1
|
Tchiloemba B, Kauke M, Haug V, Abdulrazzak O, Safi AF, Kollar B, Pomahac B. Long-term Outcomes After Facial Allotransplantation: Systematic Review of the Literature. Transplantation 2021; 105:1869-1880. [PMID: 33148976 DOI: 10.1097/tp.0000000000003513] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Facial vascularized composite allotransplantation (fVCA) represents a reconstructive approach that enables superior improvements in functional and esthetic restoration compared with conventional craniomaxillofacial reconstruction. Outcome reports of fVCA are usually limited to short-term follow-up or single-center experiences. We merge scientific literature on reported long-term outcome data to better define the risks and benefits of fVCA. METHODS We conducted a systematic review of PubMed/MEDLINE databases in accordance with PRISMA guidelines. English full-text articles providing data on at least 1 unique fVCA patient, with ≥3 years follow-up, were included. RESULTS The search yielded 1812 articles, of which 28 were ultimately included. We retrieved data on 23 fVCA patients with mean follow-up of 5.3 years. More than half of the patients showed improved quality of life, eating, speech, and motor and sensory function following fVCA. On average, the patients had 1 acute cell-mediated rejection and infectious episode per year. The incidence rates of acute rejection and infectious complications were high within first-year posttransplant but declined thereafter. Sixty-five percent of the patients developed at least 1 neoplastic or metabolic complication after transplantation. Chronic vascular rejection was confirmed in 2 patients, leading to allograft loss after 8 and 9 years. Two patient deaths occurred 3.5 and 10.5 years after transplant due to suicide and lung cancer, respectively. CONCLUSIONS Allograft functionality and improvements in quality of life suggest a positive risk-benefit ratio for fVCA. Recurrent acute rejection episodes, chronic rejection, immunosuppression-related complications, and heterogeneity in outcome reporting present ongoing challenges in this field.
Collapse
Affiliation(s)
- Bianief Tchiloemba
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Martin Kauke
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Valentin Haug
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Obada Abdulrazzak
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ali-Farid Safi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Branislav Kollar
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Medical Faculty of the University of Freiburg, Freiburg, Germany
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| |
Collapse
|
2
|
Long B, Brady WJ, Gragossian A, Koyfman A, Gottlieb M. A primer for managing cardiac transplant patients in the emergency department setting. Am J Emerg Med 2021; 41:130-138. [PMID: 33440325 DOI: 10.1016/j.ajem.2020.12.071] [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: 11/08/2020] [Revised: 12/26/2020] [Accepted: 12/27/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Cardiac transplant is an effective long-term management option for several severe cardiac diseases. These cardiac transplant patients may present to the emergency department with a range of issues involving the cardiac transplantation, including complications due to their transplant as well as altered presentations of disease resulting from their transplant. OBJECTIVE This narrative review provides a focused guide to the evaluation and management of patients with cardiac transplantation and its complications. DISCUSSION Cardiac transplant is an effective therapy for end-stage heart failure. A transplanted heart varies both anatomically and physiologically from a native heart. Several significant complications may occur. Graft failure, rejection, and infection are common causes of morbidity and mortality within the first year of transplant. As these patients are on significant immunosuppressive medication regimens, they are at risk of infection, but inadequate immunosuppression increases the risk of acute rejection. A variety of dysrhythmias such as atrial fibrillation and ventricular dysrhythmias may occur. These patients are also at risk of acute coronary syndrome, cardiac allograft vasculopathy, and medication adverse events. Importantly, patients with acute coronary syndrome can have an altered presentation with the so-called "painless" myocardial infarction. Consultation with the transplant physician is recommended, if available, for these patients to assist in evaluation and management. CONCLUSIONS An understanding of the presentations and various complications that may affect patients with cardiac transplant will assist emergency clinicians in the care of these patients.
Collapse
Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States of America.
| | - William J Brady
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, United States of America.
| | - Alin Gragossian
- The Mt Sinai Hospital, Institute for Critical Care Medicine, New York, NY, United States of America
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, United States of America
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America
| |
Collapse
|
3
|
Chung SJ, Tan EK, Kee T, Krishnamoorthy TL, Phua GC, Sewa DW, Ong BH, Tan TE, Sivathasan C, Gan HLV, Goh BKP, Jeyaraj PR, Tan BH. Practical Considerations for Solid Organ Transplantation During the COVID-19 Global Outbreak: The Experience from Singapore. Transplant Direct 2020; 6:e554. [PMID: 32607420 PMCID: PMC7266363 DOI: 10.1097/txd.0000000000001002] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 04/17/2020] [Indexed: 12/23/2022] Open
Abstract
The current coronavirus disease 2019 (COVID-19) pandemic has not only caused global social disruptions but has also put tremendous strain on healthcare systems worldwide. With all attention and significant effort diverted to containing and managing the COVID-19 outbreak (and understandably so), essential medical services such as transplant services are likely to be affected. Closure of transplant programs in an outbreak caused by a highly transmissible novel pathogen may be inevitable owing to patient safety. Yet program closure is not without harm; patients on the transplant waitlist may die before the program reopens. By adopting a tiered approach based on outbreak disease alert levels, and having hospital guidelines based on the best available evidence, life-saving transplants can still be safely performed. We performed a lung transplant and a liver transplant successfully during the COVID-19 era. We present our guidelines and experience on managing the transplant service as well as the selection and management of donors and recipients. We also discuss clinical dilemmas in the management COVID-19 in the posttransplant recipient.
Collapse
Affiliation(s)
- Shimin Jasmine Chung
- Department of Infectious Diseases, Singapore General Hospital, Singapore
- SingHealth Duke-NUS Transplant Centre, Singapore
| | - Ek Khoon Tan
- SingHealth Duke-NUS Transplant Centre, Singapore
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Terence Kee
- SingHealth Duke-NUS Transplant Centre, Singapore
- Department of Gasteroentrology and Hepatology, Singapore General Hospital, Singapore
| | - Thinesh Lee Krishnamoorthy
- SingHealth Duke-NUS Transplant Centre, Singapore
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Ghee Chee Phua
- SingHealth Duke-NUS Transplant Centre, Singapore
- Department of Cardiothoracic Surgery, National Heart Centre, Singapore
| | - Duu Wen Sewa
- SingHealth Duke-NUS Transplant Centre, Singapore
- Department of Cardiothoracic Surgery, National Heart Centre, Singapore
| | - Boon-Hean Ong
- SingHealth Duke-NUS Transplant Centre, Singapore
- Department of Renal Medicine Singapore General Hospital, Singapore
| | - Teing Ee Tan
- SingHealth Duke-NUS Transplant Centre, Singapore
- Department of Renal Medicine Singapore General Hospital, Singapore
| | - Cumaraswamy Sivathasan
- SingHealth Duke-NUS Transplant Centre, Singapore
- Department of Renal Medicine Singapore General Hospital, Singapore
| | - Huei Li Valerie Gan
- SingHealth Duke-NUS Transplant Centre, Singapore
- Department of Urology, Singapore General Hospital, Singapore
| | - Brian Kim Poh Goh
- SingHealth Duke-NUS Transplant Centre, Singapore
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Prema Raj Jeyaraj
- SingHealth Duke-NUS Transplant Centre, Singapore
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Ban Hock Tan
- Department of Infectious Diseases, Singapore General Hospital, Singapore
- SingHealth Duke-NUS Transplant Centre, Singapore
| |
Collapse
|
4
|
Shingde R, Habachou LI, Calisa V, Craig JC, Tong A, Chen SCA, Wong G. Unexpected donor-derived infectious transmissions by kidney transplantation: A systematic review. Transpl Infect Dis 2018; 20:e12851. [PMID: 29508947 DOI: 10.1111/tid.12851] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 10/04/2017] [Accepted: 10/10/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND Unexpected donor-derived transmission of infections is rare, but is associated with significant morbidity and mortality. We aimed to provide an overview of published cases on unexpected infectious transmissions. METHODS We systematically reviewed all published evidence describing any unexpected donor-derived viral, bacterial, fungal, and parasitic infections in kidney transplant recipients. RESULTS In all, 119 studies (case reports [n = 36], case series [n = 78], cohort studies [n = 2], and case-control studies [n = 3]) involving 139 donors and 207 kidney recipients were included. Donor-derived viral (n = 116, 56.0%) infections were most prevalent, followed by bacterial (32, 15.5%), fungal (32, 15.5%), and parasitic (27, 13.0%) infections. The most commonly reported viral infections were human immunodeficiency virus (HIV) (n = 20, 9.7%), human T-cell lymphotrophic virus (HTLV) (n = 20, 9.7%), and West Nile virus (WNV) (n = 13, 6.3%). The most frequent bacterial infections were caused by Mycobacterium tuberculosis (10, 4.8%) and Pseudomonas aeruginosa (9, 4.3%). Candida species were the most frequent causes of fungal donor-derived infections (8, 3.9%). Toxoplasma gondii accounted for seven (3.4%) cases of transmitted parasitic infections. Patients with rabies experienced the highest probability of recipient death from virus-related complications at 90.0%, within a median time of 2.8 months after transplantation. CONCLUSION The frequency of donor-derived infectious transmission appears low in kidney transplantation, with viral transmissions being most commonly reported overall.
Collapse
Affiliation(s)
- Rashmi Shingde
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - L Ines Habachou
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Vaishnavi Calisa
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Jonathan C Craig
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Allison Tong
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Sharon C-A Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services, ICPMR, Westmead Hospital, Sydney, NSW, Australia
| | - Germaine Wong
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
| |
Collapse
|
5
|
Razonable RR. Liver Transplantation. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00082-4] [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: 12/01/2022] Open
|
6
|
Abstract
Over 26 years, we found 46 infectious episodes in 350 kidney transplant recipients. Fifteen were urinary tract infections, recurrent in 4 patients. There were 8 cytomegalovirus infections, three of them fatal when intravenous (IV) ganciclovir was not available. Seven patients had a reactivation of tuberculosis (TB) in the pleura, cervical spine, lumbar spine, knee, ankle, skin and peritoneum, respectively, and were all resolved satisfactorily with conventional anti-TB therapy. Three patients transplanted before routine prophylaxis with the use of acyclovir developed an extensive herpes zoster infection in the 1st 6 months after transplantation, which was resolved with the use of oral acyclovir, and 1 had a disseminated herpes simplex infection resolved with the use of IV acyclovir. Three patients transplanted before routine prophylaxis with trimethoprim sulfa developed Pneumocystis carinii pneumonia in the 1st 6 months after transplantation, which was fatal in one of them. In 2 patients, we found a Nocardia infection, confined to the lung, which was cured in one of the cases and systemic and fatal in the other. Two patients transplanted before routine prophylaxis with the use of nystatin developed esophageal candidiasis in the 1st 6 months after transplantation. One patient developed infective endocarditis in a stenotic bicuspid aortic valve and died 10 years later after another incident of infective endocarditis at the prosthetic aortic valve. Two patients developed an extensive condyloma at the penis, perianal region, and perineum owing to human papillomavirus, requiring extensive surgical resection and podophyllin applications. Another patient developed fatal post-transplantation lymphoproliferative disease due to Epstein-Barr virus infection 15 years after transplantation. One patient developed a severe and fatal mucocutaneous leishmaniasis with no response to conventional antimonial therapy. It is interesting to note that despite Chagas disease being endemic in Bolivia, we had no patients with reactivation or transmission through the graft even though many of the patients and donors were serologically positive for Chagas disease.
Collapse
Affiliation(s)
- S Arze
- Centro Médico Quirurgico Boliviano Belga, Cochabamba, Bolivia.
| | - L Arze
- Centro Médico Quirurgico Boliviano Belga, Cochabamba, Bolivia
| | - C Abecia
- Centro Médico Quirurgico Boliviano Belga, Cochabamba, Bolivia
| |
Collapse
|
7
|
Long B, Koyfman A. The emergency medicine approach to transplant complications. Am J Emerg Med 2016; 34:2200-2208. [DOI: 10.1016/j.ajem.2016.08.049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 08/18/2016] [Accepted: 08/20/2016] [Indexed: 02/07/2023] Open
|
8
|
Schmidt T, Schub D, Wolf M, Dirks J, Ritter M, Leyking S, Singh M, Zawada AM, Blaes-Eise AB, Samuel U, Sester U, Sester M. Comparative analysis of assays for detection of cell-mediated immunity toward cytomegalovirus and M. tuberculosis in samples from deceased organ donors. Am J Transplant 2014; 14:2159-67. [PMID: 25040687 DOI: 10.1111/ajt.12787] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 04/07/2014] [Accepted: 04/16/2014] [Indexed: 01/25/2023]
Abstract
Cell-mediated immunity assays could be valuable for risk assessment of organ donors, but no data exist on their feasibility in deceased donors. In this study, 105 deceased donors (52.3 ± 16.9 years) were screened at the time of organ procurement. Pathogen-specific stimulation was performed using a cytomegalovirus (CMV) lysate, tuberculin (purified protein derivative [PPD]) and soluble Mycobacterium tuberculosis-specific ESAT-6/CFP-10 proteins in combination with an in-house fluorescence-activated cell sorting (FACS) assay or commercial assay formats (QuantiFERON-CMV/TB for ELISA, T-SPOT.TB for ELISPOT). CMV-IgG antibody titers were determined as gold standard for CMV infection; 51.4% of samples were CMV seropositive. Indeterminate results were observed in 47.6% of ELISA, 12.5% of FACS and 0% of ELISPOT assays. Agreement with serology was highest for FACS (95.6%, κ = 0.91), followed by ELISPOT (84.0%, κ = 0.68) and ELISA (80.0%, κ = 0.60). Agreement between ELISA and serology increased if the CMV lysate was used as stimulus (96.7%, κ = 0.92). Among the T cell assays, agreement between ELISPOT and FACS was highest (κ = 0.70). PPD-positive results among valid samples differed between assays (26.5% for ELISA, 23.1% for FACS and 50.5% for ELISPOT); 2.0% were QuantiFERON-TB positive, 3.3% were ESAT-6/CFP-10-positive in FACS and 13.4% were positive in the T-SPOT.TB assay. In conclusion, cellular immunity may be analyzed from samples of deceased donors, although the assays differ in the rate of positivity and indeterminate results.
Collapse
Affiliation(s)
- T Schmidt
- Department of Transplant and Infection Immunology, Saarland University, Homburg, Germany
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|