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Kuisirwa mapapu ndiko kurapwa kunogamuchirwa kwechirwere chemapapu chepamusoro. Mumakumi mashoma emakore apfuura, kuisirwa mapapu kwaita kufambira mberi kunoshamisa mukuongorora uye kuongororwa kwevanogamuchira vanoisirwa, kusarudzwa, kuchengetedza uye kugoverwa kweanopa mapapu, maitiro ekuvhiya, postoperative manejimendi, complication manejimendi, uye immunosuppression.

Mumakore anopfuura makumi matanhatu, kuisirwa mapapu kwave kubva mukurapa kwekuyedza kuenda kune yakagamuchirwa kurapa chirwere chemapapu chinotyisidzira hupenyu. Kunyangwe matambudziko akajairwa senge primary graft dysfunction, chronic transplant lung dysfunction (CLAD), njodzi yakawedzera yekutapukira, cancer, uye matambudziko ehutano asingaperi ane chekuita nekudzivirira muviri, pane chivimbiso chekuvandudza kurarama kwemurwere uye hupenyu hwehupenyu kuburikidza nekusarudzwa kweanogamuchira akakodzera. Nepo kuisirwa mapapu kuri kuwanda kutenderera pasirese, huwandu hwemaoparesheni hausati hwave kuenderana nekukura kuri kudiwa. Ongororo iyi inotarisana nemamiriro azvino uye kufambira mberi munguva pfupi yapfuura mukudyara kwemapapu, pamwe nemikana yeramangwana yekuitwa kunoshanda kweiyi inonetsa asi inogona kushandura hupenyu.

Kuongororwa uye kusarudzwa kwevanokwanisa kugamuchira
Nekuda kwekuti mapapu evanopa akakodzera ari kushomeka, nzvimbo dzekutapurirana dzinodiwa kuti dzigovere nhengo dzevanopa kune vangangogamuchira vangangowana pundutso kubva mukusimwa. Tsanangudzo yechinyakare yevakadai vanogona kugamuchira ndeyekuti vane inofungidzirwa yakakura kupfuura 50% yengozi yekufa nechirwere chemapapu mukati memakore maviri uye mukana unopfuura 80% wekupona makore mashanu mushure mekusimwa, vachifungidzira kuti mapapu akasimwa ari kushanda zvizere. Zvinonyanya kuratidza zviratidzo zvekuisirwa mapapu ndeye pulmonary fibrosis, chronic obstructive pulmonary disease, pulmonary vascular disease, uye cystic fibrosis. Varwere vanotaurwa maererano nekuderera kwekushanda kwemapapu, kuderera kwekushanda kwemuviri, uye kufambira mberi kwechirwere pasinei nekushandiswa kwakanyanya kwemishonga uye kurapwa kwekuvhiya; Mamwe maitiro echirwere-chaiwo anotariswawo. Zvinetso zveprognostic zvinotsigira nzira dzekutanga dzekutumira izvo zvinobvumira zvirinani zvengozi-befit counselling yekuvandudza ruzivo rwekuita sarudzo dzakagovana uye mukana wekuchinja zvipingamupinyi zvingangoitika kune zvinobudirira mhedzisiro yekusimwa. Chikwata chevakawanda chichaongorora kudiwa kwekuisirwa mapapu uye njodzi yemurwere yekukonzeresa mushure mekudyara nekuda kwekushandisa immunosuppressant, senjodzi yezvirwere zvinogona kuuraya. Kuongororwa kwekusashanda zvakanaka kwenhengo ye-extra-pulmonary, kusimba kwemuviri, hutano hwepfungwa, systemic immune immune uye cancer yakakosha. Kuongororwa kwakananga kwema coronary uye cerebral arteries, kushanda kweitsvo, hutano hwemapfupa, esophageal function, psychosocial kugona uye kutsigirwa kwevanhu kwakakosha, nepo kutarisirwa kunotorwa kuchengetedza kujeka kudzivirira kusaenzana pakuona kukodzera kwekuisirwa.

Multiple ngozi zvinhu zvinokuvadza kupfuura imwe njodzi zvinhu. Zvipingamupinyi zvechinyakare pakusimwa zvinosanganisira zera, kufutisa, nhoroondo yegomarara, hurwere hwakakomba, uye concomitant systemic chirwere, asi izvi zvinhu zvakapikiswa nguva pfupi yadarika. Zera revagamuchiri riri kuramba richiwedzera, uye panosvika 2021, 34% yevanogamuchira muUnited States vachange vakura kupfuura makumi matanhatu neshanu, zvichiratidza kuwedzera kusimbiswa kwezera rebhayoloji pazera rekurongeka. Ikozvino, pamusoro pechinhambwe chekufamba kwemaminetsi matanhatu, panowanzove nekuongorora kwakarongeka kwehutera, kutarisisa pane zvakachengetwa zvemuviri uye zvinotarisirwa mhinduro kune zvinonetsa. Kusasimba kunosanganisirwa nemhedzisiro yakaipa mushure mekuisirwa mapapu, uye kushaya simba kunowanzobatanidzwa nekuumbwa kwemuviri. Nzira dzekuverenga kufutisa uye kuumbwa kwemuviri zvinoramba zvichishanduka, zvichitarisa zvishoma paBMI uye zvimwe pane mafuta emukati uye mhasuru. Zvishandiso zvinovimbisa kuverengera kuderera, oligomyosis, uye kusimba zviri kugadzirwa kuti zvinyatso kufanotaura kugona kupora mushure mekuisirwa mapapu. Nekugadziriswa kwemapapu kusati kwaitwa, zvinokwanisika kugadzirisa kuumbwa kwemuviri uye kupera simba, nokudaro nekuvandudza migumisiro.

Muchiitiko chechirwere chakakomba, kuona kuwanda kwekuora mwoyo uye kukwanisa kupora kunonyanya kunetsa. Kutapurirana muvarwere vanowana mechanical ventilation kwaimbove kushoma, asi iko zvino kwave kuwanda. Pamusoro pezvo, kushandiswa kweiyo extracorporeal hupenyu tsigiro senge pre-transplant transitional kurapwa kwakawedzera mumakore achangopfuura. Kufambira mberi mune tekinoroji uye kuwanikwa kwevascular kwakaita kuti zvikwanise kuziva, varwere vakanyatsosarudzwa vanowana rubatsiro rwehupenyu hweextracorporeal kuti vatore chikamu mumiganho yemvumo uye kudzoreredzwa kwemuviri, uye kuwana mhedzisiro mushure mekusimwa kwakafanana neiyo yevarwere vaisada kutsigirwa kwehupenyu hweextracorporeal vasati vadyarwa.
Concomitant systemic chirwere chaimboonekwa sechinopesana zvachose, asi mabatiro ayo pamhedzisiro yekutapurirana zvinofanirwa kunyatso kuongororwa. Tichifunga kuti transplant-inoenderana ne immunosuppression inowedzera mukana wekudzokazve kwegomarara, nhungamiro dzekutanga pamusoro peiyo preexisting malignancies yakasimbisa chisungo chekuti varwere vasave negomarara kwemakore mashanu vasati vaiswa pachirongwa chekumirira. Nekudaro, sezvo marapiro egomarara achiwedzera kushanda, zvave kukurudzirwa kuongorora mukana wekudzoka kwegomarara pahwaro hwemurwere. Systemic autoimmune hosha yagara ichionekwa seyakapikiswa, maonero ane dambudziko nekuti chirwere chemapapu chepamusoro chinoda kudzikamisa hupenyu hwevarwere vakadaro. Nhungamiro mitsva inokurudzira kuti kuisirwa kwemapapu kunofanirwa kutangirwa nekuongororwa kwechirwere chakanangana uye kurapwa kuderedza zviratidzo zvechirwere zvinogona kukanganisa mhedzisiro, senge esophageal matambudziko ane chekuita nescleroderma.
Kutenderedza masoja ekudzivirira chirwere achipesana neaka HLA madiki-diki anogona kuita kuti vamwe vangango gamuchira vaomerwe nenhengo dzevanopa, zvichikonzera nguva refu yekumirira, kuderedzwa kwemukana wekuisirwa, kurambwa kwenhengo, uye njodzi yakakwira yeCLAD. Nekudaro, kumwe kuisirwa pakati peanogashira masoja ekudzivirira chirwere uye marudzi evanopa vakawana mhedzisiro yakafanana ne preoperative desensitization regimens, kusanganisira plasma exchange, intravenous immunoglobulin, uye anti-B cell therapy.

Kusarudzwa uye kushandiswa kwevanopa mapapu
Kupa nhengo chiito chekuzvipira. Kuwana mvumo yevanopa uye kuremekedza kuzvitonga kwavo ndizvo zvinonyanya kukosha zvetsika. Mapapu evanopa anogona kukuvadzwa nekukuvara kwechipfuva, CPR, aspiration, embolism, kukuvara kwakabatana nemhepo kana kutapukirwa, kana kukuvara kweurogenic, saka mapapu mazhinji evanopa haana kukodzera kuisirwa. ISHLT (International Society for Heart and Lung Transplantation)
Lung Transplantation inotsanangura maitiro anogamuchirwa evanopa, ayo anosiyana kubva panzvimbo yekuchinjisa kuenda kunzvimbo yekuchinjisa. Muchokwadi, vashoma vanopa vanosangana neiyo "yakanaka" nzira yekupa mapapu (Mufananidzo 2). Kuwedzera kwekushandiswa kwemapapu evanopa kwave kuwanikwa kuburikidza nekudzoreredzwa kwemaitiro evanopa (kureva, vanopa vasingasangane neyakajairwa miitiro), kunyatsoongorora, kushingaira kwevanopa, uye in vitro ongororo (Mufananidzo 2). Nhoroondo yekusvuta kusvuta neanopa injodzi yekukonzeresa kusashanda zvakanaka kwemutambi, asi njodzi yekufa kubva mukushandiswa kwenhengo dzakadaro ishoma uye inofanirwa kuyerwa maererano nemhedzisiro yerufu yekumirira kwenguva refu kweanopa bapu kubva kune asina kumbobvira aputa. Kushandiswa kwemapapu kubva kune vakuru (vakura kupfuura makore makumi manomwe) vanopa vakasarudzwa zvine hukasha uye vasina zvimwe zvengozi zvinogona kuwana zvakafanana kupona kwemugamuchiri uye kushanda kwemapapu seaya kubva kune vadiki vanopa.

Kuchengeta kwakaringana kwevanopa nhengo dzakawanda uye kufunga nezvekugona kupa kwemapapu kwakakosha kuti uve nechokwadi chekuti mapapu evanopa ane mukana wakakura wekukodzera kuisirwa. Nepo mashoma emapapu akapihwa parizvino achisangana netsanangudzo yechinyakare yeakakodzera mapapu evanopa, kudzoreredza maitiro kupfuura aya echinyakare maitiro anogona kutungamira mukushandiswa kunobudirira kwenhengo pasina kukanganisa mhedzisiro. Nzira dzakamisikidzwa dzekuchengetedza mapapu dzinobatsira kuchengetedza kuvimbika kwenhengo isati yasimwa mune anogamuchira. Organs inogona kutakurwa kuenda kuisina zvivakwa pasi pemamiriro akasiyana, senge cryostatic kuchengetedza kana mechanical perfusion pahypothermia kana tembiricha yemuviri. Mapapu asina kunzi akakodzera kuisirwa pakarepo anogona kuongororwa zvine mutsindo uye anogona kurapwa ne in vitro lung perfusion (EVLP) kana kuchengetedzwa kwenguva yakareba kuti akunde zvipingamupinyi zvesangano pakusimwa. Rudzi rwekuisirwa mapapu, maitirwo, uye tsigiro yekuvhiya zvese zvinoenderana nezvinodiwa nemurwere uye ruzivo rwachiremba uye zvaanoda. Kune vanogona kugamuchira kuisirwa mapapu vane chirwere chinodzikira zvakanyanya vachimirira kuisirwa, tsigiro yehupenyu hwekunze inogona kutorwa senge pre-transplant transitional treatment. Matambudziko ekutanga mushure mekuvhiyiwa anogona kusanganisira kubuda ropa, kuvharika kwemhepo kana vascular anastomosis, uye hutachiona hwemaronda. Kukuvadza kune phrenic kana vagus nerve mubhokisi kunogona kutungamirira kune mamwe matambudziko, kukanganisa diaphragm basa uye gastric emptying, maererano. Bapu revanopa rinogona kuve nekukuvara kwemapapu kwekutanga mushure mekudyara uye kudzoreredzwa, kureva kusashanda zvakanaka kwepapfuti. Zvine chirevo kurongedza uye kubata kuomarara kwekutanga kusashanda zvakanaka kwegraft, uko kwakabatana nenjodzi huru yekufa kwekutanga. Nekuti kukuvara kwemapapu kunogona kuitika mukati memaawa ekutanga kukuvara kwehuropi, kutonga kwemapapu kunofanirwa kusanganisira kwakaringana kufefetera Settings, alveolar reexpansion, bronchoscopy uye aspiration uye lavage (yesampling tsika), kutonga kwemvura yemurwere, uye kugadzirisa chinzvimbo chechipfuva. ABO inomirira blood group A, B, AB and O, CVP inomirira central venous pressure, DCD inomirira mapapu donor from heart death, ECMO inomirira extracorporeal membrane oxygenation, EVLW inomirira extravascular pulmonary water, PaO2/FiO2 inomirira reshiyo yearerial partial oxygen pressure to inhaled-PEX pressure stand for inhaled-oxygen stand. PiCCO inomiririra kubuda kwemoyo kweiyo pulse index waveform.
Mune dzimwe nyika, kushandiswa kweanodzorwa donor mapapu (DCD) kwakwira kusvika pa30-40% muvarwere vane kufa kwemoyo, uye miyero yakafanana yekurambwa kwenhengo yakaoma, CLAD, uye kupona kwave kuwanikwa. Pachivanhu, nhengo dzinobva kune vanopa hutachiona hwehutachiona dzinofanirwa kudziviswa kuitira kuisirwa kune vanogamuchira vasina utachiona; Mumakore achangopfuura, zvisinei, mishonga inorwisa mavhairasi inoshanda zvakananga kurwisa utachiona hwehepatitis C (HCV) yakaita kuti mapapu evanopa ane HCV akwanise kuisirwa zvisina njodzi muvanhu vanogamuchira HCV. Saizvozvo, human immunodeficiency virus (HIV) positive donor mapapu anogona kuisirwa kune vanogamuchira HIV, uye hepatitis B virus (HBV) positive donor mapapu anogona kuisirwa kune vanogamuchira vakabaiwa nhomba yeHBV uye avo vasina kudzivirirwa. Pave paine mishumo yekutapurirana mapapu kubva kune vanoshanda kana vasati vatanga SARS-CoV-2 vane hutachiona. Tinoda humwe humbowo hwekuona kuchengetedzeka kwekutapurira mapapu evanopa nehutachiona hwekutapurira.
Nekuda kwekuoma kwekuwana nhengo dzakawanda, zvinonetsa kuongorora mhando yemapapu evanopa. Kushandisa in vitro lung perfusion system yekuongorora inobvumira kuongororwa kwakadzama kwevanopa mapapu basa uye kugona kuigadzirisa usati washandisa (Mufananidzo 2). Sezvo mapapu evanopa ari kukonzeresa kukuvara, iyo in vitro lung perfusion system inopa chikuva chekutonga kweiyo chaiyo biological marapirwo ekugadzirisa akakanganisika donor mapapu (Mufananidzo 2). Miyedzo miviri isina kurongeka yakaratidza kuti in vitro yakajairika tembiricha yemapapu kupfachura kweanopa mapapu anosangana neakajairwa maitiro akachengeteka uye kuti timu yekutapurirana inogona kuwedzera nguva yekuchengetedza nenzira iyi. Kuchengetedza mapapu evanopa pane yakakwirira hypothermia (6 kusvika 10 ° C) pane 0 kusvika 4 ° C paaizi yakashumwa kuvandudza hutano hwemitochondrial, kuderedza kukuvadzwa, nekuvandudza kushanda kwemapapu. Kune semi-selective day transplants, kuchengetedzwa kwenguva refu kwehusiku kwakataurwa kuti uwane zvakanaka mushure mekutapurirana mhedzisiro. Muedzo mukuru usiri wakaderera wekuchengetedza uchienzanisa kuchengetedzwa pa10 ° C neyakajairwa cryopreservation ikozvino iri kuitika (nhamba yekunyoresa NCT05898776 paClinicalTrials.gov). Vanhu vari kuwedzera kukurudzira kudzoreredzwa kwenhengo panguva kuburikidza nenzvimbo dzakawanda dzevanopa vanopa uye kuvandudza mashandiro enhengo kuburikidza nenzvimbo dzekugadzirisa nhengo, kuitira kuti nhengo dzemhando yepamusoro dzigone kushandiswa pakusimwa. Mhedzisiro yekuchinja uku mukudyara ecosystem ichiri kuongororwa.
Kuti uchengetedze nhengo dzeDCD dzinodzoreka, kunyungudika kwenzvimbo kweyakajairika tembiricha yemuviri mu situ kuburikidza ne extracorporeal membrane oxygenation (ECMO) inogona kushandiswa kuongorora mashandiro enhengo dzedumbu uye kutsigira kutorwa kwakananga uye kuchengetedzwa kwenhengo dze thoracic, kusanganisira mapapu. Chiitiko chekuisirwa mapapu mushure mekutapurwa kwenzvimbo kwekushisa kwemuviri kwakajairwa muchipfuva nemudumbu kunogumira uye mhedzisiro inosanganiswa. Pane kutyira kuti nzira iyi inogona kukonzera kukanganisa kune vakafa vanopa uye kutyora misimboti yetsika yekukohwewa kwenhengo; Naizvozvo, kuputika kwepanzvimbo pakupisa kwemuviri kwakajairwa hakusati kwabvumidzwa munyika dzakawanda.

Kenza
Chiitiko chegomarara muhuwandu mushure mekuisirwa mapapu chakakwira kupfuura muhuwandu hwevanhu, uye fungidziro yacho inoita kunge yakashata, ichiverengera 17% yevakafa. Kenza yemapapu uye post-transplant lymphoproliferative chirwere (PTLD) ndizvo zvinowanzokonzera kufa kwekenza. Kwenguva refu immunosuppression, migumisiro yekusvuta kwekare, kana njodzi yechirwere chemapapu chepamusoro zvose zvinotungamirira kune ngozi yekuva nekenza yemapapu mumapapu ega ega, asi muzviitiko zvisingawanzoitiki, kenza yemapapu yemapapu inogona kuitikawo mumapapu akaiswa. Gomarara reganda risiri-melanoma ndiro gomarara rinowanzo zivikanwa pakati pevanogamuchira, saka kugara uchitarisisa gomarara reganda kwakakosha. B-cell PTLD yakakonzerwa nehutachiona hweEpstein-Barr ndicho chikonzero chakakosha chechirwere nerufu. Kunyangwe PTLD inogona kugadzirisa nekushomeka kwekudzivirira muviri, B-cell yakanangwa kurapa ne rituximab, systemic chemotherapy, kana zvese zviri zviviri zvinowanzodiwa.
Kupona uye mhedzisiro yenguva refu
Kupona mushure mekutapurwa kwemapapu kunoramba kuri kushoma kana kuchienzaniswa nedzimwe nhengo dzemuviri, nepakati pemakore 6.7, uye kufambira mberi kushoma kwakaitwa mumurwere kwenguva refu kwemakumi matatu emakore. Zvisinei, varwere vakawanda vakawana kuvandudzwa kwakakosha muhutano hwehupenyu, chimiro chemuviri, uye zvimwe zvakagadziriswa nevarwere; Kuti uite kuongororwa kwakazara kwemaitiro ekurapa kwekuchinja kwemapapu, zvinodikanwa kubhadhara zvakanyanya kune zvakaburitswa nevarwere ava. Chinhu chakakosha chisina kukwana chekiriniki chinodiwa ndechekugadzirisa kufa kweanogamuchira kubva kune zvinouraya zvinokonzeresa zvekunonoka kubatanidza kutadza kana kuramba kwenguva refu immunosuppression. Kune vanogashira mapapu ekudyarwa, kutarisirwa kwenguva refu kunofanirwa kupihwa, izvo zvinoda kushanda pamwe kuchengetedza hutano hwese hweanogamuchira nekutarisa nekuchengetedza basa regraft kune rumwe rutivi, kuderedza mhedzisiro yakaipa yekudzivirira uye kutsigira hutano hwemuviri nepfungwa hwemugamuchiri kune rumwe rutivi (Mufananidzo 1).
Nhungamiro yeramangwana
Lung transplantation kurapwa kwauya kure munguva pfupi, asi kusati kwasvika pakukwanisa kwayo. Kushomeka kwemapapu akakodzera evanopa kunoramba kuri dambudziko guru, uye nzira itsva dzekuongorora nekuchengetedza vanopa, kurapa nekugadzirisa mapapu evanopa, nekuvandudza kuchengetedza kwevanopa vachiri kugadzirwa. Izvo zvinodikanwa kuvandudza marongero ekugoverwa kwenhengo nekuvandudza kuenzanisa pakati pevanopa nevanogamuchira kuti uwedzere kuwedzera mabhenefiti. Pane kufarira kuri kukura mukuona kurambwa kana utachiona kuburikidza nekuongorora kwema molecular, kunyanya nevanopa-inotorwa yemahara DNA, kana kutungamira kudzikisira kwekudzivirira kwekudzivirira muviri; Nekudaro, mashandisiro eiyi diagnostics seanopindirana neazvino kiriniki yegraft yekutarisa nzira inoramba ichitemwa.
Munda wekudyara mapapu wakagadzirwa kuburikidza nekuumbwa kwe consortiums (semuenzaniso, ClinicalTrials.gov nhamba yekunyoresa NCT04787822; https://lungtransplantconsortium.org) nzira yekushanda pamwe chete, ichabatsira mukudzivirira uye kurapwa kwekutanga kusashanda zvakanaka kwegraft, kufanotaura kweCLAD, kuongororwa kwekutanga uye kufambira mberi kwemukati (endofting syndrome, kufambira mberi kwechidzidzo kwave kuchiitwa). kusashanda, kurambwa kweantibody-mediated, ALAD uye CLAD maitiro. Kuderedza mhedzisiro uye kudzikisira njodzi yeALAD neCLAD kuburikidza neako immunosuppressive therapy, pamwe nekutsanangura zvakanangana nemurwere uye nekuzvibatanidza mumatanho emhedzisiro, zvichave zvakakosha mukuvandudza budiriro yenguva refu yekuisirwa mapapu.