330.4 📋 章末速記 Summary

330.4.1 🔑 一句話總結

Lung transplantation = end-stage lung disease 唯一治癒性治療；top indications：IPF (most common)、COPD、CF、PAH、α1-AT deficiency、ILD (CTD-associated, HP fibrotic, sarcoid)、bronchiectasis、Eisenmenger syndrome (heart-lung)；bilateral lung transplant preferred for most；organ allocation = LAS (Lung Allocation Score) based on urgency + transplant benefit；listing criteria disease-specific (IPF FVC < 50%, COPD FEV1 < 20%, CF FEV1 < 30%, PAH NYHA III-IV)；contraindications：active malignancy < 5y, active infection, substance abuse < 6 mo, severe comorbidities, BMI > 30-35；immunosuppression triple therapy：tacrolimus (CNI) + MMF (antiproliferative) + prednisone；outcomes：1-yr 85%, 5-yr 55%, 10-yr 30% (improving)；complications：primary graft dysfunction (PGD) within 72h、acute rejection (ACR cellular + AMR antibody-mediated)、chronic lung allograft dysfunction (CLAD = BOS + RAS) is top cause of long-term graft loss；infections：CMV (most common viral), Aspergillus (most fungal), PCP, BK；malignancy：PTLD (EBV-driven, lymphoproliferative), skin cancer, solid organs；renal dysfunction from CNI 25-30% develop ESRD；EVLP (ex-vivo lung perfusion) + DCD (donation after circulatory death) expanding donor pool。

330.4.2 💊 治療精要

• immunosuppression triple therapy：tacrolimus (CNI, trough 10-15 early, 5-10 chronic) + MMF (antiproliferative) + prednisone (taper over months)
• induction：basiliximab (IL-2 receptor antagonist) or ATG + high-dose steroids
• prophylaxis：TMP-SMX (PCP)、valganciclovir (CMV high-risk)、voriconazole/itraconazole (fungal)
• acute cellular rejection：pulse methylprednisolone 500-1000 mg × 3 d → taper；rATG for refractory
• AMR (antibody-mediated rejection)：plasmapheresis + IVIG + rituximab + bortezomib
• CLAD (BOS + RAS)：azithromycin chronic + optimize IS + treat GERD + photopheresis (RAS especially) + re-transplant for end-stage
• PTLD：reduce immunosuppression + rituximab (CD20+) + chemo for high-grade
• infection prevention：vaccinations pre-transplant (no live post-transplant)、annual flu + pneumococcal + COVID + RSV ≥ 60 + valganciclovir/voriconazole prophylaxis

330.4.3 🎯 盧醫師的考前提醒

1. lung transplant indications top 4：IPF (most common) + COPD + CF + PAH；其他 ILD、bronchiectasis、α1-AT、Eisenmenger (heart-lung) 也是 indications
2. LAS (Lung Allocation Score) 2005 取代 wait-time system：urgency + transplant benefit；higher LAS = priority；IPF 通常 higher LAS than COPD
3. bilateral lung transplant preferred for most (vs single)；single lung 適合 COPD without infection 在 older patients；heart-lung for Eisenmenger
4. absolute contraindications：active malignancy < 5y、active uncontrolled infection、substance abuse < 6 mo、severe comorbidities、severe psychosocial issues、BMI > 30-35
5. immunosuppression rule of three：tacrolimus + MMF + prednisone maintenance；induction 通常 basiliximab or ATG
6. PGD (primary graft dysfunction) within 72 hours：bilateral infiltrates + hypoxemia；severity 0-3；ECMO if severe；risk factor for chronic dysfunction
7. CLAD (chronic lung allograft dysfunction) is top long-term cause of graft loss：分 BOS (obstructive, bronchiolitis obliterans, small airway scarring) vs RAS (restrictive, pleural + parenchymal fibrosis, worse prognosis)；treatment azithromycin + photopheresis + re-transplant
8. CMV is most common viral infection post-transplant；D+/R- highest risk；valganciclovir prophylaxis 6-12 months；can cause pneumonitis, GI, hepatitis, retinitis
9. Aspergillus is most common fungal infection in lung transplant；voriconazole / isavuconazole；watch CYP interactions with tacrolimus
10. EVLP (ex-vivo lung perfusion) + DCD donors expanding donor pool；marginal lungs assessable + treatable ex vivo；comparable outcomes to standard donors