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Mechanistic Deep Dive
CNI Nephrotoxicity
- Tacrolimus + cyclosporine
- Renal afferent vasoconstriction
- Long-term: chronic kidney disease
- CKD in 25-30% by 5 years
- Renal-protective strategies emerging
CMV Pathogenesis Post-Transplant
- Donor-positive / recipient-negative highest risk
- Primary infection vs reactivation
- Pneumonitis, gastroenteritis, hepatitis, retinitis
- BAL viral cultures + PCR
BOS Pathology
- Small airway lymphocytic + fibrotic obliteration
- Lumen narrowing or obliteration
- Reduced FEV1
- Treatment limited
RAS Pathology
- Pleural + parenchymal fibrosis
- Restrictive pattern
- Worse prognosis than BOS
- Some respond to extracorporeal photopheresis
Recent Trials & Updates
EVLP Long-Term Data
- Reasonable outcomes from marginal donors
- Expanding donor pool
DCD Lung Transplant
- Comparable outcomes to DBD
- Increasing utilization
Acute Rejection Treatments
- Photopheresis emerging
- Combinations
- Cell therapy
CLAD Treatments
- Azithromycin (Wijdicks long-term)
- Photopheresis for select
- Re-transplantation
Pirfenidone + Nintedanib for BOS
- Off-label use
- Mixed evidence
High-Yield Specialist Points
Tacrolimus Pharmacology
- CYP3A4 metabolism
- Interactions with azoles, macrolides
- Trough monitoring
- 5-10 ng/mL long-term
MMF Mechanism
- IMPDH inhibitor
- B + T cell proliferation
- Diarrhea, cytopenias
CMV Prevention Strategy
- Universal prophylaxis (D+/R-, R+ high-risk)
- Preemptive monitoring
- Valganciclovir 6-12 months
EBV + PTLD
- D+/R-: highest risk
- Monitor EBV PCR
- Reduce IS
- Rituximab for CD20+ PTLD
Skin Cancer Surveillance
- Annual dermatology
- Sunscreen, avoid sun
- Voriconazole increases SCC risk
Pre-Transplant Issues
- Pulmonary rehabilitation
- Smoking cessation 6 months
- Nutrition
- Vaccinations (before transplant)
Post-Transplant Vaccinations
- Inactivated only (no live)
- Annual flu
- Pneumococcal
- COVID-19
- RSV (⥠60)
Bronchiolitis Obliterans Treatment
- Optimize IS
- Azithromycin
- Treat GERD
- Lung washing rare
- Re-transplant for end-stage
Lung Transplant + CF
- M. abscessus and B. cepacia: relative contraindication at many centers
- ETI (Trikafta) era changing CF transplant indications
Lung Transplant in PAH
- Bilateral
- Heart-lung for biventricular failure
- Outcomes improving
Pearls
- IPF most common indication
- LAS allocates organs
- Bilateral preferred over single
- Heart-lung for Eisenmenger
- Tacrolimus + MMF + steroid maintenance
- PGD within 72 hours
- CLAD = BOS + RAS long-term
- CMV + Aspergillus common infections
- PTLD + skin cancer common malignancies
- 1-yr 85%, 5-yr 55%, 10-yr 30% survival
- EVLP + DCD expanding donor pool