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Wednesday, September 10, 2008

Stanford University Medical Center Lung Transplant Support Group

The following is a presentation and interaction between members of the lung transplant support group at Stanford University and the medical staff that care for them (us) particularly Dr. David Weill. Thanks for letting me post this valuable information.

Notes: Stanford Transplant Support Group,
June 6, 2008 Dr. Weill (2:00 -3:30 p.m.)
1. There are 3 types of Rejection

A. Acute i. 100% treatable ii. Is reversible iii. Occurs with 60% of recipients in the 1st year post transplant iv. Defined as a 20% drop of the FEV1 number that recovers with treatment v. Treated with intravenous steroids (Solumedrol)

B. Chronic i. Also known as BOS (Bronchiolitis Obliterans Syndrome) ii. 4 stages, 1 thru 4 iii. At stage 1, FEV1 number has dropped 20% over a three month period iv. Stages 3 and 4 are worse, patient may become 24/7 oxygen dependent, may consider re-transplant v. Stage 4 re-transplants are becoming more common when they can’t slow the rejection. With re-transplantations, the surgery is much harder as it takes a longer time to remove the transplanted lungs; the ICU stay is generally rougher also.

C. Antibody Mediated [discussed later] 1. Treatments for Rejection 1. Steroids, change immunosuppressant medications 2. ATG – IV heavy duty immunosuppressant which attack of t-cells, hospitalized to watch for infection 3. GERD can cause aspirations which may result in inflammation or fungal plitation (sp?) in the lungs, treated with RAP (long name that I didn’t get written down), with 5-6 patients who were still showing signs of GERD, surgery was performed 7 days after treatmentQuestions and Answers: 1. How do viruses fit in with rejection? 1. RSV – seasonal 2. Pera influenza 1 and 3 – detected with nasal swabs, treated with inhaled rhybovirin in the hospital 3. MAC – unknown 4. MRSA – unknown 5. A virus is where an upper respiratory infection does not go away in 3 days, see the transplant team 2. How many lung transplants and patients is Stanford working with? 1. 30 transplants so far this year, expecting to do around 60 total. 2. Treating 350 outpatients 3. The numbers are increasing! 3. How are lungs allocated? 1. A lung allocation score based on a number of criteria is assigned, a 35-45 score out of 100 places you fairly high on the wait list 2. Re-transplants receive lungs faster 3. Transplant waiting times are a matter of weeks

2. What about age – what is the philosophy for a cut off?

Stanford looks at the individual, if a patient is exceptional (like Dennis), they will transplant at any age 2. The published age cut off for lungs is 65

3. When are re-transplants not a consideration?

When a patient has severe kidney or liver or coronary disease 2. A number of patients have received new kidneys as well as lungs

4. What constitutes the stages of chronic rejection?

(no rejection) is where the absolute FEV1 number is within 20% of your best FEV1 2. 1 if your FEV1 drops 20% 3. 2 if your FEV1 drops another 10% 4. 3 if your FEV1 drops another 10% 5. 4 if your FEV1 drops another 10%

5. What triggers a bronchoscopy? Is it how rejection is diagnosed? 1. A 10% absolute drop of the FEV1 triggers a bronch to look for rejection or infection. 2. A bronch is not necessarily a good indicator of rejection; primarily breathing test results are used.

6. How/what treatments are used to treat rejection?

1. The course of treatment is determined by the doctor on the individual. 2. IV meds are used over oral meds because of absorption 3. A number of transplant recipients require a kidney transplant because of the toxicity from the immunosuppressants

7. How are allergies related? 1. Sinus infections can cause lung infections, but allergies should not result in lung infections.

8. What about inhaled cyclosporine?
1. It is not in the next phase of trials yet. 2. There will be clinical trials for newly transplanted patients starting soon with two goals: i. Does it give the same dose as oral versions? ii. If someone is in rejection, should this be added as a treatment? iii. The medication in the trials is by ATP, the delivery system is NECTAR.

9. What about the on-going lab testing as an indicator of rejection”

It is inconclusive, still continuing the study.

10. What about antibody mediated rejection?

1. There are blood and donor specific antibodies, if mis-matched there is a compliment complex and can be treated: i. Plasma foresis – 5 day wash ii. IVIG fluid iii. Rituxinmab 2. 40-50 rejections with 3 antibodies 3. Biopsies are performed to determine if there is an issue 4. This usually occurs 6-12 months post transplant 12. What causes rejection? 1. Aspiration from GERD PCR 2. CMV – being followed more regularly 3. RSV, Para Influenza 4. Changes to white blood cell count i. If it drops reduce meds, drop Cellcept, bactrim, MMF ii. If elevated, indicates bacterial infection – will this cause rejection? Unknown 5. GCF could cause attacks on new lungs

11. How often are bronchoscopies performed?

1. Stanford follows a Surveillance Program approach for bronchs 2. Hyper vigilant the first year, then by ear 3. After 2 years, the yield from bronch is very low and may be more invasive a procedure than what it may show. 4. Basically if you feel well, all is well,

12. Will prednisone be eliminated as a post transplant med for lung patients?

1. [Emphatic] NO, not in lung transplants, coming off prednisone leads to a fast death, it too risky. 2. After 1 year, immunosuppressants are reduced with prednisone tapering down to 5 mg, tacrolimus is also reduced. This is because infections are too prevalent at high levels of immunosuppression.

13. Does exercise affect post transplant survival?

1. This is not proven, but those who exercise feel well enough to exercise so it may be an indicator of overall health.

14. What about reconnecting the bronchial artery during transplant surgery?

1. It increases circulation which is better for transplant recipients long term. 2. It protects against rejection. 3. The surgery is risky as it adds 45-60 minutes to the surgery 4. Under consideration, but not high on the transplant surgeon’s planning

15. What about dietary supplements of antioxidants?

Are they OK with all our meds? 1. There is no data, do inform the transplant team if you are taking any

16. What about probiotics?

Unknown, no data

17. I am pre-transplant, should we remove the carpets in our home? 1. No

18. What about animals?

No birds, no cat litter – somebody else will need to clean the litter box (cheers from the crowd)

19. What about foods post transplant

No sushi, raw oysters grapefruit or grapefruit juice, cook things through (this is what he would do), but the grapefruit can affect absorption of immunosuppressants

20. What about West Nile Virus? 1. He has seen 3 cases, avoid being outdoors at dawn and dusk, use insect repellent

21. What about mental status post transplant – I seem to forget more post transplant and have to write things down?

Neurological affect of immunosuppressants is common 2. Also blindness and seizures have occurred 3. Cycloclosporine causes more issues than prograf

22. What about Wart treatments?

Systemic, localized treatment is OK

23. What are the long term side effects of immunosuppressants?

High blood pressure 2. Kidney damage 3. One-half of transplant recipients have these

24. The transplant doctors aren’t talking to each other, we are getting conflicting courses of treatment – what are you doing about that?

Three of the 4 attending physicians are on the same page, the other is overly aggressive. Sometimes, it’s better to wait and see vs. treating it since every treatment can cause harm. 2. The team takes the top 10% of patients with issues and discuss them on Friday mornings 3. With the large number of patients, it is impossible to follow every individual all the time 4. They are looking to expand the staff from social worker, to nurses, to physicians, but don’t have the finances approved 5. What can we do about this? (audience comment) – write letters to hospital administration [Allyson to provide address!]

25. What about pseudomonas and solumedrol?

Is one of the possible side effects death? 1. Treatment of solumedrol when a patient has pseudomonas is not recommended, and no it won’t kill you. 2. One of the attending physicians said it could kill you (audience comment).

26. How prevalent is RSV?

There have been 12-15 cases at Stanford in the Dr.’s experience. 2. This is much lower than he saw in Colorado

27. What other changes are taking place?

The pulmonary rehab is closing down as a number of other rehab facilities 2. This is not a money maker (audience comment)

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