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Mohanka M, Banga A. Alterations in Pulmonary Physiology with Lung Transplantation. Compr Physiol 2023; 13:4269-4293. [PMID: 36715279 DOI: 10.1002/cphy.c220008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Lung transplant is a treatment option for patients with end-stage lung diseases; however, survival outcomes continue to be inferior when compared to other solid organs. We review the several anatomic and physiologic changes that result from lung transplantation surgery, and their role in the pathophysiology of common complications encountered by lung recipients. The loss of bronchial circulation into the allograft after transplant surgery results in ischemia-related changes in the bronchial artery territory of the allograft. We discuss the role of bronchopulmonary anastomosis in blood circulation in the allograft posttransplant. We review commonly encountered complications related to loss of bronchial circulation such as allograft airway ischemia, necrosis, anastomotic dehiscence, mucociliary dysfunction, and bronchial stenosis. Loss of dual circulation to the lung also increases the risk of pulmonary infarction with acute pulmonary embolism. The loss of lymphatic drainage during transplant surgery also impairs the management of allograft interstitial fluid, resulting in pulmonary edema and early pleural effusion. We discuss the role of lymphatic drainage in primary graft dysfunction. Besides, we review the association of late posttransplant pleural effusion with complications such as acute rejection. We then review the impact of loss of afferent and efferent innervation from the allograft on control of breathing, as well as lung protective reflexes. We conclude with discussion about pulmonary function testing, allograft monitoring with spirometry, and classification of chronic lung allograft dysfunction phenotypes based on total lung capacity measurements. We also review factors limiting physical exercise capacity after lung transplantation, especially impairment of muscle metabolism. © 2023 American Physiological Society. Compr Physiol 13:4269-4293, 2023.
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Affiliation(s)
- Manish Mohanka
- Pulmonary and Critical Care Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Amit Banga
- Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, California, USA
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Boffini M, Cassoni P, Gambella A, Simonato E, Delsedime L, Marro M, Fanelli V, Costamagna A, Lausi PO, Solidoro P, Scalini F, Barbero C, Brazzi L, Rinaldi M, Bertero L. Is there life on the airway tree? A pilot study of bronchial cell vitality and tissue morphology in the ex vivo lung perfusion (EVLP) era of lung transplantation. Artif Organs 2022; 46:2234-2243. [PMID: 35717633 PMCID: PMC9796079 DOI: 10.1111/aor.14342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/24/2022] [Accepted: 06/13/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Ex vivo lung perfusion (EVLP) is a relevant procedure to increase the lung donor pool but could potentially increase the airway tree ischemic injury risk. METHODS This study aimed to evaluate the direct effect of EVLP on the airway tree by evaluating bronchial cell vitality and tissue signs of injury on a series of 117 bronchial rings collected from 40 conventional and 19 EVLP-treated lung grafts. Bronchial rings and related scraped bronchial epithelial cells were collected before the EVLP procedure and surgical anastomosis. RESULTS The preimplantation interval was significantly increased in the EVLP graft group (p < 0.01). Conventional grafts presented cell viability percentages of 47.07 ± 23.41 and 49.65 ± 21.25 in the first and second grafts which did not differ significantly from the EVLP group (first graft 50.54 ± 25.83 and second graft 50.22 ± 20.90 cell viability percentage). No significant differences in terms of histopathological features (edema, inflammatory infiltrate, and mucosa ulceration) were observed comparing conventional and EVLP samples. A comparison of bronchial cell viability and histopathology of EVLP samples retrieved at different time intervals revealed no significant differences. Accordingly, major bronchial complications after lung transplant were not observed in both groups. CONCLUSIONS Based on these data, we observed that EVLP did not significantly impact bronchial cell vitality and airway tissue preservation nor interfere with bronchial anastomosis healing, further supporting it as a safe and useful procedure.
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Affiliation(s)
- Massimo Boffini
- Cardiac Surgery Division, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Paola Cassoni
- Pathology Unit, Department of Medical SciencesUniversity of TurinTurinItaly
| | | | - Erika Simonato
- Cardiac Surgery Division, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Luisa Delsedime
- Pathology Unit, AOU Città della Salute e della ScienzaUniversity HospitalTurinItaly
| | - Matteo Marro
- Cardiac Surgery Division, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Vito Fanelli
- Department of Anesthesia and Intensive Care Medicine, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Andrea Costamagna
- Department of Anesthesia and Intensive Care Medicine, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Paolo Olivo Lausi
- Thoracic Surgery Division, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Paolo Solidoro
- Pneumology Division, Department of Medical SciencesUniversity of TurinTurinItaly
| | - Fabrizio Scalini
- Cardiac Surgery Division, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Cristina Barbero
- Cardiac Surgery Division, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Luca Brazzi
- Department of Anesthesia and Intensive Care Medicine, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Mauro Rinaldi
- Cardiac Surgery Division, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Luca Bertero
- Pathology Unit, Department of Medical SciencesUniversity of TurinTurinItaly
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Park S, Kim YT. Technical Aspects of Lung Transplantation: General Considerations. J Chest Surg 2022; 55:301-306. [PMID: 35924537 PMCID: PMC9358160 DOI: 10.5090/jcs.22.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 07/19/2022] [Accepted: 07/21/2022] [Indexed: 11/16/2022] Open
Abstract
Surgical approaches to lung transplantation in adults vary substantially among surgeons and institutions, but the underlying principles are consistent. This article provides a surgical overview of bilateral sequential lung transplantation.
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Affiliation(s)
- Samina Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Young Tae Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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[The bronchial arteries: a small but vital contribution to lung perfusion after lung transplantation]. Pneumologie 2022; 76:552-559. [PMID: 35878603 DOI: 10.1055/a-1845-0286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Blood supply to the lungs is carried out by the pulmonary and bronchial-arterial system. The bronchial-arterial vessels are involved in supplying the small airways all the way up to the terminal bronchioles. The bronchial-arterial system is also necessary for the regulation of airway temperature, humidity and mucociliary clearance. Chronic ischaemia of the small airways due to damage or injury to bronchial arterial supply increases the risk of fibrosis of the small airways (bronchiolitis obliteration), especially in lung transplantation (LTx). Although survival after LTx has improved over time, it is, with a 5-year survival rate of only 50 to 60%, still significantly worse than that of other organ transplants. It is likely that bronchial arterial revascularisation at the time of LTx plays an important transplant-preserving function.
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Liburd ST, Shi AA, Pober JS, Tietjen GT. Wanted: An endothelial cell targeting atlas for nanotherapeutic delivery in allograft organs. Am J Transplant 2022; 22:1754-1759. [PMID: 35373446 PMCID: PMC9651180 DOI: 10.1111/ajt.17050] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/20/2022] [Accepted: 03/30/2022] [Indexed: 01/25/2023]
Abstract
Despite the profound shortage of organs available for transplant in the U.S., over 5,000 donated organs were declined for use in 2020. Many of these organs were declined due to donor comorbidities or preservation injuries that predispose grafts to rejection and loss. The risks of these poor outcomes can potentially be reduced by pre-transplant application of normothermic machine perfusion (NMP). To date, the clinical use of NMP has focused on extending preservation and improving organ assessment, but the opportunity for ex situ therapeutic delivery may be the most transformative aspect of this technology. In this Personal Viewpoint, we argue that the endothelial cells (ECs) that line the graft vasculature are an accessible, under-exploited, and attractive target for transplant therapeutics delivered during NMP. We further contend that molecularly targeted nanoparticles (NPs) represent a promising therapeutic vehicle particularly well-suited to NMP. However, to achieve this potential, we need to answer the following three key questions: (1) What EC sub-populations exist within an organ? (2) How can these cells be accessed? (3) And most important, how can preferential retention of NPs by the cells of interest be maximized? Here we argue for creating an EC-targeting atlas as a body of knowledge that answers these questions.
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Affiliation(s)
- Samuel T. Liburd
- MD-PhD Program, Yale School of Medicine, New Haven, Connecticut
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut
| | - Audrey A. Shi
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Jordan S. Pober
- Department of Immunobiology, Yale University, New Haven, Connecticut
| | - Gregory T. Tietjen
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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Khan MA, Ashoor GA, Shamma T, Alanazi F, Altuhami A, Kazmi S, Ahmed HA, Mohammed Assiri A, Clemens Broering D. IL-10 Mediated Immunomodulation Limits Subepithelial Fibrosis and Repairs Airway Epithelium in Rejecting Airway Allografts. Cells 2021; 10:1248. [PMID: 34069395 PMCID: PMC8158696 DOI: 10.3390/cells10051248] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/01/2021] [Accepted: 04/20/2021] [Indexed: 12/11/2022] Open
Abstract
Interleukin-10 plays a vital role in maintaining peripheral immunotolerance and favors a regulatory immune milieu through the suppression of T effector cells. Inflammation-induced microvascular loss has been associated with airway epithelial injury, which is a key pathological source of graft malfunctioning and subepithelial fibrosis in rejecting allografts. The regulatory immune phase maneuvers alloimmune inflammation through various regulatory modulators, and thereby promotes graft microvascular repair and suppresses the progression of fibrosis after transplantation. The present study was designed to investigate the therapeutic impact of IL-10 on immunotolerance, in particular, the reparative microenvironment, which negates airway epithelial injury, and fibrosis in a mouse model of airway graft rejection. Here, we depleted and reconstituted IL-10, and serially monitored the phase of immunotolerance, graft microvasculature, inflammatory cytokines, airway epithelium, and subepithelial collagen in rejecting airway transplants. We demonstrated that the IL-10 depletion suppresses FOXP3+ Tregs, tumor necrosis factor-inducible gene 6 protein (TSG-6), graft microvasculature, and establishes a pro-inflammatory phase, which augments airway epithelial injury and subepithelial collagen deposition while the IL-10 reconstitution facilitates FOXP3+ Tregs, TSG-6 deposition, graft microvasculature, and thereby favors airway epithelial repair and subepithelial collagen suppression. These findings establish a potential reparative modulation of IL-10-associated immunotolerance on microvascular, epithelial, and fibrotic remodeling, which could provide a vital therapeutic option to rescue rejecting transplants in clinical settings.
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Affiliation(s)
- Mohammad Afzal Khan
- Organ Transplant Centre of Excellence, King Faisal Specialist Hospital and Research Centre, Riyadh 12713, Saudi Arabia; (T.S.); (F.A.); (A.A.); (S.K.); (D.C.B.)
| | | | - Talal Shamma
- Organ Transplant Centre of Excellence, King Faisal Specialist Hospital and Research Centre, Riyadh 12713, Saudi Arabia; (T.S.); (F.A.); (A.A.); (S.K.); (D.C.B.)
| | - Fatimah Alanazi
- Organ Transplant Centre of Excellence, King Faisal Specialist Hospital and Research Centre, Riyadh 12713, Saudi Arabia; (T.S.); (F.A.); (A.A.); (S.K.); (D.C.B.)
| | - Abdullah Altuhami
- Organ Transplant Centre of Excellence, King Faisal Specialist Hospital and Research Centre, Riyadh 12713, Saudi Arabia; (T.S.); (F.A.); (A.A.); (S.K.); (D.C.B.)
| | - Shadab Kazmi
- Organ Transplant Centre of Excellence, King Faisal Specialist Hospital and Research Centre, Riyadh 12713, Saudi Arabia; (T.S.); (F.A.); (A.A.); (S.K.); (D.C.B.)
| | - Hala Abdalrahman Ahmed
- Comparative Medicine Department, King Faisal Specialist Hospital and Research Centre, Riyadh 12713, Saudi Arabia; (H.A.A.); (A.M.A.)
| | - Abdullah Mohammed Assiri
- Comparative Medicine Department, King Faisal Specialist Hospital and Research Centre, Riyadh 12713, Saudi Arabia; (H.A.A.); (A.M.A.)
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
| | - Dieter Clemens Broering
- Organ Transplant Centre of Excellence, King Faisal Specialist Hospital and Research Centre, Riyadh 12713, Saudi Arabia; (T.S.); (F.A.); (A.A.); (S.K.); (D.C.B.)
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Hemoptysis after Lung Transplantation Caused by Bronchial Arterial Neovascularization: Angiographic Analysis and Successful Embolization. J Vasc Interv Radiol 2020; 32:56-60. [PMID: 33132025 DOI: 10.1016/j.jvir.2020.07.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/28/2020] [Accepted: 07/29/2020] [Indexed: 11/21/2022] Open
Abstract
This report discusses 3 bilateral lung transplant recipients (2 female, 1 male) who presented with late hemoptysis (10 y, 18 y, and 19 y after transplantation). All patients had a history of pulmonary infections, bronchiectasis, and/or Aspergillus infection. Arteriography, through catherization of the common femoral artery, demonstrated spontaneous bronchial and systemic neovascularization arising from the thyrocervical trunk, internal thoracic artery, intercostal arteries, and dorsal scapular artery. Embolization was performed with microspheres, polyvinyl alcohol microparticles, and/or glue and effectively terminated hemoptysis. One patient died 10 d later as a result of fungal infection, and the 2 others remained in stable condition (18- and 26-mo postembolization follow-up available).
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Clinical Outcomes of Lung Transplants From Donors With Unexpected Pulmonary Embolism. Ann Thorac Surg 2020; 112:387-394. [PMID: 33506764 DOI: 10.1016/j.athoracsur.2020.08.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/28/2020] [Accepted: 08/27/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND Pulmonary embolism (PE) is unexpectedly detected in some donor lungs during organ procurement for lung transplantation. Anecdotally, such lungs are usually implanted; however, the impact of this finding on recipient outcomes remains unclear. We hypothesized that incidentally detected donor PE is associated with adverse short-term and long-term outcomes among lung transplant recipients. METHODS We analyzed a prospectively maintained database of all lung donors procured by a single surgeon and transplanted at our institution between 2009 and 2018. A standardized approach was used for all procurements and included antegrade and retrograde flush. Pulmonary embolism was defined as macroscopic thrombus seen in the pulmonary artery during the donor procurement operation. RESULTS A total of 501 consecutive lung procurements were performed during the study period. The incidence of donor PE was 4.4% (22 of 501). No organs were discarded owing to PE. Donors with PE were similar to donors without PE in baseline characteristics and Pao2. Recipients in the two groups were also similar. Pulmonary embolism was associated with a higher likelihood of acute cellular rejection grade 2 or more (10 of 22 [45.5%] vs 120 of 479 [25.1%], P = .03). Multivariable Cox modeling demonstrated an association between PE and the development of chronic lung allograft dysfunction (hazard ratio 2.02; 95% confidence interval, 1.23 to 3.30; P = .005). CONCLUSIONS Lungs from donors with incidentally detected PE may be associated with a higher incidence of recipient acute cellular rejection as well as reduced chronic lung allograft dysfunction-free survival. Surgeons must use caution when transplanting lungs with incidentally discovered PE. These preliminary findings warrant corroboration in larger data sets.
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Yang YY, Lin CJ, Wang CC, Chen CM, Kao WJ, Chen YH. Consecutive Hypoxia Decreases Expression of NOTCH3, HEY1, CC10, and FOXJ1 via NKX2-1 Downregulation and Intermittent Hypoxia-Reoxygenation Increases Expression of BMP4, NOTCH1, MKI67, OCT4, and MUC5AC via HIF1A Upregulation in Human Bronchial Epithelial Cells. Front Cell Dev Biol 2020; 8:572276. [PMID: 33015064 PMCID: PMC7500169 DOI: 10.3389/fcell.2020.572276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 08/17/2020] [Indexed: 01/11/2023] Open
Abstract
Previous studies have shown that the experimental models of hypoxia-reoxygenation (H/R) mimics the physiological conditions of ischemia-reperfusion and induce oxidative stress and injury in various types of organs, tissues, and cells, both in vivo and in vitro, including human lung adenocarcinoma epithelial cells. Nonetheless, it had not been reported whether H/R affected proliferation, apoptosis, and expression of stem/progenitor cell markers in the bronchial epithelial cells. In this study, we investigated differential effects of consecutive hypoxia and intermittent 24/24-h cycles of H/R on human bronchial epithelial (HBE) cells derived from the same-race and age-matched healthy subjects (i.e., NHBE) and subjects with chronic obstructive pulmonary disease (COPD) (i.e., DHBE). To analyze gene/protein expression during differentiation, both the NHBE and DHBE cells at the 2nd passage were cultured at the air-liquid interface (ALI) in the differentiation medium under normoxia for 3 days, followed by either culturing under hypoxia (1% O2) for consecutively 9 days and then returning to normoxia for another 9 days, or culturing under 24/24-h cycles of H/R (i.e., 24 h of 1% O2 followed by 24 h of 21% O2, repetitively) for 18 days in total, so that all differentiating HBE cells were exposed to hypoxia for a total of 9 days. In both the normal and diseased HBE cells, intermittent H/R significantly increased HIF1A, BMP4, NOTCH1, MKI67, OCT4, and MUC5AC expression, while consecutive hypoxia significantly decreased NKX2-1, NOTCH3, HEY1, CC10, and FOXJ1 expression. Inhibition of HIF1A or NKX2-1 expression by siRNA transfection respectively decreased BMP4/NOTCH1/MKI67/OCT4/MUC5AC and NOTCH3/HEY1/CC10/FOXJ1 expression in the HBE cells cultured under intermittent H/R to the same levels under normoxia. Overexpression of NKX2-1 via cDNA transfection caused more than 2.8-fold increases in NOTCH3, HEY1, and FOXJ1 mRNA levels in the HBE cells cultured under consecutive hypoxia compared to the levels under normoxia. Taken together, our results show for the first time that consecutive hypoxia decreased expression of the co-regulated gene module NOTCH3/HEY1/CC10 and the ciliogenesis-inducing transcription factor gene FOXJ1 via NKX2-1 mRNA downregulation, while intermittent H/R increased expression of the co-regulated gene module BMP4/NOTCH1/MKI67/OCT4 and the predominant airway mucin gene MUC5AC via HIF1A mRNA upregulation.
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Affiliation(s)
- Yung-Yu Yang
- Department of General Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chao-Ju Lin
- Graduate Institute of Aerospace and Undersea Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Cheng-Chin Wang
- Graduate Institute of Aerospace and Undersea Medicine, National Defense Medical Center, Taipei, Taiwan.,Section of Respiratory Therapy, Rueifang Miner Hospital, New Taipei City, Taiwan
| | - Chieh-Min Chen
- Graduate Institute of Microbiology and Immunology, National Defense Medical Center, Taipei, Taiwan
| | - Wen-Jen Kao
- Graduate Institute of Aerospace and Undersea Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Yi-Hui Chen
- Graduate Institute of Aerospace and Undersea Medicine, National Defense Medical Center, Taipei, Taiwan
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VEGF synthesis and VEGF receptor 2 expression in patients with bronchiolitis obliterans syndrome after lung transplantation. Respir Med 2020; 166:105944. [DOI: 10.1016/j.rmed.2020.105944] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/19/2020] [Accepted: 03/20/2020] [Indexed: 11/18/2022]
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Bronchial-arterial-circulation-sparing Lung Preservation: A New Organ Protection Approach for Lung Transplantation. Transplantation 2020; 104:490-499. [DOI: 10.1097/tp.0000000000002984] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Fallis RJ, Jablonski L, Moss S, Axelrod P, Clauss H. Infectious complications of bronchial stenosis in lung transplant recipients. Transpl Infect Dis 2019; 21:e13100. [PMID: 31056837 DOI: 10.1111/tid.13100] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 03/13/2019] [Accepted: 04/21/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Bronchial stenosis is a known complication of lung transplantation, but there are limited data regarding whether transplant recipients with bronchial stenosis develop more infectious complications than those without bronchial stenosis. METHODS We conducted a retrospective single-center observational cohort study between January 1, 2011 and September 29, 2016 of 35 lung transplant recipients diagnosed with bronchial stenosis and a random sample of 35 lung transplant recipients without bronchial stenosis. Data collected included donor/recipient demographic and anatomic information, respiratory cultures, episodes of respiratory infections diagnosed using CDC-NNIS criteria, hospitalizations, and 1-year all-cause mortality. Patients were followed up to 1 year after transplant. RESULTS Bronchial stenosis occurred at a median of 54 days post-transplant (range 5-365 days). Bronchial stenosis patients spent more time in the hospital (87.4 vs 46.8 days, P = 0.011) and had more total hospitalizations (4.54 vs 2.37, P < 0.01) than their counterparts. The relative risk of pneumonia among cases vs controls was 4.0 (95% CI 2.2-7.3, P < 0.01); for purulent tracheobronchitis the relative risk was 3.1 (95% CI 1.6-6.1, P < 0.01). Patients with bronchial stenosis were significantly more likely to have respiratory cultures growing Staphylococcus aureus (RR 5.0; P = 0.001) and Pseudomonas aeruginosa (RR 2.1, P = 0.026). Mortality within the first year following transplant was equal in both the groups (14.3% vs 14.3%). CONCLUSIONS There was no significant increase in 1-year mortality for lung transplant patients who developed bronchial stenosis. However, bronchial stenosis patients had significantly higher risks of pneumonia and tracheobronchitis, and spent more days in the hospital than those without bronchial stenosis.
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Affiliation(s)
- Rebecca J Fallis
- Section of Infectious Diseases, Department of Internal Medicine, Temple University Hospital, Philadelphia, Pennsylvania
| | | | - Sean Moss
- Section of Infectious Diseases Tufts Medical Center, Boston, Massachusetts
| | - Peter Axelrod
- Section of Infectious Diseases, Department of Internal Medicine, Temple University Hospital, Philadelphia, Pennsylvania
| | - Heather Clauss
- Section of Infectious Diseases, Department of Internal Medicine, Temple University Hospital, Philadelphia, Pennsylvania
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The Bronchial Arterial Circulation in Lung Transplantation: Bedside to Bench to Bedside, and Beyond. Transplantation 2019; 102:1240-1249. [PMID: 29557912 DOI: 10.1097/tp.0000000000002180] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Chronic allograft dysfunction (CLAD) remains a major complication, causing the poor survival after lung transplantation (Tx). Although strenuous efforts have been made at preventing CLAD, surgical approaches for lung Tx have not been updated over the last 2 decades. The bronchial artery (BA), which supplies oxygenated blood to the airways and constitutes a functional microvasculature, has occasionally been revascularized during transplants, but this technique did not gain popularity and is not standard in current lung Tx protocols, despite the fact that a small number of studies have shown beneficial effects of BA revascularization on limiting CLAD. Also, recent basic and clinical evidence has demonstrated the relationship between microvasculature damage and CLAD. Thus, the protection of the bronchial circulation and microvasculature in lung grafts may be a key factor to overcome CLAD. This review revisits the history of BA revascularization, discusses the role of the bronchial circulation in lung Tx, and advocates for novel bronchial-arterial-circulation sparing approaches as a future direction for overcoming CLAD. Although there are some already published review articles summarizing the surgical techniques and their possible contribution to outcomes in lung Tx, to the best of our knowledge, this review is the first to elaborate on bronchial circulation that will contribute to prevent CLAD from both scientific and clinical perspectives: from bedside to bench to bedside, and beyond.
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Keeley TP, Mann GE. Defining Physiological Normoxia for Improved Translation of Cell Physiology to Animal Models and Humans. Physiol Rev 2019; 99:161-234. [PMID: 30354965 DOI: 10.1152/physrev.00041.2017] [Citation(s) in RCA: 183] [Impact Index Per Article: 36.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The extensive oxygen gradient between the air we breathe (Po2 ~21 kPa) and its ultimate distribution within mitochondria (as low as ~0.5-1 kPa) is testament to the efforts expended in limiting its inherent toxicity. It has long been recognized that cell culture undertaken under room air conditions falls short of replicating this protection in vitro. Despite this, difficulty in accurately determining the appropriate O2 levels in which to culture cells, coupled with a lack of the technology to replicate and maintain a physiological O2 environment in vitro, has hindered addressing this issue thus far. In this review, we aim to address the current understanding of tissue Po2 distribution in vivo and summarize the attempts made to replicate these conditions in vitro. The state-of-the-art techniques employed to accurately determine O2 levels, as well as the issues associated with reproducing physiological O2 levels in vitro, are also critically reviewed. We aim to provide the framework for researchers to undertake cell culture under O2 levels relevant to specific tissues and organs. We envisage that this review will facilitate a paradigm shift, enabling translation of findings under physiological conditions in vitro to disease pathology and the design of novel therapeutics.
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Affiliation(s)
- Thomas P Keeley
- King's British Heart Foundation Centre of Research Excellence, School of Cardiovascular Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London , London , United Kingdom
| | - Giovanni E Mann
- King's British Heart Foundation Centre of Research Excellence, School of Cardiovascular Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London , London , United Kingdom
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Abstract
Lung transplantation is a life-saving operation for patients with advanced lung disease. Pulmonary allografts eventually fail because of infection, thromboembolism, malignancy, airway complications, and chronic rejection, otherwise known as chronic lung allograft dysfunction (CLAD). Emerging evidence suggests that a highly-compromised airway circulation contributes to the evolution of airway complications and CLAD. There are two significant causes of poor perfusion and airway hypoxia in lung transplantation: an abnormal bronchial circulation which causes airway complications and microvascular rejection which induces CLAD. At the time of transplantation, the bronchial artery circulation, a natural component of the airway circulatory anatomy, is not surgically connected, and bronchi distal to the anastomosis become hypoxic. Subsequently, the bronchial anastomosis is left to heal under ischemic conditions. Still later, the extant microvessels in transplant bronchi are subjected to alloimmune insults that can further negatively impact pulmonary function. This review describes how airway tissue hypoxia evolves in lung transplantation, why depriving oxygenation in the bronchi and more distal bronchioles contributes to disease pathology and what therapeutic interventions are currently emerging to address these vascular injuries. Improving anastomotic vascular healing at the time of transplantation and preventing microvascular loss during acute rejection episodes are two steps that could limit airway hypoxia and improve patient outcomes.
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Affiliation(s)
- Shravani Pasnupneti
- VA Palo Alto Health Care System/Stanford University, 3801 Miranda Ave., Palo Alto CA 94304 USA
| | - Mark R. Nicolls
- VA Palo Alto Health Care System/Stanford University, 3801 Miranda Ave., Palo Alto CA 94304 USA
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Yamamoto T, Yoshida S, Nakajima T, Fujiwara T, Suzuki H, Iwata T, Sato Y, Yoshino I. Bronchoscopic assessment of bronchial anastomosis by visualizing local circulation status-index of hemoglobin (IHb) imaging. J Thorac Dis 2018; 10:2196-2205. [PMID: 29850123 DOI: 10.21037/jtd.2018.03.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Healing of airway anastomosis is largely affected by local circulation. Index of hemoglobin (IHb) imaging is a color enhancement technique that clarifies local circulation in the gastrointestinal endoscopic field. In this study, we investigated the relationship between bronchoscopic assessment of bronchial anastomosis using IHb mode and occurrence of anastomosis-related complications. Methods IHb was calculated by logarithmic transformation for each pixel of the electronic endoscopic images and expressed by colors of red, green, and blue. The distribution of each color area was automatically calculated by the summation of pixels. A preliminary experiment spraying vasodilator on swine was performed to confirm the relationship between bronchial mucosal circulation and the IHb image. Forty consecutive patients who underwent bronchoplasty were divided into retrospective training and prospective validation cohorts, and anastomosis-related complications and IHb images were analyzed. Results The IHb images immediately and accurately reflected the mucosal changes in the animal experiment. Among 25 cases in the retrospective training cohort, 6 cases experienced complications, with significantly lower red and higher blue values in IHb observed (P=0.03 and P=0.01, respectively). A receiver operating characteristic (ROC) curve for IHb red and blue distributions revealed the thresholds to differentiate cases with complications as 89.2 and 109.0, respectively. An analysis of the prospective validation cohort revealed that IHb blue on POD 7 was a potentially reliable predictor of complications, with 60.0% sensitivity and 90.0% specificity. Conclusions IHb mode of bronchoscopy may be useful for assessing the local circulatory condition of bronchoplasty, which can predict anastomosis-related morbidity.
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Affiliation(s)
- Takayoshi Yamamoto
- Department of General Thoracic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shigetoshi Yoshida
- Department of General Thoracic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan.,Department of Thoracic Surgery, International University of Health and Welfare, School of Medicine, Chiba, Japan
| | - Takahiro Nakajima
- Department of General Thoracic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Taiki Fujiwara
- Department of General Thoracic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hidemi Suzuki
- Department of General Thoracic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takekazu Iwata
- Department of General Thoracic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yasunori Sato
- Department of Global Clinical Research, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Ichiro Yoshino
- Department of General Thoracic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
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17
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Bontha SV, Fernandez-Piñeros A, Maluf DG, Mas VR. Messengers of tolerance. Hum Immunol 2018; 79:362-372. [PMID: 29402484 DOI: 10.1016/j.humimm.2018.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 01/16/2018] [Accepted: 01/19/2018] [Indexed: 12/21/2022]
Abstract
The use of immunosuppressant drugs after organ transplantation has brought great success in the field of organ transplantation with respect to short-term outcome. However, major challenges (i.e., limited improvement of long-term survival, immunosuppressant toxicity, infections and carcinoma) demand alternate treatment approaches that minimizes the use of immunosuppressants. Interestingly, few studies have identified groups of transplant patients who developed operational tolerance and thereby keep their allograft without complications in absence of immunosuppressants. These rare groups of patients are of particular interest as study subjects for understanding mechanisms of graft tolerance that could be leveraged in future for inducing tolerance and for understanding mechanisms involved in improving long-term allograft outcomes. Also, biomarkers from these studies could benefit the larger transplant population by their application in immunosuppressant tailoring and identification of tolerant patients among patients with stably functioning allografts. This review compiles several gene expression studies performed in samples from tolerant patients in different solid organ transplantations to identify key genes and associated molecular pathways relevant to tolerance. This review is aimed at putting forth all this important work done thus far and to identify research gaps that need to be filled, in order to achieve the greater purpose of these studies.
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Affiliation(s)
- Sai Vineela Bontha
- Translational Genomics and Transplant Laboratory, Department of Surgery, University of Virginia, Charlottesville 22903, United States
| | - Angela Fernandez-Piñeros
- Translational Genomics and Transplant Laboratory, Department of Surgery, University of Virginia, Charlottesville 22903, United States
| | - Daniel G Maluf
- Translational Genomics and Transplant Laboratory, Department of Surgery, University of Virginia, Charlottesville 22903, United States; Transplant Surgery, Department of Surgery, University of Virginia, Charlottesville 22903, United States
| | - Valeria R Mas
- Translational Genomics and Transplant Laboratory, Department of Surgery, University of Virginia, Charlottesville 22903, United States.
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18
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Abstract
PURPOSE OF REVIEW Airway microvessel injury following transplantation has been implicated in the development of chronic rejection. This review focuses on the most recent developments in the field describing preclinical and clinical findings that further implicate the loss of microvascular integrity as an important pathological event in the evolution of irreversible fibrotic remodeling. RECENT FINDINGS When lungs are transplanted, the airways appear vulnerable from the perspective of perfusion. Two vascular systems are lost, the bronchial artery and the lymphatic circulations, and the remaining vasculature in the airways expresses donor antigens susceptible to alloimmune-mediated injury via innate and adaptive immune mechanisms. Preclinical studies indicate the importance of hypoxia-inducible factor-1α in mediating microvascular repair and that hypoxia-inducible factor-1α can be upregulated to bolster endogenous repair. SUMMARY Airway microvascular injury is a feature of lung transplantation that limits short-term and long-term organ health. Although some problems are attributable to a missing bronchial artery circulation, another significant issue involves alloimmune-mediated injury to transplant airway microvessels. For a variety of reasons, bronchial artery revascularization surgery at the time of transplantation has not been widely adopted, and the current best hope for this era may be new medical approaches that offer protection against immune-mediated vascular injury or that promote microvascular repair.
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19
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Kocbek L, Rakuša M. The right intercostobronchial trunk: anatomical study in respect of posterior intercostal artery origin and its clinical application. Surg Radiol Anat 2017; 40:67-73. [DOI: 10.1007/s00276-017-1943-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 11/02/2017] [Indexed: 11/30/2022]
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20
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Noda K, Tane S, Haam SJ, Hayanga AJ, D’Cunha J, Luketich JD, Shigemura N. Optimal ex vivo lung perfusion techniques with oxygenated perfusate. J Heart Lung Transplant 2017; 36:466-474. [PMID: 27914896 DOI: 10.1016/j.healun.2016.10.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Revised: 10/23/2016] [Accepted: 10/26/2016] [Indexed: 12/23/2022] Open
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21
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Montero MA, Osadolor T, Khiroya R, Salcedo MT, Robertus JL, Rice A, Nicholson AG, Roman A, Monforte V. Restrictive allograft syndrome and idiopathic pleuroparenchymal fibroelastosis: do they really have the same histology? Histopathology 2017; 70:1107-1113. [DOI: 10.1111/his.13171] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 01/21/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Maria A Montero
- Histopathology Department; Royal Brompton and Harefield NHS Foundation Trust; London UK
- Biomedical Respiratory Unit; Imperial College London; London UK
| | - Tina Osadolor
- Biomedical Respiratory Unit; Imperial College London; London UK
| | - Reena Khiroya
- Histopathology Department; Royal Brompton and Harefield NHS Foundation Trust; London UK
| | | | - Jan L Robertus
- Histopathology Department; Royal Brompton and Harefield NHS Foundation Trust; London UK
| | - Alexandra Rice
- Histopathology Department; Royal Brompton and Harefield NHS Foundation Trust; London UK
| | - Andrew G Nicholson
- Histopathology Department; Royal Brompton and Harefield NHS Foundation Trust; London UK
| | - Antonio Roman
- Respiratory Medicine; Vall d'Hebron University Hospitals; Barcelona Spain
| | - Victor Monforte
- Respiratory Medicine; Vall d'Hebron University Hospitals; Barcelona Spain
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22
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Kristensen AW, Mortensen J, Berg RMG. Pulmonary thromboembolism as a complication of lung transplantation. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.12922] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Anna Warncke Kristensen
- Department of Clinical Physiology, Nuclear Medicine & PET; University Hospital Rigshospitalet; Copenhagen Denmark
| | - Jann Mortensen
- Department of Clinical Physiology, Nuclear Medicine & PET; University Hospital Rigshospitalet; Copenhagen Denmark
| | - Ronan M. G. Berg
- Department of Clinical Physiology and Nuclear Medicine; Bispebjerg and Frederiksberg Hospitals; Copenhagen Denmark
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23
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Gielis JF, Beckers PAJ, Briedé JJ, Cos P, Van Schil PE. Oxidative and nitrosative stress during pulmonary ischemia-reperfusion injury: from the lab to the OR. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:131. [PMID: 28462211 DOI: 10.21037/atm.2017.03.32] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Oxidative and nitrosative stress are an umbrella term for pathophysiological processes that involve free radical generation during inflammation. In this review, the involvement of reactive oxygen and nitrogen species is evaluated during lung ischemia-reperfusion injury (LIRI) from a surgical point of view. The main biochemical and cellular mechanisms behind free radical generation are discussed, together with surgical procedures that may cause reperfusion injury. Finally, different therapeutic strategies are further explored. A literature search was performed, searching for "lung ischemia reperfusion injury", "reperfusion injury", "large animal model" and different search terms for each section: "surgery", "treatment", "cellular mechanism", or "enzyme". Although reperfusion injury is not an uncommon entity and there is a lot of evidence concerning myocardial ischemia-reperfusion injury, in the lung this phenomenon is less extensively described and studies in large animals are not easy to come by. With increasing number of patients on waiting lists for lung transplant, awareness for this entity should all but rise.
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Affiliation(s)
- Jan F Gielis
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium.,Laboratory for Microbiology, Parasitology and Hygiene, Antwerp University, Antwerp, Belgium
| | - Paul A J Beckers
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Jacco J Briedé
- Department of Toxicogenomics, Maastricht University, Maastricht, The Netherlands
| | - Paul Cos
- Laboratory for Microbiology, Parasitology and Hygiene, Antwerp University, Antwerp, Belgium
| | - Paul E Van Schil
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium
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24
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Pasupneti S, Manouvakhova O, Nicolls MR, Hsu JL. Aspergillus-related pulmonary diseases in lung transplantation. Med Mycol 2016; 55:96-102. [PMID: 27816902 DOI: 10.1093/mmy/myw121] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 09/14/2016] [Accepted: 10/05/2016] [Indexed: 12/31/2022] Open
Abstract
While lung transplantation is an attractive treatment option for many end stage lung diseases, the relatively high 5-year mortality continues to be a significant limiting factor. Among the foremost reasons for this is the eventual development of obstructive chronic lung allograft dysfunction. Infections, which the lung allograft is especially prone to, are a major risk factor. Specifically, the Aspergillus species cause a higher burden of disease among lung transplant recipients, due to unique risk factors, such as relative hypoxemia. However, these risk factors also provide unique opportunities for treatment and preventative strategies, as outlined in this review.
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Affiliation(s)
- S Pasupneti
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, California, USA.,Veterans Affairs Palo Alto Health Care System, Medical Service, Palo Alto, California, USA
| | - O Manouvakhova
- Veterans Affairs Palo Alto Health Care System, Medical Service, Palo Alto, California, USA
| | - M R Nicolls
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, California, USA.,Veterans Affairs Palo Alto Health Care System, Medical Service, Palo Alto, California, USA
| | - J L Hsu
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, California, USA .,Veterans Affairs Palo Alto Health Care System, Medical Service, Palo Alto, California, USA
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25
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Awori Hayanga J, Aboagye JK, Shigemura N, Hayanga HK, Murphy E, Khaghani A, D’Cunha J. Airway complications after lung transplantation: Contemporary survival and outcomes. J Heart Lung Transplant 2016; 35:1206-1211. [DOI: 10.1016/j.healun.2016.04.019] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 04/15/2016] [Accepted: 04/21/2016] [Indexed: 10/21/2022] Open
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26
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Chiu S, Fernandez R, Subramanian V, Sun H, DeCamp MM, Kreisel D, Perlman H, Budinger GRS, Mohanakumar T, Bharat A. Lung Injury Combined with Loss of Regulatory T Cells Leads to De Novo Lung-Restricted Autoimmunity. THE JOURNAL OF IMMUNOLOGY 2016; 197:51-7. [PMID: 27194786 DOI: 10.4049/jimmunol.1502539] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 04/21/2016] [Indexed: 01/02/2023]
Abstract
More than one third of patients with chronic lung disease undergoing lung transplantation have pre-existing Abs against lung-restricted self-Ags, collagen type V (ColV), and k-α1 tubulin (KAT). These Abs can also develop de novo after lung transplantation and mediate allograft rejection. However, the mechanisms leading to lung-restricted autoimmunity remain unknown. Because these self-Ags are normally sequestered, tissue injury is required to expose them to the immune system. We previously showed that respiratory viruses can induce apoptosis in CD4(+)CD25(+)Foxp3(+) regulatory T cells (Tregs), the key mediators of self-tolerance. Therefore, we hypothesized that lung-tissue injury can lead to lung-restricted immunity if it occurs in a setting when Tregs are impaired. We found that human lung recipients who suffer respiratory viral infections experienced a decrease in peripheral Tregs. Pre-existing lung allograft injury from donor-directed Abs or gastroesophageal reflux led to new ColV and KAT Abs post respiratory viral infection. Similarly, murine parainfluenza (Sendai) respiratory viral infection caused a decrease in Tregs. Intratracheal instillation of anti-MHC class I Abs, but not isotype control, followed by murine Sendai virus infection led to development of Abs against ColV and KAT, but not collagen type II (ColII), a cartilaginous protein. This was associated with expansion of IFN-γ-producing CD4(+) T cells specific to ColV and KAT, but not ColII. Intratracheal anti-MHC class I Abs or hydrochloric acid in Foxp3-DTR mice induced ColV and KAT, but not ColII, immunity, only if Tregs were depleted using diphtheria toxin. We conclude that tissue injury combined with loss of Tregs can lead to lung-tissue-restricted immunity.
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Affiliation(s)
- Stephen Chiu
- Northwestern University Feinberg School of Medicine, Chicago, IL 60611; and
| | - Ramiro Fernandez
- Northwestern University Feinberg School of Medicine, Chicago, IL 60611; and
| | | | - Haiying Sun
- Northwestern University Feinberg School of Medicine, Chicago, IL 60611; and
| | - Malcolm M DeCamp
- Northwestern University Feinberg School of Medicine, Chicago, IL 60611; and
| | - Daniel Kreisel
- Washington University School of Medicine, St. Louis, MO 63110
| | - Harris Perlman
- Northwestern University Feinberg School of Medicine, Chicago, IL 60611; and
| | - G R Scott Budinger
- Northwestern University Feinberg School of Medicine, Chicago, IL 60611; and
| | | | - Ankit Bharat
- Northwestern University Feinberg School of Medicine, Chicago, IL 60611; and
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27
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Abstract
Long-term survival of lung-transplant patients is 53% at 5 years and 31% at 10 years, lagging behind the survival of other solid organs recipients. Modern lung transplantation has seen a shift from early mortality and complications related to the bronchial anastomosis to late mortality secondary to progressive organ dysfunction; the complex disease process may include elements of bronchiolitis obliterans syndrome, obliterative bronchiolitis, chronic rejection, or chronic lung allograft dysfunction. Initial goals of bronchial artery revascularization include reducing the incidence of airway ischemia and improving bronchial healing. Benefits of restored bronchial artery circulation may extend beyond bronchial healing alone.
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28
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Tanaka Y, Noda K, Isse K, Tobita K, Maniwa Y, Bhama JK, D'Cunha J, Bermudez CA, Luketich JD, Shigemura N. A novel dual ex vivo lung perfusion technique improves immediate outcomes in an experimental model of lung transplantation. Am J Transplant 2015; 15:1219-30. [PMID: 25777770 DOI: 10.1111/ajt.13109] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 11/10/2014] [Accepted: 11/16/2014] [Indexed: 01/25/2023]
Abstract
The lungs are dually perfused by the pulmonary artery and the bronchial arteries. This study aimed to test the feasibility of dual-perfusion techniques with the bronchial artery circulation and pulmonary artery circulation synchronously perfused using ex vivo lung perfusion (EVLP) and evaluate the effects of dual-perfusion on posttransplant lung graft function. Using rat heart-lung blocks, we developed a dual-perfusion EVLP circuit (dual-EVLP), and compared cellular metabolism, expression of inflammatory mediators, and posttransplant graft function in lung allografts maintained with dual-EVLP, standard-EVLP, or cold static preservation. The microvasculature in lung grafts after transplant was objectively evaluated using microcomputed tomography angiography. Lung grafts subjected to dual-EVLP exhibited significantly better lung graft function with reduced proinflammatory profiles and more mitochondrial biogenesis, leading to better posttransplant function and compliance, as compared with standard-EVLP or static cold preservation. Interestingly, lung grafts maintained on dual-EVLP exhibited remarkably increased microvasculature and perfusion as compared with lungs maintained on standard-EVLP. Our results suggest that lung grafts can be perfused and preserved using dual-perfusion EVLP techniques that contribute to better graft function by reducing proinflammatory profiles and activating mitochondrial respiration. Dual-EVLP also yields better posttransplant graft function through increased microvasculature and better perfusion of the lung grafts after transplantation.
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Affiliation(s)
- Y Tanaka
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Division of Thoracic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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29
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Hartert M, Senbaklavacin O, Gohrbandt B, Fischer BM, Buhl R, Vahld CF. Lung transplantation: a treatment option in end-stage lung disease. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 111:107-16. [PMID: 24622680 DOI: 10.3238/arztebl.2014.0107] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 11/12/2013] [Accepted: 11/12/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND Lung transplantation is the final treatment option in the end stage of certain lung diseases, once all possible conservative treatments have been exhausted. Depending on the indication for which lung transplantation is performed, it can improve the patient's quality of life (e.g., in emphysema) and/ or prolong life expectancy (e.g., in cystic fibrosis, pulmonary fibrosis, and pulmonary arterial hypertension). The main selection criteria for transplant candidates, aside from the underlying pulmonary or cardiopulmonary disease, are age, degree of mobility, nutritional and muscular condition, and concurrent extrapulmonary disease. The pool of willing organ donors is shrinking, and every sixth candidate for lung transplantation now dies while on the waiting list. METHOD We reviewed pertinent articles (up to October 2013) retrieved by a selective search in Medline and other German and international databases, including those of the International Society for Heart and Lung Transplantation (ISHLT), Eurotransplant, the German Institute for Applied Quality Promotion and Research in Health-Care (Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen, AQUA-Institut), and the German Foundation for Organ Transplantation (Deutsche Stiftung Organtransplantation, DSO). RESULTS The short- and long-term results have markedly improved in recent years: the 1-year survival rate has risen from 70.9% to 82.9%, and the 5-year survival rate from 46.9% to 59.6%. The 90-day mortality is 10.0%. The postoperative complications include acute (3.4%) and chronic (29.0%) transplant rejection, infections (38.0%), transplant failure (24.7%), airway complications (15.0%), malignant tumors (15.0%), cardiovascular events (10.9%), and other secondary extrapulmonary diseases (29.8%). Bilateral lung transplantation is superior to unilateral transplantation (5-year survival rate 57.3% versus 47.4%). CONCLUSION Seamless integration of the various components of treatment will be essential for further improvements in outcome. In particular, the follow-up care of transplant recipients should always be provided in close cooperation with the transplant center.
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Affiliation(s)
- Marc Hartert
- Department of Cardiothoracic and Vascular Surgery at the University Medical Center of the Johannes Gutenberg University Mainz, Department of Hematology, Pneumology and Oncology at the University Medical Center of the Johannes Gutenberg University Mainz
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30
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Hydrogen preconditioning during ex vivo lung perfusion improves the quality of lung grafts in rats. Transplantation 2014; 98:499-506. [PMID: 25121557 DOI: 10.1097/tp.0000000000000254] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although the benefits of ex vivo lung perfusion (EVLP) have been globally advocated, the potentially deleterious effects of applying EVLP, in particular activation of proinflammatory cascades and alteration of metabolic profiles, are rarely discussed. This study examined proinflammatory events and metabolic profiles in lung grafts on EVLP and tested whether preconditioning lung grafts with inhaled hydrogen, a potent, cytoprotective gaseous signaling molecule, would alter the lungs' response to EVLP. METHODS Rat heart-lung blocks were mounted on an acellular normothermic EVLP system for 4 hr and ventilated with air or air supplemented with 2% hydrogen. Arterial and airway pressures were monitored continuously; perfusate was sampled hourly to examine oxygenation. After EVLP, the lung grafts were transplanted orthotopically into syngeneic rats, and lung function was examined. RESULTS Placing lung grafts on EVLP resulted in significant upregulation of the messenger RNAs for several proinflammatory cytokines, higher glucose consumption, and increased lactate production. Hydrogen administration attenuated proinflammatory changes during EVLP through upregulation of the heme oxygenase-1. Hydrogen administration also promoted mitochondrial biogenesis and significantly decreased lactate production. Additionally, in the hydrogen-treated lungs, the expression of hypoxia-inducible factor-1 was significantly attenuated during EVLP. These effects were maintained throughout EVLP and led to better posttransplant lung graft function in the recipients of hydrogen-treated lungs. CONCLUSIONS Lung grafts on EVLP exhibited prominent proinflammatory changes and compromised metabolic profiles. Preconditioning lung grafts using inhaled hydrogen attenuated these proinflammatory changes, promoted mitochondrial biogenesis in the lungs throughout the procedure, and resulted in better posttransplant graft function.
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31
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32
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Hayanga JWA, D'Cunha J. The surgical technique of bilateral sequential lung transplantation. J Thorac Dis 2014; 6:1063-9. [PMID: 25132973 DOI: 10.3978/j.issn.2072-1439.2014.07.02] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 06/19/2014] [Indexed: 11/14/2022]
Abstract
Since the first successful lung transplant performed three decades ago, the technique of lung transplantation has evolved with acceptable short- and long-term outcomes such that it has become the standard for those with end stage pulmonary disease. Herein, we describe our current favored approach and discuss some of the current areas in need of further investigation as they relate to the technical aspects of the operation.
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Affiliation(s)
- J W Awori Hayanga
- 1 Spectrum Health, Richards DeVos Heart & Lung Transplantation Program, Grand Rapids, MI, USA ; 2 Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jonathan D'Cunha
- 1 Spectrum Health, Richards DeVos Heart & Lung Transplantation Program, Grand Rapids, MI, USA ; 2 Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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33
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Noda K, Shigemura N, Tanaka Y, Bhama JK, D'Cunha J, Luketich JD, Bermudez CA. Successful prolonged ex vivo lung perfusion for graft preservation in rats. Eur J Cardiothorac Surg 2014; 45:e54-e60. [PMID: 24431161 DOI: 10.1093/ejcts/ezt598] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2024] Open
Abstract
OBJECTIVES Ex vivo lung perfusion (EVLP) strategies represent a new frontier in lung transplantation technology, and there have been many clinical studies of EVLP in lung transplantation. The establishment of a reliable EVLP model in small animals is crucial to facilitating translational research using an EVLP strategy. The main objective of this study was to develop a reproducible rat EVLP (R-EVLP) model that enables prolonged evaluation of the explanted lung during EVLP and successful transplantation after EVLP. METHODS The donor heart-lung blocks were procured with cold low-potassium dextran solution and immersed in the solution for 1 h at 4 °C. And then, the heart-lung blocks were flushed retrogradely and warmed up to 37 °C in a circuit perfused antegradely with acellular perfusate. The perfusate was deoxygenated with a gas mixture (6% O2, 8% CO2, 86% N2). The perfusion flow was maintained at 20% of the entire cardiac output. At 37 °C, the lungs were mechanically ventilated and perfusion continued for 4 h. Every hour, the perfused lung was evaluated for gas exchange, dynamic lung compliance (Cdyn) and pulmonary vascular resistance (PVR). RESULTS R-EVLP was performed for 4 h. Pulmonary oxygenation ability (pO2/pCO2) was stable for 4 h during EVLP. It was noted that Cdyn and PVR were also stable. After 4 h of EVLP, pO2 was 303 ± 19 mmHg, pCO2 was 39.6 ± 1.2 mmHg, PVR was 1.75 ± 0.10 mmHg/ml/min and Cdyn was 0.37 ± 0.03 ml/cmH2O. Lungs that were transplanted after 2 h of R-EVLP resulted in significantly better post-transplant oxygenation and compliance when compared with those after standard cold static preservation. CONCLUSIONS Our R-EVLP model maintained stable lung oxygenation, compliance and vascular resistance for up to 4 h of perfusion duration. This reliable model should facilitate further advancement of experimental work using EVLP.
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Affiliation(s)
- Kentaro Noda
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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34
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Abstract
Long-term allograft survival is a major challenge facing solid organ transplantation. Recent studies have shown a negative correlation between infiltration of memory T cells and allograft survival. Furthermore, blockade of leukocyte activation increases acceptance of transplanted organs, including heart, liver, and kidney. Lung allografts are associated with high rates of rejection, and therapies that increase acceptance of other transplanted organs have not translated into the lung. In this issue of the JCI, Krupnick and colleagues demonstrate in a murine model that lung allograft acceptance requires infiltration of a specific T cell population into the graft. This study highlights the unique immunobiology of the lung and the complexity of lung transplant tolerance.
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35
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Jiang X, Malkovskiy AV, Tian W, Sung YK, Sun W, Hsu JL, Manickam S, Wagh D, Joubert LM, Semenza GL, Rajadas J, Nicolls MR. Promotion of airway anastomotic microvascular regeneration and alleviation of airway ischemia by deferoxamine nanoparticles. Biomaterials 2013; 35:803-813. [PMID: 24161166 DOI: 10.1016/j.biomaterials.2013.09.092] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 09/24/2013] [Indexed: 01/25/2023]
Abstract
Airway tissue ischemia and hypoxia in human lung transplantation is a consequence of the sacrifice of the bronchial circulation during the surgical procedure and is a major risk factor for the development of airway anastomotic complications. Augmented expression of hypoxia-inducible factor (HIF)-1α promotes microvascular repair and alleviates allograft ischemia and hypoxia. Deferoxamine mesylate (DFO) is an FDA-approved iron chelator which has been shown to upregulate cellular HIF-1α. Here, we developed a nanoparticle formulation of DFO that can be topically applied to airway transplants at the time of surgery. In a mouse orthotopic tracheal transplant (OTT) model, the DFO nanoparticle was highly effective in enhancing airway microvascular perfusion following transplantation through the production of the angiogenic factors, placental growth factor (PLGF) and stromal cell-derived factor (SDF)-1. The endothelial cells in DFO treated airways displayed higher levels of p-eNOS and Ki67, less apoptosis, and decreased production of perivascular reactive oxygen species (ROS) compared to vehicle-treated airways. In summary, a DFO formulation topically-applied at the time of surgery successfully augmented airway anastomotic microvascular regeneration and the repair of alloimmune-injured microvasculature. This approach may be an effective topical transplant-conditioning therapy for preventing airway complications following clinical lung transplantation.
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Affiliation(s)
- Xinguo Jiang
- Division of Pulmonary/Critical Care, Department of Medicine, VA Palo Alto Health Care System/Stanford University School of Medicine, Stanford, CA, USA
| | | | - Wen Tian
- Division of Pulmonary/Critical Care, Department of Medicine, VA Palo Alto Health Care System/Stanford University School of Medicine, Stanford, CA, USA
| | - Yon K Sung
- Division of Pulmonary/Critical Care, Department of Medicine, VA Palo Alto Health Care System/Stanford University School of Medicine, Stanford, CA, USA
| | - Wenchao Sun
- Stanford BioADD Laboratory, Stanford, CA, USA
| | - Joe L Hsu
- Division of Pulmonary/Critical Care, Department of Medicine, VA Palo Alto Health Care System/Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | | - Gregg L Semenza
- Vascular Program, Institute for Cell Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.,Departments of Pediatrics, Medicine, Oncology, Radiation Oncology, and Biological Chemistry, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.,McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | | | - Mark R Nicolls
- Division of Pulmonary/Critical Care, Department of Medicine, VA Palo Alto Health Care System/Stanford University School of Medicine, Stanford, CA, USA
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Jie B, Sun XW, Yu D, Jiang S. Bilateral subclavian origin of the bronchial arteries combined with absence of other origins. Surg Radiol Anat 2013; 36:607-11. [PMID: 24026391 DOI: 10.1007/s00276-013-1202-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 08/31/2013] [Indexed: 12/20/2022]
Affiliation(s)
- Bing Jie
- Department of Radiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, 507 Zhengmin Road, Shanghai, 200433, China
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Pettersson GB, Karam K, Thuita L, Johnston DR, McCurry KR, Kapadia SR, Budev MM, Avery RK, Mason DP, Murthy SC, Blackstone EH. Comparative study of bronchial artery revascularization in lung transplantation. J Thorac Cardiovasc Surg 2013; 146:894-900.e3. [PMID: 23820173 DOI: 10.1016/j.jtcvs.2013.04.030] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 03/22/2013] [Accepted: 04/18/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Restoring dual blood supply to transplanted lungs by bronchial artery revascularization (BAR) remains controversial. We compared outcomes after lung transplantation performed with and without BAR. METHODS From December 2007 to July 2010, 283 patients underwent transplantation; 187 were 18 years or older, without previous or concomitant cardiac surgery. Of these patients, 27 underwent BAR in a pilot study to test success, safety, effectiveness, and teachability. A propensity score was generated to match BAR patients and 54 routine non-BAR patients. Follow-up was 1.3 ± 0.68 years. RESULTS BAR was angiographically successful in 26 (96%) of 27 patients. BAR and non-BAR patients had similar skin-to-skin time (P = .07) and postoperative hospital stays (P = .2), but more reoperations for bleeding (P = .002). Tracheostomy was performed in 9 (33%) of 27 BAR and 10 (19%) of 54 non-BAR patients (P = .2, log-rank). One BAR (3.7%) and 4 non-BAR (7.4%) patients required extracorporeal membrane oxygenation (P = .7). Airway ischemia was observed in 1 BAR (3.7%) versus 12 non-BAR (22%) patients (P = .03); anastomotic intervention was required in no BAR versus 8 non-BAR (15%) patients (P = .04). Hospital mortality was 1 of 27 versus 2 of 54 (P = .9). BAR patients had lower early biopsy tissue rejection grades (P = .008) and fewer pulmonary (P < .04) and bloodstream (P < .02) infections. Forced 1-second expiratory volume was similar (P > .2); 3 BAR versus 9 non-BAR patients developed bronchiolitis obliterans syndrome (BOS) (P = .14, log-rank). During follow-up, 4 BAR and 8 non-BAR patients died (P = .6, log-rank). CONCLUSIONS BAR is safe, with comparable early outcomes. Benefits of BAR include reduced airway ischemia and complications, lower biopsy tissue grades, fewer infections, and delay of BOS. A multicenter study is needed to establish these benefits.
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Affiliation(s)
- Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
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Moua J, Nussbaum E, Liao E, Randhawa IS. Beta-blocker management of refractory hemoptysis in cystic fibrosis: a novel treatment approach. Ther Adv Respir Dis 2013; 7:217-23. [DOI: 10.1177/1753465813482744] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background/objective: Recurrent hemoptysis is a debilitating complication of cystic fibrosis (CF) and likely results from mucosal erosions into abnormal bronchial blood vessels due to chronic respiratory infection. We hypothesize that the use of beta-blockade will decrease mean arterial pressure resulting in lower bronchial artery blood flow and, subsequently, decrease the frequency and severity of hemoptysis, rate of hospitalizations, and usage of intravenous antibiotics. Methods: Retrospective chart review was performed on 12 CF patients with recurrent hemoptysis, aged 13–40 years old, along with a follow-up telephone survey to assess the effectiveness of beta-blockade for hemoptysis, tolerance of inhaled respiratory medications, activity tolerance, and potential adverse effects. A beta-blocker, specifically atenolol, was initiated in all subjects within 24 hours after experiencing recurrent hemoptysis episodes. Results: A majority of patients (72.7%) had complete cessation of hemoptysis. There were significant decreases in the frequency of hemoptysis ( p = 0.02) and the amount of hemoptysis ( p = 0.004). The rate of hospitalizations significantly decreased from 1.33 to 0.67 ( p = 0.05) after initiation of atenolol. There was a trend toward statistical significance in the reduction of intravenous antibiotics use ( p = 0.08). No statistical difference was found when comparing the pre- and post-treatment means of forced expiratory volume in 1-second ( p = 0.59). Very minimal adverse effects were observed with only one patient reporting intermittent facial flushing. Conclusion: Beta-blockade, particularly with atenolol, appears to successfully treat, if not resolve, recurrent hemoptysis refractory to conservative therapy in CF. Beta-blocker therapy appears to maintain an effective safety profile in CF.
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Affiliation(s)
- John Moua
- Department of Pediatric Pulmonary, Miller Children’s Hospital, Long Beach/University of California, Irvine, CA, USA
| | - Eliezer Nussbaum
- Department of Pediatric Pulmonary, Miller Children’s Hospital, Long Beach/University of California, Irvine, CA, USA
| | - Eileen Liao
- Department of Biostatistics, University of California, Los Angeles, CA, USA
| | - Inderpal S. Randhawa
- Miller Children’s Hospital, Department of Pediatric Pulmonary/Allergy and Immunology, 2801 Atlantic Avenue, Ground Floor, Long Beach, CA 90806, USA
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Complement-mediated microvascular injury leads to chronic rejection. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2013; 735:233-46. [PMID: 23402031 DOI: 10.1007/978-1-4614-4118-2_16] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Microvascular loss may be an unappreciated root cause of chronic rejection for all solid organ transplants. As the only solid organ transplant that does not undergo primary systemic arterial revascularization at the time of surgery, lung transplants rely on the establishment of a microcirculation and are especially vulnerable to the effects of microvascular loss. Microangiopathy, with its attendant ischemia, can lead to tissue infarction and airway fibrosis. Maintaining healthy vasculature in lung allografts may be critical for preventing terminal airway fibrosis, also known as the bronchiolitis obliterans syndrome (BOS). BOS is the major obstacle to lung transplant success and affects up to 60% of patients surviving 5 years. The role of complement in causing acute microvascular loss and ischemia during rejection has recently been examined using the mouse orthotopic tracheal transplantation; this is an ideal model for parsing the role of airway vasculature in rejection. Prior to the development of airway fibrosis in rejecting tracheal allografts, C3 deposits on the vascular endothelium just as tissue hypoxia is first detected. With the eventual destruction of vessels, microvascular blood flow to the graft stops altogether for several days. Complement deficiency and complement inhibition lead to markedly improved tissue oxygenation in transplants, diminished airway remodeling, and accelerated vascular repair. CD4+ T cells and antibody-dependent complement activity independently mediate vascular destruction and sustained tissue ischemia during acute rejection. Consequently, interceding against complement-mediated microvascular injury with adjunctive therapy during acute rejection episodes, in addition to standard immunosuppression which targets CD4+ T cells, may help prevent the subsequent development of chronic rejection.
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Khan MA, Dhillon G, Jiang X, Lin YC, Nicolls MR. New methods for monitoring dynamic airway tissue oxygenation and perfusion in experimental and clinical transplantation. Am J Physiol Lung Cell Mol Physiol 2012; 303:L861-9. [PMID: 23002078 DOI: 10.1152/ajplung.00162.2012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
A dual circulation, supplied by bronchial and pulmonary artery-derived vessels, normally perfuses the airways from the trachea to the terminal bronchioles. This vascular system has been highly conserved through mammalian evolution and is disrupted at the time of lung transplantation. In most transplant centers, this circulation is not restored. The Papworth Hospital Autopsy study has revealed that an additional attrition of periairway vessels is associated with the development of chronic rejection, otherwise known as the bronchiolitis obliterans syndrome (BOS). Experimental studies subsequently demonstrated that airway vessels are subject to alloimmune injury and that the loss of a functional microvascular system identifies allografts that cannot be rescued with immunosuppressive therapy. Therefore, surgical and medical strategies, which preserve the functionality of the existent vasculature in lung transplant patients, may conceivably limit the incidence of BOS. Given these unique anatomic and physiological considerations, there is an emerging rationale to better understand the perfusion and oxygenation status of airways in transplanted lungs. This article describes novel methodologies, some newly developed by our group, for assessing airway tissue oxygenation and perfusion in experimental and clinical transplantation.
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Mason DP, Brown CR, Murthy SC, Vakil N, Lyon C, Budev MM, Pettersson GB. Growing Single-Center Experience With Lung Transplantation Using Donation After Cardiac Death. Ann Thorac Surg 2012; 94:406-11; discussion 411-2. [DOI: 10.1016/j.athoracsur.2012.03.059] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 03/13/2012] [Accepted: 03/19/2012] [Indexed: 11/24/2022]
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Lee JC, Diamond JM, Christie JD. Critical care management of the lung transplant recipient. CURRENT RESPIRATORY CARE REPORTS 2012; 1:168-176. [PMID: 32288970 PMCID: PMC7102351 DOI: 10.1007/s13665-012-0018-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Lung transplantation provides the prospect of improved survival and quality of life for patients with end stage lung and pulmonary vascular diseases. Given the severity of illness of such patients at the time of surgery, lung transplant recipients require particular attention in the immediate post-operative period to ensure optimal short-term and long-term outcomes. The management of such patients involves active involvement of a multidisciplinary team versed in common post-operative complications. This review provides an overview of such complications as they pertain to the practitioners caring for post-operative lung transplant recipients. Causes and treatment of conditions affecting early morbidity and mortality in lung transplant recipients will be detailed, including primary graft dysfunction, cardiovascular and surgical complications, and immunologic and infectious issues. Additionally, lung donor management issues and bridging the critically ill potential lung transplant recipient to transplantation will be discussed.
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Affiliation(s)
- James C. Lee
- Penn Lung Transplant Program, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, 826 West Gates Pavilion, 3400 Spruce Street, Philadelphia, PA 19104 USA
| | - Joshua M. Diamond
- Penn Lung Transplant Program, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, 826 West Gates Pavilion, 3400 Spruce Street, Philadelphia, PA 19104 USA
| | - Jason D. Christie
- Department of Biostatistics and Epidemiology, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104 USA
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Gade J, Greisen G, Larsen IK, Bibby BM, Olsen PS. Tissue hypoxaemia causes oedema, inflammation and fibrosis in porcine bronchial transsection. SCAND CARDIOVASC J 2012; 46:286-94. [PMID: 22607392 DOI: 10.3109/14017431.2012.695086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Bronchial artery revascularization in lung transplantation is disputed. This study examined the physiological consequences of porcine bronchial transsection and reanastomosis with and without bronchial artery blood supply with relation to lung transplantation. DESIGN Translational, controlled animal study. Twelve pigs were operated through a left lateral thoracotomy. The left bronchus was transsected and reanastomosed. In the control group (n = 6), the bronchial arteries were preserved and in the study group (n = 6) they were severed. Bronchial mucosa blood flow (BMBF) was measured with laser-Doppler velocimetry and bronchial mucosa haemoglobin saturation and concentration with diffuse reflectance spectrophotometry. Measurements were made preoperatively, postoperatively and after 1 week. RESULTS In the study group, left postoperative BMBF was significantly lower than preoperatively (115 vs. 210 PU/s, p = 0.0001) and lower than in the control group (115 vs. 205 PU/s, p = 0.002). Repeated measurement ANOVA showed a significant treatment effect depending on time (p = 0.0034). The left mucosal haemoglobin saturation in the study group was significantly reduced postoperatively, 92% versus 61%, with a treatment effect depending on time (p = 0.0080). The reduction in left/right ratio of the mucosal haemoglobin concentration 1 week postoperatively in the study group was insignificant. CONCLUSION Bronchial transsection and reanastomosis without bronchial artery blood supply was followed by significant decrease in mucosal blood flow and saturation postoperatively, and also in tissue haemoglobin concentration at section, and provides a physiologic explanation of histological changes.
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Affiliation(s)
- John Gade
- Department of Cardiothoracic Surgery RT, Rigshospitalet, Copenhagen University Hospital, Denmark.
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Osiro S, Wear C, Hudson R, Ma XX, Zurada A, Michalak M, Loukas M. A friend to the airways: a review of the emerging clinical importance of the bronchial arterial circulation. Surg Radiol Anat 2012; 34:791-8. [PMID: 22552583 DOI: 10.1007/s00276-012-0974-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 04/14/2012] [Indexed: 10/28/2022]
Abstract
Lungs receive the bulk of their blood supply through the pulmonary arteries. The bronchial arteries, on the other hand, vascularize the bronchi and their surroundings. These two arteries anastomose near the alveolar ducts. Contrary to the pulmonary circulation which is fairly well studied, the bronchial arteries have been appreciated more by their absence, and in some cases, by an interruption in the pulmonary arterial flow. Therefore, a more accurate anatomical and functional knowledge of these atherosclerosis-resistant vessels is needed to help surgeons and clinicians to avoid iatrogenic injuries during pulmonary interventions. In this review, we have revisited the anatomy and pathophysiology of the bronchial arteries in humans, considering the recent advances in imaging techniques. We have also elaborated on the known clinical applications of these arteries in both the pathogenesis and management of common pulmonary conditions.
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Affiliation(s)
- Stephen Osiro
- Department of Anatomical Sciences, School of Medicine, St. George's University, Grenada, West Indies
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Mitsani D, Nguyen MH, Shields RK, Toyoda Y, Kwak EJ, Silveira FP, Pilewski JM, Crespo MM, Bermudez C, Bhama JK, Clancy CJ. Prospective, observational study of voriconazole therapeutic drug monitoring among lung transplant recipients receiving prophylaxis: factors impacting levels of and associations between serum troughs, efficacy, and toxicity. Antimicrob Agents Chemother 2012; 56:2371-7. [PMID: 22330924 PMCID: PMC3346665 DOI: 10.1128/aac.05219-11] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 12/24/2011] [Indexed: 12/28/2022] Open
Abstract
Voriconazole prophylaxis is common following lung transplantation, but the value of therapeutic drug monitoring is unknown. A prospective, observational study of lung transplant recipients (n = 93) receiving voriconazole prophylaxis was performed. Serum voriconazole troughs (n = 331) were measured by high-pressure liquid chromatography. The median initial and subsequent troughs were 1.91 and 1.46 μg/ml, respectively. The age of the patient directly correlated with initial troughs (P = 0.005). Patients that were ≥ 60 years old and cystic fibrosis patients were significantly more likely to have higher and lower initial troughs, respectively. In 95% (88/93) of patients, ≥ 2 troughs were measured. In 28% (25/88) and 32% (28/88) of these patients, all troughs were ≤ 1.5 μg/ml or >1.5 μg/ml, respectively. Ten percent (10/93) and 27% (25/93) of the patients developed invasive fungal infection (tracheobronchitis) and fungal colonization, respectively. The median troughs at the times of positive and negative fungal cultures were 0.92 and 1.72 μg/ml (P = 0.07). Invasive fungal infections or colonization were more likely with troughs of ≤ 1.5 μg/ml (P = 0.01) and among patients with no trough of >1.5 μg/ml (P = 0.007). Other cutoff troughs correlated less strongly with microbiologic outcomes. Troughs correlated directly with aspartate transferase levels (P = 0.003), but not with other liver enzymes. Voriconazole was discontinued due to suspected toxicity in 27% (25/93) of the patients. The troughs did not differ at the times of suspected drug-induced hepatotoxicity, central nervous system (CNS) toxicity, or nausea/vomiting and in the absence of toxicity. Voriconazole prophylaxis was most effective at troughs of >1.5 μg/ml. A cutoff for toxicity was not identified, but troughs of >4 μg/ml were rare. The data support a target range of >1.5 to 4 μg/ml.
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Affiliation(s)
| | | | | | - Yoshiya Toyoda
- Department of Cardiothoracic Surgery, University of Pittsburgh
| | | | | | | | | | | | - Jay K. Bhama
- Department of Cardiothoracic Surgery, University of Pittsburgh
| | - Cornelius J. Clancy
- Divisions of Infectious Diseases
- V.A. Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
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Khan MA, Jiang X, Dhillon G, Beilke J, Holers VM, Atkinson C, Tomlinson S, Nicolls MR. CD4+ T cells and complement independently mediate graft ischemia in the rejection of mouse orthotopic tracheal transplants. Circ Res 2011; 109:1290-301. [PMID: 21998328 DOI: 10.1161/circresaha.111.250167] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
RATIONALE While microvascular injury is associated with chronic rejection, the cause of tissue ischemia during alloimmune injury is not yet elucidated. OBJECTIVE We investigated the contribution of T lymphocytes and complement to microvascular injury-associated ischemia during acute rejection of mouse tracheal transplants. METHODS AND RESULTS Using novel techniques to assess microvascular integrity and function, we evaluated how lymphocyte subsets and complement specifically affect microvascular perfusion and tissue oxygenation in MHC-mismatched transplants. To characterize T cell effects on microvessel loss and recovery, we transplanted functional airway grafts in the presence and absence of CD4(+) and CD8(+) T cells. To establish the contribution of complement-mediated injury to the allograft microcirculation, we transplanted C3-deficient and C3-inhibited recipients. We demonstrated that CD4(+) T cells and complement are independently sufficient to cause graft ischemia. CD8(+) T cells were required for airway neovascularization to occur following CD4-mediated rejection. Activation of antibody-dependent complement pathways mediated tissue ischemia even in the absence of cellular rejection. Complement inhibition by CR2-Crry attenuated graft hypoxia, complement/antibody deposition on vascular endothelium and promoted vascular perfusion by enhanced angiogenesis. Finally, there was a clear relationship between the burden of tissue hypoxia (ischemia×time duration) and the development of subsequent airway remodeling. CONCLUSIONS These studies demonstrated that CD4(+) T cells and complement operate independently to cause transplant ischemia during acute rejection and that sustained ischemia is a precursor to chronic rejection.
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Affiliation(s)
- Mohammad A Khan
- Veterans Affairs Palo Alto Health Care System/Stanford University School of Medicine, CA 94304, USA
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Jiang X, Khan MA, Tian W, Beilke J, Natarajan R, Kosek J, Yoder MC, Semenza GL, Nicolls MR. Adenovirus-mediated HIF-1α gene transfer promotes repair of mouse airway allograft microvasculature and attenuates chronic rejection. J Clin Invest 2011; 121:2336-49. [PMID: 21606594 DOI: 10.1172/jci46192] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Accepted: 03/30/2011] [Indexed: 01/27/2023] Open
Abstract
Chronic rejection, manifested as small airway fibrosis (obliterative bronchiolitis [OB]), is the main obstacle to long-term survival in lung transplantation. Recent studies demonstrate that the airways involved in a lung transplant are relatively hypoxic at baseline and that OB pathogenesis may be linked to ischemia induced by a transient loss of airway microvasculature. Here, we show that HIF-1α mediates airway microvascular repair in a model of orthotopic tracheal transplantation. Grafts with a conditional knockout of Hif1a demonstrated diminished recruitment of recipient-derived Tie2⁺ angiogenic cells to the allograft, impaired repair of damaged microvasculature, accelerated loss of microvascular perfusion, and hastened denudation of epithelial cells. In contrast, graft HIF-1α overexpression induced via an adenoviral vector prolonged airway microvascular perfusion, preserved epithelial integrity, extended the time window for the graft to be rescued from chronic rejection, and attenuated airway fibrotic remodeling. HIF-1α overexpression induced the expression of proangiogenic factors such as Sdf1, Plgf, and Vegf, and promoted the recruitment of vasoreparative Tie2⁺ cells. This study demonstrates that a therapy that enhances vascular integrity during acute rejection may promote graft health and prevent chronic rejection.
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Affiliation(s)
- Xinguo Jiang
- Department of Medicine, VA Palo Alto Health Care System/Stanford University School of Medicine, Stanford, California, USA
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