nakli 10 ay 1969 Fritz Derom’un sağ AC nakli 10 ay yaşadıyaşadı
Derom F, Barbier F, Ringoir S. Ten month survival Derom F, Barbier F, Ringoir S. Ten month survival after lung homotransplantation in man after lung homotransplantation in man J Thorac Cardiovasc Surg 1971; 61: 835-846J Thorac Cardiovasc Surg 1971; 61: 835-846
Bruce Reitz ilk uzun Bruce Reitz ilk uzun yaşayan kalp akciğer yaşayan kalp akciğer
naklini gerçekleştiriyornaklini gerçekleştiriyor
Reitz B, Wallwork J, Hunt S. N Eng J Med 1982; 306: 557
Toronto 1983: Tom HallToronto 1983: Tom Hall
Toronto 1986: İlk Toronto 1986: İlk Bilateral NakilBilateral Nakil
REGISTRY DATABASE:REGISTRY DATABASE:Number of Transplants Number of Transplants
ReportedReported
ORGANTransplants Reported from 7/1/2009 through
6/30/2010
Total Transplants Reported through
6/30/2010
Heart 3,608 100,210
Heart-Lung 69 4,248
Lung 3,168 38,119
ISHLT 2011ISHLTJ Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
REGISTRY DATABASE:REGISTRY DATABASE:Number of Centers Reporting Lung TransplantsNumber of Centers Reporting Lung Transplants
0
25
50
75
100
125
150
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Year of Transplant
# o
f C
en
ters
Re
po
rtin
g
ISHLT 2011ISHLTJ Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
REGISTRY DATABASE:REGISTRY DATABASE:Number of Centers Reporting Lung TransplantsNumber of Centers Reporting Lung Transplants
0
25
50
75
100
125
150
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Year of Transplant
# o
f C
en
ters
Re
po
rtin
g
Other
North America
Europe
ISHLT 2011ISHLTJ Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
NUMBER OF LUNG TRANSPLANTS REPORTED NUMBER OF LUNG TRANSPLANTS REPORTED BY YEAR AND PROCEDURE TYPEBY YEAR AND PROCEDURE TYPE
5 7 38 89204
449
758
972
11601291
13891509 1548 1559
16991783
19712008
2216
2567
2791
3272
2972
1411
2917
0
500
1000
1500
2000
2500
3000
3500
Nu
mb
er
of
tra
ns
pla
nts
Bilateral/Double LungSingle Lung
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.
ISHLT 2011ISHLTJ Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
AVERAGE CENTER VOLUMEAVERAGE CENTER VOLUMELung Transplants: January 1, 2000 - June 30, 2010Lung Transplants: January 1, 2000 - June 30, 2010
54
39
2316
7
28
70
10
20
30
40
50
60
1-4 5-9 10-19 20-29 30-39 40-49 50+
Average number of lung transplants per year
Nu
mb
er
of
ce
nte
rs
0
4
8
12
16
20
24
Number of centers Percentage of transplants
Per
cen
tag
e o
f tr
ansp
lan
ts
ISHLT 2011ISHLTJ Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
LUNG TRANSPLANTS:LUNG TRANSPLANTS: Transplant Recipient Age by Year of TransplantTransplant Recipient Age by Year of Transplant
Transplants: January 1, 1987 – June 30, 2010Transplants: January 1, 1987 – June 30, 2010
0%
20%
40%
60%
80%
100%
0
12
24
36
48
60
0-11 12-17 18-34 35-49 50-59 60-65 66+ Median Age
Med
ian
rec
ipie
nt
age
(yea
rs)
% o
f tr
an
sp
lan
tsrs
Year of Transplant
ISHLT 2011ISHLTJ Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
AGE DISTRIBUTION OF LUNG TRANSPLANT RECIPIENTS AGE DISTRIBUTION OF LUNG TRANSPLANT RECIPIENTS (1/1985-6/2010)(1/1985-6/2010)
0
5
10
15
20
25
30
35
0-11 12-17 18-29 30-39 40-49 50-59 60-65 >65
Recipient Age
% o
f tr
an
sp
lan
ts
ISHLT 2011ISHLTJ Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
AGE DISTRIBUTION OF LUNG TRANSPLANT AGE DISTRIBUTION OF LUNG TRANSPLANT RECIPIENTS BY ERARECIPIENTS BY ERA
0
5
10
15
20
25
30
35
40
0-11 12-17 18-29 30-39 40-49 50-59 60-65 >65
% o
f tr
ansp
lan
ts
1985-1994 (N = 4,975)
1995-1999 (N = 7,412)
2000-6/2010 (N = 25,716)
p < 0.0001
Transplants with unknown recipient age were excluded from this tabulation.ISHLT 2011ISHLT
J Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
LUNG TRANSPLANTS: LUNG TRANSPLANTS: Donor Age by Year of TransplantDonor Age by Year of Transplant
Transplants: January 1, 1987 – June 30, 2010 Transplants: January 1, 1987 – June 30, 2010
0%
20%
40%
60%
80%
100%
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Year of Transplant
0
10
20
30
40
50
0-11 12-17 18-34 35-49 50-59 60+ Median Donor Age
% o
f tr
ansp
lan
ts
Med
ian
do
no
r ag
e (y
ears
)
ISHLT 2011ISHLTJ Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
AGE DISTRIBUTION OF ADULT LUNG AGE DISTRIBUTION OF ADULT LUNG TRANSPLANT RECIPIENTS BY ERATRANSPLANT RECIPIENTS BY ERA
0
2
4
6
8
10
12
14
16
18
20
18-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-65 >65
1985-1995 (N = 6,059)
1996-6/2010 (N = 30,380)
p < 0.0001
Median age by era1985-1995 = 47 years1996-6/2010 = 53 years
% o
f tr
ansp
lan
ts
ISHLT 2011ISHLTJ Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
AGE DISTRIBUTION OF ADULT LUNG AGE DISTRIBUTION OF ADULT LUNG TRANSPLANT RECIPIENTS BY ERATRANSPLANT RECIPIENTS BY ERA
0
2
4
6
8
10
12
14
16
18
20
22
18-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-65 >65
1985-1994 (N=4,742)1995-1999 (N=6,970)2000-6/2010 (N=24,727)
p < 0.0001
Median age by era1985-1994 = 47 years1995-1999 = 50 years2000-6/2010 = 54 years
% o
f tr
ansp
lan
ts
ISHLT 2011ISHLTJ Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
ADULT LUNG TRANSPLANTATIONADULT LUNG TRANSPLANTATIONKaplan-Meier Survival Kaplan-Meier Survival (Transplants: January 1994 - June 2009)(Transplants: January 1994 - June 2009)
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Years
Bilateral/Double Lung (N=16,628)
Single Lung (N=12,085)
All Lungs (N= 28,727)
Double lung: 1/2-life = 6.8 Years; Conditional 1/2-life = 9.3 YearsSingle lung: 1/2-life = 4.7 Years; Conditional 1/2-life = 6.5 YearsAll lungs: 1/2-life = 5.5 Years; Conditional 1/2-life = 7.8 Years
P < 0.0001
Su
rviv
al (
%)
ISHLT 2011ISHLTJ Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
ADULT LUNG TRANSPLANTATION: Indications for Single Lung ADULT LUNG TRANSPLANTATION: Indications for Single Lung Transplants Transplants (Transplants: January 1995 - June 2010)(Transplants: January 1995 - June 2010)
*Other includes:
Pulmonary Fibrosis, Other: 3.4%
Sarcoidosis: 1.9%
Bronchiectasis: 0.4%
Congenital Heart Disease: 0.3%
LAM: 0.8%
Connective Tissue Disease: 1.0%
OB (non-ReTx): 0.6%
Miscellaneous: 0.9%
47%
32%
3%
1%2%
6%
10%
Alpha-1 COPD CF IPF IPAH Re-Tx Other*
ISHLT 2011ISHLTJ Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
ADULT LUNG TRANSPLANTATION: Indications for Bilateral/Double ADULT LUNG TRANSPLANTATION: Indications for Bilateral/Double Lung Transplants Lung Transplants (Transplants: January 1995 - June 2010)(Transplants: January 1995 - June 2010)
26%
16%
17%
7%
27%
5% 2%
Alpha-1 COPD CF IPF IPAH Re-Tx Other*
*Other includes:
Pulmonary Fibrosis, Other: 2.9%
Sarcoidosis: 3.0%
Bronchiectasis: 4.4%
Congenital Heart Disease: 1.2%
LAM: 1.1%
Connective Tissue Disease: 1.3%
OB (non-ReTx): 1.3%
Miscellaneous: 1.7%
ISHLT 2011ISHLTJ Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
ADULT LUNG TRANSPLANTATIONADULT LUNG TRANSPLANTATIONMajor Indications By Year (Number)Major Indications By Year (Number)
0
10
20
30
40
50
60
70
Myopathy
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
19940
250
500
750
1000
1250
1500
1750
2000
2250
2500
2750
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Transplant Year
Nu
mb
er
of
tra
ns
pla
nts
CF IPF COPD Alpha-1 IPAH Re-Tx
ISHLT 2011ISHLTJ Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
ADULT LUNG TRANSPLANTATIONADULT LUNG TRANSPLANTATIONKaplan-Meier Survival By DiagnosisKaplan-Meier Survival By Diagnosis (Transplants: January 1990 – June 2009)(Transplants: January 1990 – June 2009)
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14Years
Su
rviv
al (
%)
Alpha-1 (N=2,349) CF (N=4,828) COPD (N=10,741)IPF (N=6,478) IPAH (N=1,189) Sarcoidosis (N=756)
HALF-LIFE Alpha-1: 6.3 Years; CF: 7.4 Years; COPD: 5.3 Years; IPF: 4.5 Years; IPAH: 4.9 Years; Sarcoidosis: 5.3 Years
Survival comparisonsAll comparisons with Alpha-1 and CF are statistically significant at < 0.01
COPD vs. IPF: p < 0.0001
ISHLT 2011ISHLTJ Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
ADULT LUNG TRANSPLANTS ADULT LUNG TRANSPLANTS (1997-6/2009)(1997-6/2009) Risk Factors for 1 Year MortalityRisk Factors for 1 Year Mortality
(N=13,937)
ISHLT 2011
DONOR CHARACTERISTICSDONOR CHARACTERISTICS NN RelativRelative Riske Risk
P-P-valuevalue
95% Conf. 95% Conf. IntervalInterval
Donor history of diabetesDonor history of diabetes 560560 1.441.44 <.000<.00011
1.21 -1.21 - 1.721.72
RECIPIENT CHARACTERISTICSRECIPIENT CHARACTERISTICS
Recipient on dialysisRecipient on dialysis 6161 2.662.66 <.000<.00011
1.84 -1.84 - 3.843.84
IV inotropesIV inotropes 4949 1.741.74 0.00760.0076 1.16 -1.16 - 2.602.60
Hospitalized (including ICU)Hospitalized (including ICU) 1,511,5133
1.701.70 <.000<.00011
1.50 -1.50 - 1.931.93
VentilatorVentilator 491491 1.571.57 <.000<.00011
1.31 -1.31 - 1.881.88
ISHLTJ Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
(N=13,937)
*Other = All diagnoses other than COPD, IPAH, IPF, cystic fibrosis, pulmonary fibrosis, bronchiectasis, alpha-1 antitrypsin deficiency, retransplant and LAM.
Reference group = COPD/Emphysema, Single lung
ISHLT 2011
RECIPIENT CHARACTERISTICSRECIPIENT CHARACTERISTICS NN RelativRelative Riske Risk
P-valueP-value 95% Conf. 95% Conf. IntervalInterval
Diagnosis = BronchiectasisDiagnosis = Bronchiectasis 273273 1.341.34 0.05820.0582 0.99 0.99 --
1.801.80
Prior SternotomyPrior Sternotomy 319319 1.221.22 0.08100.0810 0.98 0.98 --
1.521.52
Diagnosis = COPD/Emphysema, Diagnosis = COPD/Emphysema, double lungdouble lung
1,9401,940 1.161.16 0.05170.0517 1.00 1.00 --
1.341.34
Recipient history of diabetesRecipient history of diabetes 1,7481,748 1.111.11 0.09270.0927 0.98 0.98 --
1.251.25
Chronic steroid useChronic steroid use 6,6066,606 1.091.09 0.05060.0506 1.00 1.00 --
1.181.18
ADULT LUNG TRANSPLANTS ADULT LUNG TRANSPLANTS (1997-6/2009)(1997-6/2009) Borderline SignificantBorderline Significant Risk Factors for 1 Year Mortality Risk Factors for 1 Year Mortality
ISHLTJ Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
ADULT LUNG TRANSPLANTSADULT LUNG TRANSPLANTS (1/1997-6/2009)(1/1997-6/2009) Risk Factors for 1 Year MortalityRisk Factors for 1 Year Mortality
ISHLT 2011
Continuous Factors (see figures)Continuous Factors (see figures)
Recipient ageRecipient age BilirubinBilirubin
Transplant center Transplant center volume volume
Recipient oxygen Recipient oxygen required at restrequired at rest
Cardiac outputCardiac output Height differenceHeight difference
Recipient FVC % Recipient FVC % predictedpredicted
ISHLTJ Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
ADULT LUNG RECIPIENTSADULT LUNG RECIPIENTSCross-Sectional AnalysisCross-Sectional Analysis
Functional Status of Surviving RecipientsFunctional Status of Surviving Recipients(Follow-ups: April 1994 – June 2010)(Follow-ups: April 1994 – June 2010)
0%
20%
40%
60%
80%
100%
1 Year (N = 6,882) 3 Year (N = 4,423) 5 Year (N = 2,544)
No Activity Limitations Performs with Some Assistance Requires Total Assistance
ISHLT 2011ISHLTJ Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
ADULT LUNG TRANSPLANT RECIPIENTS: ADULT LUNG TRANSPLANT RECIPIENTS: Relative Incidence of Leading Causes of DeathRelative Incidence of Leading Causes of Death
(Deaths: January 1992 - June 2010)(Deaths: January 1992 - June 2010)
0
10
20
30
40
50
0-30 Days (N=2,204)
31 Days – 1Year
(N=3,781)
>1 Year – 3Years
(N=3,425)
>3 Years – 5Years
(N=1,962)
>5 Years – 10Years
(N=2,336)
>10 Years (N=675)
Bronchiolitis Malignancy (non-Lymph/PTLD)
Infection (non-CMV) Graft Failure
Cardiovascular
Pe
rce
nta
ge
of
De
ath
s
ISHLT 2011ISHLTJ Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132