Lung transplantation for cystic fibrosis: 6-year follow-up

Current state of clinical trials regarding lung transplant rejection

BACKGROUND

Over the last several decades, the field of lung transplantation has made significant advances. Despite these advancements, morbidity and mortality rates are still high when compared to other solid organ transplants. Clinical trials have a significant role bringing new medications with better effects than their predecessors. Our study is critical in evaluating and tracking clinical trials involving rejection of lung transplant, with a focus on interventional therapeutic trials.

METHODS

On November 3, 2021, we searched clinicaltrial.gov for interventional clinical trials related to lung transplant rejection. A total of 39 clinical trials are included in this study. Characteristics on each trial were gathered. Linked publications were searched using Medline/PubMed and Embase/Scopus, and their content reviewed and summarized.

RESULTS

The majority of trials were divided into completed (15 out of 39) and recruiting (12 out of 39). 17 trials had between 11 and 50 participants, and 8 had above 100. Only 1 trial lasted >10 years, and the average length of all trials was 3.6 years. The majority of trials were conducted in Europe/UK/Russia and the United States/Canada (17 and 18 trials, respectively). The results were provided in 3 trials, and also published in 3, showing a decrease in the rate of patients reaching an endpoint after chronic rejection with liposomal aerosol cyclosporine, a decrease in their cytokines level, and an increase in their 5-year-survival rate compared to the oral conventional immunosuppressant, the benefit of sirolimus in decreasing the acute rejection rate and severity in comparison to azathioprine, and its efficacy against cytomegalovirus infections. Other trials revealed the benefits of azithromycin in remarkably decreasing airways and systemic inflammation, with a concomitant decline in the risk of both BOS and CLAD; highlighting the deleterious effects of air pollution after transplantation surgery; and using the grading biopsy as a post-transplantation assessment tool.

CONCLUSION

This study is a descriptive analysis of clinical trials targeting lung transplant rejection. This study shows the low number of trials, lack of variety in location and low publishing rates. Although focus of published trials was mainly towards azithromycin, bronchiolitis obliterans syndrome, air pollution, and biopsy in grading, a remarkable progress was realized concerning therapies, leading to less complications with a delay of chronic rejection onset, and an increase in overall survival. This sheds the light on the need for managing research efforts to fulfill any lack in specific domain, leading to new, effective therapies, and providing thereby much more benefit.

Pneumocystis jirovecii in Patients With Cystic Fibrosis: A Review

Pneumocystis pneumonia (PCP) remains the most frequent AIDS-defining illness in developed countries. This infection also occurs in non-AIDS immunosuppressed patients, e.g., those who have undergone an organ transplantation. Moreover, mild Pneumocystis jirovecii infections related to low pulmonary fungal burden, frequently designated as pulmonary colonization, occurs in patients with chronic pulmonary diseases, e.g., cystic fibrosis (CF). Indeed, this autosomal recessive disorder alters mucociliary clearance leading to bacterial and fungal colonization of the airways. This mini-review compiles and discusses available information on P. jirovecii and CF. It highlights significant differences in the prevalence of P. jirovecii pulmonary colonization in European and Brazilian CF patients. It also describes the microbiota associated with P. jirovecii in CF patients colonized by P. jirovecii. Furthermore, we have described P. jirovecii genomic diversity in colonized CF patients. In addition of pulmonary colonization, it appears that PCP can occur in CF patients specifically after lung transplantation, thus requiring preventive strategies. In other respects, Pneumocystis primary infection is a worldwide phenomenon occurring in non-immunosuppressed infants within their first months. The primary infection is mostly asymptomatic but it can also present as a benign self-limiting infection. It probably occurs in the same manner in CF infants. Nonetheless, two cases of severe Pneumocystis primary infection mimicking PCP in CF infants have been reported, the genetic disease appearing in these circumstances as a risk factor of PCP while the host-pathogen interaction in older children and adults with pulmonary colonization remains to be clarified.

Single Lung Transplantation With Concomitant Cardiac Surgery in a Patient With Cystic Fibrosis: A Case Report

BACKGROUND

Cystic fibrosis is a congenital, progressive disease affecting many organs. It frequently leads to severe respiratory failure, which can be treated by means of a double lung transplantation. Single lung transplantation is justified only in certain cases.

CASE REPORT

This is a case report describing a 20-year-old female patient who became the recipient of a single lung transplant as a result of cystic fibrosis. The transplant was performed during cardiothoracic surgery, which included an intervention in the right atrium. At the age of 14, the patient underwent left pneumonectomy. In addition, the patient had a percutaneous endoscopic gastrostomy placed and a vascular port implanted. During preoperative evaluation, she presented with clinical symptoms of chronic respiratory failure. The patient was approved for lung transplantation at the age of 16. After 2 years on the national lung transplant waiting list, in 2018, the patient underwent right lung transplantation and removal of numerous thrombi in the right atrium during 1 procedure. This surgery was accomplished with the use of extracorporeal circulation, which is an extracorporeal membrane oxygenator combined with cardiopulmonary bypass. The patient was discharged 3 weeks after the procedure in good general condition. Presently, her pulmonary function is excellent and she presents with normal respiratory capacity.

CONCLUSIONS

Patients with cystic fibrosis often require double lung transplantation. Under normal circumstances, performing only a single lung transplantation would be considered medical malpractice. However, in certain cases, a single lung transplant is a life-saving procedure.

Pseudomonas aeruginosa antibody response in cystic fibrosis decreases rapidly following lung transplantation

BACKGROUND

Specific Pseudomonas aeruginosa (PA) precipitating immunoglobulin G antibodies in serum are correlated with PA biofilm infection and are used as diagnostic and prognostic markers in cystic fibrosis (CF). The aim of this study was to examine the change of PA antibody response in CF patients after bilateral sequential lung transplantation (LTx).

METHODS

PA antibodies and airway bacteriology were retrospectively evaluated in 20 chronically infected CF patients, who underwent LTx between 2001 and 2016 at Rigshospitalet, Copenhagen. Yearly precipitin counts from one year before LTx and up to five years after LTx were compared. Monthly airway cultures were examined in the five-year period after LTx. In addition, crossed immunoelectrophoresis (CIE) were analysed for each patient for antigenic similarities from time of infection, pre-LTx and post-LTx.

RESULTS

All patients experienced a significant drop in PA antibodies from one year pre-LTx to one year post-LTx (p < 0.0001). The PA antibody level did not differ between those, who became reinfected immediately after LTx, and those, who did not. No patients regained the high pre-LTx precipitin levels in the following five years. The antigenic specificities of the sera post-LTx were in each patient similar to the antigenic specificities at the beginning of infection indicating a decades long memory of their immune response like an "immunological fingerprint".

CONCLUSIONS

After LTx a significant and continuous reduction in PA antibodies was observed. The reduction was independent of immediate reinfection after LTx. A novel three-factor explanatory model is presented.

Low early posttransplant serum tacrolimus levels are associated with poor patient survival in lung transplant patients

BACKGROUND:

Low-dose tacrolimus-based immunosuppression is a standard therapy in kidney and liver transplantation; however, the optimal therapeutic level of tacrolimus has not been established in lung transplantation. We aimed to identify the tacrolimus level associated with better outcomes in lung transplant patients.

METHODS:

This retrospective study included patients who underwent lung transplantation at Seoul National University Hospital between 2006 and 2016. Kaplan–Meier survival analysis and Cox regression were performed according to tacrolimus levels at several time-points within 1-year posttransplantation.

RESULTS:

A total of 43 patients received bilateral lung transplantation. The median age was 53 years and the median follow-up was 20.5 months. Overall and 1-year patient survival rates were 55.8% and 74.4%, respectively. Infection was the most common cause of death (78.9%). Chronic lung allograft dysfunction was observed in 16.3%. A tacrolimus level <9 ng/ml at 1 month was associated with lower rejection-free survival (P = 0.009). A time-averaged tacrolimus level <10 ng/ml within 1 month posttransplantation was an independent risk factor for poor patient survival (hazard ratio: 4.904; 95% confidence interval: 1.930–12.459; P= 0.001). Furthermore, higher tacrolimus levels did not increase infectious complications.

CONCLUSIONS:

These finding suggest that tacrolimus levels ≥10 ng/ml within 1 month after lung transplantation appear to be associated with better patient survival.

Survival After Lung Transplant for Cystic Fibrosis in Italy: A Single Center Experience With 20 Years of Follow-up

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.

Outcomes of lung transplantation in adults with bronchiectasis

Background

Lung transplantation is a well-established treatment for end-stage non-cystic fibrosis bronchiectasis (BR), though information regarding outcomes of transplantation remains limited. Our results of lung transplantation for Br are reported here.

Methods

A retrospective review of case notes and transplantation databases was conducted for patients that had underwent lung transplantation for bronchiectasis at the Freeman Hospital between 1990 and 2013.

Results

Fourty two BR patients underwent lung transplantation, the majority (39) having bilateral sequential lung transplantation. Mean age at transplantation was 47.1 years. Pre-transplantation osteoporosis was a significant non-pulmonary morbidity (48%). Polymicrobial infection was common, with Pseudomonas aeruginosa infection frequently but not universally observed (67%). Forced expiratory volume in 1 second (% predicted) improved from a pre-transplantation mean of 0.71 L (22% predicted) to 2.56 L (79 % predicted) at 1-year post-transplantation. Our survival results were 74% at 1 year, 64% at 3 years, 61% at 5 years and 48% at 10 years. Sepsis was a common cause of early post-transplantation deaths.

Conclusions

Lung transplantation for end-stage BR is a useful therapeutic option, with good survival and lung function outcomes. Survival values were similar to other bilateral lung transplants at our centre. Pre-transplantation Pseudomonas infection is common.

Lung Transplantation in Cystic Fibrosis and the Impact of Extracorporeal Circulation

INTRODUCTION

Lung disease is the major cause of death among cystic fibrosis (CF) patients, affecting 80% of the population. The impact of extracorporeal circulation (ECC) during transplantation has not been fully clarified. This study aimed to evaluate the outcomes of lung transplantation for CF in a single center, and to assess the impact of ECC on survival.

METHODS

We performed a retrospective observational study of all trasplanted CF patients in a single center between 1992 and 2011. During this period, 64 lung transplantations for CF were performed.

RESULTS

Five- and 10-year survival of trasplanted patients was 56.7% and 41.3%, respectively. Pre-transplantation supplemental oxygen requirements and non-invasive mechanical ventilation (NIMV) do not seem to affect survival (P=.44 and P=.63, respectively). Five- and 10-year survival among patients who did not undergo ECC during transplantation was 75.69% and 49.06%, respectively, while in those did undergo ECC during the procedure, 5- and 10-year survival was 34.14% and 29.87%, respectively (P=.001). PaCO₂ is an independent risk factor for the need for ECC.

CONCLUSIONS

The survival rates of CF patients undergoing lung transplantation in our hospital are similar to those described in international registries. Survival is lower among patients receiving ECC during the procedure. PaCO₂ is a risk factor for the need for ECC during lung transplantation.

Airway anastomosis for lung transplantation

Lung transplantation (LT) is the only viable option for a selected group of patients with end stage pulmonary diseases. During the recent years satisfactory results in terms of long-term survival and quality of life have been achieved with improvements in surgical technique, immunosuppression and perioperative management. Since the beginning, the airway anastomosis has been considered crucial and significant efforts have been made to understand the healing process. A number of experimental studies allowed improving the surgical technique by modifying the technique of suturing, the anastomotic protection and type and dose of immunosuppression, reducing the risk of airway complications. Furthermore, a huge progress has been made in the management of such complications. Early diagnosis of bronchial complications and their prompt and correct management are crucial to achieve long-term survival.

Techniques of protection and revascularization of the bronchial anastomosis

Airway anastomosis has been traditionally considered at risk for the onset of complications, particularly dehiscence with consequent infection and erosion in the adjacent vessels. Although the modifications and improvements of the surgical technique has contributed to reduce the incidence of complications, the protection and revascularization of the anastomotic site is still considered mandatory at many centers Many techniques have been proposed for encircling the bronchial anastomosis.

Dental care before lung transplantation: are we being too rigorous?

OBJECTIVE

Poor dental status is known to cause infections in severely sick and in elderly patients. In patients awaiting lung transplantation, rigorous dental treatment is a common prerequisite, although evidence-based data are lacking with regard to extent, necessity and effect on post-transplantation infectious status.

MATERIALS AND METHODS

In the present retrospective study, dental status [dental history (missing teeth, caries, tooth restorations and extractions, prevalence of periodontitis) and dental treatment prior transplantation] was assessed in 85 lung transplant candidates at the University Hospital of Freiburg, Germany and evaluated for infectious foci in the first 3 years following transplantation.

RESULTS

Forty-nine patients got transplanted in the observed timespan. Total tooth count differed significantly between chronic obstructive pulmonary disease (16 ± 9), pulmonary fibrosis (22 ± 7) or cystic fibrosis (30 ± 3) patients prior transplantation (P > 0.001). Periodontitis prevalence yielded no difference and was mainly not treated prior transplantation. No dental-related infectious focus could be diagnosed post-transplantation. However, 15% of post-transplantation infections were of unknown focus, and infection rate was increased in year 2 post-transplantation in patients without periodontitis.

CONCLUSION

No clearly defined dental foci were registered following transplantation. This raises the question of whether current dental treatment in these highly compromised patients is too rigorous with regard to tooth extractions. However, no focus could be detected in 15% of the registered infections. Therefore, controversially, post-transplantation dental care could also be insufficient with regard to undertreated periodontitis.

Pretransplant HRCT Characteristics Are Associated with Worse Outcome of Lung Transplantation for Cystic Fibrosis Patients

Objectives

Peri- and postoperative complications diminish the outcome of lung transplantation (LTx) in patients with cystic fibrosis (CF). We hypothesized that the degree of pathological findings on pre-LTx high resolution computed tomography (HRCT) is associated with higher morbidity and mortality in CF.

Methods

All our CF patients undergoing LTx between 2001 and 2011 were included. HRCT examinations were evaluated according to a scoring system for pulmonary disease in CF patients, the Severe Advanced Lung Disease (SALD) score and for pleural involvement.

Results

Fifty-three patients were included. Dominant infectious/inflammatory disease according to the SALD score was observed in 10 patients (19%). Five (50%) of those patients died within one week after LTx, compared to 2 (5%) patients without dominant infectious/inflammatory disease (p<0.001). This difference in survival percentage remained also significant in multivariate analysis. Patients with infectious/inflammatory disease received more packed red blood cells; 26 versus 8 in the first week (p<0.001). Pleural thickening was associated with higher requirement (10 units) for blood transfusion during LTx, compared to patients with normal pleura (4 units).

Conclusions

The analysis of HRCT in CF patients according to the SALD score showed that dominant infectious/inflammatory disease is associated with a higher mortality after LTx. If confirmed in other studies, HRCT might aid estimation of surgical risk in some adult CF patients.

Longitudinal impact of demographic and clinical variables on health-related quality of life in cystic fibrosis

OBJECTIVES

The insights that people with cystic fibrosis have concerning their health are important given that aspects of health-related quality of life (HRQoL) are independent predictors of survival and a decrease in lung function is associated with a decrease in HRQoL over time. Cross-sectional data suggest that key variables, other than lung function, are also associated with HRQoL--although study results are equivocal. This work evaluates the relationship between these key demographic and clinical variables and HRQoL longitudinally.

DESIGN

Longitudinal observational study. Observations were obtained at seven time points: approximately every 2 years over a 12-year period.

SETTING

Large adult cystic fibrosis centre in the UK.

PARTICIPANTS

234 participants aged 14-48 years at recruitment.

OUTCOME MEASURE

Nine domains of HRQoL (Cystic Fibrosis Quality of Life Questionnaire) in relation to demographic (age, gender) and clinical measures (forced expiratory volume in 1 s, (FEV1)% predicted, body mass index (BMI), cystic fibrosis-related diabetes, Burkholderia cepacia complex, totally implantable vascular access device, nutritional and transplant status).

RESULTS

A total of 770 patient assessments were obtained for 234 patients. The results of random coefficients modelling indicated that demographic and clinical variables were identified as being significant for HRQoL over time. In addition to lung function, transplant status, age, having a totally implantable vascular access device, cystic fibrosis-related diabetes, BMI and B. cepacia complex impacted on many HRQoL domains longitudinally. Gender was important for the domain of body image.

CONCLUSIONS

Demographic and changes in clinical variables were independently associated with a change in HRQoL over time. Compared with these longitudinal data, cross-sectional data are inadequate when evaluating the relationships between HRQoL domains and key demographic and clinical variables, as they fail to recognise the full impact of the CF disease trajectory and its treatments on quality of life.

Contamination of hypertonic saline solutions in use by cystic fibrosis patients in Israel

BACKGROUND

Treatment of cystic fibrosis (CF) patients with inhaled hypertonic saline (HS) solutions is safe, beneficial and reduces exacerbation rates. We studied contamination of solutions used by Israeli CF patients for prolonged periods.

METHODS

The study addressed whether daily opening of previously unopened solutions caused contamination, survival of 6 CF-associated bacteria in artificially inoculated solutions, in-use contamination of solutions and patterns of their use by patients.

RESULTS

Repeated opening did not contaminate solutions and survival of indicator bacteria was variable. Mycobacterium abscessus survived in 3% HS solution for 6 weeks and Burkholderia cenocepacia and Pseudomonas aeruginosa were longer. In 30/76 (39.5%) of used solutions 49 contaminants were found, none being common CF-associated pathogens.

CONCLUSIONS

Most CF-related bacteria survived to some degree in HS. Approximately 40% of solutions used by patients were contaminated by organisms of uncertain significance. Our findings highlight the potential risk posed by contamination of HS solutions and support recommendations to use sterile unit-dose formulations.

Respiratory infections in patients with cystic fibrosis undergoing lung transplantation

Cystic fibrosis is an inherited disease characterised by chronic respiratory infections associated with bronchiectasis. Lung transplantation has helped to extend the lives of patients with cystic fibrosis who have advanced lung disease. However, persistent, recurrent, and newly acquired infections can be problematic. Classic cystic fibrosis-associated organisms, such as Staphylococcus aureus and Pseudomonas aeruginosa, are generally manageable post-transplantation, and are associated with favourable outcomes. Burkholderia cenocepacia poses particular challenges, although other Burkholderia species are less problematic. Despite concerns about non-tuberculous mycobacteria, especially Mycobacterium abscessus, post-transplantation survival has not been definitively shown to be less than average in patients with these infections. Fungal species can be prevalent before and after transplantation and are associated with high morbidity, so should be treated aggressively. Appropriate viral screening and antiviral prophylaxis are necessary to prevent infection with and reactivation of Epstein-Barr virus and cytomegalovirus and their associated complications. Awareness of drug pharmacokinetics and interactions in cystic fibrosis is crucial to prevent toxic effects and subtherapeutic or supratherapeutic drug dosing. With the large range of potential infectious organisms in patients with cystic fibrosis, infection control in hospital and outpatient settings is important. Despite its complexity, lung transplantation in the cystic fibrosis population is safe, with good outcomes if the clinician is aware of all the potential pathogens and remains vigilant by means of surveillance and proactive treatment.

Myocardial infarction in an adult with cystic fibrosis and heart and lung transplant

We present a case of myocardial infarction in a 19 year old female with cystic fibrosis who had a heart and lung transplant performed at the age of four years old. She presented atypically with a one day history of severe, intermittent, central, sharp chest pain, radiating to her back and down her left arm. A coronary angiogram showed proximal stenosis of the left anterior descending artery and right coronary artery. She was treated with percutaneous coronary intervention, involving drug eluting stents to the left anterior descending artery (LAD) and the right coronary artery (RCA). In this study we discuss the pathophysiology, investigations and treatment of cardiac transplant vasculopathy. Although complete reversal of LAD and RCA stenosis was achieved, routine follow-up with coronary angiography and careful control of cardiac risk factors will be important to identify and reduce future restenosis and adverse cardiac events.

Prospective multicenter study of Pneumocystis jirovecii colonization among cystic fibrosis patients in France

Pneumocystis carriage was detected in 12.5% of 104 cystic fibrosis (CF) patients during a prospective multicenter French study, with a prevalence of genotype 85C/248C and geographic variations. It was significantly associated with the absence of Pseudomonas aeruginosa colonization and a greater forced expiratory volume in 1 s. Results are discussed considering the natural history of CF.

Management issues for adolescents with cystic fibrosis

The healthy adolescent will encounter major changes in biological and psychosocial domains. The adolescent period can be greatly affected by a chronic illness. Cystic fibrosis is a terminal illness that can significantly affect an adolescent's biological, mental and psychosocial health. This paper discusses general issues to consider when managing an adolescent with a chronic medical condition, and specifically how cystic fibrosis may impact upon puberty, body image, risk-taking behaviours, mental health, independence, nonadherence, reproductive health, transition, lung transplantation, and end of life care.

Clinical significance of microbial infection and adaptation in cystic fibrosis

A select group of microorganisms inhabit the airways of individuals with cystic fibrosis. Once established within the pulmonary environment in these patients, many of these microbes adapt by altering aspects of their structure and physiology. Some of these microbes and adaptations are associated with more rapid deterioration in lung function and overall clinical status, whereas others appear to have little effect. Here we review current evidence supporting or refuting a role for the different microbes and their adaptations in contributing to poor clinical outcomes in cystic fibrosis.

A roadmap to the brittle bones of cystic fibrosis

Cystic fibrosis (CF) is an autosomal recessive disorder which despite advances in medical care continues to be a life-limiting and often fatal disease. With increase in life expectancy of the CF population, bone disease has emerged as a common complication. Unlike the osteoporosis seen in postmenopausal population, bone disease in CF begins at a young age and is associated with significant morbidity due to fractures, kyphosis, increased pain, and decreased lung function. The maintenance of bone health is essential for the CF population during their lives to prevent pain and fractures but also as they approach lung transplantation since severe bone disease can lead to exclusion from lung transplantation. Early recognition, prevention, and treatment are key to maintaining optimal bone health in CF patients and often require a multidisciplinary approach. This article will review the pathophysiology, current clinical practice guidelines, and potential future therapies for treating CF-related bone disease.

Cystic fibrosis and the thoracic surgeon

Indications for thoracic surgery in patients with cystic fibrosis (CF) are principally represented by pleural diseases including pneumothorax, pleural effusion, and empyema and by parenchymal lung diseases including bronchiectasis, hemoptysis, and pulmonary abscess. Moreover, lung transplantation has proved a viable therapeutic option for progressive respiratory failure due to end-stage CF. Main surgical experiences in this setting are reviewed and discussed.

Renal impairment in children with cystic fibrosis

BACKGROUND

Due to the improvement in life expectancy in cystic fibrosis (CF), co-morbidities such as renal function impairment may be more frequent.

AIM

To determine the prevalence of renal disease in children with CF and to identify associated risk factors.

METHODS

A single-center retrospective study analyzing the genetic, clinical and therapeutic characteristics of 112 children. The estimated glomerular filtration rate (GFR), microalbuminuria and lithiasic risk factors were assessed.

RESULTS

The median calculated GFR (Schwartz) was 123, 161 and 155ml/min/1.73m(2) in children aged 1, 6 and 15years, respectively. The cumulative dose of aminoglycosides was not correlated to GFR. Microalbuminuria was present in 22/38 patients. Hyperoxaluria was observed in 58/83 patients and was associated with a severe genotype, pancreas insufficiency and liver disease. Hypercalciuria, hyperuricuria and hypocitraturia were identified in 16/87, 15/83 and 57/76 patients, respectively.

CONCLUSION

Renal impairment in CF has various presentations. There appears to be low levels of renal impairment in children with CF. However, the risk of oxalocalcic urolithiasis is enhanced, and GFR may be underestimated by the Schwartz formula. Further studies using measured GFR techniques are thus warranted.

[Medical complications of lung transplantation]

In 2010, lung transplantation is a valuable therapeutic option for a number of patients suffering from of end-stage non-neoplastic pulmonary diseases. The patients frequently regain a very good quality of life, however, long-term survival is often hampered by the development of complications such as the bronchiolitis obliterans syndrome, metabolic and infectious complications. As the bronchiolitis obliterans syndrome is the first cause of death in the medium and long term, an intense immunosuppressive treatment is maintained for life in order to prevent or stabilize this complication. The immunosuppression on the other hand induces a number of potentially severe complications including metabolic complications, infections and malignancies. The most frequent metabolic complications are arterial hypertension, chronic renal insufficiency, diabetes, hyperlipidemia and osteoporosis. Bacterial, viral and fungal infections are the second cause of mortality. They are to be considered as medical emergencies and require urgent assessment and targeted therapy after microbiologic specimens have been obtained. They should not, under any circumstances, be treated empirically and it has also to be kept in mind that the lung transplant recipient may present several concomitant infections. The most frequent malignancies are skin cancers, the post-transplant lymphoproliferative disorders, Kaposi's sarcoma and some types of bronchogenic carcinomas, head/neck and digestive cancers. Lung transplantation is no longer an exceptional procedure; thus, the pulmonologist will be confronted with such patients and should be able to recognize the symptoms and signs of the principal non-surgical complications. The goal of this review is to give a general overview of the most frequently encountered complications. Their assessment and treatment, though, will most often require the input of other specialists and a multidisciplinary and transversal approach.

Renal dysfunction in cystic fibrosis: is there cause for concern?

Most people associate cystic fibrosis (CF) with lung disease. Although this is the major cause of morbidity and mortality, CF is in fact a multi-organ disease. Patients with CF are living longer. Accompanying their increased life expectancy are complications not previously encountered. One of the less obvious concerns is that of renal dysfunction associated with long-term exposure to aminoglycosides as well as renally toxic immunosuppressants in lung transplant recipients. This article reviews what is known about the extent of the problem, summarizes what the current practices of measuring and monitoring renal function in patients with CF, and makes suggestions for alternative approaches. In particular, the potential role of cystatin C will be discussed.

Health-related quality of life measurement in cystic fibrosis: advances and limitations

Health-related quality of life (HRQoL) measurement in cystic fibrosis (CF) allows the inclusion of the patient's perspective in research and clinical practice. HRQoL scales have been used for many purposes and this review focuses on how HRQoL measurement has been implemented in CF research and care. Specifically, the review considers 1) the instruments used to measure HRQoL, 2) the factors that influence how people report HRQoL, 3) the monitoring of HRQoL in clinical practice, 4) HRQoL as an outcome measure in interventions and clinical trials and 5) whether HRQoL can predict survival. The challenge for the future is to use the available information to develop and evaluate psychological interventions that would be expected to improve HRQoL in children and adults with CF.

Impact of cyclosporine upon emotional and social behavior in mice

BACKGROUND

Cyclosporine induces psychological side effects but its mechanisms of action remain to be elucidated.

METHODS

Mice were injected with cyclosporine (0, 10, 60 mg/kg intraperitoneal) and indexes of both anxiety-related and social behaviors were examined. Release of serotonin and dopamine in the prefrontal cortex was also investigated by microdialysis.

RESULTS

Intraperitoneal administration of cyclosporine increased cyclosporine concentrations in the blood and brains in mice. Cyclosporine administration at a higher-dose reduced motor activity, increased indexes of anxiety-related behavior, and decreased an index of social interaction. The administration reduced release of serotonin and dopamine in the prefrontal cortex. Clozapine administration abolished the reduced release of dopamine and partially restored the index of social behavior in cyclosporine-injected mice.

CONCLUSIONS

This in vivo model suggests that cyclosporine at a high dose induced hypo-function of the prefrontal cortex as a result of reduced release of serotonin and dopamine, increased anxiety-related behavior, and disturbed social behavior. Clozapine partially restored an index of social behavior. The present findings are pathologically relevant in patients who take cyclosporine.

Lung transplantation for cystic fibrosis

PURPOSE OF REVIEW

To examine recent publications on lung transplantation for cystic fibrosis for changes in surgical techniques, selection criteria of patients, and impact on quality of life.

RECENT FINDINGS

Recent evidence focuses on cystic fibrosis patient subsets enabling better decisions about listing for lung transplantation as a therapeutic option. There is information about Burkholderia cepacia infection, ventilator dependence, young age, and arthropathy. In the US, the United Network for Organ Sharing has addressed perceived inequities in organ distribution by allocating organs by illness severity rather than time on the waiting list. A Lung Allocation Score ranks severity for patients 12 years of age and older for transplantation based on variables including lung function, oxygen and ventilatory needs, diabetes, weight and physical performance. Some recently studied important variables that influence survival in cystic fibrosis and after lung transplantation, including airway infections, pancreatic exocrine function and acute exacerbations, are not included in the Lung Allocation Score. Few publications have examined quality of life after transplantation, and a definitive work has yet to appear.

SUMMARY

New information has refined decision-making about lung transplantation for patients with cystic fibrosis. We examine recent findings and make recommendations for patients, families and medical providers.