Lung transplantation in patients with cystic fibrosis

The cost of lung transplantation in the United States: How high is too high?

Objectives

To identify patient and process factors that contribute to the high cost of lung transplantation (LTx) in the perioperative period, which may allow transplant centers to evaluate situations in which transplantation is most cost-effective to inform judicious resource allocation, avoid futile care, and reduce costs.

Methods

The MarketScan Research databases were used to identify 582 privately insured patients undergoing single or bilateral LTx between 2013 and 2019. The patients were subdivided into groups by disease etiology using the United Network of Organ Sharing classification system. Multivariable generalized linear models using a gamma distribution with a log link were fit to examine the associations between the etiology of lung disease and costs during the index admission, 3 months before admission, and 3 months after discharge.

Results

Our results indicate that the index admission contributed the most to the total transplantation costs compared to the 3 months before admission and after discharge. The regression-adjusted mean index hospitalization cost was 35% higher for patients with pulmonary vascular disease compared to those with obstructive lung disease ($527,156 vs $389,055). The use of extracorporeal membrane oxygenation, mechanical ventilation, and surgical complications in the post-transplantation period were associated with higher costs during the index admission. Surprisingly, age ≥55 was associated with lower costs during the index admission.

Conclusions

This analysis identifies pivotal factors influencing the high cost of LTx, emphasizing the significant impact of the index admission, particularly for patients with pulmonary vascular disease. These insights offer transplant centers an opportunity to enhance cost-effectiveness through judicious resource allocation and service bundling, ultimately reducing overall transplantation costs.

Risk factors of wound infection after lung transplantation: a narrative review

Background and Objective

The incidence of incision infection after lung transplantation is prominently high which affect the prognosis. Summarizing the risk factors related to incision infection after lung transplantation contribute to the control of incision infection by pre-controlling the risk factors. The objective is to summarize risk factors related to wound infection after lung transplantation.

Methods

PubMed was used to research the literature relating to the risk factors to incision infection after lung transplantation through 1990 to 2022. The retrieval strategy were Medical Subject Heading (MeSH) terms combined entry terms. Two researchers conducted the literature retrieval independently. Two researchers independently evaluate the quality of the literature and summarize the indicators.

Key Content and Findings

A total of 98 researches were collected from PubMed and 8 articles described the related risk factors of incision infection after lung transplantation. All of the 8 articles were retrospective studies, of which 4 articles were grouped by the delayed chest closure (DCC) execution and the other 4 articles were grouped by the surgical site infection (SSI) occurred. Two articles performed multivariate regression analysis to determine the independent risk factors of SSI after lung transplantation and the other 6 articles compared the SSI rate in different patients population. The integrated results showed that bronchoalveolar lavages (BALs), smoking status, body mass index (BMI), diabetes, operation duration, thoracic drainage tube placement time and DCC were related to the SSI after lung transplantation.

Conclusions

BALs, smoking status, BMI, diabetes, operation duration, thoracic drainage tube placement time and DCC were related to the SSI after lung transplantation.

Evaluation of autonomic modulation of lung function and heart rate in children with cystic fibrosis

The autonomic nervous system (ANS) plays an important role in modulating bronchial smooth muscle contractility, which is altered in cystic fibrosis (CF). A convenient approach to probe ANS regulation is the quantitative analysis of heart rate variability (HRV). The purpose of this study was to evaluate ANS regulation in children with CF and to investigate the influence of colonization by Pseudonomas aeruginosa via assessment of HRV in colonized CF (CCF) children and noncolonized CF (NCCF) children. Sixteen children with CF (7 CCF and 9 NCCF) and seven healthy age-matched control children were enrolled in the study. Heart rate was recorded for 10 min at rest in the supine and standing positions and HRV analysis was carried out using autoregressive spectral analysis. The CCF group was characterized by lower forced expiratory volume than NCCF, indicating an impairment of respiratory function. The HRV parameters further confirmed the possible sympathetic overactivity in CCF. Children with CF exhibited hyperactivity of the sympathetic nervous system. In particular, the CCF group presented a greater impairment of ANS modulation. Both CCF and NCCF children showed lower supine vagal activation in the HRV indices related to sympathetic activation and reduction of indices indicating vagal activity with the postural change from supine to standing when compared to the NCCF group.

Lung transplant programs in developing countries: challenges, solutions, and outcomes

PURPOSE OF REVIEW

The majority of lung transplants (LT) performed are in developed countries. In contrast, little is known about the status of LT in developing nations. The objective is to summarize the challenges, present solutions, and review outcomes of LT in developing countries. We hope this review will guide healthcare providers in such countries that are contemplating embarking on this journey.

RECENT FINDINGS

The key challenges that programs in developing countries encountered included shortage and marginal quality of donated organs, lack of dedicated multi-disciplinary LT team, limited availability of advanced technology and high risk of post-transplant infections. Education and collaboration among government, public, and healthcare sectors was seen as fundamental to building and maintaining a successful program. Despite minimal resources and huge challenges, LT survival rates in developing countries improved and were comparable with outcomes reported by the International Society for Heart and Lung Transplantation (ISHLT) Registry.

SUMMARY

Starting a new LT program is a daunting task that is complex and resource intensive, especially in developing countries. Improving outcomes indeed provide impetus to continue to persevere in this endeavor with support from all sectors. The findings presented here could help new programs to better anticipate and tackle challenges.

Cystic Fibrosis Lung Transplant Recipients Have Suppressed Airway Interferon Responses during Pseudomonas Infection

Lung transplantation can be lifesaving in end-stage cystic fibrosis (CF), but long-term survival is limited by chronic lung allograft dysfunction (CLAD). Persistent upper airway Pseudomonas aeruginosa (PsA) colonization can seed the allograft. While de novo PsA infection is associated with CLAD in non-CF recipients, this association is less clear for CF recipients experiencing PsA recolonization. Here, we evaluate host and pathogen contributions to this phenomenon. In the context of PsA infection, brushings from the airways of CF recipients demonstrate type 1 interferon gene suppression. Airway epithelial cell (AEC) cultures demonstrate similar findings in the absence of pathogens or immune cells, contrasting with the pre-transplant CF AEC phenotype. Type 1 interferon promoters are relatively hypermethylated in CF AECs. CF subjects in this cohort have more mucoid PsA, while non-CF PsA subjects have decreased microbiome α diversity. Peri-transplant protocols may benefit from consideration of this host and microbiome equilibrium.

Lung allograft Pseudomonas infection outcomes are better for recipients with CF

In CF, infected allograft airway cells demonstrate suppression of interferon genes

Differential DNA methylation may contribute to this distinct epithelial phenotype

Increased α diversity and mucoid forms characterize CF Pseudomonas infection

Indications for lung resection surgery and lung transplant in South American children with cystic fibrosis

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.

Lung transplantation for cystic fibrosis: results, indications, complications, and controversies

Survival in patients with cystic fibrosis (CF) has improved dramatically over the past 30 to 40 years, with mean survival now approximately 40 years. Nonetheless, progressive respiratory insufficiency remains the major cause of mortality in CF patients, and lung transplantation (LT) is eventually required. Timing of listing for LT is critical, because up to 25 to 41% of CF patients have died while awaiting LT. Globally, approximately 16.4% of lung transplants are performed in adults with CF. Survival rates for LT recipients with CF are superior to other indications, yet LT is associated with substantial morbidity and mortality (∼50% at 5-year survival rates). Myriad complications of LT include allograft failure (acute or chronic), opportunistic infections, and complications of chronic immunosuppressive medications (including malignancy). Determining which patients are candidates for LT is difficult, and survival benefit remains uncertain. In this review, we discuss when LT should be considered, criteria for identifying candidates, contraindications to LT, results post-LT, and specific complications that may be associated with LT. Infectious complications that may complicate CF (particularly Burkholderia cepacia spp., opportunistic fungi, and nontuberculous mycobacteria) are discussed.