nkhani

Kuika m'mapapo ndi chithandizo chovomerezeka cha matenda apamwamba a m'mapapo. M'zaka makumi angapo zapitazi, kupatsirana mapapu kwapita patsogolo modabwitsa pakuwunika ndi kuwunika omwe alandila, kusankha, kusunga ndi kugawa mapapu opereka, njira zopangira opaleshoni, kuyang'anira pambuyo pa opaleshoni, kuyang'anira zovuta, ndi chitetezo chamthupi.

M’zaka zopitirira 60, kuikidwa m’mapapo kwasintha kuchoka ku chithandizo choyesera kupita ku chithandizo chovomerezeka cha matenda a m’mapapo oika moyo pachiswe. Ngakhale pali zovuta zambiri monga kusagwira bwino ntchito kwa ma graft, kusagwira bwino ntchito kwamapapo (CLAD), chiwopsezo chowonjezeka cha matenda otengera mwayi, khansa, komanso zovuta zathanzi zokhudzana ndi chitetezo chamthupi, pali lonjezano lothandizira kupulumuka kwa odwala komanso moyo wabwino posankha wolandila woyenera. Ngakhale kupatsirana mapapu kukuchulukirachulukira padziko lonse lapansi, kuchuluka kwa maopaleshoni sikukuyendabe ndi kuchuluka komwe kukukulirakulira. Ndemangayi ikuyang'ana momwe zilili pano komanso kupita patsogolo kwaposachedwa pakuika mapapo, komanso mwayi wamtsogolo wogwiritsa ntchito bwino chithandizo chamankhwala chovutachi koma chomwe chingasinthe moyo.

Kuwunika ndi kusankha kwa omwe angakhale olandira
Chifukwa mapapu oyenerera opereka ndi osowa, malo oti aperekedwe amafunikira kuti agawire ziwalo zoperekedwa kwa omwe angakhale olandira omwe ali ndi mwayi wopeza phindu lalikulu powaika. Tanthauzo lachikhalidwe laomwe angalandire ndi lakuti ali ndi chiopsezo chachikulu choposa 50% cha kufa ndi matenda a m'mapapo mkati mwa zaka ziwiri ndi mwayi woposa 80% wokhala ndi moyo zaka 5 atawaika, poganiza kuti mapapu oikidwawo akugwira ntchito mokwanira. Zizindikiro zofala kwambiri zopatsirana mapapo ndi pulmonary fibrosis, matenda osatha a m'mapapo, matenda a pulmonary vascular disease, ndi cystic fibrosis. Odwala amatchulidwa chifukwa cha kuchepa kwa mapapu, kuchepa kwa thupi, ndi kupitirira kwa matenda ngakhale kuti kugwiritsa ntchito kwambiri mankhwala ndi mankhwala opangira opaleshoni; Njira zina zokhudzana ndi matenda zimaganiziridwanso. Zovuta zamtsogolo zimathandizira njira zotumizira zoyambilira zomwe zimalola upangiri wabwino wopindulitsa pachiwopsezo kuti apititse patsogolo kupanga zisankho zomwe akudziwa bwino komanso mwayi wosintha zopinga zomwe zingakhalepo kuti pakhale zotsatira zabwino zosinthira. Gulu lamagulu osiyanasiyana lidzawunika kufunikira koika mapapo komanso chiopsezo cha wodwalayo chokumana ndi zovuta pambuyo pa kumuika chifukwa chogwiritsa ntchito chitetezo chamthupi, monga chiopsezo cha matenda omwe angaphatikizepo moyo. Kuwunika kwa chiwalo chowonjezera cha m'mapapo, kulimbitsa thupi, thanzi labwino, chitetezo chamthupi komanso khansa ndikofunikira. Kuwunika kwachindunji kwa mitsempha ya m'mitsempha ya m'mitsempha ndi ubongo, ntchito ya impso, thanzi la mafupa, ntchito ya m'mitsempha, mphamvu zamaganizo ndi chithandizo cha chikhalidwe cha anthu ndizofunikira, pamene chisamaliro chimatengedwa kuti chikhale chowonekera kuti tipewe kusagwirizana pakuwona kuyenera kuikidwa.

Ziwopsezo zingapo ndizowopsa kuposa zomwe zingayambitse chiopsezo chimodzi. Zolepheretsa zachikhalidwe pakuyikapo zimaphatikizira kukalamba, kunenepa kwambiri, mbiri ya khansa, matenda oopsa, komanso matenda ophatikizika a systemic, koma zinthu izi zatsutsidwa posachedwa. Zaka za olandira ndalama zikuchulukirachulukira, ndipo pofika 2021, 34% ya olandira ku United States adzakhala achikulire kuposa 65, kusonyeza kugogomezera kwambiri zaka zachilengedwe pazaka zakubadwa. Tsopano, kuwonjezera pa mtunda woyenda wa mphindi zisanu ndi chimodzi, nthawi zambiri pamakhala kuwunika kokhazikika kwa zofooka, kuyang'ana pa nkhokwe zakuthupi ndi mayankho oyembekezeredwa ku zovuta. Kufooka kumayendera limodzi ndi zotsatira zoyipa pambuyo pa kuikidwa m'mapapo, ndipo kufooka nthawi zambiri kumalumikizidwa ndi kapangidwe ka thupi. Njira zowerengera kunenepa kwambiri ndi kapangidwe ka thupi zimapitilirabe kusinthika, ndikungoyang'ana pang'ono pa BMI komanso zambiri pamafuta ndi minofu. Zida zomwe zimalonjeza kuti zitha kufooketsa, oligomyosis, ndi kulimba mtima zikupangidwa kuti zidziwike bwino kuti zitha kuchira pambuyo pa kupatsirana mapapu. Ndi preoperative rehabilitation mapapu, ndizotheka kusintha thupi ndi kufowoketsa, potero kusintha zotsatira.

Pankhani ya matenda oopsa kwambiri, kudziwa kuchuluka kwa kufowokeka ndi kuthekera kochira kumakhala kovuta kwambiri. Kuika odwala omwe akulandira mpweya wabwino wa makina kunali kosowa, koma tsopano kukuchulukirachulukira. Kuonjezera apo, kugwiritsa ntchito chithandizo cha moyo wa extracorporeal monga chithandizo chosinthira chisanadzedwe chawonjezeka m'zaka zaposachedwa. Kupita patsogolo kwa luso lamakono ndi mitsempha ya mitsempha yapangitsa kuti odwala azindikire, osankhidwa mosamala omwe akulandira chithandizo cha moyo wa extracorporeal kuti athe kutenga nawo mbali pazovomerezeka zovomerezeka ndi kukonzanso thupi, ndikupeza zotsatira pambuyo pa kuikidwa kwa odwala omwe sanafune thandizo la moyo wa extracorporeal asanalowemo.
Matenda ophatikizana a systemic m'mbuyomu amawonedwa ngati osagwirizana, koma zotsatira zake pazotsatira zapambuyo pa kumuika ziyenera kuyesedwa mwatsatanetsatane. Popeza kuti immunosuppression yokhudzana ndi kumuika kumawonjezera mwayi woti khansa ibwerenso, malangizo am'mbuyomu onena za matenda omwe analipo kale adatsindika kufunikira koti odwala azikhala opanda khansa kwa zaka zisanu asanaikidwe pamndandanda wodikirira wowaika. Komabe, pamene mankhwala a khansa ayamba kugwira ntchito bwino, tsopano tikulimbikitsidwa kuti tiwunikenso mwayi woti khansa ibwererenso pamaziko a wodwala. Matenda a systemic autoimmune nthawi zambiri amawonedwa ngati otsutsana, malingaliro omwe ndi ovuta chifukwa matenda apamwamba am'mapapo amakonda kuchepetsa nthawi ya moyo wa odwala otere. Malangizo atsopanowa amalimbikitsa kuti kupatsirana kwa mapapu kuyenera kutsogozedwa ndi kuyezetsa kwambiri kwa matenda ndi chithandizo kuti muchepetse mawonekedwe a matenda omwe angasokoneze zotsatira zake, monga mavuto am'mitsempha okhudzana ndi scleroderma.
Kuzungulira ma antibodies motsutsana ndi magawo ena amtundu wa HLA kumatha kupangitsa kuti ena omwe angalandire asamagwirizane ndi ziwalo zinazake zomwe opereka, zomwe zimapangitsa kuti azikhala ndi nthawi yodikirira, kuchepetsa mwayi woti amuike, kukana chiwalo chachikulu, komanso chiwopsezo chokwera cha CLAD. Komabe, zoikamo zina pakati pa ma antibodies omwe alandila ndi mitundu yopereka apezanso zofananira ndi machitidwe odetsa nkhawa asanachitike opaleshoni, kuphatikiza kusinthana kwa plasma, intravenous immunoglobulin, ndi anti-B cell therapy.

Kusankha ndi kugwiritsa ntchito mapapo opereka
Kupereka chiwalo ndi ntchito yodzipereka. Kupeza chilolezo chaopereka ndi kulemekeza ufulu wawo wodzilamulira ndizofunikira kwambiri zamakhalidwe abwino. Mapapo opereka amatha kuonongeka ndi kupwetekedwa mtima pachifuwa, CPR, aspiration, embolism, kuvulala kokhudzana ndi mpweya wabwino kapena matenda, kapena kuvulala kwa neurogenic, mapapu ambiri opereka ndalama sali oyenera kuikidwa. ISHLT (International Society for Heart and Lung Transplantation)
Lung Transplantation imatanthawuza njira zovomerezeka za opereka, zomwe zimasiyana kuchokera ku malo oikapo kupita kumalo opangira. M'malo mwake, opereka ndalama ochepa kwambiri amakwaniritsa zofunikira "zabwino" zoperekera m'mapapo (Chithunzi 2). Kugwiritsa ntchito kwambiri mapapu opereka chithandizo kwatheka chifukwa cha kupumula kwa njira za opereka (mwachitsanzo, opereka ndalama omwe samakwaniritsa zofunikira zanthawi zonse), kuunika mosamalitsa, chisamaliro chaothandizira, komanso kuunika kwa in vitro (Chithunzi 2). Mbiri ya kusuta yogwira ndi wopereka ndi chiopsezo chachikulu kumezanitsa kukanika mwa wolandira, koma chiopsezo imfa chifukwa ntchito ziwalo zimenezi ndi ochepa ndipo ayenera kuyezedwa ndi imfa zotsatira kuyembekezera kwa nthawi yaitali kwa wopereka mapapo kwa wosasuta konse. Kugwiritsiridwa ntchito kwa mapapu kuchokera kwa okalamba (oposa zaka 70) opereka omwe asankhidwa molimba mtima ndipo alibe zifukwa zina zomwe zingawopsyeze atha kupeza zotsatira zofananira za kupulumuka kwa wolandira ndi mapapu monga za opereka achichepere.

Kusamaliridwa koyenera kwa opereka ziwalo zingapo ndikuganiziranso zopereka zomwe zingatheke m'mapapo ndikofunikira kuwonetsetsa kuti mapapu opereka ali ndi mwayi waukulu woti akhale oyenera kuwaika. Ngakhale mapapo ochepa omwe aperekedwa pano amakwaniritsa matanthauzo achikhalidwe a mapapu abwino opereka chithandizo, kupumula njira zomwe zimadutsa njira zachikhalidwezi zitha kupangitsa kugwiritsa ntchito bwino ziwalo popanda kusokoneza zotsatira zake. Njira zokhazikika zotetezera mapapu zimathandiza kuteteza kukhulupirika kwa chiwalo chisanabzalidwe mwa wolandira. Ziwalo zimatha kutengedwa kupita kumalo opangira zinthu zosiyanasiyana, monga cryostatic preservation kapena mechanical perfusion pa hypothermia kapena kutentha kwa thupi. Mapapo omwe sali oyenerera kuikidwa m'mapapo angaunikenso moyenera ndipo akhoza kuthandizidwa ndi in vitro lung perfusion (EVLP) kapena kusungidwa kwa nthawi yaitali kuti athe kuthana ndi zolepheretsa za bungwe kuti asinthe. Mtundu wa kuika mapapo, kachitidwe, ndi chithandizo choloŵa m’mapapo zonse zimadalira pa zosowa za wodwalayo ndi zimene dokotala wa opaleshoniyo wadziŵa ndi zimene amakonda. Kwa omwe atha kutengera mapapo omwe matenda awo amawonongeka kwambiri podikirira kuti awasinthidwe, chithandizo chamoyo cha extracorporeal chikhoza kuganiziridwa ngati chithandizo chosinthira chisanadze. Zovuta zoyamba pambuyo pa opaleshoni zingaphatikizepo kutuluka magazi, kutsekeka kwa mpweya kapena vascular anastomosis, ndi matenda a bala. Kuwonongeka kwa mitsempha ya phrenic kapena vagus pachifuwa kungayambitse zovuta zina, zomwe zimakhudza ntchito ya diaphragm ndi kutuluka kwa m'mimba, motero. Mapapo opereka amatha kuvulala koyambirira pambuyo pa kuikidwa m'mapapo ndi kulowetsedwanso, mwachitsanzo, kusagwira ntchito bwino kwa kumezanitsa. Ndikofunikira kugawa ndi kuchiza kuopsa kwa kusagwira bwino ntchito kwa graft, komwe kumalumikizidwa ndi chiopsezo chachikulu cha kufa msanga. Chifukwa kuwonongeka kwa mapapo omwe angapereke kumachitika patangotha ​​​​maola ochepa kuchokera kuvulala koyambirira kwaubongo, kuyang'anira mapapu kuyenera kukhala ndi makonzedwe oyenera a mpweya wabwino, kufutukuka kwa alveolar, bronchoscopy ndi aspiration ndi lavage (potengera zikhalidwe), kasamalidwe ka madzi a odwala, ndi kusintha kwa chifuwa. ABO amaimira gulu la magazi A, B, AB ndi O, CVP imayimira chapakati venous pressure, DCD imayimira mapapu opereka kuchokera ku imfa ya mtima, ECMO imayimira extracorporeal membrane oxygenation, EVLW imayimira extravascular pulmonary water, PaO2/FiO2 imayimira chiŵerengero cha mpweya wochepa wa okosijeni kuti mupumule mpweya wabwino wa oxygen, kupuma kwa mpweya wa mpweya wa mpweya ndi mpweya wabwino. PiCCO imayimira kutulutsa kwamtima kwa pulse index waveform.
M'mayiko ena, kugwiritsa ntchito mapapu oyendetsedwa opereka chithandizo (DCD) kwakwera kufika pa 30-40% mwa odwala omwe ali ndi imfa yamtima, ndipo chiwerengero chofanana cha kukana chiwalo chachikulu, CLAD, ndi kupulumuka kwatheka. Mwachizoloŵezi, ziwalo zochokera kwa opereka kachilombo koyambitsa matenda ziyenera kupewedwa kuti ziwaike kwa omwe alibe kachilombo; Komabe, m’zaka zaposachedwapa, mankhwala oletsa tizilombo toyambitsa matenda amene amalimbana mwachindunji ndi kachilombo koyambitsa matenda a hepatitis C (HCV) athandiza kuti mapapo opereka chithandizo amene ali ndi HCV alowetsedwe m’mapapo amene alibe HCV. Momwemonso, mapapo opereka kachilombo ka HIV (HIV) amatha kuwaika m'mapapo omwe ali ndi kachilombo ka HIV, ndipo mapapo opereka kachilombo ka hepatitis B (HBV) amatha kuwaika m'mapapo omwe alandira katemera wa HBV ndi omwe ali ndi chitetezo chamthupi. Pakhala pali malipoti okhudza kuikidwa m'mapapo kuchokera kwa omwe adapereka kachilombo ka SARS-CoV-2 omwe adagwira kapena kale. Tikufuna umboni wochulukirapo kuti tidziwe chitetezo chopatsira mapapu opereka ma virus ndi ma virus omwe amapatsirana.
Chifukwa cha zovuta kupeza ziwalo zingapo, ndizovuta kuyesa momwe mapapo operekera amapereka. Kugwiritsa ntchito in vitro lung perfusion system kuti muwunikire kumathandizira kuwunika mwatsatanetsatane momwe mapapo opereka amagwirira ntchito komanso kuthekera kokonzanso musanagwiritse ntchito (Chithunzi 2). Popeza mapapu opereka chithandizo amatha kuvulala kwambiri, makina a in vitro lung perfusion amapereka njira yoyendetsera chithandizo chamankhwala kuti akonze mapapu omwe awonongeka (Chithunzi 2). Mayesero awiri osankhidwa mwachisawawa awonetsa kuti mu vitro kutentha kwapang'onopang'ono kwa m'mapapo kwa mapapu opereka omwe amakwaniritsa zofunikira ndizotetezeka komanso kuti gulu loikamo likhoza kuwonjezera nthawi yosungira motere. Kusunga mapapo opereka chithandizo ku hypothermia yapamwamba (6 mpaka 10 ° C) osati 0 mpaka 4 ° C pa ayezi kwanenedwa kuti kumapangitsa thanzi la mitochondrial, kuchepetsa kuwonongeka, ndi kupititsa patsogolo ntchito ya mapapu. Pazosankha zamasiku osankhidwa, kusungidwa kwautali kwanthawi yayitali kwanenedwa kuti kukwaniritse zotsatira zabwino pambuyo pa kumuika. Kuyesa kwakukulu kopanda chitetezo kuyerekeza kusungidwa kwa 10 ° C ndi cryopreservation yokhazikika pakali pano (nambala yolembetsa NCT05898776 ku ClinicalTrials.gov). Anthu akuchulukirachulukira kulimbikitsa kuchira kwa ziwalo munthawi yake kudzera m'malo osamalira opereka ziwalo zambiri ndikuwongolera magwiridwe antchito a ziwalo kudzera m'malo okonza ziwalo, kuti ziwalo zamtundu wabwino zitha kugwiritsidwa ntchito kuyika. Zotsatira za kusintha kumeneku m'dongosolo loikamo zachilengedwe zikuwunikidwabe.
Pofuna kuteteza ziwalo za DCD zokhazikika, kutulutsa kwapakati kwa kutentha kwa thupi mu situ kudzera mu extracorporeal membrane oxygenation (ECMO) kungagwiritsidwe ntchito kuyesa ntchito ya ziwalo za m'mimba ndikuthandizira kupeza mwachindunji ndi kusunga ziwalo za thoracic, kuphatikizapo mapapu. Zochitika ndi kupatsirana m'mapapo pambuyo popaka kutentha kwa thupi m'chifuwa ndi pamimba kumakhala kochepa ndipo zotsatira zake zimasakanizidwa. Pali nkhawa kuti njirayi ingayambitse kuwonongeka kwa anthu omwe anamwalira komanso kuphwanya mfundo zoyendetsera ntchito yokolola ziwalo; Choncho, m'mayiko ambiri kutentha kwa thupi sikuloledwa.

Khansa
Chiwopsezo cha khansa mwa anthu pambuyo pa kuikidwa m'mapapo ndichokwera kuposa cha anthu wamba, ndipo matendawa amakhala osauka, zomwe zimapangitsa 17% kufa. Khansara ya m'mapapo ndi matenda a post-transplant lymphoproliferative (PTLD) ndizomwe zimayambitsa imfa yokhudzana ndi khansa. Kuchepa kwa chitetezo chamthupi kwa nthawi yayitali, zotsatira za kusuta koyambirira, kapena chiwopsezo cha matenda a m'mapapo zonse zimatsogolera pachiwopsezo chokhala ndi khansa ya m'mapapo m'mapapo amodzi omwe amalandila m'mapapo, koma nthawi zina, khansa ya m'mapapo yopatsirana ndi othandizira imatha kuchitikanso m'mapapo osinthidwa. Khansara yapakhungu yopanda melanoma ndi khansa yofala kwambiri pakati pa omwe amawasinthitsa, kotero kuyang'anira khansa yapakhungu nthawi zonse ndikofunikira. B-cell PTLD yoyambitsidwa ndi kachilombo ka Epstein-Barr ndichomwe chimayambitsa matenda ndi imfa. Ngakhale PTLD imatha kuthana ndi kuchepa kwa chitetezo chamthupi, B-cell target therapy ndi rituximab, systemic chemotherapy, kapena zonse ziwiri zimafunikira.
Kupulumuka ndi zotsatira za nthawi yayitali
Kupulumuka pambuyo pa kupatsirana mapapu kumakhalabe kochepa poyerekeza ndi kuyika ziwalo zina, ndi zaka zapakati pa 6.7, ndipo kupita patsogolo kochepa kwapangidwa kwa zotsatira za nthawi yaitali za odwala pazaka makumi atatu. Komabe, odwala ambiri adawona kusintha kwakukulu kwa moyo, chikhalidwe cha thupi, ndi zotsatira zina za odwala; Kuti mufufuze mozama za zotsatira za chithandizo cha kupatsirana mapapu, m'pofunika kumvetsera kwambiri zotsatira zomwe odwalawa adanena. Chofunikira chomwe sichinakwaniritsidwe chachipatala ndikuthana ndi imfa ya wolandirayo chifukwa cha zovuta zowopsa za kuchedwa kulephera kwa kumezanitsa kapena kupumitsidwa kwanthawi yayitali. Kwa omwe alandila mapapu am'mapapo, chisamaliro chanthawi yayitali chiyenera kuperekedwa, chomwe chimafuna kugwirira ntchito limodzi kuteteza thanzi lonse la wolandirayo poyang'anira ndi kusunga ntchito ya kumezanitsa mbali imodzi, kuchepetsa zotsatira zoyipa za immunosuppression ndikuthandizira wolandirayo thanzi lakuthupi ndi m'maganizo kumbali inayo (Chithunzi 1).
Malangizo amtsogolo
Kuika m'mapapo ndi mankhwala omwe abwera kutali kwambiri m'kanthawi kochepa, koma sanakwaniritsidwebe. Kuperewera kwa mapapo opereka oyenerera kukadali vuto lalikulu, ndipo njira zatsopano zowunika ndi kusamalira opereka, kuchiza ndi kukonza mapapo opereka, ndikuwongolera kusungidwa kwa opereka zikupangidwabe. Ndikofunikira kukonza ndondomeko zogawira ziwalo pokonza mafananidwe pakati pa opereka ndi olandira kuti awonjezere phindu. Pali chidwi chochulukirachulukira pakuzindikira kukanidwa kapena matenda kudzera m'maselo a maselo, makamaka ndi DNA yaulere yochokera kwa opereka, kapena kutsogolera kuchepetsa kutetezedwa kwa chitetezo chamthupi; Komabe, kugwiritsidwa ntchito kwa matenda awa monga chothandizira ku njira zamakono zowunikira kumezanitsa sikunatsimikizidwe.
Njira yolumikizira mapapo yakula kudzera mukupanga ma consortiums (mwachitsanzo, nambala yolembetsa ya ClinicalTrials.gov NCT04787822; https://lungtransplantconsortium.org) njira yogwirira ntchito limodzi, zithandizira kupewa ndi kuchiza kusagwira bwino ntchito kwa graft, kuneneratu kwa CLAD, kuzindikira koyambirira komanso kupita patsogolo kwamkati (endofting syndrome) kukanika, kukana kwa anti-mediated, njira za ALAD ndi CLAD. Kuchepetsa zotsatira zoyipa ndikuchepetsa chiwopsezo cha ALAD ndi CLAD kudzera mwa munthu payekhapayekha ma immunosuppressive therapy, komanso kufotokozera zotsatira zomwe zimayang'aniridwa ndi odwala ndikuziphatikiza pazotsatira zake, zidzakhala chinsinsi chothandizira kuti kupatsirana mapapo kwanthawi yayitali.