Wednesday 24 February 2021  

1 Criteria for establishment of a lung transplant center

The transplant committee at the SCOT has laid down certain criteria for establishment of lung transplant centers in Saudi Arabia. They include:

 

1.1 Working staff:
1.1.1 Consultant lung transplant surgeons.
There should be a team of chest and vascular surgeons with good experience in performing lung transplantation acquired from a recognized international center and they should have performed a sufficient number of these transplantations themselves.
1.1.2 ICU specialists.
There should be an ICU specialist with experience in follow-up of patients after lung surgery, preferably having experience in the follow-up of lung transplant recipients.
1.1.3 Consultants in chest medicine.
There should be a team of consultants in chest medicine who are capable of performing all respiratory investigations by conventional or advanced methods including lung biopsies and who have experience in the evaluation of patients before and after transplantation.
1.1.4 Nursing staff.
They must be highly experienced in taking care of patients during and after lung transplantation.
1.1.5 A transplant coordinator.
1.1.6 A social worker.
1.1.7 A dietitian.

 

1.2 Technical facilities required
The hospital in which the lung transplantation center will be established should have the following departments:
1.2.1 Gastroenterology, radiology, hematology, pathology, biochemical laboratory, nephrology with hemodialysis unit, immunology, Cardiology, and Cardiac surgery.
1.2.2 One fully equipped lung Transplantation Theater.
– ICU with isolation possibilities.
1.2.3 The following specialists should be available in the hospital:
1.2.3.1 A nephrologist experienced in follow-up of organ transplantation.
1.2.3.2 An immunologist.
1.2.3.3 A cardiologist.
1.2.3.4 A physiotherapist.
1.2.3.5 A team for infection control.
1.2.3.6 A pathologist with experience in interpreting lung biopsies.
1.2.3.7 A psychiatrist to evaluate patients before and after transplantation.

 

1.3 Support services
1.3.1 Laboratory
1.3.1.1 All routine investigations for the patients either before or after transplantation must be available.
1.3.1.2 Tissue typing and cytotoxic antibodies and measurement of drug levels including cyclosporine or similar drugs should be available in addition to other immunological tests.

1.3.2 Radiology
1.3.2.1 X-ray facilities for conventional and advanced lung investigations (e.g., CT scan, radioisotope scanning…etc.).

 

1.4 Drugs
The following drugs must be permanently available in the center:
1.4.1 Immunosuppressive drugs:
· Calcineurin inhibitors,
· Azathioprine,
· Prednisolone,
· Anti metabolite,
· Sirolimus, and
· Other similar drugs.

1.4.2 Drugs for treating rejection episodes such as methylprednisolone, anti-lymphocyte or anti-thymocyte globulin, and monoclonal antibodies.
1.4.3 Solution for perfusing the organs such as Eurocollins solution, Wisconsin University solution or HT solution.
1.4.4 Drugs for treating bacterial, viral, fungal, and parasitic infections.

 

2 Indications for lung transplantation

2.1 The SCOT through transplant committee has laid down the indications for lung transplant, which are end-stage respiratory failure resulting from:
2.1.1 Severe obstructive lung disease of any cause.
2.1.2 Restrictive lung disease.
2.1.3 Primary pulmonary hypertension or secondary pulmonary hypertension with Eisenmenger syndrome.
2.1.4 Suppurative lung disease.
(Appendix 19 for investigations to be done on a potential recipient for lung transplantation).

 

2.2 Contraindications for lung transplantation
2.2.1 Absolute contraindications:*
2.2.1.1 Active extra-pulmonary infection or active pulmonary infection when single lung transplantation is contemplated.
2.2.1.2 Associated systemic disease such as renal failure or liver failure.
2.2.1.3 Significant coronary artery disease or dysfunction of left or right ventricles (with ejection fraction <25%) unless the patient is considered for a combined heart-lung transplantation.
2.2.1.4 Significant psychological problems, which could preclude compliance with follow-up and treatment.
2.2.1.5 History and evidence of incurable malignant disease.
2.2.1.6 Patients who have a life expectancy of 18 to 24 months with their respiratory disease, who are not yet oxygen dependent, and whose dynamic pulmonary function is still within acceptable limits.
*Age is not a contraindication provided acceptable cardiac, hepatic, and renal functions are present.
2.2.2 Relative contraindications
2.2.2.1 Patients on prolonged mechanical ventilator support, though many centers do not consider this a contraindication anymore, especially if the patient is well motivated and has acceptable cardiac, hepatic,
and renal functions.
2.2.2.2 If the patients are receiving high-dose systemic steroids (>15 mg of prednisolone per day). There is a new trend to accept such patients for lung transplantation even if they are not weanable from pre-operative steroids, as newer techniques of broncho-plastic procedures have led to acceptable bronchial anastomotic healing, thereby avoiding risk of bronchial dehiscence.
2.2.2.3 Patients who have had thoracotomy with pleurectomy or pleurodesis, though there is a new trend to accept such patients for lung transplantations such as single lung transplant or bilateral sequential lung transplants using anterior sterno-thoracotomy.
2.2.2.4 Patients should wait for at least one year after discontinuation of smoking to be listed for transplantation.

 

2.3 Distribution of lungs
Lungs will be distributed as follows:
2.3.1 Each lung transplant center should establish a local waiting list and send it to the SCOT, which will add the names to the national waiting list.
2.3.2 Lung transplant centers should report the names of patients in need of urgent lung transplantation so that they will be included in a special urgent waiting list.
2.3.3 The patients on the urgent waiting list have absolute priority for lung transplant wherever they are.
2.3.4 If there is no patient on the urgent waiting list, the lung is distributed to the transplant centers according to rota.
*Suitable patient is the patient who fulfills medical fitness and priority criteria and has a compatible chest size match with the donor.