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Rando HJ, Fanning JP, Cho SM, Kim BS, Whitman G, Bush EL, Keller SP. Extracorporeal membrane oxygenation as a bridge to lung transplantation: Practice patterns and patient outcomes. J Heart Lung Transplant 2024; 43:77-84. [PMID: 37394023 PMCID: PMC10756924 DOI: 10.1016/j.healun.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/02/2023] [Accepted: 06/25/2023] [Indexed: 07/04/2023] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is increasingly relied on to bridge patients with respiratory failure to lung transplantation despite limited evidence for its use in this setting. This study evaluated longitudinal trends in practice patterns, patient characteristics, and outcomes in patients bridged with ECMO to lung transplant. METHODS A retrospective review of all adult isolated lung transplant patients in the United Network for Organ Sharing database between 2000 and 2019 was performed. Patients were classified as "ECMO" if supported with ECMO at the time of listing or transplantation and "non-ECMO" otherwise. Linear regression was used to evaluate trends in patient demographics during the study period. Trends in mortality were evaluated using Cox proportional hazards modeling, with time period as the primary covariate (2000-2004, 2005-2009, 2010-2014, or 2015-2019) and age, time on the waitlist, and underlying diagnosis as covariates. RESULTS The number of patients included were 40,866, of whom 1,387 (3.4%) were classified as ECMO and 39,479 (96.6%) as no ECMO. Average age and initial Lung Allocation Score increased significantly during the study period in both cohorts, but occurred at a slower rate in the ECMO population. The hazard of death was significantly lower in more recent years (2015-2019) for both the ECMO and non-ECMO cohorts (aHR (adjusted hazards ratio) 0.59, 95% confidence interval (CI) 0.37-0.96 and aHR 0.74, 95% CI 0.70-0.79) when compared to the early years (2000-2004) of the study period. CONCLUSIONS Post-transplantation survival for patients bridged to transplantation with ECMO demonstrates ongoing improvement despite cannulation of progressively older and sicker patients.
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Affiliation(s)
- Hannah J Rando
- From the Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland.
| | - Jonathon P Fanning
- From the Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Sung-Min Cho
- From the Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland; Division of Neuroscience Critical Care, Department of Neurology and Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Bo S Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Glenn Whitman
- From the Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Errol L Bush
- Division of General Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Steven P Keller
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Johns Hopkins University, Baltimore, Maryland; and the Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
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Al-Adhami A, Al-Aloul M, Rushton S, Thompson RD, Carby M, Lordan J, Clark S, Spencer H, Tsui S, Parmar J. Early experience of a new national lung allocation scheme in the UK based on clinical urgency. Thorax 2023; 78:1206-1214. [PMID: 37487710 DOI: 10.1136/thorax-2022-219475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 06/21/2023] [Indexed: 07/26/2023]
Abstract
INTRODUCTION A new UK Lung Allocation Scheme (UKLAS) was introduced in 2017, replacing the previous geographic allocation system. Patients are prioritised according to predefined clinical criteria into a three-tier system: the super-urgent lung allocation scheme (SULAS), the urgent lung allocation scheme (ULAS) and the non-urgent lung allocation scheme (NULAS). This study assessed the early impact of this scheme on waiting-list and post-transplant outcomes. METHODS A cohort study of adult lung transplant registrations between March 2015 and November 2016 (era-1) and between May 2017 and January 2019 (era-2). Outcomes from registration were compared between eras and stratified by urgency tier and diagnostic group. RESULTS During era-1, 461 patients were registered. In era-2, 471 patients were registered (19 (4.0%) SULAS, 82 (17.4%) ULAS and 370 (78.6%) NULAS). SULAS patients were younger (median age 35 vs 50 and 55 for urgent and non-urgent, respectively, p=0.0015) and predominantly suffered from cystic fibrosis (53%) or pulmonary fibrosis (37%). Between eras 1 and 2, the odds of transplantation within 6 months of registration were increased (OR=1.41, 95% CI 1.07 to 1.85, p=0.0142) despite only a 5% increase in transplant activity. Median time-to-transplantation during era-1 was 427 days compared with waiting times in era-2 of 8 days for SULAS, 15 days for ULAS and 585 days for NULAS patients. Waiting-list mortality (15% era-1 vs 13% era-2; p=0.5441) and post-transplant survival at 1 year (81.3% era-1 vs 83.3% era-2; p=0.6065) were similar between eras. CONCLUSION The UKLAS scheme prioritises the critically ill and improves transplantation odds. The true impact on waiting-list mortality and post-transplant survival requires further follow-up.
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Affiliation(s)
- Ahmed Al-Adhami
- Cardiothoracic Transplantation, Royal Papworth Hospital, Cambridge, UK
| | - Mohamed Al-Aloul
- Cardiothoracic Transplantation, Wythenshawe Hospital, Manchester, UK
| | - Sally Rushton
- Statistics and Clinical Studies, NHS Blood and Transplant Organ Donation and Transplantation Directorate, Bristol, UK
| | | | - Martin Carby
- Department of Cardiothoracic Transplantation, Royal Brompton and Harefield NHS Foundation Trust, Harefield, UK
| | - Jordan Lordan
- Cardiothoracic Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Stephen Clark
- Cardiothoracic Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Helen Spencer
- Department of Cardiothoracic Transplantation, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Steven Tsui
- Cardiothoracic Transplantation, Royal Papworth Hospital, Cambridge, UK
| | - Jasvir Parmar
- Cardiothoracic Transplantation, Royal Papworth Hospital, Cambridge, UK
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Sinha N, Balayla G, Braghiroli J. Coronary artery disease in lung transplant patients. Clin Transplant 2020; 34:e14078. [PMID: 32940380 DOI: 10.1111/ctr.14078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/13/2020] [Accepted: 08/28/2020] [Indexed: 01/11/2023]
Abstract
Coronary artery disease (CAD) is a pathology often found in patients with end-stage lung disease. Although in the past CAD might have been considered an absolute contraindication, modern revascularization techniques have helped increase the number of transplants performed in this population. However, discrepancies in the guidelines for perioperative evaluation and risk mitigation strategies for the ischemic cardiac burden are present in the current literature. This is a review of the available data regarding perioperative evaluation, revascularization tactics, postoperative management, and survival rate that patients with different grades of coronary artery disease present after lung transplantation.
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Affiliation(s)
- Neeraj Sinha
- Division of Pulmonary and Critical Care Medicine, Transplant Pulmonology, University of Miami, Miami, FL, USA
| | - Galit Balayla
- Department of General Medicine, Central University of Venezuela, Caracas, Venezuela
| | - Joao Braghiroli
- Division of Interventional Cardiology, Jackson Health System, Miami, FL, USA
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Krishnan A, Hsu J, Ha JS, Broderick SR, Shah PD, Higgins RS, Merlo CA, Bush EL. Elevated neutrophil to lymphocyte ratio is associated with poor long-term survival and graft failure after lung transplantation. Am J Surg 2020; 221:731-736. [PMID: 32334799 DOI: 10.1016/j.amjsurg.2020.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 04/05/2020] [Accepted: 04/07/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE We aimed to assess the prognostic value of Neutrophil to Lymphocyte Ratio (NLR) on long-term outcomes and graft dysfunction after lung transplantation. METHODS We retrospectively reviewed all patients receiving a lung transplant at our institution from 2011 to 2014. The primary exposure was elevated NLR at the time of transplant, defined by NLR>4. The primary outcomes were graft failure and three-year all-cause mortality. Multivariate logistic regression and Kaplan-Meier survival analysis were used to analyze outcomes. RESULTS 95 patients were included. 40 patients (42%) had an elevated NLR. Elevated NLR was associated with graft failure (OR: 4.7 [1.2-18.8], p = 0.02), and three-year mortality (OR: 5.4 [1.3-23.2], p = 0.03) on multivariate logistic regression. Patients with elevated NLR demonstrated significantly lower survival on Kaplan-Meier analysis (50% versus 74%, p = 0.02). The c-statistic for our multivariate model was 0.91. CONCLUSION Elevated neutrophil to lymphocyte ratio is associated with poor long-term survival and graft failure after lung transplantation.
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Affiliation(s)
- Aravind Krishnan
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, USA
| | - Joshua Hsu
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, USA
| | - Jinny S Ha
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, USA
| | - Stephen R Broderick
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, USA
| | - Pali D Shah
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, USA
| | - Robert Sd Higgins
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, USA
| | - Christian A Merlo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, USA
| | - Errol L Bush
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, USA.
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Lertjitbanjong P, Thongprayoon C, Cheungpasitporn W, O'Corragain OA, Srivali N, Bathini T, Watthanasuntorn K, Aeddula NR, Salim SA, Ungprasert P, Gillaspie EA, Wijarnpreecha K, Mao MA, Kaewput W. Acute Kidney Injury after Lung Transplantation: A Systematic Review and Meta-Analysis. J Clin Med 2019; 8:jcm8101713. [PMID: 31627379 PMCID: PMC6833042 DOI: 10.3390/jcm8101713] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 10/03/2019] [Accepted: 10/15/2019] [Indexed: 02/06/2023] Open
Abstract
Background: Lung transplantation has been increasingly performed worldwide and is considered an effective therapy for patients with various causes of end-stage lung diseases. We performed a systematic review to assess the incidence and impact of acute kidney injury (AKI) and severe AKI requiring renal replacement therapy (RRT) in patients after lung transplantation. Methods: A literature search was conducted utilizing Ovid MEDLINE, EMBASE, and Cochrane Database from inception through June 2019. We included studies that evaluated the incidence of AKI, severe AKI requiring RRT, and mortality risk of AKI among patients after lung transplantation. Pooled incidence and odds ratios (ORs) with 95% confidence interval (CI) were obtained using random-effects meta-analysis. The protocol for this meta-analysis is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42019134095). Results: A total of 26 cohort studies with a total of 40,592 patients after lung transplantation were enrolled. Overall, the pooled estimated incidence rates of AKI (by standard AKI definitions) and severe AKI requiring RRT following lung transplantation were 52.5% (95% CI: 45.8–59.1%) and 9.3% (95% CI: 7.6–11.4%). Meta-regression analysis demonstrated that the year of study did not significantly affect the incidence of AKI (p = 0.22) and severe AKI requiring RRT (p = 0.68). The pooled ORs of in-hospital mortality in patients after lung transplantation with AKI and severe AKI requiring RRT were 2.75 (95% CI, 1.18–6.41) and 10.89 (95% CI, 5.03–23.58). At five years, the pooled ORs of mortality among patients after lung transplantation with AKI and severe AKI requiring RRT were 1.47 (95% CI, 1.11–1.94) and 4.79 (95% CI, 3.58–6.40), respectively. Conclusion: The overall estimated incidence rates of AKI and severe AKI requiring RRT in patients after lung transplantation are 52.5% and 9.3%, respectively. Despite advances in therapy, the incidence of AKI in patients after lung transplantation does not seem to have decreased. In addition, AKI after lung transplantation is significantly associated with reduced short-term and long-term survival.
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Affiliation(s)
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA.
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA.
| | - Oisín A O'Corragain
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA 19140, USA.
| | - Narat Srivali
- Department of Internal Medicine, St. Agnes Hospital, Baltimore, MD 21229, USA.
| | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, AZ 85721, USA.
| | | | | | - Sohail Abdul Salim
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA.
| | - Patompong Ungprasert
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio 44195, USA.
| | - Erin A Gillaspie
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN 37212, USA.
| | | | - Michael A Mao
- Department of Medicine, Mayo Clinic, Jacksonville, FL 32224, USA.
| | - Wisit Kaewput
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok 10400, Thailand.
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Tawil JN, Adams BA, Nicoara A, Boisen ML. Noteworthy Literature Published in 2018 for Thoracic Organ Transplantation. Semin Cardiothorac Vasc Anesth 2019; 23:171-187. [PMID: 31064319 DOI: 10.1177/1089253219845408] [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: 11/17/2022]
Abstract
Publications of note from 2018 are reviewed for the cardiothoracic transplant anesthesiologist. Strategies to expand the availability of donor organs were highlighted, including improved donor management, accumulating experience with increased-risk donors, ex vivo perfusion techniques, and donation after cardiac death. A number of reports examined posttransplant outcomes, including outcomes other than mortality, with new data-driven risk models. Use of extracorporeal support in cardiothoracic transplantation was a prominent theme. Major changes in adult heart allocation criteria were implemented, aiming to improve objectivity and transparency in the listing process. Frailty and prehabilitation emerged as targets of comprehensive perioperative risk mitigation programs.
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Affiliation(s)
| | | | | | - Michael L Boisen
- 4 University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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