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Abstract
Survival after lung transplantation is limited in large part due to the high incidence of chronic rejection, known as chronic lung allograft dysfunction (CLAD). Pulmonary infections are a frequent complication in lung transplant recipients, due both to immunosuppressive medications and constant exposure of the lung allograft to the external environment via the airways. Infection is a recognized risk factor for the development of CLAD, and both acute infection and chronic lung allograft colonization with microorganisms increase the risk for CLAD. Acute infection by community acquired respiratory viruses, and the bacteria Pseudomonas aeruginosa and Staphylococcus aureus are increasingly recognized as important risk factors for CLAD. Colonization by the fungus Aspergillus may also augment the risk of CLAD. Fostering this transition from healthy lung to CLAD in each of these infectious episodes is the persistence of an inflammatory lung allograft environment.
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Affiliation(s)
- Aric L Gregson
- Division of Infectious Diseases, Department of Medicine, University of California, Box 957119, Warren Hall 14-154, Los Angeles, CA, 90995-7119, USA.
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Rademacher J, Ringshausen FC, Suhling H, Fuge J, Marsch G, Warnecke G, Haverich A, Welte T, Gottlieb J. Lung transplantation for non-cystic fibrosis bronchiectasis. Respir Med 2016; 115:60-5. [PMID: 27215505 DOI: 10.1016/j.rmed.2016.04.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 04/04/2016] [Accepted: 04/17/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Lung transplantation (LTx) is a well-established treatment for end-stage pulmonary disease. However, data regarding microbiology and outcome of patients with non-cystic fibrosis bronchiectasis (NCFB) after lung transplantation are limited. METHODS A retrospective analysis between August 1992 and September 2014 of all patients undergoing lung transplantation at our program of all recipients with a primary diagnosis of bronchiectasis was performed. Microbiology of sputum and bronchoalveolar lavage specimens, lung function and clinical parameters pre- and post-LTx were assessed retrospectively. Overall survival was compared to the total cohort of lung transplant recipients at institution. The survival and development of chronic lung allograft dysfunction (CLAD) was compared in patients with and without chronic Pseudomonas aeruginosa (PSA) infection after LTx. RESULTS 34 patients were transplanted. Median age at transplantation was 40 (IQR 33-52) years. The most common etiologies of bronchiectasis were idiopathic (41%), chronic obstructive pulmonary disease (COPD) (21%) and post-infectious (15%). The most common organism of pre- and posttransplant chronic airway infection was PSA. One-year Kaplan-Meier survival for patients with bronchiectasis was 85% and 5-year survival was 73% and similar to the entire cohort. All three patients with an associated diagnosis of immunodeficiency died due to infection and sepsis within the first year. Patients with persistent colonization with Pseudomonas aeruginosa after transplantation had worse long-term survival by trend and developed chronic lung allograft dysfunction more frequently. CONCLUSIONS Overall survival of patients with bronchiectasis after LTx is comparable to other underlying diseases. A reduced survival was observed in patients with the underlying diagnosis of immunodeficiency.
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Affiliation(s)
- Jessica Rademacher
- Dept. of Respiratory Medicine, Hannover Medical School, Carl- Neuberg Str. 1, Hannover, Germany.
| | - Felix C Ringshausen
- Dept. of Respiratory Medicine, Hannover Medical School, Carl- Neuberg Str. 1, Hannover, Germany; BREATH, Biomedical Research in End-stage and Obstructive Lung Disease, Hannover Medical School, Member of the German Center for Lung Research (DZL), Carl- Neuberg Str. 1, Germany
| | - Hendrik Suhling
- Dept. of Respiratory Medicine, Hannover Medical School, Carl- Neuberg Str. 1, Hannover, Germany
| | - Jan Fuge
- BREATH, Biomedical Research in End-stage and Obstructive Lung Disease, Hannover Medical School, Member of the German Center for Lung Research (DZL), Carl- Neuberg Str. 1, Germany
| | - Georg Marsch
- Dept. of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Carl- Neuberg Str. 1, Hannover, Germany
| | - Gregor Warnecke
- BREATH, Biomedical Research in End-stage and Obstructive Lung Disease, Hannover Medical School, Member of the German Center for Lung Research (DZL), Carl- Neuberg Str. 1, Germany; Dept. of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Carl- Neuberg Str. 1, Hannover, Germany
| | - Axel Haverich
- BREATH, Biomedical Research in End-stage and Obstructive Lung Disease, Hannover Medical School, Member of the German Center for Lung Research (DZL), Carl- Neuberg Str. 1, Germany; Dept. of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Carl- Neuberg Str. 1, Hannover, Germany
| | - Tobias Welte
- Dept. of Respiratory Medicine, Hannover Medical School, Carl- Neuberg Str. 1, Hannover, Germany; BREATH, Biomedical Research in End-stage and Obstructive Lung Disease, Hannover Medical School, Member of the German Center for Lung Research (DZL), Carl- Neuberg Str. 1, Germany
| | - Jens Gottlieb
- Dept. of Respiratory Medicine, Hannover Medical School, Carl- Neuberg Str. 1, Hannover, Germany; BREATH, Biomedical Research in End-stage and Obstructive Lung Disease, Hannover Medical School, Member of the German Center for Lung Research (DZL), Carl- Neuberg Str. 1, Germany
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Cornberg M, Schlevogt B, Rademacher J, Schwarz A, Sandherr M, Maschmeyer G. [Specific infections in organ transplantation]. Internist (Berl) 2016; 57:38-48. [PMID: 26782282 DOI: 10.1007/s00108-015-3807-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
This article is concerned with the important topic of infections associated with organ transplantation and includes a discussion on four subtopics. The first section describes the current options in the prevention and therapy of viral hepatitis in association with liver transplantation. Infections with hepatitis B, C, D (delta) and E are discussed with special emphasis on the interferon-free treatment of hepatitis C with the new antiviral drugs.The second section deals with Pseudomonas aeruginosa (PA) infections following lung transplantation (LuTx), which is one of the most frequently detected pathogens in the airway after LuTx. Patients with cystic fibrosis are particularly affected. This is important because studies have shown a clear correlation between chronic PA infections after LuTx and development of chronic transplant failure. Even if the data are still sparse, recommendations on prevention and therapeutic strategies are given. The theme of the third section is the high importance of viral infections after kidney transplantation. In addition to acquired infections, the transplanted organ as well as the recipient can be the source of the infection. The better the transplanted organ is tolerated under moderate immunosuppression, the less common and severe virus infections are. The focus of this section is on three common pathogens: cytomegalovirus, polyomavirus BK and hepatitis viruses.The final section deals with Aspergillus infections following transplantation of various organs. In this context Aspergillus spp. are one of the most commonly occurring fungal diseases. The epidemiology, risk factors, diagnostics, prophylaxis and therapy of invasive aspergillosis are presented.
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Affiliation(s)
- M Cornberg
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30623, Hannover, Deutschland.
| | - B Schlevogt
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30623, Hannover, Deutschland
| | - J Rademacher
- Klinik für Pneumologie, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - A Schwarz
- Klinik für Nieren- und Hochdruckerkrankungen, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - M Sandherr
- Gemeinschaftspraxis für Hämatologie und Onkologie, Röntgenstr. 4, 82362, Weilheim, Deutschland.
| | - G Maschmeyer
- Klinik für Hämatologie, Onkologie und Palliativmedizin, Klinikum Ernst von Bergmann, Potsdam, Deutschland
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Pritchard J, Thakrar MV, Somayaji R, Surette MG, Rabin HR, Helmersen D, Lien D, Purighalla S, Waddell B, Parkins MD. Epidemic Pseudomonas aeruginosa infection in patients with cystic fibrosis is not a risk factor for poor clinical Outcomes following lung transplantation. J Cyst Fibros 2015; 15:392-9. [PMID: 26657575 DOI: 10.1016/j.jcf.2015.11.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 11/08/2015] [Accepted: 11/08/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Epidemic strains of Pseudomonas aeruginosa (ePA) causing infection in cystic fibrosis (CF) have been commonly identified from clinics around the world. ePA disproportionally impacts CF patient pre-transplant outcomes manifesting in increased exacerbation frequency, worsened treatment burden and increased rate of lung function decline, and disproportionally leads to death and/or transplantation. As other CF factors such as pre-transplant infection with multi-resistant organisms, and isolation of P. aeruginosa in the post transplant graft, may impact post-transplant outcomes, we sought to determine if infection with ePA similarly adversely impact post-transplant outcomes. METHODS Between 1991-2014, 53 CF patients from our center received lung transplants. Bacterial strain typing was performed retrospectively on isolates collected prior to transplantation. Comprehensive chart reviews were performed to obtain baseline patient characteristics and post-transplant outcomes. RESULTS Of the 53 transplanted patients, 57% of patients were infected with ePA prior to transplant; the other 43% of patients had unique strains of P. aeruginosa. Mean age at transplant was 29.0years for ePA and 33.3years for unique (p=0.04). There were no differences in overall survival (HR=0.75, 95% CI 0.31-1.79), bronchiolitis obliterans syndrome (BOS) free survival (HR 1.43, 95% CI 0.54-4.84) or all other assessed outcomes including exacerbation frequency, chronic renal failure, acute cellular rejections, Aspergillus infection, airway stenosis, and post-transplant lymphoproliferative disorder. CONCLUSION Unlike pre-transplant outcomes, CF patients infected with ePA do not experience worse post-transplant outcomes than those infected with unique strains. Therefore, lung transplantation should be considered for all patients with P. aeruginosa infection and end stage lung disease, irrespective of infection with ePA.
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Affiliation(s)
- Julia Pritchard
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB T2N 4N1, Canada
| | - Mitesh V Thakrar
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB T2N 4N1, Canada
| | - Ranjani Somayaji
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB T2N 4N1, Canada
| | - Michael G Surette
- Department of Biochemistry, and the Farncombe Family Digestive Health Research Institute, McMaster University, 1280 Main Street West, Hamilton ON L8S 4L8, Canada; Department of Microbiology, Immunology & Infectious Diseases, University of Calgary, 3330 Hospital Drive NW, Calgary, AB T2N 4N1, Canada
| | - Harvey R Rabin
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB T2N 4N1, Canada; Department of Microbiology, Immunology & Infectious Diseases, University of Calgary, 3330 Hospital Drive NW, Calgary, AB T2N 4N1, Canada
| | - Doug Helmersen
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB T2N 4N1, Canada
| | - Dale Lien
- Department of Medicine, The University of Alberta, 8440 112 Street, Edmonton, AB T6G 2B7, Canada
| | - Swathi Purighalla
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB T2N 4N1, Canada
| | - Barbara Waddell
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB T2N 4N1, Canada
| | - Michael D Parkins
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB T2N 4N1, Canada; Department of Microbiology, Immunology & Infectious Diseases, University of Calgary, 3330 Hospital Drive NW, Calgary, AB T2N 4N1, Canada.
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56
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Dickson RP, Erb-Downward JR, Martinez FJ, Huffnagle GB. The Microbiome and the Respiratory Tract. Annu Rev Physiol 2015; 78:481-504. [PMID: 26527186 DOI: 10.1146/annurev-physiol-021115-105238] [Citation(s) in RCA: 528] [Impact Index Per Article: 58.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Although the notion that "the normal lung is free from bacteria" remains common in textbooks, it is virtually always stated without citation or argument. The lungs are constantly exposed to diverse communities of microbes from the oropharynx and other sources, and over the past decade, novel culture-independent techniques of microbial identification have revealed that the lungs, previously considered sterile in health, harbor diverse communities of microbes. In this review, we describe the topography and population dynamics of the respiratory tract, both in health and as altered by acute and chronic lung disease. We provide a survey of current techniques of sampling, sequencing, and analysis of respiratory microbiota and review technical challenges and controversies in the field. We review and synthesize what is known about lung microbiota in various diseases and identify key lessons learned across disease states.
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Affiliation(s)
- Robert P Dickson
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan 48109;
| | - John R Erb-Downward
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan 48109;
| | - Fernando J Martinez
- Department of Internal Medicine, Weill Cornell Medical College, New York, NY 10065
| | - Gary B Huffnagle
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan 48109; .,Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, Michigan 48109
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Bittinger K, Charlson ES, Loy E, Shirley DJ, Haas AR, Laughlin A, Yi Y, Wu GD, Lewis JD, Frank I, Cantu E, Diamond JM, Christie JD, Collman RG, Bushman FD. Improved characterization of medically relevant fungi in the human respiratory tract using next-generation sequencing. Genome Biol 2015; 15:487. [PMID: 25344286 PMCID: PMC4232682 DOI: 10.1186/s13059-014-0487-y] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fungi are important pathogens but challenging to enumerate using next-generation sequencing because of low absolute abundance in many samples and high levels of fungal DNA from contaminating sources. RESULTS Here, we analyze fungal lineages present in the human airway using an improved method for contamination filtering. We use DNA quantification data, which are routinely acquired during DNA library preparation, to annotate output sequence data, and improve the identification and filtering of contaminants. We compare fungal communities and bacterial communities from healthy subjects, HIV+ subjects, and lung transplant recipients, providing a gradient of increasing lung impairment for comparison. We use deep sequencing to characterize ribosomal rRNA gene segments from fungi and bacteria in DNA extracted from bronchiolar lavage samples and oropharyngeal wash. Comparison to clinical culture data documents improved detection after applying the filtering procedure. CONCLUSIONS We find increased representation of medically relevant organisms, including Candida, Cryptococcus, and Aspergillus, in subjects with increasingly severe pulmonary and immunologic deficits. We analyze covariation of fungal and bacterial taxa, and find that oropharyngeal communities rich in Candida are also rich in mitis group Streptococci,a community pattern associated with pathogenic polymicrobial biofilms. Thus, using this approach, it is possible to characterize fungal communities in the human respiratory tract more accurately and explore their interactions with bacterial communities in health and disease.
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Affiliation(s)
- Kyle Bittinger
- Department of Microbiology, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
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Fuehner T, Clajus C, Fuge J, Jonigk D, Welte T, Haverich A, Greer M, Gottlieb J. Lung transplantation after endoscopic lung volume reduction. Respiration 2015; 90:243-50. [PMID: 26138023 DOI: 10.1159/000434685] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 05/29/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Endoscopic lung volume reduction (ELVR) has become an established treatment option in selected patients with end-stage lung emphysema. ELVR, however, does not always prevent disease progression, and patients may inevitably be considered for lung transplantation. OBJECTIVES Currently, limited data exist regarding the impact of preceding ELVR on lung transplantation outcomes. METHODS A retrospective, single-center analysis of lung transplantation (LTx) waiting list candidates, who had previously undergone ELVR for emphysema between 2010 and 2014, was performed. Outcomes were compared to matched (1:2) controls who underwent LTx for emphysema without previous ELVR. The 12-month survival after LTx represented the primary end point. RESULTS In total 23/693 (3%) patients listed for LTx between January 2010 and May 2014 had undergone ELVR, of whom 20/23 (87%) proceeded to LTx (ELVR group). Forty matched non-ELVR emphysema patients acted as controls. Bronchiectasis on CT prior to LTx was more evident in ELVR patients [11/20 (55%) vs. 12/40 (30%); p = 0.04] as well as airway colonization after LTx [10/20 (50%) vs. 6/40 (15%); p = 0.004]. Among ELVR patients, the most prevalent colonizing organism was Stenotrophomonas maltophilia (4/10 patients, 40%). No significant differences were observed in LTx waiting list time, duration of LTx procedure, ventilatory support, ICU stay after LTx or time to hospital discharge. One ELVR patient (5%) died 189 days after LTx from pneumonia, compared to 1 non-ELVR patient (3%) who died after 269 days (p = 0.61). CONCLUSIONS Previous ELVR treatment was not associated with differing outcomes following LTx. Increased bacterial colonization rates were evident and warrant further investigation.
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Affiliation(s)
- Thomas Fuehner
- Department of Respiratory Medicine, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
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Microbiology, genomics, and clinical significance of the Pseudomonas fluorescens species complex, an unappreciated colonizer of humans. Clin Microbiol Rev 2015; 27:927-48. [PMID: 25278578 DOI: 10.1128/cmr.00044-14] [Citation(s) in RCA: 144] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Pseudomonas fluorescens is not generally considered a bacterial pathogen in humans; however, multiple culture-based and culture-independent studies have identified it at low levels in the indigenous microbiota of various body sites. With recent advances in comparative genomics, many isolates originally identified as the "species" P. fluorescens are now being reclassified as novel Pseudomonas species within the P. fluorescens "species complex." Although most widely studied for its role in the soil and the rhizosphere, P. fluorescens possesses a number of functional traits that provide it with the capability to grow and thrive in mammalian hosts. While significantly less virulent than P. aeruginosa, P. fluorescens can cause bacteremia in humans, with most reported cases being attributable either to transfusion of contaminated blood products or to use of contaminated equipment associated with intravenous infusions. Although not suspected of being an etiologic agent of pulmonary disease, there are a number of reports identifying it in respiratory samples. There is also an intriguing association between P. fluorescens and human disease, in that approximately 50% of Crohn's disease patients develop serum antibodies to P. fluorescens. Altogether, these reports are beginning to highlight a far more common, intriguing, and potentially complex association between humans and P. fluorescens during health and disease.
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Gregson AL, Wang X, Injean P, Weigt SS, Shino M, Sayah D, DerHovanessian A, Lynch JP, Ross DJ, Saggar R, Ardehali A, Li G, Elashoff R, Belperio JA. Staphylococcus via an interaction with the ELR+ CXC chemokine ENA-78 is associated with BOS. Am J Transplant 2015; 15:792-9. [PMID: 25683785 PMCID: PMC4336208 DOI: 10.1111/ajt.13029] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 08/22/2014] [Accepted: 09/12/2014] [Indexed: 01/25/2023]
Abstract
Staphylococcus aureus is the most commonly isolated gram-positive bacterium after lung transplantation (LT) and has been associated with poor posttransplant outcomes, but its effect on bronchiolitis obliterans syndrome (BOS) and death in the context of the allograft inflammatory environment has not been studied. A three-state Cox semi-Markovian model was used to determine the influence of allograft S. aureus and the ELR+ CXC chemokines on the survival rates and cause-specific hazards for movement from lung transplant (State 1) to BOS (State 2), from transplant (State 1) to death (State 3), and from BOS (State 2) to death (State 3). Acute rejection, pseudomonas pneumonia, bronchoalveolar lavage fluid (BALF) CXCL5 and its interaction with S. aureus all increased the likelihood of transition from transplant to BOS. Transition to death from transplant was facilitated by pseudomonas infection and single lung transplant. Movement from BOS to death was affected by the interaction between aspergillus, pseudomonas and CXCL5, but not S. aureus. S. aureus isolation had state specific effects after LT and only in concert with elevated BALF CXCL5 concentrations did it augment the risk of BOS. Pseudomonas and elevated BALF concentrations of CXCL5 continued as significant risk factors for BOS and death after BOS in lung transplantation.
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Affiliation(s)
- Aric L Gregson
- Division of Infectious Diseases, Department of Medicine, University of California, Los Angeles, CA Authorship Criteria: Conception, hypothesis, design, data collection, analysis, interpretation, manuscript writing/revision
| | - Xiaoyan Wang
- Division of Statistics Core, Department of Medicine, University of California, Los Angeles, CA Authorship Criteria: Design, analysis, interpretation, manuscript writing/revision
| | - Patil Injean
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, Los Angeles, CA Authorship Criteria: Data collection, interpretation
| | - S Sam Weigt
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, Los Angeles, CA Authorship Criteria: Data collection, interpretation
| | - Michael Shino
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, Los Angeles, CA Authorship Criteria: Data collection
| | - David Sayah
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, Los Angeles, CA Authorship Criteria: Data collection
| | - Ariss DerHovanessian
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, Los Angeles, CA Authorship Criteria: Data collection
| | - Joseph P Lynch
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, Los Angeles, CA Authorship Criteria: Data collection
| | - David J Ross
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, Los Angeles, CA Authorship Criteria: Data collection
| | - Rajan Saggar
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, Los Angeles, CA Authorship Criteria: Data collection
| | - Abbas Ardehali
- Division of Cardiothoracic Surgery, Department of Surgery, University of California, Los Angeles, CA Authorship Criteria: Data collection
| | - Gang Li
- Department of Biostatistics, School of Public Health, University of California, Los Angeles, CA Authorship Criteria: Design, interpretation, manuscript revision
| | - Robert Elashoff
- Department of Biomathematics/Biostatistics, School of Public Health, University of California, Los Angeles, CA Authorship Criteria: Design, interpretation, manuscript revision
| | - John A Belperio
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, Los Angeles, CA Authorship Criteria: Hypothesis, design, data collection, interpretation, manuscript writing/revision
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Abstract
Lung transplantation survival remains significantly impacted by infections and the development of chronic rejection manifesting as bronchiolitis obliterans syndrome (BOS). Traditional microbiologic data has provided insight into the role of infections in BOS. Now, new non-culture-based techniques have been developed to characterize the entire population of microbes resident on the surfaces of the body, also known as the human microbiome. Early studies have identified that lung transplant patients have a different lung microbiome and have demonstrated the important finding that the transplant lung microbiome changes over time. Furthermore, both unique bacterial populations and longitudinal changes in the lung microbiome have now been suggested to play a role in the development of BOS. In the future, this technology will need to be combined with functional assays and assessment of the immune responses in the lung to help further explain the microbiome's role in the failing lung allograft.
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Affiliation(s)
- Julia Becker
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
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Meyer KC, Raghu G, Verleden GM, Corris PA, Aurora P, Wilson KC, Brozek J, Glanville AR. An international ISHLT/ATS/ERS clinical practice guideline: diagnosis and management of bronchiolitis obliterans syndrome. Eur Respir J 2014; 44:1479-503. [PMID: 25359357 DOI: 10.1183/09031936.00107514] [Citation(s) in RCA: 382] [Impact Index Per Article: 38.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Bronchiolitis obliterans syndrome (BOS) is a major complication of lung transplantation that is associated with poor survival. The International Society for Heart and Lung Transplantation, American Thoracic Society, and European Respiratory Society convened a committee of international experts to describe and/or provide recommendations for 1) the definition of BOS, 2) the risk factors for developing BOS, 3) the diagnosis of BOS, and 4) the management and prevention of BOS. A pragmatic evidence synthesis was performed to identify all unique citations related to BOS published from 1980 through to March, 2013. The expert committee discussed the available research evidence upon which the updated definition of BOS, identified risk factors and recommendations are based. The committee followed the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) approach to develop specific clinical recommendations. The term BOS should be used to describe a delayed allograft dysfunction with persistent decline in forced expiratory volume in 1 s that is not caused by other known and potentially reversible causes of post-transplant loss of lung function. The committee formulated specific recommendations about the use of systemic corticosteroids, cyclosporine, tacrolimus, azithromycin and about re-transplantation in patients with suspected and confirmed BOS. The diagnosis of BOS requires the careful exclusion of other post-transplant complications that can cause delayed lung allograft dysfunction, and several risk factors have been identified that have a significant association with the onset of BOS. Currently available therapies have not been proven to result in significant benefit in the prevention or treatment of BOS. Adequately designed and executed randomised controlled trials that properly measure and report all patient-important outcomes are needed to identify optimal therapies for established BOS and effective strategies for its prevention.
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Affiliation(s)
- Keith C Meyer
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Ganesh Raghu
- School of Medicine, University of Washington, Seattle, WA, USA
| | | | | | - Paul Aurora
- Great Ormond Street Hospital for Children, London, UK
| | | | - Jan Brozek
- McMaster University, Hamilton, ON, Canada
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63
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Dickson RP, Erb-Downward JR, Freeman CM, Walker N, Scales BS, Beck JM, Martinez FJ, Curtis JL, Lama VN, Huffnagle GB. Changes in the lung microbiome following lung transplantation include the emergence of two distinct Pseudomonas species with distinct clinical associations. PLoS One 2014; 9:e97214. [PMID: 24831685 PMCID: PMC4022512 DOI: 10.1371/journal.pone.0097214] [Citation(s) in RCA: 137] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 04/16/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Multiple independent culture-based studies have identified the presence of Pseudomonas aeruginosa in respiratory samples as a positive risk factor for bronchiolitis obliterans syndrome (BOS). Yet, culture-independent microbiological techniques have identified a negative association between Pseudomonas species and BOS. Our objective was to investigate whether there may be a unifying explanation for these apparently dichotomous results. METHODS We performed bronchoscopies with bronchoalveolar lavage (BAL) on lung transplant recipients (46 procedures in 33 patients) and 26 non-transplant control subjects. We analyzed bacterial communities in the BAL fluid using qPCR and pyrosequencing of 16S rRNA gene amplicons and compared the culture-independent data with the clinical metadata and culture results from these subjects. FINDINGS Route of bronchoscopy (via nose or via mouth) was not associated with changes in BAL microbiota (p = 0.90). Among the subjects with positive Pseudomonas bacterial culture, P. aeruginosa was also identified by culture-independent methods. In contrast, a distinct Pseudomonas species, P. fluorescens, was often identified in asymptomatic transplant subjects by pyrosequencing but not detected via standard bacterial culture. The subject populations harboring these two distinct pseudomonads differed significantly with respect to associated symptoms, BAL neutrophilia, bacterial DNA burden and microbial diversity. Despite notable differences in culturability, a global database search of UM Hospital Clinical Microbiology Laboratory records indicated that P. fluorescens is commonly isolated from respiratory specimens. INTERPRETATION We have reported for the first time that two prominent and distinct Pseudomonas species (P. fluorescens and P. aeruginosa) exist within the post-transplant lung microbiome, each with unique genomic and microbiologic features and widely divergent clinical associations, including presence during acute infection.
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Affiliation(s)
- Robert P. Dickson
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, United States of America
| | - John R. Erb-Downward
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, United States of America
| | - Christine M. Freeman
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, United States of America
- Research Service, Department of Veterans Affairs Health Care System, Ann Arbor, Michigan, United States of America
| | - Natalie Walker
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, United States of America
| | - Brittan S. Scales
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, United States of America
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, Michigan, United States of America
| | - James M. Beck
- Department of Medicine, University of Colorado Denver, Aurora, Colorado and Medicine Service, Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado, United States of America
| | - Fernando J. Martinez
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, United States of America
| | - Jeffrey L. Curtis
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, United States of America
- Pulmonary & Critical Care Medicine Section, Medical Service, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States of America
| | - Vibha N. Lama
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, United States of America
| | - Gary B. Huffnagle
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, United States of America
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, Michigan, United States of America
- * E-mail:
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Díaz-Ravetllat V, Greer M, Haverich A, Warnecke G, Dierich M, Welte T, Gottlieb J. Significance of new lung infiltrates in outpatients after lung and heart-lung transplantation. Transpl Infect Dis 2014; 16:359-68. [PMID: 24725092 PMCID: PMC7169667 DOI: 10.1111/tid.12209] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 07/04/2013] [Accepted: 11/23/2013] [Indexed: 11/28/2022]
Abstract
Background Infection and rejection represent major complications following lung transplantation and are often associated with pulmonary infiltrates. The differential diagnosis of these infiltrates depends on their timing after transplantation. The aim of this study was to characterize lung transplant recipients (LTR) presenting with new pulmonary infiltrates. Methods A retrospective analysis of all LTR and heart–lung transplant recipients attending outpatient follow‐up at our institution between September 1, 2006 and October 14, 2011 was performed. All patients presenting with new pulmonary infiltrates on chest x‐ray who underwent bronchoscopy were included. Results A total of 913 patients accounted for 13,156 attendances, with 3,912 bronchoscopies being performed. Seventy‐eight patients (9%) exhibited new pulmonary infiltrates and proceeded to bronchoscopy. Infiltrates occurred at a median 15 (interquartile range [IQR] 5–39) months after transplantation. Forty‐eight patients (62%) were male, and median patient age was 47 (IQR 29–57) years. Subsequent investigation revealed pneumonia to be the underlying cause in 63 patients (81%). In the remaining patients, chronic lung allograft dysfunction (CLAD) was responsible in 6 (8%), acute rejection in 5 (6%), and toxic pneumonitis in 4 (5%) patients. Overall 1‐year survival in LTR presenting with new infiltrates was 97%, compared with 96% for all LTR attending our Outpatient Department. Conclusions New pulmonary infiltrates occurring after the first month in LTR are most likely due to infection. Through prompt diagnosis and treatment, early mortality appears unaffected. Late mortality remains attributable to CLAD.
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Affiliation(s)
- V Díaz-Ravetllat
- Department of Thoracic Surgery, Hospital Clinic of Barcelona, Barcelona, Spain
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65
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Practical guidelines: lung transplantation in patients with cystic fibrosis. Pulm Med 2014; 2014:621342. [PMID: 24800072 PMCID: PMC3988894 DOI: 10.1155/2014/621342] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 01/08/2014] [Accepted: 01/09/2014] [Indexed: 12/12/2022] Open
Abstract
There are no European recommendations on issues specifically related to lung transplantation (LTX) in cystic fibrosis (CF). The main goal of this paper is to provide CF care team members with clinically relevant CF-specific information on all aspects of LTX, highlighting areas of consensus and controversy throughout Europe. Bilateral lung transplantation has been shown to be an important therapeutic option for end-stage CF pulmonary disease. Transplant function and patient survival after transplantation are better than in most other indications for this procedure. Attention though has to be paid to pretransplant morbidity, time for referral, evaluation, indication, and contraindication in children and in adults. This review makes extensive use of specific evidence in the field of lung transplantation in CF patients and addresses all issues of practical importance. The requirements of pre-, peri-, and postoperative management are discussed in detail including bridging to transplant and postoperative complications, immune suppression, chronic allograft dysfunction, infection, and malignancies being the most important. Among the contributors to this guiding information are 19 members of the ECORN-CF project and other experts. The document is endorsed by the European Cystic Fibrosis Society and sponsored by the Christiane Herzog Foundation.
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66
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Suhling H, Rademacher J, Zinowsky I, Fuge J, Greer M, Warnecke G, Smits JM, Bertram A, Haverich A, Welte T, Gottlieb J. Conventional vs. tablet computer-based patient education following lung transplantation--a randomized controlled trial. PLoS One 2014; 9:e90828. [PMID: 24608864 PMCID: PMC3946627 DOI: 10.1371/journal.pone.0090828] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 01/21/2014] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Accurate immunosuppression is of critical importance in preventing rejection, while avoiding toxicity following lung transplantation. The mainstay immunosuppressants are calcineurin inhibitors, which require regular monitoring due to interactions with other medications and diet. Adherence to immunosuppression and patient knowledge is vital and can be improved through patient education. Education using tablet-computers was investigated. OBJECTIVE To compare tablet-PC education and conventional education in improving immunosuppression trough levels in target range 6 months after a single education. Secondary parameters were ratio of immunosuppression level measurements divided by per protocol recommended measurements, time and patient satisfaction regarding education. DESIGN Single-centre, open labelled randomised controlled trial. PARTICIPANTS Patients >6 months after lung-transplantation with <50% of calcineurin inhibitor trough levels in target range. INTERVENTION Tablet-pc education versus personal, nurse-led education. MEASUREMENTS Calcineurin inhibitor levels in target range 6 months after education, level variability, interval adherence, knowledge and adherence was studied. As outcome parameter, renal function was measured and adverse events registered. RESULTS Sixty-four patients were 1:1 randomised for either intervention. Levels of immunosuppression 6 months after education were equal (tablet-PC 58% vs. conventional 48%, p = 0.27), both groups improved in achieving a CNI trough level within target range by either education method (delta tablet-PC 29% vs. conventional 20%). In all patients, level variability decreased (-20.4%), whereas interval adherence remained unchanged. Knowledge about immunosuppression improved by 7% and compliance tests demonstrated universal improvements with no significant difference between groups. CONCLUSION Education is a simple, effective tool in improving adherence to immunosuppression. Tablet-PC education was non-inferior to conventional education. TRIAL REGISTRATION ClinicalTrials.gov NCT01398488 http://clinicaltrials.gov/ct2/show/NCT01398488? term=gottlieb+tablet+pc+education&rank=1.
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Affiliation(s)
- Hendrik Suhling
- Dept. of Respiratory Medicine, Hannover Medical School, Hannover, Germany
- * E-mail:
| | - Jessica Rademacher
- Dept. of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Imke Zinowsky
- Dept. of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Jan Fuge
- Dept. of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Mark Greer
- Dept. of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Gregor Warnecke
- Dept. of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | | | - Anna Bertram
- Dept. of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Dept. of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Tobias Welte
- Dept. of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Jens Gottlieb
- Dept. of Respiratory Medicine, Hannover Medical School, Hannover, Germany
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Mainz JG, Schädlich K, Schien C, Michl R, Schelhorn-Neise P, Koitschev A, Koitschev C, Keller PM, Riethmüller J, Wiedemann B, Beck JF. Sinonasal inhalation of tobramycin vibrating aerosol in cystic fibrosis patients with upper airway Pseudomonas aeruginosa colonization: results of a randomized, double-blind, placebo-controlled pilot study. DRUG DESIGN DEVELOPMENT AND THERAPY 2014; 8:209-17. [PMID: 24596456 PMCID: PMC3930477 DOI: 10.2147/dddt.s54064] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Rationale In cystic fibrosis (CF), the paranasal sinuses are sites of first and persistent colonization by pathogens such as Pseudomonas aeruginosa. Pathogens subsequently descend to the lower airways, with P. aeruginosa remaining the primary cause of premature death in patients with the inherited disease. Unlike conventional aerosols, vibrating aerosols applied with the PARI Sinus™ nebulizer deposit drugs into the paranasal sinuses. This trial assessed the effects of vibrating sinonasal inhalation of the antibiotic tobramycin in CF patients positive for P. aeruginosa in nasal lavage. Objectives To evaluate the effects of sinonasal inhalation of tobramycin on P. aeruginosa quantification in nasal lavage; and on patient quality of life, measured with the Sino-Nasal Outcome Test (SNOT-20), and otologic and renal safety and tolerability. Methods Patients were randomized to inhalation of tobramycin (80 mg/2 mL) or placebo (2 mL isotonic saline) once daily (4 minutes/nostril) with the PARI Sinus™ nebulizer over 28 days, with all patients eligible for a subsequent course of open-label inhalation of tobramycin for 28 days. Nasal lavage was obtained before starting and 2 days after the end of each treatment period by rinsing each nostril with 10 mL of isotonic saline. Results Nine patients participated, six initially receiving tobramycin and three placebo. Sinonasal inhalation was well tolerated, with serum tobramycin <0.5 mg/L and stable creatinine. P. aeruginosa quantity decreased in four of six (67%) patients given tobramycin, compared with zero of three given placebo (non-significant). SNOT-20 scores were significantly lower in the tobramycin than in the placebo group (P=0.033). Conclusion Sinonasal inhalation of vibrating antibiotic aerosols appears promising for reducing pathogen colonization of paranasal sinuses and for control of symptoms in patients with CF.
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Affiliation(s)
- Jochen G Mainz
- Cystic Fibrosis Centre, Department of Pediatrics, Jena University Hospital, Jena, Germany
| | - Katja Schädlich
- Cystic Fibrosis Centre, Department of Pediatrics, Jena University Hospital, Jena, Germany
| | - Claudia Schien
- Cystic Fibrosis Centre, Department of Pediatrics, Jena University Hospital, Jena, Germany
| | - Ruth Michl
- Cystic Fibrosis Centre, Department of Pediatrics, Jena University Hospital, Jena, Germany
| | | | | | | | | | | | | | - James F Beck
- Cystic Fibrosis Centre, Department of Pediatrics, Jena University Hospital, Jena, Germany
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Sommerwerck U, Rabis T, Fleimisch P, Carstens H, Teschler H, Kamler M. [Lung transplantation]. Herz 2014; 39:74-83. [PMID: 24477632 DOI: 10.1007/s00059-013-4044-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Lung transplantation is a therapeutic option for patients with end-stage lung diseases. Selection of candidates requires careful consideration of the disease-specific indications and contraindications for transplantation. Advances have been made in candidate selection via the ability to prognosticate outcomes of various lung diseases and through the implementation of the lung allocation score (LAS) with specific consideration of the degree of urgency and good postoperative survival rate, after neglecting the waiting time. This system has resulted in decreased mortality on the waiting list for lung transplantation. The availability of donor organs can possibly be increased by implementation of ex vivo lung perfusion as an alternative to conventional organ preservation. Risk factors for poor outcomes post-lung transplantation have been identified and understanding of the physiological, cellular and molecular mechanisms responsible for lung and airway damage has been extensively expanded. Primary graft dysfunction, infectious diseases, acute rejection, antibody-mediated rejection, lymphocytic bronchiolitis, obliterative bronchiolitis, restrictive allograft syndrome, and chronic lung allograft dysfunction are well defined complications and continue to be common causes of morbidity and mortality. This article provides a comprehensive update on these topics for the non-transplantation clinician.
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Affiliation(s)
- U Sommerwerck
- Abt. f. Pneumologie, Ruhrlandklinik, Westdeutsches Lungenzentrum, Universitätsklinikum Essen, Universität Duisburg-Essen, Tüschener Weg 40, 45239, Essen, Deutschland,
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Lobo LJ, Noone PG. Respiratory infections in patients with cystic fibrosis undergoing lung transplantation. THE LANCET RESPIRATORY MEDICINE 2013; 2:73-82. [PMID: 24461904 DOI: 10.1016/s2213-2600(13)70162-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Cystic fibrosis is an inherited disease characterised by chronic respiratory infections associated with bronchiectasis. Lung transplantation has helped to extend the lives of patients with cystic fibrosis who have advanced lung disease. However, persistent, recurrent, and newly acquired infections can be problematic. Classic cystic fibrosis-associated organisms, such as Staphylococcus aureus and Pseudomonas aeruginosa, are generally manageable post-transplantation, and are associated with favourable outcomes. Burkholderia cenocepacia poses particular challenges, although other Burkholderia species are less problematic. Despite concerns about non-tuberculous mycobacteria, especially Mycobacterium abscessus, post-transplantation survival has not been definitively shown to be less than average in patients with these infections. Fungal species can be prevalent before and after transplantation and are associated with high morbidity, so should be treated aggressively. Appropriate viral screening and antiviral prophylaxis are necessary to prevent infection with and reactivation of Epstein-Barr virus and cytomegalovirus and their associated complications. Awareness of drug pharmacokinetics and interactions in cystic fibrosis is crucial to prevent toxic effects and subtherapeutic or supratherapeutic drug dosing. With the large range of potential infectious organisms in patients with cystic fibrosis, infection control in hospital and outpatient settings is important. Despite its complexity, lung transplantation in the cystic fibrosis population is safe, with good outcomes if the clinician is aware of all the potential pathogens and remains vigilant by means of surveillance and proactive treatment.
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Affiliation(s)
- Leonard J Lobo
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Peadar G Noone
- Pulmonary Division, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.
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Abstract
Lung transplantation has become an accepted therapeutic procedure for the treatment of end‐stage pulmonary parenchymal and vascular disease. Despite improved survival rates over the decades, lung transplant recipients have lower survival rates than other solid organ transplant recipients. The morbidity and mortality following lung transplantation is largely due to infection‐ and rejection‐related complications. This article will review the common infections that develop in the lung transplant recipient, including the general risk factors for infection in this population, and the most frequent bacterial, viral, fungal and other less frequent opportunistic infections. The epidemiology, diagnosis, prophylaxis, treatment and outcomes for the different microbial pathogens will be reviewed. The effects of infection on lung transplant rejection will also be discussed.
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Affiliation(s)
- Sergio R Burguete
- Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of Texas Health Science Center at San Antonio, Texas 78229-3900, USA
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71
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Weigt SS, DerHovanessian A, Wallace WD, Lynch JP, Belperio JA. Bronchiolitis obliterans syndrome: the Achilles' heel of lung transplantation. Semin Respir Crit Care Med 2013; 34:336-51. [PMID: 23821508 PMCID: PMC4768744 DOI: 10.1055/s-0033-1348467] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Lung transplantation is a therapeutic option for patients with end-stage pulmonary disorders. Unfortunately, chronic lung allograft dysfunction (CLAD), most commonly manifest as bronchiolitis obliterans syndrome (BOS), continues to be highly prevalent and is the major limitation to long-term survival. The pathogenesis of BOS is complex and involves alloimmune and nonalloimmune pathways. Clinically, BOS manifests as airway obstruction and dyspnea that are classically progressive and ultimately fatal; however, the course is highly variable, and distinguishable phenotypes may exist. There are few controlled studies assessing treatment efficacy, but only a minority of patients respond to current treatment modalities. Ultimately, preventive strategies may prove more effective at prolonging survival after lung transplantation, but their remains considerable debate and little data regarding the best strategies to prevent BOS. A better understanding of the risk factors and their relationship to the pathological mechanisms of chronic lung allograft rejection should lead to better pharmacological targets to prevent or treat this syndrome.
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Affiliation(s)
- S Samuel Weigt
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California 90095, USA.
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72
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Suhling H, de Wall C, Rademacher J, Greer M, Boemke A, Dettmer S, Haverich A, Warnecke G, Welte T, Gottlieb J. Low Exercise Tolerance Correlates With Reduced Inspiratory Capacity and Respiratory Muscle Function in Recipients With Advanced Chronic Lung Allograft Dysfunction. Transplantation 2013; 95:1045-50. [DOI: 10.1097/tp.0b013e31828555d0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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van Duin D, van Delden C. Multidrug-resistant gram-negative bacteria infections in solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:31-41. [PMID: 23464996 DOI: 10.1111/ajt.12096] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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74
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Willner DL, Hugenholtz P, Yerkovich ST, Tan ME, Daly JN, Lachner N, Hopkins PM, Chambers DC. Reestablishment of recipient-associated microbiota in the lung allograft is linked to reduced risk of bronchiolitis obliterans syndrome. Am J Respir Crit Care Med 2013; 187:640-7. [PMID: 23328523 DOI: 10.1164/rccm.201209-1680oc] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
RATIONALE Bronchiolitis obliterans syndrome (BOS) is the primary limiting factor for long-term survival after lung transplantation, and has previously been associated with microbial infections. OBJECTIVES To cross-sectionally and longitudinally characterize microbial communities in allografts from transplant recipients with and without BOS using a culture-independent method based on high-throughput sequencing. METHODS Allografts were sampled by bronchoalveolar lavage, and microbial communities were profiled using 16S rRNA gene amplicon pyrosequencing. Community profiles were compared using the weighted Unifrac metric and the relationship between microbial populations, BOS, and other covariates was explored using PERMANOVA and logistic regression. MEASUREMENTS AND MAIN RESULTS Microbial communities in transplant patients fell into two main groups: those dominated by Pseudomonas or those dominated by Streptococcus and Veillonella, which seem to be mutually exclusive lung microbiomes. Aspergillus culture was also negatively correlated with the Pseudomonas-dominated group. The reestablishment of dominant populations present in patients pretransplant, notably Pseudomonas in individuals with cystic fibrosis, was negatively correlated with BOS. CONCLUSIONS Recolonization of the allograft by Pseudomonas in individuals with cystic fibrosis is not associated with BOS. In general, reestablishment of pretransplant lung populations in the allograft seems to have a protective effect against BOS, whereas de novo acquisition of microbial populations often belonging to the same genera may increase the risk of BOS.
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Affiliation(s)
- Dana L Willner
- Australian Centre for Ecogenomics, School of Chemistry and Molecular Biosciences, University of Queensland, St. Lucia, QLD, Australia.
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Gregson AL, Wang X, Weigt SS, Palchevskiy V, Lynch JP, Ross DJ, Kubak BM, Saggar R, Fishbein MC, Ardehali A, Li G, Elashoff R, Belperio JA. Interaction between Pseudomonas and CXC chemokines increases risk of bronchiolitis obliterans syndrome and death in lung transplantation. Am J Respir Crit Care Med 2013; 187:518-26. [PMID: 23328531 DOI: 10.1164/rccm.201207-1228oc] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
RATIONALE Pseudomonas aeruginosa is the most commonly isolated gram-negative bacterium after lung transplantation and has been shown to up-regulate glutamic acid-leucine-arginine-positive (ELR(+)) CXC chemokines associated with bronchiolitis obliterans syndrome (BOS), but the effect of pseudomonas on BOS and death has not been well defined. OBJECTIVES To determine if the influence of pseudomonas isolation and ELR(+) CXC chemokines on the subsequent development of BOS and the occurrence of death is time dependent. METHODS A three-state model was developed to assess the likelihood of transitioning from lung transplant (state 1) to BOS (state 2), from transplant (state 1) to death (state 3), and from BOS (state 2) to death (state 3). This Cox semi-Markovian approach determines state survival rates and cause-specific hazards for movement from one state to another. MEASUREMENTS AND MAIN RESULTS The likelihood of transition from transplant to BOS was increased by acute rejection, CXCL5, and the interaction between pseudomonas and CXCL1. The pseudomonas effect in this transition was due to infection rather than colonization. Movement from transplant to death was facilitated by pseudomonas infection and single lung transplant. Transition from BOS to death was affected by the length of time in state 1 and by the interactions between any pseudomonas isolation and CXCL5 and aspergillus, either independently or in combination. CONCLUSIONS Our model demonstrates that common post-transplantation events drive movement from one post-transplantation state to another and influence outcomes differently depending upon when after transplantation they occur. Pseudomonas and the ELR(+) CXC chemokines may interact to negatively influence lung transplant outcomes.
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Affiliation(s)
- Aric L Gregson
- Division of Infectious Diseases, Department of Medicine, School of Public Health, University of California, Los Angeles, CA 90095, USA.
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Meyer KC, Glanville AR. Bronchiolitis Obliterans Syndrome and Chronic Lung Allograft Dysfunction: Evolving Concepts and Nomenclature. BRONCHIOLITIS OBLITERANS SYNDROME IN LUNG TRANSPLANTATION 2013. [PMCID: PMC7122385 DOI: 10.1007/978-1-4614-7636-8_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Bronchiolitis obliterans syndrome (BOS) eventually occurs in the majority of lung transplant recipients who survive beyond 1 year, can greatly impair quality of life, and is, directly or indirectly, the major cause of delayed allograft dysfunction and recipient death. A number of associated events or conditions are strongly associated with the risk for developing BOS; these include acute rejection, gastroesophageal reflux, infections, and autoimmune reactions that can occur in the setting of alloimmune responses to the lung allograft as recipients are given intense immunosuppression to prevent allograft rejection. The term chronic lung allograft dysfunction (CLAD) is being increasingly used to refer to recipients with late allograft dysfunction that meets the spirometric criteria for the diagnosis of BOS, but clinicians should recognize that such dysfunction can occur for a variety of reasons other than BOS. The recently identified entity of restrictive allograft syndrome, which is now recognized as a relatively distinct phenotype of CLAD, has features that differentiate it from classic obstructive BOS. A number of other entities that can also significantly affect allograft function must also be considered when significant allograft dysfunction is encountered following lung transplantation.
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The Role of Infections in BOS. BRONCHIOLITIS OBLITERANS SYNDROME IN LUNG TRANSPLANTATION 2013. [PMCID: PMC7121969 DOI: 10.1007/978-1-4614-7636-8_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Infectious agents, particularly cytomegalovirus (CMV), have long been considered to be potential triggers for BOS, although the exact magnitude of the role of infections and the mechanisms thereof remain an area of active research. Methods: This chapter will review previous literature and newer results concerning the possible roles of CMV, other herpesviruses, community-acquired respiratory viruses, bacteria (including Pseudomonas, other gram-negative, gram-positive, and atypical organisms), and fungi, including colonization as well as invasive infection. Results: The text reviews and evaluates the body of literature supporting a role for these infectious agents as risk factors for BOS and time to BOS. Changing patterns of infection over time are taken into account, and studies that have shown an association between BOS (or lack thereof) and CMV are reviewed. Strategies for prevention or early treatment of infections are discussed as potential means of preserving allograft function long term. Immunizations, stringent infection-control practices, and antimicrobial treatment including newer therapies will be discussed. Conclusion: In addition to the classic literature that has focused on CMV, an expanding spectrum of infectious organisms has been implicated as possible risk factors for BOS. Increasing knowledge of the impact of long-term antiviral suppression, prophylaxis, and outcomes of early therapy will help guide future recipient management.
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Kreisel D, Goldstein DR. Innate immunity and organ transplantation: focus on lung transplantation. Transpl Int 2012; 26:2-10. [PMID: 22909350 DOI: 10.1111/j.1432-2277.2012.01549.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Ischemia reperfusion injury (IRI) that occurs with solid organ transplantation activates the innate immune system to induce inflammation. This leads to enhanced acute allograft rejection, impaired transplant tolerance and accelerated progression of chronic rejection. In this review, we discuss the innate immune signaling pathways that have been shown to play a role in organ transplantation. In particular, we focus on Toll-like receptor signaling pathways and how they have influenced outcomes after organ transplantation both experimentally and from clinical studies. Furthermore, we describe the substances that trigger the innate immune system after transplantation and several of the key cellular mediators of inflammation. We specifically point out unique aspects of activation of the innate immune system after lung transplantation. Finally, we discuss the areas that should be investigated in the future to more clearly understand the influence of the innate immune system after organ transplantation.
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Affiliation(s)
- Daniel Kreisel
- Department of Surgery, Washington University in St Louis, St. Louis, MO, USA
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79
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Shteinberg M, Raviv Y, Bishara J, Stein N, Rosengarten D, Bakal I, Kramer MR. The impact of fluoroquinolone resistance of Gram-negative bacteria in respiratory secretions on the outcome of lung transplant (non-cystic fibrosis) recipients. Clin Transplant 2012; 26:884-90. [DOI: 10.1111/j.1399-0012.2012.01665.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2012] [Indexed: 11/27/2022]
Affiliation(s)
- Michal Shteinberg
- Pulmonary Institute; Carmel Medical Center; The B. Rappaport Faculty of Medicine; Haifa; Israel
| | - Yael Raviv
- Pulmonary Institute; Rabin Medical Center; Sackler School of Medicine; Tel-Aviv; Israel
| | - Jihad Bishara
- Infectious Disease Unit; Rabin Medical Center; Sackler School of Medicine; Tel-Aviv; Israel
| | - Nili Stein
- Department of Community Medicine and Epidemiology; Carmel Medical Center; Haifa; Israel
| | - Dror Rosengarten
- Pulmonary Institute; Rabin Medical Center; Sackler School of Medicine; Tel-Aviv; Israel
| | - Ilana Bakal
- Pulmonary Institute; Rabin Medical Center; Sackler School of Medicine; Tel-Aviv; Israel
| | - Mordechai R. Kramer
- Pulmonary Institute; Rabin Medical Center; Sackler School of Medicine; Tel-Aviv; Israel
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Neurohr C, Huppmann P, Leuschner S, von Wulffen W, Meis T, Leuchte H, Ihle F, Zimmermann G, Baezner C, Hatz R, Winter H, Frey L, Ueberfuhr P, Bittmann I, Behr J. Exhaled Nitric Oxide: A Valuable Tool for Early Diagnosis and Phenotyping of Bronchiolitis Obliterans Syndrome. Am J Transplant 2011. [DOI: 10.1111/j.1600-6143.2011.03787.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Affiliation(s)
- C. Neurohr
- Department of Internal Medicine I, Division of Pulmonary Diseases, Klinikum Grosshadern, Ludwig‐Maximilians University, Munich, Germany
| | - P. Huppmann
- Department of Internal Medicine I, Division of Pulmonary Diseases, Klinikum Grosshadern, Ludwig‐Maximilians University, Munich, Germany
| | - S. Leuschner
- Department of Internal Medicine I, Division of Pulmonary Diseases, Klinikum Grosshadern, Ludwig‐Maximilians University, Munich, Germany
| | - W. von Wulffen
- Department of Internal Medicine I, Division of Pulmonary Diseases, Klinikum Grosshadern, Ludwig‐Maximilians University, Munich, Germany
| | - T. Meis
- Department of Internal Medicine I, Division of Pulmonary Diseases, Klinikum Grosshadern, Ludwig‐Maximilians University, Munich, Germany
| | - H. Leuchte
- Department of Internal Medicine I, Division of Pulmonary Diseases, Klinikum Grosshadern, Ludwig‐Maximilians University, Munich, Germany
| | - F. Ihle
- Department of Internal Medicine I, Division of Pulmonary Diseases, Klinikum Grosshadern, Ludwig‐Maximilians University, Munich, Germany
| | - G. Zimmermann
- Department of Internal Medicine I, Division of Pulmonary Diseases, Klinikum Grosshadern, Ludwig‐Maximilians University, Munich, Germany
| | - C. Baezner
- Department of Internal Medicine I, Division of Pulmonary Diseases, Klinikum Grosshadern, Ludwig‐Maximilians University, Munich, Germany
| | - R. Hatz
- Department of Surgery and Thoracic Surgery, Klinikum Grosshadern, Ludwig‐Maximilians University, Munich, Germany
| | - H. Winter
- Department of Surgery and Thoracic Surgery, Klinikum Grosshadern, Ludwig‐Maximilians University, Munich, Germany
| | - L. Frey
- Department of Anesthesiology, Klinikum Grosshadern, Ludwig‐Maximilians University, Munich, Germany
| | - P. Ueberfuhr
- Department of Cardiac Surgery, Klinikum Grosshadern, Ludwig‐Maximilians University, Munich, Germany
| | - I. Bittmann
- Institute of Pathology, Ludwig‐Maximilians University, Munich, Germany
| | - J. Behr
- Department of Internal Medicine I, Division of Pulmonary Diseases, Klinikum Grosshadern, Ludwig‐Maximilians University, Munich, Germany
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83
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Husain S, Mooney ML, Danziger-Isakov L, Mattner F, Singh N, Avery R, Ison M, Humar A, Padera RF, Lawler LP, Fisher A, Drew RJ, Gould KF, Sole A, Studer S, Munoz P, Singer LG, Hannan M. A 2010 working formulation for the standardization of definitions of infections in cardiothoracic transplant recipients. J Heart Lung Transplant 2011; 30:361-74. [PMID: 21419994 PMCID: PMC7172457 DOI: 10.1016/j.healun.2011.01.701] [Citation(s) in RCA: 160] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Accepted: 01/17/2011] [Indexed: 02/06/2023] Open
Affiliation(s)
- Shahid Husain
- Division of Infectious Diseases, Transplant Infectious Diseases, University Health Network, University of Toronto, 100 Elizabeth Street, Toronto, Ontario, Canada.
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Affiliation(s)
- Karen D. Sims
- Discovery Medicine, Virology, Bristol-Myers Squibb, PO Box 5400, Princeton, NJ 08543-5400, USA
| | - Emily A. Blumberg
- Division of Infectious Diseases, University of Pennsylvania Medical Center, University of Pennsylvania School of Medicine, 3 Silverstein Pavilion, Suite E, 3400 Spruce Street, Philadelphia, PA 19104, USA
- Corresponding author.
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85
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Vos R, Vanaudenaerde BM, Verleden SE, De Vleeschauwer SI, Willems-Widyastuti A, Van Raemdonck DE, Dupont LJ, Verleden GM. Diagnostic value of antibodies against Pseudomonas aeruginosa in bronchoalveolar lavage fluid after lung transplantation. Transplant Proc 2011; 42:4415-20. [PMID: 21168710 DOI: 10.1016/j.transproceed.2010.07.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pseudomonal airway colonization is a risk factor for chronic allograft dysfunction after lung transplantation (LTx). Pseudomonas aeruginosa exoproteases are involved in initiating colonization, and immune complexes directed against these proteases may activate innate immune responses. OBJECTIVE To investigate whether specific antibodies against pseudomonal proteases could be measured in bronchoalveolar lavage (BAL) fluid, whether they are associated with innate immune responses, and whether they could identify patients with chronic P. aeruginosa colonization after LTx. MATERIALS AND METHODS BAL fluid from 40 noncolonized and 25 chronically colonized LTx recipients was retrospectively assayed for IgG antibodies against P. aeruginosa alkaline protease (AP), elastase (Ela), and exotoxin (Exo), and for BAL total and differential cell counts and IL-8 protein concentration. RESULTS BAL anti-Ela and anti-Exo antibody titers were significantly increased in colonized compared with noncolonized patients (P = .009 and P = .02, respectively), whereas anti-AP titers were comparable (P = .79). Antibody titers strongly correlated with each other, and anti-Ela and anti-Exo titers, but not anti-AP titers, also correlated with BAL total cellularity, neutrophilia, and IL-8 protein concentration. Anti-Ela antibodies demonstrated the greatest diagnostic value in receiver operating characteristic analysis to detect chronic airway colonization (P = .009), followed by anti-Exo (P = .02) and anti-AP (P = .79). A combination of all 3 antibodies resulted in overall sensitivity of 45% (95% confidence interval [CI], 29.3-61.5), specificity of 88% (95% CI, 68.8-97.5), and positive predictive value of 55% (95% CI, 38.5-70.7). CONCLUSION P. aeruginosa proteases in BAL may be associated with local innate immune responses, and could have the potential to enable detection of chronic colonization after LTx.
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Affiliation(s)
- R Vos
- Pneumology Laboratory and the Lung Transplantation Unit, K.U. Leuven and University Hospital Gasthuisberg, Leuven, Belgium.
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Nakajima T, Palchevsky V, Perkins DL, Belperio JA, Finn PW. Lung transplantation: infection, inflammation, and the microbiome. Semin Immunopathol 2011; 33:135-56. [DOI: 10.1007/s00281-011-0249-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2010] [Accepted: 01/12/2011] [Indexed: 12/29/2022]
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87
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Endoscopic Indicators for Obstructive Airway Complications After Lung Transplantation. Transplantation 2010; 90:1210-4. [DOI: 10.1097/tp.0b013e3181fa945f] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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88
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Long-term azithromycin therapy for bronchiolitis obliterans syndrome: Divide and conquer? J Heart Lung Transplant 2010; 29:1358-68. [DOI: 10.1016/j.healun.2010.05.023] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Revised: 05/10/2010] [Accepted: 05/26/2010] [Indexed: 11/22/2022] Open
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