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Evans RA, Walter KS, Lobo LJ, Coakley R, Doligalski CT. Pharmacotherapy of chronic lung allograft dysfunction post lung transplantation. Clin Transplant 2022; 36:e14770. [PMID: 35801376 DOI: 10.1111/ctr.14770] [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: 01/30/2022] [Revised: 05/30/2022] [Accepted: 07/05/2022] [Indexed: 11/30/2022]
Abstract
Chronic lung allograft dysfunction (CLAD) remains the primary cause of death in lung transplant recipients (LTRs) in spite of improvements in immunosuppression management. Despite advances in knowledge regarding the pathogenesis of CLAD, treatments that are currently available are usually ineffective and delay progression of disease at best. There are currently no evidence-based guidelines for the optimal treatment of CLAD, and management varies widely across transplant centers. Additionally, there are minimal publications available to summarize data for currently available therapies and outcomes in LTRs. We identified the major domains of the medical management of CLAD and conducted a comprehensive search of PubMed and Embase databases to identify articles published from inception to December 2021 related to CLAD in LTRs. Studies published in English pertaining to the pharmacologic prevention and treatment of CLAD were included; highest priority was given to prospective, randomized, controlled trials if available. Prospective observational and retrospective controlled trials were prioritized next, followed by retrospective uncontrolled studies, case series, and finally case reports if the information was deemed to be pertinent. Reference lists of qualified publications were also reviewed to find any other publications of interest that were not found on initial search. In the absence of literature published in the aforementioned databases, additional articles were identified by reviewing abstracts presented at the International Society for Heart and Lung Transplantation and American Transplant Congress annual meetings between 2010-2021. This document serves to provide a comprehensive review of the literature and considerations for the prevention and medical management of CLAD. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Rickey A Evans
- Department of Pharmacy, University of Kentucky Healthcare, Lexington, KY, USA
| | - Krysta S Walter
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
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Immunosuppression in Lung Transplantation. Handb Exp Pharmacol 2021; 272:139-164. [PMID: 34796380 DOI: 10.1007/164_2021_548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Immunosuppression in lung transplantation is an area devoid of robust clinical data. This chapter will review the history of immunosuppression in lung transplantation. Additionally, it will evaluate the three classes of induction, maintenance, and rescue immunosuppression in detail. Induction immunosuppression in lung transplantation aims to decrease incidence of lung allograft rejection, however infectious risk must be considered when determining if induction is appropriate and which agent is most favorable. Similar to other solid organ transplant patient populations, a multi-drug approach is commonly prescribed for maintenance immunosuppression to minimize single agent drug toxicities. Emphasis of this review is placed on key medication considerations including dosing, adverse effects, and drug interactions. Clinical considerations will be reviewed per drug class given available literature. Finally, acute cellular, antibody mediated, and chronic rejection are reviewed.
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Induction and maintenance immunosuppression in lung transplantation. Indian J Thorac Cardiovasc Surg 2021; 38:300-317. [DOI: 10.1007/s12055-021-01225-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 06/04/2021] [Accepted: 06/13/2021] [Indexed: 10/20/2022] Open
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Panchabhai TS, Chaddha U, McCurry KR, Bremner RM, Mehta AC. Historical perspectives of lung transplantation: connecting the dots. J Thorac Dis 2018; 10:4516-4531. [PMID: 30174905 DOI: 10.21037/jtd.2018.07.06] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Lung transplantation is now a treatment option for many patients with end-stage lung disease. Now 55 years since the first human lung transplant, this is a good time to reflect upon the history of lung transplantation, to recognize major milestones in the field, and to learn from others' unsuccessful transplant experiences. James Hardy was instrumental in developing experimental thoracic transplantation, performing the first human lung transplant in 1963. George Magovern and Adolph Yates carried out the second human lung transplant a few days later. With a combined survival of only 26 days for these first 2 lung transplant recipients, the specialty of lung transplantation clearly had a long way to go. The first "successful" lung transplant, in which the recipient survived for 10.5 months, was reported by Fritz Derom in 1971. Ten years later, Bruce Reitz and colleagues performed the first successful en bloc transplantation of the heart and one lung with a single distal tracheal anastomosis. In 1988, Alexander Patterson performed the first successful double lung transplant. The modern technique of sequential double lung transplantation and anastomosis performed at the mainstem bronchus level was originally described by Henri Metras in 1950, but was not reintroduced into the field until Pasque reported it again in 1990. Since then, lung transplantation has seen landmark changes: evolving immunosuppression regimens, clarifying the definition of primary graft dysfunction (PGD), establishing the lung allocation score (LAS), introducing extracorporeal membrane oxygenation (ECMO) as a bridge to transplant, allowing donation after cardiac death, and implementing ex vivo perfusion, to name a few. This article attempts to connect the historical dots in this field of research, with the hope that our effort helps summarize what has been achieved, and identifies opportunities for future generations of transplant pulmonologists and surgeons alike.
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Affiliation(s)
- Tanmay S Panchabhai
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Udit Chaddha
- Department of Pulmonary and Critical Care Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Kenneth R McCurry
- Department of Cardiothoracic Surgery, Sydell and Arnold Miller Family Heart and Vascular Institute
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Atul C Mehta
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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Abstract
Immunosuppressive therapy is arguably the most important component of medical care after lung transplantation. The goal of immunosuppression is to prevent acute and chronic rejection while maximizing patient survival and long-term allograft function. However, the benefits of immunosuppressive therapy must be balanced against the side effects and major toxicities of these medications. Immunosuppressive agents can be classified as induction agents, maintenance therapies, treatments for acute rejection and chronic rejection and antibody directed therapies. Although induction therapy remains an area of controversy in lung transplantation, it is still used in the majority of transplant centers. On the other hand, maintenance immunosuppression is less contentious; but, unfortunately, since the creation of three-drug combination therapy, including a glucocorticoid, calcineurin inhibitor and anti-metabolite, there have been relatively modest improvements in chronic maintenance immunosuppressive regimens. The presence of HLA antibodies in transplant candidates and development of de novo antibodies after transplantation remain a major therapeutic challenge before and after lung transplantation. In this chapter we review the medications used for induction and maintenance immunosuppression along with their efficacy and side effect profiles. We also review strategies and evidence for HLA desensitization prior to lung transplantation and management of de novo antibody formation after transplant. Finally, we review immune tolerance and the future of lung transplantation to limit the toxicities of conventional immunosuppressive therapy.
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Affiliation(s)
- Luke J Benvenuto
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Michaela R Anderson
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Selim M Arcasoy
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, USA
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Van Herck A, Verleden SE, Vanaudenaerde BM, Verleden GM, Vos R. Prevention of chronic rejection after lung transplantation. J Thorac Dis 2017; 9:5472-5488. [PMID: 29312757 DOI: 10.21037/jtd.2017.11.85] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Long-term survival after lung transplantation (LTx) is limited by chronic rejection (CR). Therapeutic strategies for CR have been largely unsuccessful, making prevention of CR an important and challenging therapeutic approach. In the current review, we will discuss current clinical evidence regarding prevention of CR after LTx.
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Affiliation(s)
- Anke Van Herck
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
| | - Stijn E Verleden
- Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
| | - Bart M Vanaudenaerde
- Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
| | - Geert M Verleden
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
| | - Robin Vos
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
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Abstract
Heart lung transplantation is a viable treatment option for patients with many end-stage heart and lung pathologies. However, given the complex nature of the procedure, it is imperative that patients are selected appropriately, and the clinician is aware of the many unique aspects in management of this population. This review seeks to describe updated organ selection policies, perioperative and postoperative management strategies, monitoring of graft function, and clinical outcomes for patients after combined heart-lung transplantation in the current era.
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Kyriakidis I, Tragiannidis A, Zündorf I, Groll AH. Invasive fungal infections in paediatric patients treated with macromolecular immunomodulators other than tumour necrosis alpha inhibitors. Mycoses 2017; 60:493-507. [DOI: 10.1111/myc.12621] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/06/2017] [Accepted: 03/07/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Ioannis Kyriakidis
- 2nd Department of Pediatrics; Aristotle University of Thessaloniki; AHEPA University General Hospital; Thessaloniki Greece
| | - Athanasios Tragiannidis
- 2nd Department of Pediatrics; Aristotle University of Thessaloniki; AHEPA University General Hospital; Thessaloniki Greece
| | - Ilse Zündorf
- Institute of Pharmaceutical Biology; Goethe-University of Frankfurt; Frankfurt am Main Germany
| | - Andreas H. Groll
- Infectious Disease Research Program; Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology; University Childrens Hospital; Muenster Germany
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Risks and Epidemiology of Infections After Lung or Heart–Lung Transplantation. TRANSPLANT INFECTIONS 2016. [PMCID: PMC7123746 DOI: 10.1007/978-3-319-28797-3_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Nowadays, lung transplantation is an established treatment option of end-stage pulmonary parenchymal and vascular disease. Post-transplant infections are a significant contributor to overall morbidity and mortality in the lung transplant recipient that, in turn, are higher than in other solid organ transplant recipients. This is likely due to several specific factors such as the constant exposure to the outside environment and the colonized native airway, and the disruption of usual mechanisms of defense including the cough reflex, bronchial circulation, and lymphatic drainage. This chapter will review the common infections that develop in the lung or heart–lung transplant recipient, including the general risk factors for infection in this population, and specific features of prophylaxis and treatment for the most frequent bacterial, viral, and fungal infections. The effects of infection on lung transplant rejection will also be discussed.
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Abstract
Lung transplantation has become an important therapeutic option for patients with end-stage organ dysfunction; however, its clinical usefulness has been limited by the relatively early onset of chronic allograft dysfunction and progressive clinical decline. Obliterative bronchiolitis is characterized histologically by luminal fibrosis of the respiratory bronchioles and clinically by bronchiolitis obliterans syndrome (BOS) which is defined by a measured decline in lung function based on forced expiratory volume (FEV1). Since its earliest description, a number of risk factors have been associated with the development of BOS, including acute rejection, lymphocytic bronchiolitis, primary graft dysfunction, infection, donor specific antibodies, and gastroesophageal reflux disease. However, despite this broadened understanding, the pathogenesis underlying BOS remains poorly understood and once begun, there are relatively few treatment options to battle the progressive deterioration in lung function.
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Affiliation(s)
- Christine M Lin
- 1University of Colorado, Denver - Anschutz Medical Campus, 12700 East 19th Avenue, Room 9470E, Aurora, CO 80045 USA
| | - Martin R Zamora
- 2University of Colorado, Denver - Anschutz Medical Campus, 1635 Aurora Court, Room 7082, Mail Stop F749, Aurora, CO 80045 USA
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Mullen JC, Kuurstra EJ, Oreopoulos A, Bentley MJ, Wang S. A randomized controlled trial of daclizumab versus anti-thymocyte globulin induction for heart transplantation. Transplant Res 2014; 3:14. [PMID: 25093077 PMCID: PMC4120716 DOI: 10.1186/2047-1440-3-14] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 07/18/2014] [Indexed: 12/04/2022] Open
Abstract
Background The purpose of this study was to test the efficacy and safety of daclizumab (DZM) versus anti-thymocyte globulin (ATG) as a component of induction therapy in heart transplant recipients. Methods Thirty heart transplant patients were randomized to receive either ATG or DZM during induction therapy. Patients in the DZM group received an initial dose of 2 mg/kg intravenous (IV) at the time of transplant and 1 mg/kg IV on postoperative day 4. Discussion Recipient, donor, and intraoperative variables did not differ significantly between groups. The cost of induction therapy, total drug cost, and hospital ward costs were significantly less for the DZM group. Average absolute lymphocyte and platelet counts were significantly higher in the DZM group. There were no significant differences in the incidence of rejection, infection, malignancy, or steroid-induced diabetes. One year survival was excellent in both groups (87%, P = 0.1). Daclizumab is a safe component of induction therapy in heart transplantation.
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Affiliation(s)
- John C Mullen
- Division of Cardiac Surgery, University of Alberta Hospital, Edmonton, AB, Canada ; Division of Cardiac Surgery, University of Alberta Hospital, 2D2.18 WMC, 8440 112 Street, Edmonton, AB T6G 2B7, Canada
| | - Emily J Kuurstra
- Division of Cardiac Surgery, University of Alberta Hospital, Edmonton, AB, Canada
| | - Antigone Oreopoulos
- Division of Cardiac Surgery, University of Alberta Hospital, Edmonton, AB, Canada
| | - Michael J Bentley
- Division of Cardiac Surgery, University of Alberta Hospital, Edmonton, AB, Canada
| | - Shaohua Wang
- Division of Cardiac Surgery, University of Alberta Hospital, Edmonton, AB, Canada
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Abstract
The enduring success of lung transplantation is built on the use of immunosuppressive drugs to stop the immune system from rejecting the newly transplanted lung allograft. Most patients receive a triple-drug maintenance immunosuppressive regimen consisting of a calcineurin inhibitor, an antiproliferative and corticosteroids. Induction therapy with either an antilymphocyte monoclonal or an interleukin-2 receptor antagonist are prescribed by many centres aiming to achieve rapid inhibition of recently activated and potentially alloreactive T lymphocytes. Despite this generic approach acute rejection episodes remain common, mandating further fine-tuning and augmentation of the immunosuppressive regimen. While there has been a trend away from cyclosporine and azathioprine towards a preference for tacrolimus and mycophenolate mofetil, this has not translated into significant protection from the development of chronic lung allograft dysfunction, the main barrier to the long-term success of lung transplantation. This article reviews the problem of lung allograft rejection and the evidence for immunosuppressive regimens used both in the short- and long-term in patients undergoing lung transplantation.
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Abstract
PURPOSE OF REVIEW Lung transplantation for infants and children is an accepted but rarely exercised option for the treatment of end-stage lung disease, with outcomes equivalent to those for adults. However, widespread misconceptions regarding pediatric outcomes often confound timely and appropriate referral to specialty centers. We present the updated information for primary pediatricians to utilize when counseling families with children confronted by progressive end-stage pulmonary or cardiovascular disease. RECENT FINDINGS We provide general guidelines to consider for referral, and discuss allocation of organs in children, information regarding standard treatment protocols, and survival outcomes. SUMMARY Lung transplantation is a worthwhile treatment option to consider in children with end-stage lung disease. The treatment is complex, but lung transplant provides substantial survival benefit and markedly improved quality of life for children and their families. This timely review provides comprehensive information for pediatricians who are considering options for treatment of children with end-stage lung disease.
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Affiliation(s)
- Carol Conrad
- aDivision of Pediatric Pulmonary Medicine bDivision of Critical Care, Department of Pediatrics, Center for Excellence in Pulmonary Biology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Stanford, California, USA
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Whitson BA, Lehman A, Wehr A, Hayes D, Kirkby S, Pope-Harman A, Kilic A, Higgins RS. To induce or not to induce: a 21st century evaluation of lung transplant immunosuppression's effect on survival. Clin Transplant 2014; 28:450-61. [DOI: 10.1111/ctr.12339] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Bryan A. Whitson
- Division of Cardiac Surgery; Department of Surgery; Wexner Medical Center; The Ohio State University; Columbus OH USA
| | - Amy Lehman
- Center for Biostatistics; College of Medicine; The Ohio State University; Columbus OH USA
| | - Allison Wehr
- Center for Biostatistics; College of Medicine; The Ohio State University; Columbus OH USA
| | - Don Hayes
- Division of Pulmonary, Allergy, and Critical Care & Sleep Medicine; Department of Internal Medicine; Wexner Medical Center; The Ohio State University; Columbus OH USA
- Department of Pediatrics; Nationwide Children's Hospital; The Ohio State University; Columbus OH USA
| | - Stephen Kirkby
- Division of Pulmonary, Allergy, and Critical Care & Sleep Medicine; Department of Internal Medicine; Wexner Medical Center; The Ohio State University; Columbus OH USA
- Department of Pediatrics; Nationwide Children's Hospital; The Ohio State University; Columbus OH USA
| | - Amy Pope-Harman
- Division of Pulmonary, Allergy, and Critical Care & Sleep Medicine; Department of Internal Medicine; Wexner Medical Center; The Ohio State University; Columbus OH USA
| | - Ahmet Kilic
- Division of Cardiac Surgery; Department of Surgery; Wexner Medical Center; The Ohio State University; Columbus OH USA
| | - Robert S.D. Higgins
- Division of Cardiac Surgery; Department of Surgery; Wexner Medical Center; The Ohio State University; Columbus OH USA
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Hayes D, Kirkby S, Wehr AM, Lehman AM, McConnell PI, Galantowicz M, Higgins RS, Whitson BA. A contemporary analysis of induction immunosuppression in pediatric lung transplant recipients. Transpl Int 2014; 27:211-218. [DOI: 10.1111/tri.12240] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Don Hayes
- Department of Pediatrics; The Ohio State University; Columbus OH USA
- Department of Internal Medicine; The Ohio State University; Columbus OH USA
- Nationwide Children's Hospital; Columbus OH USA
| | - Stephen Kirkby
- Department of Pediatrics; The Ohio State University; Columbus OH USA
- Department of Internal Medicine; The Ohio State University; Columbus OH USA
- Nationwide Children's Hospital; Columbus OH USA
| | - Allison M. Wehr
- Center for Biostatistics; The Ohio State University; Columbus OH USA
| | - Amy M. Lehman
- Center for Biostatistics; The Ohio State University; Columbus OH USA
| | - Patrick I. McConnell
- Department of Pediatrics; The Ohio State University; Columbus OH USA
- Nationwide Children's Hospital; Columbus OH USA
| | - Mark Galantowicz
- Department of Pediatrics; The Ohio State University; Columbus OH USA
- Nationwide Children's Hospital; Columbus OH USA
| | | | - Bryan A. Whitson
- Department of Surgery; The Ohio State University; Columbus OH USA
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Penninga L, Møller CH, Penninga EI, Iversen M, Gluud C, Steinbrüchel DA. Antibody induction therapy for lung transplant recipients. Cochrane Database Syst Rev 2013; 2013:CD008927. [PMID: 24282128 PMCID: PMC6486205 DOI: 10.1002/14651858.cd008927.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Lung transplantation has become a valuable and well-accepted treatment option for most end-stage lung diseases. Lung transplant recipients are at risk of transplanted organ rejection, and life-long immunosuppression is necessary. Clear evidence is essential to identify an optimal, safe and effective immunosuppressive treatment strategy for lung transplant recipients. Consensus has not yet been achieved concerning use of immunosuppressive antibodies against T-cells for induction following lung transplantation. OBJECTIVES We aimed to assess the benefits and harms of immunosuppressive T-cell antibody induction with ATG, ALG, IL-2RA, alemtuzumab, or muromonab-CD3 for lung transplant recipients. SEARCH METHODS We searched the Cochrane Renal Group's Specialised Register to 4 March 2013 through contact with the Trials Search Co-ordinator using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE and EMBASE. SELECTION CRITERIA We included all randomised controlled trials (RCTs) that compared immunosuppressive monoclonal and polyclonal T-cell antibody induction for lung transplant recipients. An inclusion criterion was that all participants must have received the same maintenance immunosuppressive therapy within each study. DATA COLLECTION AND ANALYSIS Three authors extracted data. We derived risk ratios (RR) for dichotomous data and mean differences (MD) for continuous data with 95% confidence intervals (CI). Methodological risk of bias was assessed using the Cochrane risk of bias tool and trial sequential analyses were undertaken to assess the risk of random errors (play of chance). MAIN RESULTS Our review included six RCTs (representing a total of 278 adult lung transplant recipients) that assessed the use of T-cell antibody induction. Evaluation of the included studies found all to be at high risk of bias.We conducted comparisons of polyclonal or monoclonal T-cell antibody induction versus no induction (3 studies, 140 participants); polyclonal T-cell antibody versus no induction (3 studies, 125 participants); interleukin-2 receptor antagonists (IL-2RA) versus no induction (1 study, 25 participants); polyclonal T-cell antibody versus muromonab-CD3 (1 study, 64 participants); and polyclonal T-cell antibody versus IL-2RA (3 studies, 100 participants). Overall we found no significant differences among interventions in terms of mortality, acute rejection, adverse effects, infection, pneumonia, cytomegalovirus infection, bronchiolitis obliterans syndrome, post-transplantation lymphoproliferative disease, or cancer.We found a significant outcome difference in one study that compared antithymocyte globulin versus muromonab-CD3 relating to adverse events (25/34 (74%) versus 12/30 (40%); RR 1.84, 95% CI 1.13 to 2.98). This suggested that antithymocyte globulin increased occurrence of adverse events. However, trial sequential analysis found that the required information size had not been reached, and the cumulative Z-curve did not cross the trial sequential alpha-spending monitoring boundaries.None of the studies reported quality of life or kidney injury. Trial sequential analyses indicated that none of the meta-analyses achieved required information sizes and the cumulative Z-curves did not cross the trial sequential alpha-spending monitoring boundaries, nor reached the area of futility. AUTHORS' CONCLUSIONS No clear benefits or harms associated with the use of T-cell antibody induction compared with no induction, or when different types of T-cell antibodies were compared were identified in this review. Few studies were identified that investigated use of antibodies against T-cells for induction after lung transplantation, and numbers of participants and outcomes were also limited. Assessment of the included studies found that all were at high risk of methodological bias.Further RCTs are needed to perform robust assessment of the benefits and harms of T-cell antibody induction for lung transplant recipients. Future studies should be designed and conducted according to methodologies to reduce risks of systematic error (bias) and random error (play of chance).
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Affiliation(s)
- Luit Penninga
- Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812Blegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Christian H Møller
- Rigshospitalet, Copenhagen University HospitalDepartment of Cardiothoracic Surgery, RT 2152Blegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Elisabeth I Penninga
- Bispebjerg HospitalDepartment of Clinical PharmacologyBispebjerg Bakke 23CopenhagenDenmarkDK‐2400
| | - Martin Iversen
- Rigshospitalet, Copenhagen University HospitalMedical Department B‐2142, Division of Lung TransplantationBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Daniel A Steinbrüchel
- Rigshospitalet, Copenhagen University HospitalDepartment of Cardiothoracic Surgery, RT 2152Blegdamsvej 9CopenhagenDenmarkDK‐2100
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Lung cancer following lung transplant: single institution 10 year experience. Lung Cancer 2013; 81:451-454. [PMID: 23831244 DOI: 10.1016/j.lungcan.2013.05.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 05/27/2013] [Accepted: 05/28/2013] [Indexed: 01/20/2023]
Abstract
BACKGROUND Lung cancer following lung transplantation is an infrequent occurrence of post-transplant neoplasia. Tumors are classified based on donor or recipient origin. Recipient tumors can be diagnosed in explanted specimens or found in contralateral native lungs which remain in place during single lung transplant (SLTx). The aim of our study was to review our institution's incidence of post lung transplant lung cancer, describe tumor histology, and review our experience with their outcomes. METHODS A total of 335 lung transplants from 2001 to 2010 were reviewed. Patients were identified with a post-transplant diagnosis of lung cancer, neoplasia, or mass. Fifteen patients were identified; two were excluded due to concomitant cancers with which the lung cancer would represent a metastasis. Retrospective chart review was undertaken for thirteen patients for descriptive statistics, tumor characteristics and overall survival. RESULTS Overall incidence of lung cancer following transplant was 13 cases (3.88%). Six tumors were found in native explanted lungs and six developed subsequently in native lungs. One tumor was confirmed to be of donor origin. Histology included squamous cell in five (38.4%), adenocarcinoma in four (30.7%), and one patient each with adenosquamous (7.6%), carcinoid (7.6%), small cell (7.6%), or malignant solitary fibrous tumor (7.6%). Mean age at transplant was 65 ± 3 years. Mean time from transplant to diagnosis is reported as 241 ± 7 days (range 1-1170). Each patient had at least a 20 pack year smoking history with a mean of 45 ± 3 years. One-year survival for those with lung cancer following transplant was 42.8% while 1 year survival of all lung transplants at our institution is 85.7%. CONCLUSION Lung cancer incidentally found at the time of transplant or following transplantation is a serious complication with a noted effect on overall survival. The infrequent occurrence of donor tumors represents an adequate screening process of potential young donor lungs. The recognition of cancers in explanted specimens brings to question policies regarding screening of potential recipients with extensive smoking history. A high index of suspicion for native tumors is needed when conducting post-transplant surveillance as these tumors tend to be stage 4 at time diagnosis.
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Abstract
Lung transplantation has become an accepted therapeutic procedure for the treatment of end‐stage pulmonary parenchymal and vascular disease. Despite improved survival rates over the decades, lung transplant recipients have lower survival rates than other solid organ transplant recipients. The morbidity and mortality following lung transplantation is largely due to infection‐ and rejection‐related complications. This article will review the common infections that develop in the lung transplant recipient, including the general risk factors for infection in this population, and the most frequent bacterial, viral, fungal and other less frequent opportunistic infections. The epidemiology, diagnosis, prophylaxis, treatment and outcomes for the different microbial pathogens will be reviewed. The effects of infection on lung transplant rejection will also be discussed.
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Affiliation(s)
- Sergio R Burguete
- Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of Texas Health Science Center at San Antonio, Texas 78229-3900, USA
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19
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Postoperative complications in the intensive care unit following lung transplantation in adults: results in University Hospital Reina Sofia. Transplant Proc 2013; 44:2663-5. [PMID: 23146487 DOI: 10.1016/j.transproceed.2012.09.069] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The postoperative period following lung transplantation remains critical because of several complications. Infection, primary graft failure, acute rejection, and surgical complications are risk factors for mortality and morbidity. The recognition and early treatment of these complications is important to optimize outcomes. This article provides an overview of postoperative complications observed in our center during the last year. We were particularly interested in the influence of variables, such as inotrope usage and Acute Physiology and Chronic Health Evaluation (APACHE II) score, a well-known, and validated mortality prediction model for general intensive care unit (ICU) patients only infrequently reported in the transplantation literature. High APACHE II scores were significantly associated with prolonged mechanical ventilation (P = 0.041) and a tracheostomy requirement (P = .035). The factors significantly associated with an early postoperative death were older donor age (P = .005), prolonged donor ICU period (P = .004), need for cardiopulmonary bypass (CB; P = .005), and high inotrope requirements in the ICU (P = .034). CB data were biased because we selected the worst case patients. Donor age and high inotrope requirements in the ICU have been reported previously to be prognostic factors for poor graft function. We believe that control of these variables may improve outcomes.
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Weigt SS, DerHovanessian A, Wallace WD, Lynch JP, Belperio JA. Bronchiolitis obliterans syndrome: the Achilles' heel of lung transplantation. Semin Respir Crit Care Med 2013; 34:336-51. [PMID: 23821508 PMCID: PMC4768744 DOI: 10.1055/s-0033-1348467] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Lung transplantation is a therapeutic option for patients with end-stage pulmonary disorders. Unfortunately, chronic lung allograft dysfunction (CLAD), most commonly manifest as bronchiolitis obliterans syndrome (BOS), continues to be highly prevalent and is the major limitation to long-term survival. The pathogenesis of BOS is complex and involves alloimmune and nonalloimmune pathways. Clinically, BOS manifests as airway obstruction and dyspnea that are classically progressive and ultimately fatal; however, the course is highly variable, and distinguishable phenotypes may exist. There are few controlled studies assessing treatment efficacy, but only a minority of patients respond to current treatment modalities. Ultimately, preventive strategies may prove more effective at prolonging survival after lung transplantation, but their remains considerable debate and little data regarding the best strategies to prevent BOS. A better understanding of the risk factors and their relationship to the pathological mechanisms of chronic lung allograft rejection should lead to better pharmacological targets to prevent or treat this syndrome.
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Affiliation(s)
- S Samuel Weigt
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California 90095, USA.
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Sweet SC. Induction therapy in lung transplantation. Transpl Int 2013; 26:696-703. [DOI: 10.1111/tri.12115] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Revised: 02/13/2013] [Accepted: 04/20/2013] [Indexed: 01/17/2023]
Affiliation(s)
- Stuart C. Sweet
- Pediatric Lung Transplant Program; Washington University School of Medicine; St. Louis; MO; USA
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Baughman RP, Meyer KC, Nathanson I, Angel L, Bhorade SM, Chan KM, Culver D, Harrod CG, Hayney MS, Highland KB, Limper AH, Patrick H, Strange C, Whelan T. Monitoring of nonsteroidal immunosuppressive drugs in patients with lung disease and lung transplant recipients: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012; 142:e1S-e111S. [PMID: 23131960 PMCID: PMC3610695 DOI: 10.1378/chest.12-1044] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2012] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES Immunosuppressive pharmacologic agents prescribed to patients with diffuse interstitial and inflammatory lung disease and lung transplant recipients are associated with potential risks for adverse reactions. Strategies for minimizing such risks include administering these drugs according to established, safe protocols; monitoring to detect manifestations of toxicity; and patient education. Hence, an evidence-based guideline for physicians can improve safety and optimize the likelihood of a successful outcome. To maximize the likelihood that these agents will be used safely, the American College of Chest Physicians established a committee to examine the clinical evidence for the administration and monitoring of immunosuppressive drugs (with the exception of corticosteroids) to identify associated toxicities associated with each drug and appropriate protocols for monitoring these agents. METHODS Committee members developed and refined a series of questions about toxicities of immunosuppressives and current approaches to administration and monitoring. A systematic review was carried out by the American College of Chest Physicians. Committee members were supplied with this information and created this evidence-based guideline. CONCLUSIONS It is hoped that these guidelines will improve patient safety when immunosuppressive drugs are given to lung transplant recipients and to patients with diffuse interstitial lung disease.
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Affiliation(s)
| | - Keith C Meyer
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Luis Angel
- University of Texas Health Sciences, San Antonio, TX
| | | | - Kevin M Chan
- University of Michigan Health Systems, Ann Arbor, MI
| | | | | | - Mary S Hayney
- University of Wisconsin School of Pharmacy, Madison, WI
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Improving the safety of tolerance induction: chimerism and cellular co-treatment strategies applied to vascularized composite allografts. Clin Dev Immunol 2012; 2012:107901. [PMID: 23118778 PMCID: PMC3479992 DOI: 10.1155/2012/107901] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 08/17/2012] [Indexed: 12/26/2022]
Abstract
Although vascularized composite allografts (VCAs) have been performed clinically for a variety of indications, potential complications from long-term immunosuppression and graft-versus-host disease remain important barriers to widespread applications. Recently it has been demonstrated that VCAs incorporating a vascularized long bone in a rat model provide concurrent vascularized bone marrow transplantation that, itself, functions to establish hematopoietic chimerism and donor-specific tolerance following non-myeloablative conditioning of recipients. Advances such as this, which aim to improve the safety profile of tolerance induction, will help usher in an era of wider clinical VCA application for nonlife-saving reconstructions.
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Borro JM. Advances in immunosuppression after lung transplantation. Med Intensiva 2012; 37:44-9. [PMID: 22854620 DOI: 10.1016/j.medin.2012.05.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Revised: 05/16/2012] [Accepted: 05/29/2012] [Indexed: 01/01/2023]
Abstract
Immunosuppression in transplantation has experienced changes in recent years as a result of the introduction of new drugs that act upon the different pathways of the host immune response with the purpose of securing more individualized immune suppression, with fewer side effects. Although following in the steps of other solid organ transplant modalities, lung transplantation, because of its special characteristics, has not yielded similar middle- and long-term results. Improved understanding of the underlying rejection mechanisms, the pharmacodynamic control of drugs, new administration routes designed to reduce the side effects, and new drug substances or immune modulating processes will all contribute to improve the expectations associated to lung transplantation in the near future.
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Affiliation(s)
- J M Borro
- Servicio de Cirugía Torácica y Trasplante Pulmonar, Complejo Hospitalario Universitario de A Coruña, A Coruña, España.
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Abstract
The ICU period is only one time point among many in the complex, multidisciplinary postoperative management required for patient survival and improved QOL. The care required on step-down units and after discharge to home each has unique care aspects that impact successful patient outcomes.
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Affiliation(s)
- Elisabeth L George
- Advanced Practice Nurse Critical Care, Department of Nursing, University of Pittsburgh Medical Center-Presbyterian Shadyside, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
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Mahmud N, Klipa D, Ahsan N. Antibody immunosuppressive therapy in solid-organ transplant: Part I. MAbs 2011; 2:148-56. [PMID: 20150766 DOI: 10.4161/mabs.2.2.11159] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Currently, a wide variety of both polyclonal and monoclonal antibodies are being routinely utilized to prevent and treat solid organ rejection. More commonly, these agents are also administered in order to delay introduction of calcineurin inhibitors, especially in patients with already compromised renal function. While these antibody therapies dramatically reduced the incidence of acute rejection episodes and improved both short and long-term graft survival, they are also associated with an increased incidence of opportunistic infections and neoplastic complications. Therefore, effective patient management must necessarily balance these risks against the potential benefits of the therapy.
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Elderly Transplant Recipients. PRINCIPLES AND PRACTICE OF GERIATRIC SURGERY 2011. [PMCID: PMC7120546 DOI: 10.1007/978-1-4419-6999-6_98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
While the total number of organs transplanted in this country has increased over the years, there is still an ever-widening gap between the need for organs and our capacity to meet that need as the overall waiting list continues to grow. This is due in part to significant advances in transplant techniques and outcomes such that Americans with organ failure now seek transplants in greater numbers. Additionally, life-expectancy gains in the United States are creating an aging population who are more likely to suffer organ failure than younger Americans. The national transplant waiting list has continued to shift toward older candidates. The Scientific Registry of Transplant Recipients (SRTR) reported that at the end of 2007, 59.7% of all 97,248 candidates on the waiting list for all organs were 50 years old or older, and 14.9% were 65 years or older. These percentages are substantially higher than they were in 1998 (41.5 and 8.1%, respectively) [1].
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Goldfarb SB, Gaynor JW, Fuller S, Kreindler J, Montenegro LM, Fynn-Thompson F, Visner G. Induction Therapy With Antithymocyte Globulin Before Reperfusion. Ann Thorac Surg 2010; 90:1110-4; discussion 1114-5. [DOI: 10.1016/j.athoracsur.2010.05.074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2010] [Revised: 05/24/2010] [Accepted: 05/25/2010] [Indexed: 10/19/2022]
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Campara M, Tzvetanov IG, Oberholzer J. Interleukin-2 receptor blockade with humanized monoclonal antibody for solid organ transplantation. Expert Opin Biol Ther 2010; 10:959-69. [PMID: 20415630 DOI: 10.1517/14712598.2010.485187] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPORTANCE OF THE FIELD Induction therapy has reduced the incidence of acute rejection compared with historical standards. The potency of currently available induction immunosuppression is not without risk and should be carefully considered. Induction with daclizumab, an IL-2 receptor antagonist, has been used safely and effectively for over 10 years across different transplant types. As a result of daclizumab use, transplant centers are able to implement steroid-sparing or calcineurin minimization protocols. Unfortunately, the manufacturing costs have resulted in withdrawal of this agent from the market reducing the options for patients undergoing transplantation. AREAS COVERED IN THIS REVIEW This review will update the reader on recently published daclizumab studies in adult solid organ transplant recipients, focusing on comparative studies with other induction agents. WHAT THE READER WILL GAIN This paper will provide a summary of comparative studies between daclizumab and other induction therapies focusing on their efficacy and safety. TAKE HOME MESSAGE Novel applications, such as long-term use in combination with calcineurin-inhibitor dose reduction and its value in the treatment of acute or chronic rejection have yet to be explored. Since daclizumab has been withdrawn from the market, future IL-2 receptor blockade will have to be achieved with basiliximab, which is a chimeric, monoclonal antibody directed against the same epitope.
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Affiliation(s)
- Maya Campara
- University of Illinois at Chicago, 833 S Wood St, M/C 886, Chicago, IL 60612, USA
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31
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Burton CM, Kristensen P, Lützhøft R, Rasmussen M, Milman N, Carlsen J, Christiansen CB, Andersen CB, Iversen M. Cytomegalovirus infection in lung transplant patients: The role of prophylaxis and recipient-donor serotype matching. ACTA ACUST UNITED AC 2009; 38:281-9. [PMID: 16715596 DOI: 10.1080/00365540500400936] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Cytomegalovirus (CMV) remains an important cause of morbidity and mortality in lung transplant recipients. We investigated the incidence of CMV infection in relation to CMV prophylaxis, and recipient-donor CMV serotype, in a cohort of 250 consecutive lung transplant recipients. All patients received 3 months CMV prophylaxis with acyclovir (n = 67) or gancyclovir (n = 183). Recipient-donor CMV serotype matching was performed in patients receiving acyclovir: R+/D+(n = 38), R+/D-(n = 10), R-/D+(n = 1), R- /D-(n = 16), unknown (n = 2). Recipient-donor CMV serotype matching was not performed in patients receiving gancyclovir: R+/D+(n = 71), R+/D-(n = 42), R-/D+(n = 38), R-/D-(n = 31), unknown (n = 1). The overall incidence of CMV infection was 51% (n = 34) in the acyclovir group, and 42% (n = 77) in the gancyclovir group (p = 0.14). During the first 9 months after transplantation, the rate of CMV infection was higher in the acyclovir group (42%) compared with the gancyclovir group (30%) (p = 0.005). Multivariate analysis demonstrated the incidence of CMV infection during the first 9 months was higher for acyclovir prophylaxis (p<0.001) and R-/D+ serostatus (p<0.001) and lower with R-/D- serostatus (p = 0.02). In conclusion, gancyclovir significantly delays the onset of first CMV infection among lung transplant patients. CMV surveillance and choice of prophylaxis may be modified according to donor-recipient CMV serotype.
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Affiliation(s)
- Christopher M Burton
- Division of Lung Transplantation, Department of Medicine B, Rigshospitalet, Copenhagen, Denmark.
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Immunosuppressive therapy in lung transplantation: state of the art. Eur J Cardiothorac Surg 2009; 35:1045-55. [DOI: 10.1016/j.ejcts.2009.02.035] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2008] [Revised: 02/03/2009] [Accepted: 02/20/2009] [Indexed: 11/21/2022] Open
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Abstract
The postoperative management of a patient undergoing lung transplantation involves many components of care. These components include ventilatory and hemodynamic management, immunosuppression, wound care, rehabilitation, infection control and treatment, and early detection of rejection.
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34
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Watts AB, Williams RO, Peters JI. Recent Developments in Drug Delivery to Prolong Allograft Survival in Lung Transplant Patients. Drug Dev Ind Pharm 2009; 35:259-71. [DOI: 10.1080/03639040802282904] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Hartwig MG, Snyder LD, Appel JZ, Cantu E, Lin SS, Palmer SM, Davis RD. Rabbit Anti-thymocyte Globulin Induction Therapy Does Not Prolong Survival After Lung Transplantation. J Heart Lung Transplant 2008; 27:547-53. [DOI: 10.1016/j.healun.2008.01.022] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2007] [Revised: 01/14/2008] [Accepted: 01/24/2008] [Indexed: 10/22/2022] Open
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Effects of induction immunosuppression regimen on acute rejection, bronchiolitis obliterans, and survival after lung transplantation. J Thorac Cardiovasc Surg 2008; 135:594-602. [PMID: 18329476 DOI: 10.1016/j.jtcvs.2007.10.044] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2007] [Revised: 10/12/2007] [Accepted: 10/26/2007] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Effects of daclizumab and antithymocyte globulin induction on acute rejection, bronchiolitis obliterans syndrome, and survival after lung transplantation are unknown. We hypothesized that daclizumab results in less acute rejection and bronchiolitis obliterans and better survival than antithymocyte globulin. METHODS Consecutive adult lung transplants (n = 163) at the University of Virginia from January 1998 to May 2006 were reviewed. Antithymocyte globulin induction was routinely performed before January 2002 (65 patients), after which all patients received daclizumab (98 patients). Estimates of cumulative event rate of acute rejection, bronchiolitis obliterans, and death were calculated by Kaplan-Meier method and between-group differences compared by log-rank test. Cox proportional hazards models were fitted to assess treatment effects adjusted for covariates. RESULTS Groups were similar in demographics and preoperative and intraoperative risk factors. Maintenance immunosuppression changed during the study, and mycophenolate mofetil was more commonly given to patients receiving daclizumab. By Kaplan-Meier method, daclizumab was associated with significantly less acute rejection (P = .002), less bronchiolitis obliterans (P = .02), and improved overall survival (P = .04). Induction agent was highly associated with acute rejection (P = .002), bronchiolitis obliterans (P = .02), and mortality (P = .05); antimetabolite agent was associated only with acute rejection (P = .01). Adjusting for covariates, induction agent remained significantly predictive for acute rejection (P = .02) and bronchiolitis obliterans (P = .05), approaching significance for survival (P = .07). CONCLUSION Lung transplant recipients receiving daclizumab for induction had significantly less acute rejection and bronchiolitis obliterans than those receiving antithymocyte globulin, with possibly improved survival. Improvements in acute rejection may have been confounded by the use of mycophenolate mofetil.
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Thistlethwaite JR, Bruce D. Rejection. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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39
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Lung Transplantation. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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40
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Assmann JB, Fontana V, Pansard HM, Ferreira MBC, Bianchin MM. Very early meningoencephalopathy associated with the intraoperative use of OKT3 in renal retransplant. ARQUIVOS DE NEURO-PSIQUIATRIA 2008; 66:747-8. [DOI: 10.1590/s0004-282x2008000500028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
Daclizumab is a humanized monoclonal antibody which binds to the IL-2 receptor on activated lymphocytes and blocks the production of IL-2. Its use is well established in solid organ transplantation as induction therapy, especially in high-risk patients where reduction or delayed dose of standard immunosuppression would be beneficial. It has been used effectively in both 2-dose and 5-dose regimens in conjunction with other standard immunosuppressive agents. The incidence of acute rejection appears reduced without increasing the rates of infection or post-transplant lympho-proliferative disorders. The agent is generally well tolerated in adults and children and there is no need for additional monitoring. Daclizumab has also been used outside the transplant arena in a variety of immune-mediated diseases with limited success.
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Mankidy B, Kesavan RB, Silay YS, Haddad TJ, Seethamraju H. Emerging drugs in lung transplantation. Expert Opin Emerg Drugs 2007; 12:61-73. [PMID: 17355214 DOI: 10.1517/14728214.12.1.61] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The balance between immunosuppression to ensure graft tolerance while preventing emergence of infectious complications is key in lung transplantation. Although opportunistic infection may appear to be the most important of these complications, malignancies and severe drug toxicities significantly affect the short- and long-term outcomes of the patients. The present practice is combination therapy using drugs with complementary immunosuppressive action, to achieve synergistic immunosuppression with the lowest possible toxicity. Components of immunosuppression include induction and maintenance regimens. Primary graft failure remains an important cause of mortality and morbidity in the immediate post-transplant period. Acute rejection is a common complication after lung transplant, but responds well to augmented immunosuppression and immunomodulation. Chronic rejection still is the major cause of mortality in patients who survive the initial year post-transplantation. Several new drugs have shown promise in decreasing the rate of loss of graft function. This review discusses the current and emerging therapeutic regimens.
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Affiliation(s)
- Babith Mankidy
- Baylor College of Medicine, Department of Medicine, Pulmonary and Critical Care, Lung transplant program, Houston, Texas, USA
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A randomized, controlled trial of daclizumab vs anti-thymocyte globulin induction for lung transplantation. J Heart Lung Transplant 2007; 26:504-10. [PMID: 17449421 DOI: 10.1016/j.healun.2007.01.032] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2006] [Revised: 01/04/2007] [Accepted: 01/30/2007] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Rejection remains a significant cause of morbidity and mortality after lung transplantation. The purpose of this study was to test the efficacy and safety of daclizumab (DZM) vs anti-thymocyte globulin (ATG) as a component of induction therapy. METHODS Fifty adults undergoing lung transplantation were randomized to receive either ATG or DZM during induction therapy. Patients were followed for 1 year after transplant. RESULTS Although there was no significant difference in the number of acute or chronic rejections between groups, there was a trend toward a delay in time to first acute rejection with DZM induction. Average absolute lymphocytes and average platelet count were significantly higher in the DZM group. Cytomegalovirus (CMV) serology mismatch was higher in the DZM group (7 vs 1, p = 0.05). The DZM group had a greater number of infections (83 vs 47, p = 0.02); however, the number of CMV infections was also significantly greater (18 vs 6, p = 0.03), corresponding to a higher incidence of CMV mismatch. A cost analysis revealed no difference between total drug costs, intensive-care unit (ICU) costs and total hospital costs. One-year survival was 96% in the DZM group and 88% in the ATG group. CONCLUSIONS DZM is a safe component of induction therapy in lung transplantation. In addition, DZM may prolong freedom from acute rejection. Significant infections were more frequent in the DZM group, but this was likely due to a higher incidence of CMV mismatch. Both methods of induction therapy worked well, with excellent 1-year survival.
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Laube BL, Karmazyn YJ, Orens JB, Mogayzel PJ. Albuterol Improves Impaired Mucociliary Clearance After Lung Transplantation. J Heart Lung Transplant 2007; 26:138-44. [PMID: 17258147 DOI: 10.1016/j.healun.2006.11.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2006] [Revised: 11/07/2006] [Accepted: 11/13/2006] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Previous studies have shown that mucociliary clearance (MCC) is diminished after lung transplantation. However, it is unknown how early this deficit occurs after transplantation, or whether the abnormality can be improved by pharmacologic means. We hypothesized that impairment of MCC is evident soon after lung transplantation and that the defect in MCC can be improved by inhaled beta(2)-adrenergic receptor agonists. METHODS MCC and cough clearance (CC) were quantified in seven patients at 76 +/- 48 days (mean +/- standard deviation) after lung transplantation (baseline visit) and again 1 week later after an acute inhalation of albuterol. MCC was also determined once in four healthy subjects. To measure MCC, volunteers inhaled 99m-technetium-sulfur colloid aerosol, followed by gamma-camera imaging of their lungs for 76 minutes. RESULTS Baseline MCC was significantly reduced in transplant patients, compared with healthy subjects, averaging 8.9 +/- 7.3% and 20.9 +/- 15.1%, respectively (p = 0.05). CC was not affected by transplantation. Acute inhalation of albuterol significantly improved MCC in transplant patients (31.9 +/- 21.9%) compared with baseline values (p < 0.05). CONCLUSIONS MCC is diminished within a few months after transplantation. However, the response to albuterol suggests that the deficit is not static and can be improved with inhalation of a beta(2)-adrenergic receptor agonist.
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Affiliation(s)
- Beth L Laube
- Eudowood Division of Pediatric Respiratory Sciences, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21287-2533, USA
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Lischke R, Simonek J, Davidová R, Schützner J, Stolz AJ, Vojácek J, Burkert J, Pafko P. Induction Therapy in Lung Transplantation: Initial Single-Center Experience Comparing Daclizumab and Antithymocyte Globulin. Transplant Proc 2007; 39:205-12. [PMID: 17275507 DOI: 10.1016/j.transproceed.2006.10.030] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2006] [Indexed: 11/25/2022]
Abstract
UNLABELLED Acute and chronic rejection remain unresolved problems after lung transplantation, despite heavy multidrug immunosuppression. Because acute rejection is associated with inferior outcomes in lung transplantation, we have routinely employed antithymocyte globulin (ATG) or daclizumab as adjuncts to reduce the incidence of rejection episodes. METHODS We performed a controlled clinical trial of the two therapies to evaluate differences in postoperative rejection, infection, bronchiolitis obliterans syndrome (BOS) and host survival. Twenty-five consecutive lung transplant patients received ATG (n = 12; group 1) or daclizumab (n = 13; group 2) as an induction agent. The groups showed similar demographics and immunosuppression protocols, differ only in induction agent. RESULTS No differences were observed in the immediate postoperative outcomes, such as length of hospitalization, ICU stay, or time on ventilator. There were no significant differences in the number of episodes of acute rejection, freedom from BOS, or infections. Freedom from acute rejection was significantly greater with daclizumab than with ATG (P = .037). The 1-year survival for group 1 was 67% and for group 2, 77% (P = .584). CONCLUSIONS Daclizumab constitutes a safe and effective form of induction immunosuppressive therapy. Using a two-dose administration schedule, daclizumab prolonged the time without acute rejection compared to ATG. The differences in the incidence of infectious complications, acute rejection, or BOS as well as the short-term or long-term results were not significantly different. The results of the study justify the further use of daclizumab as an induction agent in patients following lung transplantation.
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Affiliation(s)
- R Lischke
- 3rd Department of Surgery, Thoracic and Lung Transplantation Division, University Hospital Motol, Prague, Czech Republic.
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47
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Taylor JL, Palmer SM. Critical care perspective on immunotherapy in lung transplantation. J Intensive Care Med 2006; 21:327-44. [PMID: 17095497 DOI: 10.1177/0885066606292876] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Lung transplantation is now a viable therapeutic option in the care of patients with advanced pulmonary parenchymal or pulmonary vascular disease. Lung transplantation, however, with chronic posttransplant immunosuppression, creates a uniquely vulnerable population of patients likely to experience significant life-threatening complications requiring intensive care. The introduction of several novel immunosuppressive agents, such as sirolimus and mycophenolate mofetil, in conjunction with more established agents such as cyclosporine and tacrolimus, has greatly increased treatment options for lung transplant recipients and likely contributed to improved short-term transplant outcomes. Modern transplant immunosuppression, however, is associated with a host of complications such as opportunistic infections, renal failure, and thrombotic thrombocytopenic purpura. The main focus of this review is to provide a comprehensive summary of modern immunotherapy in lung transplantation and to increase awareness of the serious and potentially life-threatening complications of these medications.
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Induction immunosuppression after lung transplantation. Curr Opin Organ Transplant 2006. [DOI: 10.1097/01.mot.0000247548.82734.2a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
Since the advent of various novel immunosuppressants, including tacrolimus, rapamycin, and daclixumab. expanding variations of protocols have been developed. Little evidence exists to substantially support a single agent over another. or a combination regimen protocol over another. Therefore, the principles and the goals of immunosuppression in lung transplantation recipients will remain moving targets and continue to evolve, and the use of large-scale, multi-institutional clinical trials is imperative to develop optimal immunosuppressive strategies.
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Affiliation(s)
- Errol L Bush
- Department of Surgery, Duke University Medical Center, DUMC Box 3443, Durham, NC 27710, USA
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Al-Githmi I, Batawil N, Shigemura N, Hsin M, Lee TW, He GW, Yim A. Bronchiolitis obliterans following lung transplantation. Eur J Cardiothorac Surg 2006; 30:846-51. [PMID: 17055283 DOI: 10.1016/j.ejcts.2006.09.027] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2006] [Revised: 09/16/2006] [Accepted: 09/20/2006] [Indexed: 11/28/2022] Open
Abstract
Bronchiolitis obliterans syndrome (BOS) is the main and late chronic complication after lung transplantation. It remains a major impediment to long-term outcome. Unfortunately, the survival rate of lung transplant recipients lags behind that of other organ transplant recipients, and BOS accounts for more than 30% of all mortality after the third year following lung transplantation. Most recent studies suggest that immune injury is the main pathogenic event in small airway obliteration and the development of BOS. Early detection of BOS is possible as well as essential because prompt initiation of treatment may halt the progress of the disease and the development of chronic graft failure. Current treatment of BOS is disappointing despite advances in surgical techniques and improvements in immunosuppressive therapies. Therefore, a clear understanding of the pathogenesis of BOS plays a major role in the search for new and effective therapeutic strategies for better long-term survival and quality of life after lung transplantation.
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Affiliation(s)
- Iskander Al-Githmi
- Department of Surgery, Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR, PR China.
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