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Ravenel K, Guegan H, Gastebois A, Bouchara JP, Gangneux JP, Giraud S. Fungal Colonization of the Airways of Patients with Cystic Fibrosis: the Role of the Environmental Reservoirs. Mycopathologia 2024; 189:19. [PMID: 38407729 DOI: 10.1007/s11046-023-00818-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/23/2023] [Indexed: 02/27/2024]
Abstract
Filamentous fungi frequently colonize the airways of patients with cystic fibrosis and may cause severe diseases, such as the allergic bronchopulmonary aspergillosis. The most common filamentous fungi capable to chronically colonize the respiratory tract of the patients are Aspergillus fumigatus and Scedosporium species. Defining the treatment strategy may be challenging, the number of available drugs being limited and some of the causative agents being multiresistant microorganisms. The knowledge of the fungal niches in the outdoor and indoor environment is needed for understanding the origin of the contamination of the patients. In light of the abundance of some of the causative molds in compost, agricultural and flower fields, occupational activities related to such environments should be discouraged for patients with cystic fibrosis (CF). In addition, the microbiological monitoring of their indoor environment, including analysis of air and dust on surfaces, is essential to propose preventive measures aiming to reduce the exposure to environmental molds. Nevertheless, some specific niches were also identified in the indoor environment, in relation with humidity which favors the growth of thermotolerant molds. Potted plants were reported as indoor reservoirs for Scedosporium species. Likewise, Exophiala dermatitidis may be spread in the kitchen via dishwashers. However, genotype studies are still required to establish the link between dishwashers and colonization of the airways of CF patients by this black yeast. Moreover, as nothing is known regarding the other filamentous fungi associated with CF, further studies should be conducted to identify other potential specific niches in the habitat.
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Affiliation(s)
- Kévin Ravenel
- IRF (Infections Respiratoires Fongiques), SFR ICAT 4208, Univ Angers, Univ Brest, Angers, France
| | - Hélène Guegan
- EHESP, IRSET (Institut de Recherche en Santé Environnement et Travail), UMR_S 1085, CHU Rennes, INSERM, Univ Rennes, 35000, Rennes, France
| | - Amandine Gastebois
- IRF (Infections Respiratoires Fongiques), SFR ICAT 4208, Univ Angers, Univ Brest, Angers, France
| | - Jean-Philippe Bouchara
- IRF (Infections Respiratoires Fongiques), SFR ICAT 4208, Univ Angers, Univ Brest, Angers, France
| | - Jean-Pierre Gangneux
- EHESP, IRSET (Institut de Recherche en Santé Environnement et Travail), UMR_S 1085, CHU Rennes, INSERM, Univ Rennes, 35000, Rennes, France
| | - Sandrine Giraud
- IRF (Infections Respiratoires Fongiques), SFR ICAT 4208, Univ Angers, Univ Brest, Angers, France.
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Hahn M, Wood A, Hasse JM. Nutrition support management of organ transplant recipients in the acute posttransplant phase. Nutr Clin Pract 2024; 39:45-58. [PMID: 38081296 DOI: 10.1002/ncp.11104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/09/2023] [Accepted: 11/12/2023] [Indexed: 01/13/2024] Open
Abstract
Patients who undergo solid organ transplant can have an extensive and challenging postoperative course. The chronicity of the disease state prior to transplant in combination with transplant-specific complications and immunosuppressant medications can lead to distinct challenges that are not observed in other critically ill patients. Although the manifestation of posttransplant complications may be specific to the organ being transplanted, there are common transplant challenges that affect nutrition therapy in these patients. Effects of malnutrition, metabolic aberrations, and posttransplant organ dysfunction should be considered when developing a nutrition care plan for patients in the immediate posttransplant phase. This article addresses the various complications that can arise in the immediate posttransplant phase among patients undergoing solid organ transplant and the appropriate nutrition interventions or considerations for this specialized patient population.
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Affiliation(s)
- Michaelann Hahn
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Abby Wood
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Jeanette M Hasse
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
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Alshehri M, Ramos KJ, Sykes J, Ma X, Stanojevic S, Quon BS, Marshall BC, Cromwell E, Ostrenga JS, Faro A, Elbert A, Todd J, Chaparro C, Goss CH, Stephenson AL. Cystic fibrosis survival outcomes following second lung transplant: The north American experience. Clin Transplant 2023; 37:e15097. [PMID: 37563332 PMCID: PMC10840857 DOI: 10.1111/ctr.15097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 07/27/2023] [Accepted: 08/01/2023] [Indexed: 08/12/2023]
Abstract
INTRODUCTION Re-transplant is an option for those who develop end-stage lung disease due to rejection; however, little data exist following re-transplantation in cystic fibrosis (CF). METHODS Data from the Canadian CF Registry and US CF Foundation Patient Registry supplemented with data from United Network for Organ Sharing were used. Individuals who underwent a 2nd lung transplant between 2005 and 2019 were included. The Kaplan-Meier method was used to estimate the probability of survival post-second transplant at 1, 3, and 5-years. RESULTS Of those people who were waitlisted for a second transplant (N = 818), a total of 254 (31%) died waiting, 395 (48%) were transplanted and 169 (21%) people were alive on the waitlist. Median survival time after 2nd lung transplant was 3.3 years (95% CI: 2.8-4.1). The 1-, 3- and 5-year survival rates were 77.4% (95% CI: 73.1-82%), 52% (95% CI: 46.7-58%) and 39.4% (95% CI: 34.1-45.6%). CONCLUSIONS Survival following second lung transplant in CF patients is lower than estimates following the first transplant. Over half of subjects who are potentially eligible for a second transplant die without receiving a second organ. This warrants further investigation.
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Affiliation(s)
- Moayad Alshehri
- Department of Respirology, St. Michael's Hospital, Toronto, Ontario, Canada
- Unit of Pulmonology, Internal Medicine Department, King Saud University, Riyadh, Saudi Arabia
| | - Kathleen J Ramos
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | - Jenna Sykes
- Department of Respirology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Xiayi Ma
- Department of Respirology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Sanja Stanojevic
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Bradley S Quon
- Centre for Heart Lung Innovation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | - Albert Faro
- Cystic Fibrosis Foundation, Bethesda, Maryland, USA
| | | | | | - Cecilia Chaparro
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada
| | - Christopher H Goss
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, Washington, USA
- Division of Pediatric Pulmonary, Department of Pediatrics, University of Washington Medical Center, Seattle, Washington, USA
| | - Anne L Stephenson
- Department of Respirology, St. Michael's Hospital, Toronto, Ontario, Canada
- Keenan Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Oppelaar LM, Luijk B, Heijerman HGM, De Valk HW, van Meerkerk GB. The prevalence of vascular and metabolic complications after lung transplant in people with cystic fibrosis in a Dutch cohort. Clinics (Sao Paulo) 2023; 78:100274. [PMID: 37597473 PMCID: PMC10460949 DOI: 10.1016/j.clinsp.2023.100274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/28/2023] [Accepted: 07/28/2023] [Indexed: 08/21/2023] Open
Abstract
BACKGROUND With improvements in care for people with Cystic Fibrosis (pwCF), total survival after Lung Transplantation (LTx) will be longer. Therefore, this population's up-to-date analysis of late-onset post-transplant metabolic and vascular complications will be more relevant in current clinical practice. METHODS We studied 100 pwCF who underwent an LTx between 2001 and 2020 at the University Medical Centre Utrecht, the Netherlands. The median age at transplant was 31 years and 55 percent was male. We assessed survival, the prevalence of metabolic complications (diabetes, renal damage, dyslipidemia, and metabolic syndrome), and vascular complications (hypertension, heart rhythm disease, micro-, and macrovascular disease). In addition, differences in risks for developing complications based on sex and overall survival were analyzed. RESULTS The prevalence of macrovascular disease raised to 15.9 percent 15 years post-LTx. The prevalence of diabetes increased from 63 percent at LTx to over 90 percent 15 years post-LTx and the prevalence of dyslipidemia increased from 21 percent to over 80 percent. Survival 1-, 2-, 5-, and 10 years post-transplant were 84, 80, 76, and 58 percent respectively. No significant differences were found based on sex. CONCLUSION This study shows that the prevalence of cardiovascular risk factors increases after LTx for CF, potentially leading to major complications. These data emphasize the necessity of regular check-ups for metabolic and vascular complications after LTx with specific attention to renal damage. Early recognition of these complications is crucial and will lead to earlier intervention, which could lead to improved prognosis after lung transplantation.
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Affiliation(s)
| | - Bart Luijk
- Leiden University Medical Center, Leiden, Netherlands
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Courtwright AM, Devarajan J, Fritz AV, Martin AK, Wilkey B, Subramani S, Cassara CM, Tawil JN, Miltiades AN, Boisen ML, Bottiger BA, Pollak A, Gelzinis TA. Cardiothoracic Transplant Anesthesia: Selected Highlights: Part I-Lung Transplantation. J Cardiothorac Vasc Anesth 2023; 37:884-903. [PMID: 36868904 DOI: 10.1053/j.jvca.2023.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 01/22/2023] [Indexed: 01/30/2023]
Affiliation(s)
| | | | - Ashley Virginia Fritz
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, Jacksonville, FL
| | | | - Barbara Wilkey
- Department of Anesthesiology, University of Colorado, Aurora, CO
| | - Sudhakar Subramani
- Department of Anesthesiology, University of Iowa Hospitals & Clinics, Iowa City, IA
| | - Christopher M Cassara
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Justin N Tawil
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Andrea N Miltiades
- Department of Anesthesiology, Columbia University Medical Center, New York, NY
| | - Michael L Boisen
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Brandi A Bottiger
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Angela Pollak
- Department of Anesthesiology, Duke University, Durham, NC
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Abstract
Lung transplantation provides a treatment option for many individuals with advanced lung disease due to cystic fibrosis (CF). Since the first transplants for CF in the 1980s, survival has improved and the opportunity for transplant has expanded to include individuals who previously were not considered candidates for transplant. Criteria to be a transplant candidate vary significantly among transplant programs, highlighting that the engagement in more than one transplant program may be necessary. Individuals with highly resistant CF pathogens, malnutrition, osteoporosis, CF liver disease, and other comorbidities may be suitable candidates for lung transplant, or if needed, multi-organ transplant. The transplant process involves several phases, from discussion of prognosis and referral to a transplant center, to transplant evaluation, to listing, transplant surgery, and care after transplant. While the availability of highly effective CF transmembrane conductance regulator (CFTR) modulators for many individuals with CF has improved lung function and slowed progression to respiratory failure, early discussion regarding transplant as a treatment option and referral to a transplant program are critical to maximizing opportunity and optimizing patient and family experience. The decision to be evaluated for transplant and to list for transplant are distinct, and early referral may provide a treatment option that can be urgently executed if needed. Survival after transplant for CF is improving, to a median survival of approximately 10 years, and most transplant survivors enjoy significant improvement in quality of life.
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Abstract
Survival statistics, estimated using data from national cystic fibrosis (CF) registries, inform the CF community and monitor disease progression. This study aimed to estimate survival among people with CF in Australia and to identify factors associated with survival. This population-based cohort study used prospectively collected data from 23 Australian CF centres participating in the Australian CF Data Registry (ACFDR) from 2005-2020. Period survival analysis was used to calculate median age of survival estimates for each 5-year window from 2005-2009 until 2016-2020. The overall median survival was estimated using the Kaplan-Meier method. Between 2005-2020 the ACFDR followed 4,601 people with CF, noting 516 (11.2%) deaths including 195 following lung transplantation. Out of the total sample, more than half (52.5%) were male and 395 (8.6%) had undergone lung transplantation. Two thirds of people with CF (66.1%) were diagnosed before six weeks of age or by newborn/prenatal screening. The overall median age of survival was estimated as 54.0 years (95% CI: 51.0-57.04). Estimated median survival increased from 48.9 years (95% CI: 44.7-53.5) for people with CF born in 2005-2009, to 56.3 years (95% CI: 51.2-60.4) for those born in 2016-2020. Factors independently associated with reduced survival include receiving a lung transplant, having low FEV1pp and BMI. Median survival estimates are increasing in CF in Australia. This likely reflects multiple factors, including newborn screening, improvement in diagnosis, refinements in CF management and centre-based multidisciplinary care.
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Survival difference between high-risk and low-risk CFTR genotypes after lung transplant. J Heart Lung Transplant 2022; 41:1511-1519. [PMID: 35864004 PMCID: PMC10124119 DOI: 10.1016/j.healun.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 04/11/2022] [Accepted: 04/22/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND While cystic fibrosis transmembrane conductance regulator (CFTR) genotypes are associated with clinical outcomes in cystic fibrosis patients, it is unknown if genotype impacts lung transplant outcomes. We sought to compare lung transplant survival and time to bronchiolitis obliterans syndrome (BOS) between high-risk, low-risk, and not yet classified CFTR genotypes. METHODS We used merged data from the Organ Procurement and Transplantation Network (2005-2017) and United States Cystic Fibrosis Foundation Patient Registry (2005-2016). Cox Proportional Hazards models compared graft failure after lung transplant and time to BOS among high-risk, low-risk, and not yet classified risk CFTR genotype classes. RESULTS Among 1,830 cystic fibrosis lung transplant recipients, median survival for those with low-risk, high-risk, and not yet classified genotype was 9.83, 6.25, and 5.75 years, respectively. Adjusted Cox models showed recipients with a low-risk genotype had 39% lower risk of death or re-transplant compared to those with high-risk genotype (adjusted HR 0.61, 95% CI = 0.40, 0.91). A subset of 1,585 lung transplant recipients were included in the BOS subgroup analysis. Adjusted analyses showed no significant difference of developing BOS among high-risk, low-risk, or not yet classified genotypes. CONCLUSIONS Lung transplant recipients with low-risk CFTR genotype have better survival after transplant compared to recipients with high-risk or not yet classified genotypes. Given these differences, future studies evaluating the mechanism by which CFTR genotype affects post-transplant survival could identify potential targets for intervention.
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Blanchard AC, Waters VJ. Opportunistic Pathogens in Cystic Fibrosis: Epidemiology and Pathogenesis of Lung Infection. J Pediatric Infect Dis Soc 2022; 11:S3-S12. [PMID: 36069904 DOI: 10.1093/jpids/piac052] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022]
Abstract
Cystic fibrosis (CF) is one of the most common life-shortening genetic diseases in Caucasians. Due to abnormal accumulation of mucus, respiratory failure caused by chronic infections is the leading cause of mortality in this patient population. The microbiology of these respiratory infections includes a distinct set of opportunistic pathogens, including Pseudomonas aeruginosa, Burkholderia spp., Achromobacter spp., Stenotrophomonas maltophilia, anaerobes, nontuberculous mycobacteria, and fungi. In recent years, culture-independent methods have shown the polymicrobial nature of lung infections, and the dynamics of microbial communities. The unique environment of the CF airway predisposes to infections caused by opportunistic pathogens. In this review, we will highlight how the epidemiology and role in disease of these pathogens in CF differ from that in individuals with other medical conditions. Infectious diseases (ID) physicians should be aware of these differences and the specific characteristics of infections associated with CF.
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Affiliation(s)
- Ana C Blanchard
- Department of Pediatrics, Division of Infectious Diseases, CHU Sainte-Justine, Université de Montréal, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1C5, Canada
| | - Valerie J Waters
- Department of Pediatrics, Division of Infectious Diseases, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
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Fu H, Gan L, Tian Z, Han J, Du B, Xue G, Feng Y, Zhao H, Cui J, Yan C, Feng J, Fan Z, Fu T, Xu Z, Zhang R, Cui X, Du S, Zhou Y, Zhang Q, Cao L, Yuan J. Rapid detection of Burkholderia cepacia complex carrying the 16S rRNA gene in clinical specimens by recombinase-aided amplification. Front Cell Infect Microbiol 2022; 12:984140. [PMID: 36132989 PMCID: PMC9483118 DOI: 10.3389/fcimb.2022.984140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 08/18/2022] [Indexed: 11/13/2022] Open
Abstract
The Burkholderia cepacia complex (BCC) is a group of opportunistic pathogens, including Burkholderia cepacia, Burkholderia multivorans, Burkholderia vietnamiensis and Burkholderia ambifaria, which can cause severe respiratory tract infections and lead to high mortality rates among humans. The early diagnosis and effective treatment of BCC infection are therefore crucial. In this study, a novel and rapid recombinase-aided amplification (RAA) assay targeting the 16S rRNA gene was developed for BCC detection. The protocol for this RAA assay could be completed in 10 min at 39°C, with a sensitivity of 10 copies per reaction and no cross-reactivity with other pathogens. To characterize the effectiveness of the RAA assay, we further collected 269 clinical samples from patients with bacterial pneumonia. The sensitivity and specificity of the RAA assay were 100% and 98.5%, respectively. Seven BCC-infected patients were detected using the RAA assay, and three BCC strains were isolated from the 269 clinical samples. Our data showed that the prevalence of BCC infection was 2.60%, which is higher than the 1.40% reported in previous studies, suggesting that high sensitivity is vital to BCC detection. We also screened a patient with B. vietnamiensis infection using the RAA assay in clinic, allowing for appropriate treatment to be initiated rapidly. Together, these data indicate that the RAA assay targeting the 16S rRNA gene can be applied for the early and rapid detection of BCC pathogens in patients with an uncharacterized infection who are immunocompromised or have underlying diseases, thereby providing guidance for effective treatment.
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Affiliation(s)
- Hanyu Fu
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
- Department of Pulmonology, The Affiliated Children’s Hospital, Capital Institute of Pediatrics, Beijing, China
| | - Lin Gan
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Ziyan Tian
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Juqiang Han
- Institute of Hepatology, Chinese People Liberation Army General Hospital, Beijing, China
| | - Bing Du
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Guanhua Xue
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Yanling Feng
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Hanqing Zhao
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Jinghua Cui
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Chao Yan
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Junxia Feng
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Zheng Fan
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Tongtong Fu
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Ziying Xu
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Rui Zhang
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Xiaohu Cui
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Shuheng Du
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Yao Zhou
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Qun Zhang
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Ling Cao
- Department of Pulmonology, The Affiliated Children’s Hospital, Capital Institute of Pediatrics, Beijing, China
- *Correspondence: Jing Yuan, ; Ling Cao,
| | - Jing Yuan
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
- *Correspondence: Jing Yuan, ; Ling Cao,
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Dew MA, DiMartini AF, Posluszny DM, Myaskovsky L, Switzer GE, Puttarajappa C, Hickey GW, Sanchez PG, DeVito Dabbs AJ. Health-related quality of life and psychological indicators of thriving 15-19 years after heart or lung transplantation. Clin Transplant 2022; 36:e14768. [PMID: 35801650 PMCID: PMC9756395 DOI: 10.1111/ctr.14768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/29/2022] [Accepted: 07/05/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Survival into the second decade after cardiothoracic transplantation (CTX) is no longer uncommon. Few data exist on any health-related quality of life (HRQOL) impairments survivors face, or whether they may even experience positive psychological outcomes indicative of "thriving" (e.g., personal growth). We provide such data in a long-term survivor cohort. METHODS Among 304 patients prospectively studied across the first 2 years post-CTX, we re-interviewed patients ≥15 years post-CTX. We (a) examined levels of HRQOL and positive psychological outcomes (posttraumatic growth related to CTX, purpose in life, life satisfaction) at follow-up, (b) evaluated change since transplant with mixed-effects models, and (c) identified psychosocial and clinical correlates of study outcomes with multivariable regression. RESULTS Of 77 survivors, 64 (83%) were assessed (35 heart, 29 lung recipients; 15-19 years post-CTX). Physical HRQOL was poorer than the general population norm and earlier post-transplant levels (P's < .001). Mental HRQOL exceeded the norm (P < .001), with little temporal change (P = .070). Mean positive psychological outcome scores exceeded scales' midpoints at follow-up. Life satisfaction, assessed longitudinally, declined over time (P < .001) but remained similar to the norm at follow-up. Recent hospitalization and dyspnea increased patients' likelihood of poor physical HRQOL at follow-up (P's ≤ .022). Lower sense of mastery and poorer caregiver support lessened patients' likelihood of positive psychological outcomes (P's ≤ .049). Medical comorbidities and type of CTX were not associated with study outcomes at follow-up. CONCLUSIONS Despite physical HRQOL impairment, long-term CTX survivors otherwise showed favorable outcomes. Clinical attention to correlates of HRQOL and positive psychological outcomes may help maximize survivors' well-being.
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Affiliation(s)
- Mary Amanda Dew
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Departments of Psychology, Epidemiology, and Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Andrea F. DiMartini
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Donna M. Posluszny
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - Larissa Myaskovsky
- Department of Internal Medicine, University of New Mexico School of Medicine and Center for Healthcare Equity in Kidney Disease, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Galen E. Switzer
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Chethan Puttarajappa
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Gavin W. Hickey
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- UPMC Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | - Pablo G. Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Annette J. DeVito Dabbs
- Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
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Kotecha S, Ivulich S, Snell G. Review: immunosuppression for the lung transplant patient. J Thorac Dis 2022; 13:6628-6644. [PMID: 34992841 PMCID: PMC8662512 DOI: 10.21037/jtd-2021-11] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 02/16/2021] [Indexed: 12/19/2022]
Abstract
Lung transplantation (LTx) has evolved significantly since its inception and the improvement in LTx outcomes over the last three decades has predominantly been driven by advances in immunosuppression management. Despite the lack of new classes of immunosuppression medications, immunosuppressive strategies have evolved significantly from a universal method to a more targeted approach, reflecting a greater understanding of the need for individualized therapy and careful consideration of all factors that are influenced by immunosuppression choice. This has become increasingly important as the demographics of lung transplant recipients have changed over time, with older and more medically complex candidates being accepted and undergoing LTx. Furthermore, improved survival post lung transplant has translated into more immunosuppression related comorbidities long-term, predominantly chronic kidney disease (CKD) and malignancy, which has required further nuanced management approaches. This review provides an update on current traditional lung transplant immunosuppression strategies, with modifications based on pre-existing recipient factors and comorbidities, peri-operative challenges and long term complications, balanced against the perpetual challenge of chronic lung allograft dysfunction (CLAD). As we continue to explore and understand the complexity of LTx immunology and the interplay of different factors, immunosuppression strategies will require ongoing critical evaluation and personalization in order to continue to improve lung transplant outcomes.
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Affiliation(s)
- Sakhee Kotecha
- Lung Transplant Service, Alfred Hospital and Monash University, Melbourne, Australia
| | - Steven Ivulich
- Lung Transplant Service, Alfred Hospital and Monash University, Melbourne, Australia
| | - Gregory Snell
- Lung Transplant Service, Alfred Hospital and Monash University, Melbourne, Australia
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McCort M, MacKenzie E, Pursell K, Pitrak D. Bacterial infections in lung transplantation. J Thorac Dis 2022; 13:6654-6672. [PMID: 34992843 PMCID: PMC8662486 DOI: 10.21037/jtd-2021-12] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 02/18/2021] [Indexed: 12/30/2022]
Abstract
Lung transplantation has lower survival rates compared to other than other solid organ transplants (SOT) due to higher rates of infection and rejection-related complications, and bacterial infections (BI) are the most frequent infectious complications. Excess morbidity and mortality are not only a direct consequence of these BI, but so are subsequent loss of allograft tolerance, rejection, and chronic lung allograft dysfunction due to bronchiolitis obliterans syndrome (BOS). A wide variety of pathogens can cause infections in lung transplant recipients (LTRs), including a number of nosocomial pathogens and other multidrug-resistant (MDR) pathogens. Although pneumonia and intrathoracic infections predominate, LTRs are at risk of a number of types of infections. Risk factors include altered anatomy and function of airways, impaired immunity, the microbial flora of the donor and recipient, underlying medical conditions, and genetic factors. Further work on immune monitoring has the potential to improve outcomes. The infecting agents can be derived from the donor lung, pre-existing recipient flora, or acquired from the environment over time. Certain infections may preclude lung transplantation, but this varies from center to center, and more recent studies suggest fewer patients should be disqualified. New molecular methods allow microbiome studies of the lung, gut, and other sites that may further our knowledge of how airway colonization can result in infection and allograft loss. Surveillance, early diagnosis, and aggressive antimicrobial therapy of BI is critical in LTRs. Antibiotic resistance is a major barrier to successful management of these infections. The availability of new agents for MDR Gram-negatives may improve outcomes. Other new therapies, such as bacteriophage therapy, show promise for the future. Finally, it is important to prevent infections through peri-transplant prophylaxis, vaccination, and infection control measures.
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Affiliation(s)
- Margaret McCort
- Albert Einstein College of Medicine, Division of Infectious Disease, New York, NY, USA
| | - Erica MacKenzie
- University of Chicago Medicine, Section of Infectious Diseases and Global Health, Chicago, IL, USA
| | - Kenneth Pursell
- University of Chicago Medicine, Section of Infectious Diseases and Global Health, Chicago, IL, USA
| | - David Pitrak
- University of Chicago Medicine, Section of Infectious Diseases and Global Health, Chicago, IL, USA
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The effect of the cystic fibrosis care center on outcomes after lung transplantation for cystic fibrosis. J Heart Lung Transplant 2021; 41:300-307. [PMID: 34930671 DOI: 10.1016/j.healun.2021.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 11/02/2021] [Accepted: 11/14/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The purpose of this study was to evaluate outcomes in people with cystic fibrosis (CF) who underwent lung transplant (LT) at a transplant center with an accredited Cystic Fibrosis Care Center (CFCC) in the United States. METHODS We reviewed the Scientific Registry of Transplant Recipients for all adult patients with CF who received a first-time LT from 2005 to 2018. The primary outcome was graft failure. Unadjusted Kaplan-Meier analysis and adjusted multilevel Cox proportional hazards models were used to evaluate outcomes in CF patients undergoing lung transplantation at a CFCC. RESULTS 2,573 patients with CF underwent a first time LT during the study period. Of the 68 lung transplantation centers, 50 were CFCCs (73.5%). After adjustment for potential confounders, patients who underwent lung transplantation at a hospital with an accredited CFCC had a 33% reduction in risk of death or re-transplantation compared to those transplanted at a hospital without an accredited CFCC (HR: 0.67, 95% CI: 0.56-0.82, p < 0.001). CONCLUSIONS People with CF who undergo LT at a transplant center with a CFCC have improved graft survival and decreased need for re-transplantation compared to those who undergo LT at a non-CFCC, independent of volume.
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15
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Chin M, Brennan AL, Bell SC. Emerging non-pulmonary complications for adults with cystic fibrosis. Chest 2021; 161:1211-1224. [PMID: 34774529 DOI: 10.1016/j.chest.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/27/2021] [Accepted: 11/04/2021] [Indexed: 11/30/2022] Open
Abstract
Improved treatments of cystic fibrosis (CF) related lung disease have resulted in increased longevity, but also increasing prevalence and severity of extrapulmonary manifestations of CF, treatment related complications, age-related conditions and psychosocial effects of longstanding chronic disease. Likewise, the recognition of mild CF phenotypes has changed the landscape of CF disease. This review outlines our current understanding of the common extrapulmonary complications of CF, as well as the changing landscape and future directions of the extrapulmonary complications experienced by patients with CF.
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Affiliation(s)
- Melanie Chin
- Department of Medicine and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Amanda L Brennan
- Manchester Adult Cystic Fibrosis Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Scott C Bell
- Thoracic Medicine, The Prince Charles Hospital, Brisbane, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Australia; Translational Research Institute, Brisbane, Australia.
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16
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Courtwright AM, Wilkey B, Devarajan J, Subramani S, Martin AK, Fritz AV, Cassara CM, Boisen ML, Bottiger BA, Pollak A, Maisonave Y, Gelzinis TA. The Year in Cardiothoracic Transplant Anesthesia: Selected Highlights From 2020 Part I - Lung Transplantation. J Cardiothorac Vasc Anesth 2021; 36:33-44. [PMID: 34670721 DOI: 10.1053/j.jvca.2021.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/08/2021] [Accepted: 09/10/2021] [Indexed: 11/11/2022]
Abstract
This special article focuses on the highlights in cardiothoracic transplantation literature in the year 2020. Part I encompasses the recent literature on lung transplantation, including the advances in preoperative assessment and optimization, donor management, including the use of ex-vivo lung perfusion, recipient management, including those who have been infected with coronavirus disease 2019, updates on the perioperative management, including the use of extracorporeal membrane oxygenation, and long-term outcomes.
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Affiliation(s)
| | - Barbara Wilkey
- Department of Anesthesiology, University of Colorado, Boulder, CO
| | | | - Sudhakar Subramani
- Department of Anesthesiology, University of Iowa Hospitals & Clinics, Iowa City, IA
| | - Archer Kilbourne Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic Florida, Jacksonville, FL
| | - Ashley Virginia Fritz
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic Florida, Jacksonville, FL
| | - Christopher M Cassara
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Michael L Boisen
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - Angela Pollak
- Department of Anesthesiology, Duke University, Durham, NC
| | | | - Theresa A Gelzinis
- University of Pittsburgh, Corresponding Author, UPMC Presbyterian Hospital, Pittsburgh, PA.
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17
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Recipient Age Impacts Long-Term Survival in Adult Subjects with Cystic Fibrosis after Lung Transplantation. Ann Am Thorac Soc 2021; 18:44-50. [PMID: 32795188 DOI: 10.1513/annalsats.201908-637oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Rationale: Lung transplant is an effective treatment option providing survival benefit in patients with cystic fibrosis (CF). Several studies have suggested survival benefit in adults compared with pediatric patients with CF undergoing lung transplant. However, it remains unclear whether this age-related disparity persists in adult subjects with CF.Objectives: We investigated the impact of age at transplant on post-transplant outcomes in adult patients with CF.Methods: The United Network of Organ Sharing Registry was queried for all adult patients with CF who underwent lung transplantation between 1992 and 2016. Pertinent baseline characteristics, demographics, clinical parameters, and outcomes were recorded. The patients were divided into two groups based on age at transplant (18-29 yr old and 30 yr or older). The primary endpoint was survival time. Assessment of post-transplant survival was performed using Kaplan-Meier tests and log-rank tests with multivariable Cox proportional hazards analysis to adjust for confounding variables.Results: A total of 3,881 patients with CF underwent lung transplantation between 1992 and 2016; mean age was 31.0 (± 9.3) years. The 18-29-year-old at transplant cohort consisted of 2,002 subjects and the 30 years or older cohort had 1,879 subjects. Survival analysis demonstrated significantly higher survival in subjects in the 30 years or older cohort (9.47 yr; 95% confidence interval [CI], 8.7-10.2) compared with the 18-29-year-old cohort (5.21 yr; 95% CI, 4.6-5.8). After adjusting for confounders, survival remained higher in recipients aged 30 years or older (hazard ratio, 0.44; 95% CI, 0.2-0.9). Mortality due to allograft failure was significantly lower in patients with CF aged 30 years or older (28% vs. 36.5%; odds ratio [OR], 0.7; 95% CI, 0.6-0.8), whereas the incidence of malignancy was higher in the 30 years or older cohort (8% vs. 2.9%; OR, 3.0; 95% CI, 1.9-4.6).Conclusions: Age at transplant influences lung transplant outcomes in recipients with CF. Subjects with CF aged 30 years or older at transplant have superior survival compared with adult subjects with CF transplanted between the ages 18 and 29 years.
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Ramos KJ, Sykes J, Stanojevic S, Ma X, Ostrenga JS, Fink A, Quon BS, Marshall BC, Faro A, Petren K, Elbert A, Goss CH, Stephenson AL. Survival and Lung Transplant Outcomes for Individuals With Advanced Cystic Fibrosis Lung Disease Living in the United States and Canada: An Analysis of National Registries. Chest 2021; 160:843-853. [PMID: 33878343 DOI: 10.1016/j.chest.2021.04.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 04/02/2021] [Accepted: 04/02/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Understanding how health outcomes differ for patients with advanced cystic fibrosis (CF) lung disease living in the United States compared with Canada has health policy implications. RESEARCH QUESTION What are rates of lung transplant (LTx) and rates of death without LTx in the United States and Canada among individuals with FEV1 < 40% predicted? STUDY DESIGN AND METHODS This was a retrospective population-based cohort study, 2005 to 2016, using the US CF Foundation, United Network for Organ Sharing, and Canadian CF registries. Individuals with CF and at least two FEV1 measurements < 40% predicted within a 5-year period, age ≥ 6 years, without prior LTx were included. Multivariable competing risk regression for time to death without LTx (LTx as a competing risk) and time to LTx (death as a competing risk) was performed. RESULTS There were 5,899 patients (53% male) and 905 patients (54% male) with CF with FEV1 < 40% predicted living in the United States and Canada, respectively. Multivariable competing risk regression models identified an increased risk of death without LTx (hazard ratio [HR], 1.79; 95% CI, 1.52-2.1) and decreased LTx (HR, 0.66; 95% CI, 0.58-0.74) among individuals in the United States compared with Canada. More pronounced differences were seen in the patients in the United States with Medicaid/Medicare insurance compared with Canadians (multivariable HR for death without LTx, 2.24 [95% CI, 1.89-2.64]; multivariable HR for LTx, 0.54 [95% CI, 0.47-0.61]). Patients of nonwhite race were also disadvantaged (multivariable HR for death without LTx, 1.56 [95% CI, 1.32-1.84]; multivariable HR for LTx, 0.47 [95% CI, 0.36-0.62]). INTERPRETATION There are lower rates of LTx and an increased risk of death without LTx for US patients with CF with FEV1 < 40% predicted compared with Canadian patients. Findings are more striking among US patients with CF with Medicaid/Medicare health insurance, and nonwhite patients in both countries, raising concerns about underuse of LTx among vulnerable populations.
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Affiliation(s)
- Kathleen J Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA.
| | - Jenna Sykes
- Division of Respirology, St. Michael's Hospital, Toronto, ON, Canada
| | - Sanja Stanojevic
- Translational Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Xiayi Ma
- Division of Respirology, St. Michael's Hospital, Toronto, ON, Canada
| | | | - Aliza Fink
- Cystic Fibrosis Foundation, Bethesda, MD
| | - Bradley S Quon
- Division of Respirology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | | | | | | | - Christopher H Goss
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, WA
| | - Anne L Stephenson
- Division of Respirology, St. Michael's Hospital, Toronto, ON, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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19
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Stephenson AL, Ramos KJ, Sykes J, Ma X, Stanojevic S, Quon BS, Marshall BC, Petren K, Ostrenga JS, Fink AK, Faro A, Elbert A, Chaparro C, Goss CH. Bridging the survival gap in cystic fibrosis: An investigation of lung transplant outcomes in Canada and the United States. J Heart Lung Transplant 2021; 40:201-209. [PMID: 33386232 PMCID: PMC7925420 DOI: 10.1016/j.healun.2020.12.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/13/2020] [Accepted: 12/03/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Previous literature in cystic fibrosis (CF) has shown a 10-year survival gap between Canada and the United States (US). We hypothesized that differential access to and survival after lung transplantation may contribute to the observed gap. The objectives of this study were to compare CF transplant outcomes between Canada and the US and estimate the potential contribution of transplantation to the survival gap. METHODS Data from the Canadian CF Registry and the US Cystic Fibrosis Foundation Patient Registry supplemented with data from United Network for Organ Sharing were used. The probability of surviving after transplantation between 2005 and 2016 was calculated using the Kaplan‒Meier method. Survival by insurance status at the time of transplantation and transplant center volume in the US were compared with those in Canada using Cox proportional hazard models. Simulations were used to estimate the contribution of transplantation to the survival gap. RESULTS Between 2005 and 2016, there were 2,653 patients in the US and 470 in Canada who underwent lung transplantation for CF. The 1-, 3-, and 5-year survival rates were 88.3%, 71.8%, and 60.3%, respectively, in the US compared with 90.5%, 79.9%, and 69.7%, respectively, in Canada. Patients in the US were also more likely to die on the waitlist (p < 0.01) than patients in Canada. If the proportion of who underwent transplantation and post-transplant survival in the US were to increase to those observed in Canada, we estimate that the survival gap would decrease from 10.8 years to 7.5 years. CONCLUSIONS Differences in waitlist mortality and post-transplant survival can explain up to a third of the survival gap observed between the US and Canada.
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Affiliation(s)
- Anne L Stephenson
- Department of Respirology, St Michael's Hospital, Toronto, Ontario, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
| | - Kathleen J Ramos
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, Washington
| | - Jenna Sykes
- Department of Respirology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Xiayi Ma
- Department of Respirology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Sanja Stanojevic
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Bradley S Quon
- Centre for Heart Lung Innovation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | - Albert Faro
- Cystic Fibrosis Foundation, Bethesda, Maryland
| | | | - Cecilia Chaparro
- Department of Respirology, St Michael's Hospital, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Christopher H Goss
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, Washington; Division of Pediatric Pulmonary, Department of Pediatrics, University of Washington Medical Center, Seattle, Washington
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20
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Frost F, Nazareth D, Shaw M, Al-Aloul M. Assessing the validity and applicability of the French 3-year prognostic score in the UK cystic fibrosis population - a national cohort study. Transpl Int 2021; 34:436-444. [PMID: 33486768 DOI: 10.1111/tri.13805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 08/11/2020] [Accepted: 12/14/2020] [Indexed: 12/01/2022]
Abstract
Models that predict outcomes, aid prognostication and inform the assessment of urgency for lung transplantation (LT) in CF are in demand. A prognostic score derived from the French adult CF registry to predict death or LT over 3-year follow-up was described in 2017 and validated using Canadian CF registry data. We assessed its performance in the UK CF population. The French prognostic score was applied to untransplanted adults with CF. The index year (2014) and outcomes (Death or LT) were evaluated to 2017. Receiver operator characteristics plots and area under curve (AUC) was computed. 4407 adults with CF met the inclusion criteria. After 3 years, 7.1% (P < 0.001) were dead or had received LT compared to the French (12.8%) and Canadian (9.4%) cohorts. The French score deemed 592 (26.2%) 'High-risk' - death/LT occurred in 189/592 (30.2%), less than previously reported in France and Canada (P < 0.0001). The discriminatory power of the French score was lower (AUC 0.830) than reported. Recalibration yielded only marginal improvement in model performance (AUC 0.833). The French prognostic score does not perform as well in the UK as reported elsewhere. Bespoke UK scores are needed to aid prognostication and inform LT decision-making.
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Affiliation(s)
- Freddy Frost
- Adult CF Unit, Liverpool Heart and Chest Hospital NHS Trust, Liverpool, UK
| | - Dilip Nazareth
- Adult CF Unit, Liverpool Heart and Chest Hospital NHS Trust, Liverpool, UK
| | - Matthew Shaw
- Liverpool Heart and Chest Hospital NHS Trust, Liverpool, UK
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21
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22
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Somayaji R, Nichols DP, Bell SC. Cystic fibrosis - Ten promising therapeutic approaches in the current era of care. Expert Opin Investig Drugs 2020; 29:1107-1124. [PMID: 32744089 DOI: 10.1080/13543784.2020.1805733] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Cystic fibrosis (CF) is a genetic disease affecting multiple organ systems. Research and innovations in novel therapeutic agents and health care delivery have resulted in dramatic improvements in quality of life and survival for people with CF. Despite this, significant disease burden persists for many and this is compounded by disparities in treatment access and care which globally necessitates further work to improve outcomes. Because of the advent of numerous therapies which include gene-targeted modulators in parallel with specialized care delivery models, innovative efforts continue. AREAS COVERED In this review, we discuss the available data on investigational agents in clinical development and currently available treatments for CF. We also evaluate approaches to care delivery, consider treatment gaps, and propose future directions for advancement. EXPERT OPINION Since the discovery of the CF gene, CFTR modulators have provided a hallmark of success, even though it was thought not previously possible. This has led to reinvigorated efforts and innovations in treatment approaches and care delivery. Numerous challenges remain because of genetic and phenotypic heterogeneity, access issues, and therapeutic costs, but the collaborative approach between stakeholders for continued innovation fuels optimism. Abbreviations: CF cystic fibrosis; CFF Cystic Fibrosis Foundation (USA); CFTR cystic fibrosis transmembrane regulator; CRISPR clustered regularly interspaced short palindromic repeats; COX cyclo oxygenase; FDA US Food and Drug Administration; FEV1% forced expiratory volume in one second % predicted; F508del deletion of phenylalanine (F) in the 508th position (most common mutation); G551D substitution of the amino acid glycine by aspartate at position 551 in the nucleotide binding domain-1 of the CFTR gene; LMIC low- and middle-income country; LTB4 leukotriene B4; MDT multi-disciplinary care team; NO nitric oxide; NSAIDs non-steroidal anti-inflammatory drugs; SLPI secretory leukocyte protease inhibitor.
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Affiliation(s)
- Ranjani Somayaji
- Departments of Medicine; Microbiology, Immunology & Infectious Disease; Community Health Sciences, University of Calgary , Calgary, AB, Canada.,Snyder Institute for Chronic Diseases , Calgary, AB, Canada.,O'Brien Institute for Public Health , Calgary, AB, Canada
| | - Dave P Nichols
- Department of Pediatrics, Seattle Children's Hospital , Seattle, WA, USA.,Department of Pediatrics, University of Washington , Seattle, WA, USA.,Seattle Children's Research Institute , Seattle, WA, USA
| | - Scott C Bell
- Department of Thoracic Medicine, The Prince Charles Hospital , Brisbane, QLD, Australia.,Children's Health Research Centre, Faculty of Medicine, The University of Queensland , Brisbane, QLD, Australia.,Translational Research Institute , Brisbane, QLD, Australia
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23
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A Systematic Review for Variables to Be Collected in a Transplant Database for Improving Risk Prediction. Transplantation 2020; 103:2591-2601. [PMID: 30768569 DOI: 10.1097/tp.0000000000002652] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND This systematic review was commissioned to identify new variables associated with transplant outcomes that are not currently collected by the Organ Procurement and Transplantation Network (OPTN). METHODS We identified 81 unique studies including 1 193 410 patients with median follow-up of 36 months posttransplant, reporting 108 unique risk factors. RESULTS Most risk factors (104) were recipient related; few (4) were donor related. Most risk factors were judged to be practical and feasible to routinely collect. Relative association measures were small to moderate for most risk factors (ranging between 1.0 and 2.0). The strongest relative association measure for a heart transplant outcome with a risk factor was 8.6 (recipient with the previous Fontan operation), for a kidney transplant 2.8 (sickle cell nephropathy as primary cause of end-stage renal disease), for a liver transplant 14.3 (recipient serum ferritin >500 µg/L), and for a lung transplant 6.3 (Burkholderia cepacia complex infection for 1 y or less). OPTN may consider some of these 108 variables for future collection to enhance transplant research and clinical care. CONCLUSIONS Evidence-based approaches can be used to determine variables collected in databases and registries. Several candidate variables have been identified for OPTN.
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Perez AA, Hays SR, Soong A, Gao Y, Greenland JR, Leard LE, Shah RJ, Golden J, Kukreja J, Venado A, Kleinhenz ME, Singer JP. Improvements in frailty contribute to substantial improvements in quality of life after lung transplantation in patients with cystic fibrosis. Pediatr Pulmonol 2020; 55:1406-1413. [PMID: 32237273 PMCID: PMC8048765 DOI: 10.1002/ppul.24747] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 03/07/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND While lung transplantation (LTx) improves health-related quality of life (HRQL) in cystic fibrosis (CF), the determinants of this improvement are unknown. In other populations, frailty-a syndrome of vulnerability to physiologic stressors-is associated with disability and poor HRQL. We hypothesized that improvements in frailty would be associated with improved disability and HRQL in adults with CF undergoing LTx. METHODS In a single-center prospective cohort study from 2010 to 2017, assessments of frailty, disability, and HRQL were performed before and at 3- and 6-months after LTx. We assessed frailty by the short physical performance battery (SPPB). We assessed disability with the Lung Transplant Valued Life Activities scale (LT-VLA) and HRQL by the Medical Outcomes Study Short Form Physical and Mental Component Summary scales (SF12-PCS, -MCS), the Airway Questionnaire 20-Revised (AQ20R), and the Euroqol 5D (EQ5D). We tested the association of concurrent changes in frailty and lung function on disability and HRQL by linear mixed-effects models adjusted for sex and body mass index. RESULTS Among 23 participants with CF, improvements in frailty and lung function were independently associated with improved disability and some HRQL measures. For example, each 1-point improvement in SPPB or 200 mL improvement in FEV1 was associated with improved LT-VLA disability by 0.14 (95%CI: 0.08-0.20) and 0.07 (95%CI: 0.05-0.09) points and improved EQ5D by 0.05 (95%CI: 0.03 to 0.07) and 0.02 (95%CI: 0.01-0.03) points, respectively. CONCLUSION Improvement in frailty is a novel determinant of improved disability and HRQL in adults with CF undergoing LTx.
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Affiliation(s)
- Alyssa A Perez
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Steven R Hays
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Allison Soong
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Ying Gao
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - John R Greenland
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Lorriana E Leard
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Rupal J Shah
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Jeffrey Golden
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Jasleen Kukreja
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Aida Venado
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Mary Ellen Kleinhenz
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Jonathan P Singer
- Department of Medicine, University of California San Francisco, San Francisco, California
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25
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Li SS, Saleh M, Xiang RF, Ogbomo H, Stack D, Huston SH, Mody CH. Natural killer cells kill Burkholderia cepacia complex via a contact-dependent and cytolytic mechanism. Int Immunol 2020; 31:385-396. [PMID: 31051036 DOI: 10.1093/intimm/dxz016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 04/19/2019] [Indexed: 12/15/2022] Open
Abstract
Burkholderia cepacia complex (Bcc), which includes B. cenocepacia and B. multivorans, pose a life-threatening risk to patients with cystic fibrosis. Eradication of Bcc is difficult due to the high level of intrinsic resistance to antibiotics, and failure of many innate immune cells to control the infection. Because of the pathogenesis of Bcc infections, we wondered if a novel mechanism of microbial host defense involving direct antibacterial activity by natural killer (NK) cells might play a role in the control of Bcc. We demonstrate that NK cells bound Burkholderia, resulting in Src family kinase activation as measured by protein tyrosine phosphorylation, granule release of effector proteins such as perforin and contact-dependent killing of the bacteria. These studies provide a means by which NK cells could play a role in host defense against Bcc infection.
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Affiliation(s)
- Shu Shun Li
- Department of Microbiology, Immunology and Infectious Diseases, Alberta, Canada.,The Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, Alberta, Canada
| | - Marwah Saleh
- Department of Microbiology, Immunology and Infectious Diseases, Alberta, Canada
| | - Richard F Xiang
- Department of Microbiology, Immunology and Infectious Diseases, Alberta, Canada.,The Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, Alberta, Canada
| | - Henry Ogbomo
- Department of Microbiology, Immunology and Infectious Diseases, Alberta, Canada.,The Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, Alberta, Canada
| | - Danuta Stack
- Department of Microbiology, Immunology and Infectious Diseases, Alberta, Canada.,The Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, Alberta, Canada
| | - Shaunna H Huston
- The Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, Alberta, Canada
| | - Christopher H Mody
- Department of Microbiology, Immunology and Infectious Diseases, Alberta, Canada.,The Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, Alberta, Canada.,Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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Lehr CJ, Skeans M, Dasenbrook E, Fink A, Fernandez G, Faro A, Valapour M. Effect of Including Important Clinical Variables on Accuracy of the Lung Allocation Score for Cystic Fibrosis and Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2020; 200:1013-1021. [PMID: 31199166 DOI: 10.1164/rccm.201902-0252oc] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Clinical variables associated with shortened survival in patients with advanced-stage cystic fibrosis (CF) are not included in the lung allocation score (LAS).Objectives: To identify variables associated with wait-list and post-transplant mortality for CF lung transplant candidates using a novel database and to analyze the impact of including new CF-specific variables in the LAS system.Methods: A deterministic matching algorithm identified patients from the Scientific Registry of Transplant Recipients and the Cystic Fibrosis Foundation Patient Registry. LAS wait-list and post-transplant survival models were recalculated using CF-specific variables. This multicenter, retrospective, population-based study of all lung transplant wait-list candidates aged 12 years or older from January 1, 2011, to December 31, 2014, included 9,043 patients on the lung transplant waiting list and 6,110 lung transplant recipients between 2011 and 2014, comprising 1,020 and 677 with CF, respectively.Measurements and Main Results: Measured outcomes were changes in LAS and lung allocation rank. For CF candidates, any Burkholderia sp. (hazard ratio [HR], 2.8; 95% confidence interval [CI], 1.2-6.6), 29-42 days hospitalized (HR 2.8; CI 1.3-5.9), massive hemoptysis (HR 2.1; CI 1.1-3.9), and relative drop in FEV1 ≥30% over 12 months (HR 1.7; CI 1.0-2.8) increased wait-list mortality risk; pulmonary exacerbation time 15-28 days (1.8; 1.1-2.9) increased post-transplant mortality risk. A relative drop in FEV1 ≥10% in chronic obstructive pulmonary disease (COPD) candidates was associated with increased wait-list mortality risk (HR 2.6; CI 1.2-5.4). Variability in LAS score and rank increased in patients with CF. Priority for transplant increased for COPD candidates. Access did not change for other diagnosis groups.Conclusions: Adding CF-specific variables improved discrimination among wait-listed CF candidates and benefited COPD candidates.
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Affiliation(s)
| | - Melissa Skeans
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota; and
| | - Elliott Dasenbrook
- Cleveland Clinic, Cleveland, Ohio.,Cystic Fibrosis Foundation, Bethesda, Maryland
| | - Aliza Fink
- Cystic Fibrosis Foundation, Bethesda, Maryland
| | | | - Albert Faro
- Cystic Fibrosis Foundation, Bethesda, Maryland
| | - Maryam Valapour
- Cleveland Clinic, Cleveland, Ohio.,Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota; and
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27
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Lung Transplantation for Cystic Fibrosis. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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28
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Abstract
Although survival of individuals with cystic fibrosis (CF) has been continuously improving for the past 40 years, respiratory failure secondary to recurrent pulmonary infections remains the leading cause of mortality in this patient population. Certain pathogens such as Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, and species of the Burkholderia cepacia complex continue to be associated with poorer clinical outcomes including accelerated lung function decline and increased mortality. In addition, other organisms such as anaerobes, viruses, and fungi are increasingly recognized as potential contributors to disease progression. Culture-independent molecular methods are also being used for diagnostic purposes and to examine the interaction of microorganisms in the CF airway. Given the importance of CF airway infections, ongoing initiatives to promote understanding of the epidemiology, clinical course, and treatment options for these infections are needed.
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Affiliation(s)
- Ana C Blanchard
- Division of Infectious Diseases, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Valerie J Waters
- Division of Infectious Diseases, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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29
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Chan EY, Nguyen DT, Kaleekal TS, Goodarzi A, Graviss EA, Gaber AO, Sinha N, Suarez EE, Bruckner BA, MacGillivray TE, Huang HJ, Yau SW. The Houston Methodist Lung Transplant Risk Model: A Validated Tool for Pretransplant Risk Assessment. Ann Thorac Surg 2019; 108:1094-1100. [DOI: 10.1016/j.athoracsur.2019.03.108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 03/25/2019] [Accepted: 03/26/2019] [Indexed: 10/26/2022]
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30
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Sidhaye A, Goldswieg B, Kaminski B, Blackman SM, Kelly A. Endocrine complications after solid-organ transplant in cystic fibrosis. J Cyst Fibros 2019; 18 Suppl 2:S111-S119. [DOI: 10.1016/j.jcf.2019.08.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/18/2019] [Accepted: 08/19/2019] [Indexed: 01/07/2023]
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31
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Lehr CJ, Blackstone EH, McCurry KR, Thuita L, Tsuang WM, Valapour M. Extremes of Age Decrease Survival in Adults After Lung Transplant. Chest 2019; 157:907-915. [PMID: 31419403 DOI: 10.1016/j.chest.2019.06.042] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/11/2019] [Accepted: 06/29/2019] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Age has been implicated as a factor in the plateau of long-term survival after lung transplant. METHODS We used data from the Scientific Registry of Transplant Recipients to identify all recipients of lung transplant aged ≥18 years of age between January 1, 2006, and February 19, 2015. A total of 14,253 patients were included in the analysis. Survival was estimated using a nonproportional hazard model and random-survival forest methodology was used to examine risk factors for death. Final selection of model variables was performed using bootstrap aggregation. Age was analyzed as both a continuous and categorical variable (age <30, 30-55, and >55 years). Risk factors for death were obtained for the entire cohort and additional age-specific risk factors were identified for each age category. RESULTS The median age at transplant was 59 years. There were 1,098 (7.7%) recipients <30 years, 4,201 (29.5%) 30 to 55 years, and 8,954 (62.8%) >55 years of age. Age was the most significant risk factor for death at all time-points following transplant and its impact becomes more prominent as time from transplant increases. Risk factors for death for all patients included extremes of age, higher creatinine, single lung transplant, hospitalization before transplant, and increased bilirubin. Risk factors for death differed by age with social determinants of health disproportionately affecting survival for those in the youngest age category. CONCLUSIONS The youngest and oldest adult recipients experienced the lowest posttransplant survival through divergent pathways that may present opportunities for intervention to improve survival after lung transplant.
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Affiliation(s)
- Carli J Lehr
- Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Eugene H Blackstone
- The Respiratory Institute, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Kenneth R McCurry
- The Respiratory Institute, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Lucy Thuita
- The Respiratory Institute, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
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Baklouti S, Massip C, Mane C, Guet-Revillet H, Murris M, Concordet D, Gandia P. Comment on: In vitro activity of seven β-lactams including ceftolozane/tazobactam and ceftazidime/avibactam against Burkholderia cepacia complex, Burkholderia gladioli and other non-fermentative Gram-negative bacilli isolated from cystic fibrosis patients. J Antimicrob Chemother 2019; 74:3122-3123. [DOI: 10.1093/jac/dkz307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Sarah Baklouti
- INTHERES, Université de Toulouse, INRA, ENVT, 23 Chemin des Capelles, BP 87614, Toulouse cedex 3, France
| | - Clémence Massip
- CHU de Toulouse, Laboratoire de Bactériologie-Hygiène, Institut Fédératif de Biologie, 330 avenue de Grande-Bretagne, 31059, Toulouse cedex 9, France
| | - Camille Mane
- INTHERES, Université de Toulouse, INRA, ENVT, 23 Chemin des Capelles, BP 87614, Toulouse cedex 3, France
| | - Hélène Guet-Revillet
- CHU de Toulouse, Laboratoire de Bactériologie-Hygiène, Institut Fédératif de Biologie, 330 avenue de Grande-Bretagne, 31059, Toulouse cedex 9, France
- Observatoire Burkholderia cepacia: CHU de Toulouse, Institut Fédératif de Biologie, 330 avenue de Grande-Bretagne, 31059 Toulouse cedex 9/Vaincre la Mucoviscidose, 181 rue de Tolbiac, Paris, France
| | - Marlène Murris
- CRCM, CHU Toulouse, Hôpital Larrey, Service de Pneumologie, 20 chemin de Pourvourville, TSA 30030, Toulouse cedex 9, France
| | - Didier Concordet
- INTHERES, Université de Toulouse, INRA, ENVT, 23 Chemin des Capelles, BP 87614, Toulouse cedex 3, France
| | - Peggy Gandia
- INTHERES, Université de Toulouse, INRA, ENVT, 23 Chemin des Capelles, BP 87614, Toulouse cedex 3, France
- CHU de Toulouse, Laboratoire de Pharmacocinétique et Toxicologie Clinique, Institut Fédératif de Biologie, 330 avenue de Grande-Bretagne, Toulouse cedex 9, France
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Mainbourg S, Philit F, Touzet S, Nove-Josserand R, Durupt S, Sénéchal A, Occelli P, Poupon-Bourdy S, Maury JM, Tronc F, Mornex JF, Durieu I, Reynaud Q. Cystic fibrosis-related diabetes before lung transplantation is associated with lower survival but does not affect long-term renal function. Pediatr Pulmonol 2019; 54:977-983. [PMID: 30854801 DOI: 10.1002/ppul.24307] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 02/10/2019] [Accepted: 02/12/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To describe the prevalence of cystic fibrosis-related diabetes (CFRD) before and after lung transplantation (LT); to analyse the survival and renal function after LT according to the CFRD status before LT. METHODS Sixty cystic fibrosis (CF) patients transplanted at the Lyon University Hospital between 2004 and 2014 were included. Genotype, pancreatic status, age at LT, survival were recorded. Glucose tolerance status, daily insulin dose requirement, glomerular filtration rate (GFR), and daily glucocorticoid (GC) dose were recorded before LT and until December 2016. RESULTS The median follow-up was 5.6 (3.8-8.2) years, and nine patients died. Survival was poorest for patients with CFRD before LT compared with those without CFRD (P = 0.03) but was not correlated with the GFR before LT, with sex, age at LT, or CF genotype. The prevalence of CFRD was 68% at 2 years and 54% at 5 years. For persistent insulin-treated CFRD, the insulin requirement decreased (-2.1 IU/d/y; P < 0.01) and was correlated with the daily GC dose (+0.4 IU/d for one additional milligram, P = 0.012). Seven (11%) patients who had insulin-treated CFRD before LT became nondiabetic after LT, with a median time of 2 (1-4) years. After LT, the GFR decreased (-5.3 ml/min/1.73 m 2 /y; P < 0.001) and was not correlated with the CFRD status before LT. CONCLUSIONS CFRD before LT is associated with poor survival after LT, which should lead to better management of diabetes. Some patients with pre-LT CFRD became nondiabetic after LT. CFRD is not associated with renal insufficiency after LT.
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Affiliation(s)
- Sabine Mainbourg
- Department of Internal Medicine, Adult Cystic Fibrosis Care Center, Hospices Civils de Lyon, Lyon, France.,EA HESPER 7425, Université Claude Bernard Lyon 1, Lyon, France
| | - François Philit
- Department of Respiratory Medicine, National Reference Centre for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Sandrine Touzet
- Department of Public Health, Hospices Civils de Lyon, Lyon, France
| | - Raphaele Nove-Josserand
- Department of Internal Medicine, Adult Cystic Fibrosis Care Center, Hospices Civils de Lyon, Lyon, France.,EA HESPER 7425, Université Claude Bernard Lyon 1, Lyon, France
| | - Stéphane Durupt
- Department of Internal Medicine, Adult Cystic Fibrosis Care Center, Hospices Civils de Lyon, Lyon, France.,EA HESPER 7425, Université Claude Bernard Lyon 1, Lyon, France
| | - Agathe Sénéchal
- Department of Respiratory Medicine, National Reference Centre for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Pauline Occelli
- Department of Public Health, Hospices Civils de Lyon, Lyon, France
| | | | - Jean-Michel Maury
- Department of Thoracic Surgery, Lung and Heart-Lung Transplantation, Hospices Civils de Lyon, Louis Pradel Hospital, Lyon, France
| | - François Tronc
- Department of Thoracic Surgery, Lung and Heart-Lung Transplantation, Hospices Civils de Lyon, Louis Pradel Hospital, Lyon, France
| | - Jean-François Mornex
- Department of Respiratory Medicine, National Reference Centre for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France.,UMR 754 IVPC, INRA, Université Lyon 1, Lyon, France
| | - Isabelle Durieu
- Department of Internal Medicine, Adult Cystic Fibrosis Care Center, Hospices Civils de Lyon, Lyon, France.,EA HESPER 7425, Université Claude Bernard Lyon 1, Lyon, France
| | - Quitterie Reynaud
- Department of Internal Medicine, Adult Cystic Fibrosis Care Center, Hospices Civils de Lyon, Lyon, France.,EA HESPER 7425, Université Claude Bernard Lyon 1, Lyon, France
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34
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Winstead RJ, Waldman G, Autry EB, Evans RA, Schadler A, Kays L, Baz M, Anstead MI, Shafii A, Goetz ME. Outcomes of Lung Transplantation for Cystic Fibrosis in the Setting of Extensively Drug-Resistant Organisms. Prog Transplant 2019; 29:220-224. [DOI: 10.1177/1526924819853830] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Introduction: Since the largest study on extensively drug-resistant organisms and lung transplantation in patients with cystic fibrosis, there have been innovations and advancements in the treatment of Pseudomonas aeruginosa. Research Question: What differences exist for patients with cystic fibrosis with a history of extensively drug-resistant infections who undergo lung transplantation despite treatment advances with antimicrobial therapy? Study Design: Two-center, retrospective, cohort study conducted in 44 patients with cystic fibrosis chronically infected with extensively drug-resistant organisms who received a lung transplant from January 2008 through August 2016. Patients in the resistant cohort were chronically infected with pan-resistant P aeruginosa, polymyxin-sensitive only, or sensitive to 2 antibiotic classes (polymyxin plus one other); remaining patients with more susceptible P aeruginosa or no P aeruginosa remained in the control cohort. The primary outcome is a composite of patient survival, retransplantation, chronic lung allograft dysfunction, and acute rejection 12 months posttransplant. Categorical variables were analyzed using χ2 testing. The independent samples t test was utilized for continuous variables. Results: There was no difference in the primary outcome (40% vs 37%, P = .831). Differences between patient survival (84% vs 95%, P = .487), the incidence of acute rejection (20% vs 33%, P = .323), and the incidence of chronic lung allograft rejection (12% vs 5%, P = .441) were not different between groups. Discussion: Recipients chronically infected with an extensively resistant P aeruginosa had similar outcomes compared to those infected with more sensitive organisms.
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Affiliation(s)
| | | | - Elizabeth B. Autry
- University of Kentucky Healthcare, Lexington, KY, USA
- University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Rickey A. Evans
- University of South Carolina College of Pharmacy, Columbia, SC, USA
| | - Aric Schadler
- University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Lindsey Kays
- University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Maher Baz
- University of Kentucky Healthcare, Lexington, KY, USA
| | | | - Alexis Shafii
- University of Kentucky Healthcare, Lexington, KY, USA
| | - Megan E. Goetz
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
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35
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Ramos KJ, Smith PJ, McKone EF, Pilewski JM, Lucy A, Hempstead SE, Tallarico E, Faro A, Rosenbluth DB, Gray AL, Dunitz JM. Lung transplant referral for individuals with cystic fibrosis: Cystic Fibrosis Foundation consensus guidelines. J Cyst Fibros 2019; 18:321-333. [PMID: 30926322 PMCID: PMC6545264 DOI: 10.1016/j.jcf.2019.03.002] [Citation(s) in RCA: 122] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 03/08/2019] [Accepted: 03/09/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Provide recommendations to the cystic fibrosis (CF) community to facilitate timely referral for lung transplantation for individuals with CF. METHODS The CF Foundation organized a multidisciplinary committee to develop CF Lung Transplant Referral Consensus Guidelines. Three workgroups were formed: timing for transplant referral; modifiable barriers to transplant; and transition to transplant care. A focus group of lung transplant recipients with CF and spouses of CF recipients informed guideline development. RESULTS The committee formulated 21 recommendation statements based on literature review, committee member practices, focus group insights, and in response to public comment. Critical approaches to optimizing access to lung transplant include early discussion of this treatment option, assessment for modifiable barriers to transplant, and open communication between the CF and lung transplant centers. CONCLUSIONS These guidelines will help CF providers counsel their patients and may reduce the number of individuals with CF who die without consideration for lung transplant.
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Affiliation(s)
- Kathleen J Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Dept of Medicine, University of Washington, Seattle, WA, USA.
| | - Patrick J Smith
- Department of Psychiatry and Behavioral Sciences, Behavioral Medicine Division, Department of Medicine, Pulmonary Division, Duke University Medical Center, Durham, NC, USA.
| | - Edward F McKone
- National Referral Centre for Adult Cystic Fibrosis, St. Vincent's University Hospital, Dublin, Ireland.
| | - Joseph M Pilewski
- Division of Pulmonary, Allergy & Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Amy Lucy
- Cystic Fibrosis Foundation, Bethesda, MD, USA
| | | | | | - Albert Faro
- Cystic Fibrosis Foundation, Bethesda, MD, USA.
| | - Daniel B Rosenbluth
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Washington University School of Medicine, St. Louis, MO, USA.
| | - Alice L Gray
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA.
| | - Jordan M Dunitz
- Division of Pulmonary, Allergy, Critical Care Medicine and Sleep, Dept of Medicine, University of Minnesota, Minneapolis, MN, USA.
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36
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Koutsokera A, Varughese RA, Sykes J, Orchanian-Cheff A, Shah PS, Chaparro C, Tullis E, Singer LG, Stephenson AL. Pre-transplant factors associated with mortality after lung transplantation in cystic fibrosis: A systematic review and meta-analysis. J Cyst Fibros 2019; 18:407-415. [DOI: 10.1016/j.jcf.2018.10.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 10/16/2018] [Accepted: 10/17/2018] [Indexed: 01/17/2023]
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37
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Perez AA, Singer JP, Schwartz BS, Chin‐Hong P, Shah RJ, Kleinhenz ME, Gao Y, Venado A, Leard LE, Golden JA, Kukreja J, Greenland JR, Hays SR. Management and clinical outcomes after lung transplantation in patients with pre‐transplant
Mycobacterium abscessus
infection: A single center experience. Transpl Infect Dis 2019; 21:e13084. [DOI: 10.1111/tid.13084] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/01/2019] [Accepted: 03/17/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Alyssa A. Perez
- Department of Medicine University of California San Francisco
| | | | | | - Peter Chin‐Hong
- Department of Medicine University of California San Francisco
| | - Rupal J. Shah
- Department of Medicine University of California San Francisco
| | | | - Ying Gao
- Department of Medicine University of California San Francisco
| | - Aida Venado
- Department of Medicine University of California San Francisco
| | | | | | - Jasleen Kukreja
- Department of Surgery University of California San Francisco
| | | | - Steven R. Hays
- Department of Medicine University of California San Francisco
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38
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Decontamination and Lung Transplantation of a Patient With Cystic Fibrosis With Resistant Infections. Ann Thorac Surg 2019; 107:e239-e241. [DOI: 10.1016/j.athoracsur.2018.08.058] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/29/2018] [Accepted: 08/17/2018] [Indexed: 11/22/2022]
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Abstract
BACKGROUND Cystic fibrosis (CF) is an inherited, chronic, progressive condition affecting around 10,000 individuals in the United Kingdom and over 70,000 worldwide. Survival in CF has improved considerably over recent decades, and it is important to provide up-to-date information on patient prognosis. METHODS The UK Cystic Fibrosis Registry is a secure centralized database, which collects annual data on almost all CF patients in the United Kingdom. Data from 43,592 annual records from 2005 to 2015 on 6181 individuals were used to develop a dynamic survival prediction model that provides personalized estimates of survival probabilities given a patient's current health status using 16 predictors. We developed the model using the landmarking approach, giving predicted survival curves up to 10 years from 18 to 50 years of age. We compared several models using cross-validation. RESULTS The final model has good discrimination (C-indexes: 0.873, 0.843, and 0.804 for 2-, 5-, and 10-year survival prediction) and low prediction error (Brier scores: 0.036, 0.076, and 0.133). It identifies individuals at low and high risk of short- and long-term mortality based on their current status. For patients 20 years of age during 2013-2015, for example, over 80% had a greater than 95% probability of 2-year survival and 40% were predicted to survive 10 years or more. CONCLUSIONS Dynamic personalized prediction models can guide treatment decisions and provide personalized information for patients. Our application illustrates the utility of the landmarking approach for making the best use of longitudinal and survival data and shows how models can be defined and compared in terms of predictive performance.
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40
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Lay C, Law N, Holm AM, Benden C, Aslam S. Outcomes in cystic fibrosis lung transplant recipients infected with organisms labeled as pan-resistant: An ISHLT Registry‒based analysis. J Heart Lung Transplant 2019; 38:545-552. [PMID: 30733155 DOI: 10.1016/j.healun.2019.01.1306] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 01/09/2019] [Accepted: 01/22/2019] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The presence of pan-resistant organisms in patients with cystic fibrosis (CF) potentially impacts mortality after lung transplant (LT). In this study we aimed to study LT mortality in CF patients with and without pan-resistant infection. METHODS The International Society for Heart and Lung Transplantation (ISHLT) Thoracic Transplant Registry was used to identify adults with CF, first-time, bilateral LT from 1991 to 2015. Extracted data included demographics, clinical characteristics, post-transplant outcomes, and mortality (infection-related, overall). Multivariate binary logistic regression models were created with 90-day and 1-year mortality as primary outcomes. RESULTS Among 3,256 LT recipients with CF, 697 were labeled as having pan-resistant infection, the others were included as controls (n = 2,649). Pre-transplant, those labeled as pan-resistant were more likely to require ventilator support, have an infection requiring intravenous antibiotics, and have had ≥2 pneumonia episodes within 1 year. Ninety-day and 1-year mortality was similar between groups, but infection-related mortality at 90days (3.3% vs 1.88%, p = 0.01) and 1 year (6.6% vs 4.6%, p < 0.001) was higher in those labeled as pan-resistant. In multivariate analysis, presence of organisms labeled as pan-resistant was not associated with 90-day (odds ratio [OR] 1.5, 95% confidence interval [CI] 0.93 to 2.42, p = 0.09) or 1-year mortality (OR 1.32, 95% CI 0.95 to 1.83, p = 0.097). CONCLUSIONS CF patients with pre-transplant infection from organisms labeled as pan-resistant had similar 90-day and 1-year mortality as those without. Despite increased infection-related mortality in these patients, it was not predictive of mortality in multivariate analysis. The higher occurrence of post-transplant infections in these patients warrants diligent follow-up. A multicenter cohort study will be required to validate the findings of our study.
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Affiliation(s)
- Cecilia Lay
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, USA
| | - Nancy Law
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, USA
| | - Are Martin Holm
- Department of Respiratory Medicine, University of Oslo, Oslo, Norway
| | - Christian Benden
- Division of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Saima Aslam
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, USA.
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Cantón‐Bulnes ML, Hurtado Martínez Á, López‐Cerero L, Arenzana Seisdedos Á, Merino‐Bohorquez V, Garnacho‐Montero J. A case of pan‐resistant
Burkholderia cepacia complex
bacteremic pneumonia, after lung transplantation treated with a targeted combination therapy. Transpl Infect Dis 2019; 21:e13034. [DOI: 10.1111/tid.13034] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 11/25/2018] [Accepted: 12/03/2018] [Indexed: 11/27/2022]
Affiliation(s)
| | | | - Lorena López‐Cerero
- Unidad de Microbiología Clínica y Enfermedades Infecciosas, Hospital Universitario Virgen Macarena Sevilla Spain
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Diaz Caballero J, Clark ST, Wang PW, Donaldson SL, Coburn B, Tullis DE, Yau YCW, Waters VJ, Hwang DM, Guttman DS. A genome-wide association analysis reveals a potential role for recombination in the evolution of antimicrobial resistance in Burkholderia multivorans. PLoS Pathog 2018; 14:e1007453. [PMID: 30532201 PMCID: PMC6300292 DOI: 10.1371/journal.ppat.1007453] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 12/19/2018] [Accepted: 11/02/2018] [Indexed: 01/05/2023] Open
Abstract
Cystic fibrosis (CF) lung infections caused by members of the Burkholderia cepacia complex, such as Burkholderia multivorans, are associated with high rates of mortality and morbidity. We performed a population genomics study of 111 B. multivorans sputum isolates from one CF patient through three stages of infection including an early incident isolate, deep sampling of a one-year period of chronic infection occurring weeks before a lung transplant, and deep sampling of a post-transplant infection. We reconstructed the evolutionary history of the population and used a lineage-controlled genome-wide association study (GWAS) approach to identify genetic variants associated with antibiotic resistance. We found the incident isolate was basally related to the rest of the strains and more susceptible to antibiotics from three classes (β-lactams, aminoglycosides, quinolones). The chronic infection isolates diversified into multiple, distinct genetic lineages and showed reduced antimicrobial susceptibility to the same antibiotics. The post-transplant reinfection isolates derived from the same source as the incident isolate and were genetically distinct from the chronic isolates. They also had a level of susceptibility in between that of the incident and chronic isolates. We identified numerous examples of potential parallel pathoadaptation, in which multiple mutations were found in the same locus or even codon. The set of parallel pathoadaptive loci was enriched for functions associated with virulence and resistance. Our GWAS analysis identified statistical associations between a polymorphism in the ampD locus with resistance to β-lactams, and polymorphisms in an araC transcriptional regulator and an outer membrane porin with resistance to both aminoglycosides and quinolones. Additionally, these three loci were independently mutated four, three and two times, respectively, providing further support for parallel pathoadaptation. Finally, we identified a minimum of 14 recombination events, and observed that loci carrying putative parallel pathoadaptations and polymorphisms statistically associated with β-lactam resistance were over-represented in these recombinogenic regions. Cystic fibrosis (CF) is the most common lethal genetic disorder affecting individuals of European descent. Most CF patients die at a young age due to chronic lung infections. Among the organisms involved in these infections are bacteria from the Burkholderia cepacia complex (BCC), which are strongly associated with poor clinical prognosis. This study examines how the most prevalent BCC species among CF patients, B. multivorans, evolves within a single CF patient by studying the first B. multivorans isolate recovered from the patient, one hundred isolates recovered over a one year period during the chronic infection phase, and an additional ten isolates recovered after the reinfection of the transplanted lungs. We found that B. multivorans diversify phenotypically and genetically within the CF lung over the course of the infection, and evolves into a complex population during the chronic infection phase. We found that isolates collected from the post-transplant reinfection were more closely related to descendants of the original isolate rather than those recovered in the chronic infection. We identify genetic variants statistically associated with resistance to the antibiotics, and showed that some of these variants were found in regions that show patterns of recombination (genetic exchange) between strains. We also found that genes which were mutated multiple times during overall infection were more likely to be found in regions showing signals consistent with recombination. The presence of multiple independent mutations in a gene is a very strong signal that the gene helps bacteria adapt to their environment. Overall, this study provides insight into how pathogens adapt to the host during long-term infections, specific genes associated with antibiotic resistance, and the origin of new and recurrent infections.
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Affiliation(s)
- Julio Diaz Caballero
- Department of Cell and Systems Biology, University of Toronto, Toronto, Ontario, Canada
| | - Shawn T. Clark
- Latner Thoracic Surgery Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Pauline W. Wang
- Centre for the Analysis of Genome Evolution and Function, University of Toronto, Toronto, Ontario, Canada
| | - Sylva L. Donaldson
- Centre for the Analysis of Genome Evolution and Function, University of Toronto, Toronto, Ontario, Canada
| | - Bryan Coburn
- Division of Infectious Diseases, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - D. Elizabeth Tullis
- Adult Cystic Fibrosis Clinic, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Yvonne C. W. Yau
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatric Laboratory Medicine, Division of Microbiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Valerie J. Waters
- Department of Pediatrics, Division of Infectious Diseases, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - David M. Hwang
- Latner Thoracic Surgery Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
- Department of Pathology, University Health Network, Toronto, Ontario, Canada
| | - David S. Guttman
- Department of Cell and Systems Biology, University of Toronto, Toronto, Ontario, Canada
- Centre for the Analysis of Genome Evolution and Function, University of Toronto, Toronto, Ontario, Canada
- * E-mail:
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Sharma D, Xing S, Hung YT, Caskey RN, Dowell ML, Touchette DR. Cost-effectiveness analysis of lumacaftor and ivacaftor combination for the treatment of patients with cystic fibrosis in the United States. Orphanet J Rare Dis 2018; 13:172. [PMID: 30268148 PMCID: PMC6162947 DOI: 10.1186/s13023-018-0914-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 09/12/2018] [Indexed: 01/12/2023] Open
Abstract
Background Lumacaftor/ivacaftor was approved by the Food and Drug Administration (FDA) as a combination treatment for Cystic Fibrosis (CF) patients who are homozygous for the F508del mutation. The objective of this study was to assess the cost-effectiveness of lumacaftor/ivacaftor combination for the treatment of CF homozygous for F508del CF Transmembrane Conductance Regulator (CFTR) mutation. Methods A Markov-state transition model following a cohort of 12 year-old CF patients homozygous for F508del CFTR mutation in the United States (US) over two, four, six, eight and ten years from a payer’s perspective was developed using TreeAge Pro 2016. Markov states included: mild (percentage of predicted forced expiratory volume in 1 s or FEV1 > 70%), moderate (FEV1 40–70%), severe (FEV1 < 40%) disease, post-transplant, and death. Pulmonary exacerbation and lung transplant were included as transition states. All the input parameters were estimated from the literature. A 1-year cycle length and 3% discount rate were applied. To assess uncertainty in long-term treatment effects, several scenarios were modelled: 100% long-term effectiveness (base-case), defined as improvement in FEV1 in the first year followed by no annual FEV1 decline and a constant reduction in pulmonary exacerbations throughout, 75%, 50%, 25% and 0% (worst case) long-term effectiveness, where treatment effects were intermediate from the second year of treatment until the end of the time horizon. Other scenarios included changing the starting age of the cohort to 6 and 25 years. Primary outcome included incremental cost-effectiveness ratio (ICER) in terms of cost per quality adjusted life year (QALY) gained. One-way and probabilistic sensitivity analyses were performed to determine uncertainty. Results Under the base-case, Lumacaftor/ivacaftor resulted in higher QALYs (7.29 vs 6.84) but at a very high cost ($1,778,920.88) compared to usual care ($116,155.76) over a 10-year period. The ICER for base-case and worst-case scenarios were $3,655,352 / QALY, and $8,480,265/QALY gained, respectively. In the base-case, lumacaftor/ivacaftor was cost-effective at a threshold of $150,000/QALY-gained when annual drug costs were lower than $4153. The results were not substantially affected by the sensitivity analyses. Conclusions The intervention produces large QALY gains but at an extremely high cost, resulting in an ICER that would not typically be covered by any insurer. Lumacaftor/ivacaftor’s status as an orphan drug complicates coverage decisions.
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Affiliation(s)
- Dolly Sharma
- Department of Pharmacy Systems, Outcomes & Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Shan Xing
- Department of Pharmacy Systems, Outcomes & Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Yu-Ting Hung
- Department of Pharmacy Systems, Outcomes & Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Rachel N Caskey
- Departments of Internal Medicine and Pediatrics, University of Illinois at Chicago, Chicago, IL, USA
| | - Maria L Dowell
- Section of Pulmonary and Sleep Medicine, Department of Pediatrics, The University of Chicago, Chicago, IL, USA
| | - Daniel R Touchette
- Department of Pharmacy Systems, Outcomes & Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA.
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Li SS, Tumin D, Krone KA, Boyer D, Kirkby SE, Mansour HM, Hayes D. Risks associated with lung transplantation in cystic fibrosis patients. Expert Rev Respir Med 2018; 12:893-904. [PMID: 30198350 DOI: 10.1080/17476348.2018.1522254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Survival after lung transplantation lags behind outcomes of other solid organ transplants, and complications from lung transplant are the second most common cause of death in cystic fibrosis. Evolving surgical techniques, therapeutics, and perioperative management have improved short-term survival after lung transplantation, yet have not translated into significant improvement in long-term mortality. Areas covered: We review risk factors for poor long-term outcomes among patients with cystic fibrosis undergoing lung transplantation to highlight areas for improvement. This includes reasons for organ dysfunction, complications of immunosuppression, further exacerbation of extrapulmonary complications of cystic fibrosis, and quality of life. A literature search was performed using PubMed-indexed journals. Expert commentary: There are multiple medical and socioeconomic barriers that threaten long-term survival following lung transplant for patients with cystic fibrosis. An understanding of the causes of each could elucidate treatment options. There is a lack of prospective, multicenter, randomized control trials due to cost, complexity, and feasibility. Ongoing prospective studies should be reserved for the most promising interventions identified in retrospective studies in order to improve long-term outcomes.
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Affiliation(s)
- Susan S Li
- a Department of Pediatrics, Nationwide Children's Hospital , The Ohio State University College of Medicine , Columbus , OH , USA
| | - Dmitry Tumin
- a Department of Pediatrics, Nationwide Children's Hospital , The Ohio State University College of Medicine , Columbus , OH , USA
| | - Katie A Krone
- b Division of Respiratory Diseases, Boston Children's Hospital , Harvard Medical School , Boston , MA, OH , USA
| | - Debra Boyer
- b Division of Respiratory Diseases, Boston Children's Hospital , Harvard Medical School , Boston , MA, OH , USA
| | - Stephen E Kirkby
- a Department of Pediatrics, Nationwide Children's Hospital , The Ohio State University College of Medicine , Columbus , OH , USA
| | - Heidi M Mansour
- c Department of Pharmacology and Toxicology , The University of Arizona Colleges of Pharmacy and Medicine , Tucson , AZ , USA
| | - Don Hayes
- a Department of Pediatrics, Nationwide Children's Hospital , The Ohio State University College of Medicine , Columbus , OH , USA
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45
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Savi D, Mordenti M, Bonci E, Troiani P, Giordani B, D'Alù V, Bertasi S, Cimino G, Rossi P, Poggi C, Palange P, Quattrucci S. Survival After Lung Transplant for Cystic Fibrosis in Italy: A Single Center Experience With 20 Years of Follow-up. Transplant Proc 2018; 50:3732-3738. [PMID: 30577264 DOI: 10.1016/j.transproceed.2018.08.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 08/16/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Lung transplantation is currently the only treatment for end-stage respiratory failure in patients with cystic fibrosis (CF). In this study we retrospectively analyzed our experience since the start of the transplantation program in 1996 with focus on survival analysis. METHODS All patients with CF who underwent lung transplant at our center were included (1996-2016). Survival analysis after lung transplant was performed using the Kaplan-Meier estimate, comparing by sex and by 4 eras (1996-2000, 2001-2005, 2006-2010, and 2011-2016). RESULTS In a 20-year period, 243 patients with CF were listed for lung transplant; 123 patients (61 male, 62 female) underwent transplant, and 85 died while waiting for donor organs. The mean (SD) and median age at transplant was 27.7 (8.7) years and 26.9 years (range, 9.1 - 52.1 years), respectively. Mean (SD) forced expiratory volume in the first second was 27.6 (9.7)% predicted; 115 patients (92.0%) were pancreatic insufficient, and 43 patients (34.0%) had CF-related diabetes. Removing patients with CF who died within the first 3 postoperative months, the mean (SD) and median survival after transplant were 8.2 (5.7) years and 7.5 years (range, 3 months-20 years), respectively. Overall post-lung transplant 1-year survival was 93.6%, 5-year survival was 71.4%, 10-year survival was 53.6%, 15-year survival was 36.7%, and 20-year survival was 31.6%. We found no difference in survival between sex (P = .22) and among the 4 eras (P = .56). CONCLUSIONS Survival after lung transplant in our single center is similar to international data.
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Affiliation(s)
- D Savi
- Department of Public Health and Infectious Diseases, Adult Cystic Fibrosis Center, Sapienza University of Rome, Italy; Cystic Fibrosis Unit, Bambino Gesù Children's Hospital, Rome, Italy.
| | - M Mordenti
- Department of Public Health and Infectious Diseases, Adult Cystic Fibrosis Center, Sapienza University of Rome, Italy
| | - E Bonci
- Department of Experimental Medicine, Sapienza University of Rome, Italy
| | - P Troiani
- Department of Pediatrics, Cystic Fibrosis Center, Sapienza University of Rome, Italy
| | - B Giordani
- Lega Italiana Fibrosi Cistica ONLUS-LIFC, Rome, Italy
| | - V D'Alù
- Department of Public Health and Infectious Diseases, Adult Cystic Fibrosis Center, Sapienza University of Rome, Italy
| | - S Bertasi
- Department of Pediatrics, Cystic Fibrosis Center, Sapienza University of Rome, Italy
| | - G Cimino
- Department of Public Health and Infectious Diseases, Adult Cystic Fibrosis Center, Sapienza University of Rome, Italy
| | - P Rossi
- Department of Pediatrics, Cystic Fibrosis Center, Sapienza University of Rome, Italy
| | - C Poggi
- Department of General Surgery and Organ Transplant, Division of Thoracic Surgery, Sapienza University of Rome, Italy
| | - P Palange
- Department of Public Health and Infectious Diseases, Adult Cystic Fibrosis Center, Sapienza University of Rome, Italy
| | - S Quattrucci
- Department of Pediatrics, Cystic Fibrosis Center, Sapienza University of Rome, Italy
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White donor, younger donor and double lung transplant are associated with better survival in sarcoidosis patients. Sci Rep 2018; 8:6968. [PMID: 29725035 PMCID: PMC5934355 DOI: 10.1038/s41598-018-25144-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 04/11/2018] [Indexed: 01/03/2023] Open
Abstract
Sarcoidosis commonly affects the lung. Lung transplantation (LT) is required when there is a severe and refractory involvement. We compared post-transplant survival rates of sarcoidosis patients with chronic obstructive pulmonary disease (COPD) and idiopathic pulmonary fibrosis (IPF). We also explored whether the race and age of the donor, and double lung transplant have any effect on the survival in the post transplant setting. We analyzed 9,727 adult patients with sarcoidosis, COPD, and IPF who underwent LT worldwide between 2005–2015 based on United Network for Organ Sharing (UNOS) database. Survival rates were compared with Kaplan-Meier, and risk factors were investigated by Cox-regression analysis. 469 (5%) were transplanted because of sarcoidosis, 3,688 (38%) for COPD and 5,570 (57%) for IPF. Unadjusted survival analysis showed a better post-transplant survival rate for patients with sarcoidosis (p < 0.001, Log-rank test). In Cox-regression analysis, double lung transplant and white race of the lung donor showed to have a significant survival advantage. Since double lung transplant, those who are younger and have lower Lung Allocation Score (LAS) at the time of transplant have a survival advantage, we suggest double lung transplant as the procedure of choice, especially in younger sarcoidosis subjects and with lower LAS scores.
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47
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Castellani C, Duff AJA, Bell SC, Heijerman HGM, Munck A, Ratjen F, Sermet-Gaudelus I, Southern KW, Barben J, Flume PA, Hodková P, Kashirskaya N, Kirszenbaum MN, Madge S, Oxley H, Plant B, Schwarzenberg SJ, Smyth AR, Taccetti G, Wagner TOF, Wolfe SP, Drevinek P. ECFS best practice guidelines: the 2018 revision. J Cyst Fibros 2018; 17:153-178. [PMID: 29506920 DOI: 10.1016/j.jcf.2018.02.006] [Citation(s) in RCA: 435] [Impact Index Per Article: 72.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 01/26/2018] [Accepted: 02/08/2018] [Indexed: 12/12/2022]
Abstract
Developments in managing CF continue to drive dramatic improvements in survival. As newborn screening rolls-out across Europe, CF centres are increasingly caring for cohorts of patients who have minimal lung disease on diagnosis. With the introduction of mutation-specific therapies and the prospect of truly personalised medicine, patients have the potential to enjoy good quality of life in adulthood with ever-increasing life expectancy. The landmark Standards of Care published in 2005 set out what high quality CF care is and how it can be delivered throughout Europe. This underwent a fundamental re-write in 2014, resulting in three documents; center framework, quality management and best practice guidelines. This document is a revision of the latter, updating standards for best practice in key aspects of CF care, in the context of a fast-moving and dynamic field. In continuing to give a broad overview of the standards expected for newborn screening, diagnosis, preventative treatment of lung disease, nutrition, complications, transplant/end of life care and psychological support, this consensus on best practice is expected to prove useful to clinical teams both in countries where CF care is developing and those with established CF centres. The document is an ECFS product and endorsed by the CF Network in ERN LUNG and CF Europe.
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Affiliation(s)
- Carlo Castellani
- Cystic Fibrosis Centre, Azienda Ospedaliera Universitaria Integrata Verona, Italy; Cystic Fibrosis Centre, Gaslini Institute, Genoa, Italy
| | - Alistair J A Duff
- Regional Paediatric CF Unit, Leeds General Infirmary Leeds, UK; Department of Clinical & Health Psychology, St James' University Hospital, Leeds, UK.
| | - Scott C Bell
- Adult Cystic Fibrosis Centre, The Prince Charles Hospital, Brisbane, Australia
| | - Harry G M Heijerman
- Dept of Pulmonology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anne Munck
- Hopital Robert Debré Assistante publique-Hôpitaux de Paris, Université Paris 7, Pediatric CF Centre, Paris, France
| | - Felix Ratjen
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Canada
| | - Isabelle Sermet-Gaudelus
- Service de Pneumologie et Allergologie Pédiatriques, Centre de Ressources et de Compétence de la Mucoviscidose, Institut Necker Enfants Malades/INSERM U1151 Hôpital Necker Enfants Malades, P, France
| | - Kevin W Southern
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Jurg Barben
- Ostschweizer Kinderspital Sankt Gallen, Claudiusstrasse 6, 9006 St. Gallen, Switzerland
| | - Patrick A Flume
- Division of Pulmonary and Critical Care, Medical University of South Carolina, USA
| | - Pavla Hodková
- Department of Clinical Psychology, University Hospital, Prague, Czech Republic
| | - Nataliya Kashirskaya
- Department of Genetic Epidemiology (Cystic Fibrosis Group), Federal State Budgetary Institution, Research Centre for Medical Genetics, Moscow, Russia
| | - Maya N Kirszenbaum
- Department of Pediatric Pulmunology, CRCM, Hôpital Necker-Enfants Malades, Paris, France
| | - Sue Madge
- Cystic Fibrosis Centre, Royal Brompton Hospital, London, UK
| | - Helen Oxley
- Manchester Adult Cystic Fibrosis Centre, University Hospital of South Manchester NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Barry Plant
- Cork Adult CF Centre, Cork University Hospital, University College, Cork, Republic of Ireland
| | - Sarah Jane Schwarzenberg
- Divison of Pediatric Gastroenterology Hepatology and Nutrition, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Alan R Smyth
- Division of Child Health, Obstetrics & Gynaecology (COG), University of Nottingham, Nottingham, UK
| | - Giovanni Taccetti
- Cystic Fibrosis Centre, Department of Paediatric Medicine, Anna Meyer Children's University Hospital, Florence, Italy
| | - Thomas O F Wagner
- Frankfurter Referenzzentrum für Seltene Erkrankungen (FRZSE), Universitätsklinikum Frankfurt am Main, Wolfgang von Goethe-Universität, Frankfurt am Main, Germany
| | - Susan P Wolfe
- Regional Paediatric CF Unit, The Leeds Children's Hospital, Leeds Teaching Hospitals, Belmont Grove, Leeds, UK
| | - Pavel Drevinek
- Department of Medical Microbiology, Faculty of Medicine, Motol University Hospital, Prague, Czech Republic
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48
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Quon BS, Sykes J, Stanojevic S, Marshall BC, Petren K, Ostrenga J, Fink A, Elbert A, Faro A, Goss CH, Stephenson AL. Clinical characteristics of cystic fibrosis patients prior to lung transplantation: An international comparison between Canada and the United States. Clin Transplant 2018; 32:e13188. [PMID: 29292522 DOI: 10.1111/ctr.13188] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cystic fibrosis (CF) patients from Canada have better-reported post-lung transplant survival compared to patients from the United States. We hypothesized the clinical characteristics of CF patients prior to lung transplant differ between the two countries. METHODS Population-based cohort study utilizing combined Canadian CF Registry and US CF Foundation Patient Registry data from 1986 to 2013. Demographic and clinical variables were analyzed prior to lung transplant. RESULTS Between 1986 and 2013, 607 (10.2%) CF patients underwent lung transplantation in Canada and 3428 (7.5%) in the United States. A lower proportion of recipients had growth of B. cepacia complex prior to transplant in the United States compared to Canada (0.8% vs 4.3%). Lung function was similar between recipients from the two countries. The proportion of patients classified as underweight was significantly higher in the United States compared to Canada (39.8% vs 28.0%; SD 26.1) despite higher rates of feeding tube use (42.5% vs 28.6%; SD 29.0). CONCLUSIONS CF lung transplant recipients from the United States have similar lung function, lower rates of B. cepacia complex, and worse nutritional parameters prior to transplant compared to counterparts in Canada. Future studies are necessary to evaluate the impact of these differences on post-transplant survival.
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Affiliation(s)
- Bradley S Quon
- Centre for Heart Lung Innovation, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jenna Sykes
- Department of Respirology, St. Michael's Hospital, Toronto, ON, Canada
| | - Sanja Stanojevic
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | | | | | | | - Aliza Fink
- Cystic Fibrosis Foundation, Bethesda, MD, USA
| | | | - Albert Faro
- Cystic Fibrosis Foundation, Bethesda, MD, USA
| | - Christopher H Goss
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and Pediatrics, University of Washington Medical Center, Seattle, WA, USA
| | - Anne L Stephenson
- Department of Respirology, St. Michael's Hospital, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
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Reemergence of Lower-Airway Microbiota in Lung Transplant Patients with Cystic Fibrosis. Ann Am Thorac Soc 2018; 13:2132-2142. [PMID: 27925791 DOI: 10.1513/annalsats.201606-431oc] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
RATIONALE Chronic lung infections are a hallmark of cystic fibrosis; they are responsible for progressive airway destruction and ultimately lead to respiratory death or the requirement for life-saving bilateral lung transplant. Furthermore, recurrent isolation of airway pathogens such as Pseudomonas aeruginosa in the allograft after transplant is associated with adverse outcomes, including bronchiolitis obliterans syndrome and acute infections. Little information exists on the impact of bilateral lung transplant on the lower-airway microbiota. OBJECTIVES To compare, at a microbiome and single-pathogen level (P. aeruginosa), the bacterial communities in pre- and post-transplant samples. METHODS We retrospectively accessed our biobank of sputum samples and sputum-derived bacterial pathogens for patients who had matched samples, including those who were clinically stable before transplant, those who had a pulmonary exacerbation before transplant, and those who had pulmonary exacerbation after transplant. We used 16S ribosomal RNA gene sequencing to characterize the lower-airway microbiome of 14 adult transplant patients with cystic fibrosis. Genotyping and phenotyping of P. aeruginosa isolates from 12 of these patients with matched isolates was performed. MEASUREMENTS AND MAIN RESULTS Although α-diversity (richness and evenness) of patient microbiomes was similar before and after transplant, β- diversity (core microbiome composition) measures stratified patients evenly into two groups with more similar and more dissimilar communities. P. aeruginosa strains isolated before transplant were found to reemerge in 11 of 12 patients; however, phenotypic variation was observed. CONCLUSIONS These findings indicate that recolonization by P. aeruginosa after transplant is almost always strain specific, suggesting a within-host source. The polymicrobial colonization of the airways after transplant does not always reflect the pretransplant sputum microbiota.
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50
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Indications for lung resection surgery and lung transplant in South American children with cystic fibrosis. Paediatr Respir Rev 2018; 25:37-42. [PMID: 28366682 DOI: 10.1016/j.prrv.2017.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 02/03/2017] [Indexed: 11/21/2022]
Abstract
The current available literature evaluating lung resection surgery and lung transplantation in children with cystic fibrosis (CF) was reviewed through a PubMed search and references from selected studies were additionally included. Pulmonary resections, i.e. lobectomy, segmentectomy, and pneumonectomy, are seldom performed in CF. The main indications, in patients with a forced expiratory volume in 1second (FEV1) that is greater than 30% predicted, are localized bronchiectasis/atelectasis, severe hemoptysis, and bronchopleural fistula refractory to medical management. The potential benefits are decreased symptoms and pulmonary exacerbations, and an improved quality of life. Pre and postoperative intensive care is mandatory for surgical candidates. The risk of death should be taken into account when the procedure is considered. Selection for lung transplantation (LTx) candidates in children with CF in South America follows the International Society for Heart and Lung Transplantation (ISHLT) criteria. When compared to adults with CF, a poorer survival rate after LTx in children with CF has been observed in the literature, as well as in our LTx center in Brazil, reasons for which are still unknown. The main complications after LTx in children are early and late acute rejection, and infections. LTx is a therapeutic option for eligible children with CF, fulfilling the lung transplant candidacy criteria, as post-transplant survival rates are increasingly improving due to better management of the transplanted patient.
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