1
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Tomioka Y, Tanaka S, Otani S, Shiotani T, Yamamoto H, Miyoshi K, Okazaki M, Sugimoto S, Yamane M, Toyooka S. Elderly lung transplant recipients show acceptable long-term outcomes for lung transplantation: A propensity score-matched analysis. Surg Today 2023; 53:1286-1293. [PMID: 37269338 DOI: 10.1007/s00595-023-02699-5] [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: 12/04/2022] [Accepted: 03/15/2023] [Indexed: 06/05/2023]
Abstract
PURPOSE Although the performance lung transplantation (LTx) in the elderly (≥ 60 years) has increased globally, the situation in Japan remains quite different, because the age limit at registration for cadaveric transplantation is 60 years. We investigated the long-term outcomes of LTx in the elderly in Japan. METHODS This was a single-center retrospective study. We divided the patients into two groups according to age: the younger group (< 60 years; Y group; n = 194) and the elderly group (≥ 60 years; E group; n = 10). We performed three-to-one propensity score matching to compare the long-term survival between the E and Y groups. RESULTS In the E group, the survival rate was significantly worse (p = 0.003), and single-LTx was more frequent (p = 0.036). There was a significant difference in the indications for LTx between the two groups (p < 0.001). The 5-year survival rate after single-LTx in the E group was significantly lower than that in the Y group (p = 0.006). After propensity score matching, the 5-year survival rates of the two groups were comparable (p = 0.55). However, the 5-year survival rate after single-LTx in the E group was significantly lower than that in the Y group (p = 0.007). CONCLUSION Elderly patients showed acceptable long-term survival after LTx.
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Affiliation(s)
- Yasuaki Tomioka
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, Okayama, Japan
| | - Shin Tanaka
- Department of General Thoracic Surgery and Organ Transplant Center, Okayama University Hospital, 2-5-1 Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan.
| | - Shinji Otani
- Department of Cardiovascular and Thoracic Surgery, Ehime University Medical School, Toon City, Japan
| | - Toshio Shiotani
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, Okayama, Japan
| | - Haruchika Yamamoto
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Kentaroh Miyoshi
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, Okayama, Japan
| | - Mikio Okazaki
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, Okayama, Japan
| | - Seiichiro Sugimoto
- Department of General Thoracic Surgery and Organ Transplant Center, Okayama University Hospital, 2-5-1 Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan
| | - Masaomi Yamane
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, Okayama, Japan
| | - Shinichi Toyooka
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, Okayama, Japan
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2
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Leong SW, Bos S, Lordan JL, Nair A, Fisher AJ, Meachery G. Lung transplantation for interstitial lung disease: evolution over three decades. BMJ Open Respir Res 2023; 10:10/1/e001387. [PMID: 36854571 PMCID: PMC9980330 DOI: 10.1136/bmjresp-2022-001387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 12/14/2022] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Interstitial lung disease (ILD) has emerged as the most common indication for lung transplantation globally. However, post-transplant survival varies depending on the underlying disease phenotype and comorbidities. This study aimed to describe the demographics, disease classification, outcomes and factors associated with post-transplant survival in a large single-centre cohort. METHODS Data were retrospectively assessed for 284 recipients who underwent lung transplantation for ILD in our centre between 1987 and 2020. Patient characteristics and outcomes were stratified by three eras: 1987-2000, 2001-2010 and 2011-2020. RESULTS Median patients' age at time of transplantation was significantly higher in the most recent decade (56 (51-61) years, p<0.0001). Recipients aged over 50 years had worse overall survival compared with younger patients (adjusted HR, aHR 2.36, 95% CI 1.55 to 3.72, p=0.0001). Better survival was seen with bilateral versus single lung transplantation in patients younger than 50 years (log-rank p=0.0195). However, this survival benefit was no longer present in patients aged over 50 years. Reduced survival was observed in fibrotic non-specific interstitial pneumonia compared with idiopathic pulmonary fibrosis, which remained the most common indication throughout (aHR 2.61, 95% CI 1.40 to 4.60, p=0.0015). CONCLUSION In patients transplanted for end-stage ILD, older age and fibrotic non-specific interstitial pneumonia were associated with poorer post-transplant survival. The benefit of bilateral over single lung transplantation diminished with increasing age, suggesting that single lung transplantation might still be a feasible option in older candidates.
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Affiliation(s)
- Swee W Leong
- Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Department of Pulmonology, Serdang Hospital, Kajang, Malaysia
| | - Saskia Bos
- Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Translational and Clinical Research Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - James L Lordan
- Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Arun Nair
- Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Andrew J Fisher
- Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Translational and Clinical Research Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Gerard Meachery
- Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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3
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Vandervelde CM, Vos R, Vanluyten C, Fieuws S, Verleden SE, Van Slambrouck J, De Leyn P, Coosemans W, Nafteux P, Decaluwé H, Van Veer H, Depypere L, Dauwe DF, De Troy E, Ingels CM, Neyrinck AP, Jochmans I, Vanaudenaerde BM, Godinas L, Verleden GM, Van Raemdonck DE, Ceulemans LJ. Impact of anastomosis time during lung transplantation on primary graft dysfunction. Am J Transplant 2022; 22:1418-1429. [PMID: 35029023 DOI: 10.1111/ajt.16957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 01/07/2022] [Accepted: 01/08/2022] [Indexed: 01/25/2023]
Abstract
Primary graft dysfunction (PGD) is a major obstacle after lung transplantation (LTx), associated with increased early morbidity and mortality. Studies in liver and kidney transplantation revealed prolonged anastomosis time (AT) as an independent risk factor for impaired short- and long-term outcomes. We investigated if AT during LTx is a risk factor for PGD. In this retrospective single-center cohort study, we included all first double lung transplantations between 2008 and 2016. The association of AT with any PGD grade 3 (PGD3) within the first 72 h post-transplant was analyzed by univariable and multivariable logistic regression analysis. Data on AT and PGD was available for 427 patients of which 130 (30.2%) developed PGD3. AT was independently associated with the development of any PGD3 ≤72 h in uni- (odds ratio [OR] per 10 min 1.293, 95% confidence interval [CI 1.136-1.471], p < .0001) and multivariable (OR 1.205, 95% CI [1.022-1.421], p = .03) logistic regression analysis. There was no evidence that the relation between AT and PGD3 differed between lung recipients from donation after brain death versus donation after circulatory death donors. This study identified AT as an independent risk factor for the development of PGD3 post-LTx. We suggest that the implantation time should be kept short and the lung cooled to decrease PGD-related morbidity and mortality post-LTx.
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Affiliation(s)
| | - Robin Vos
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium.,Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Cedric Vanluyten
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Steffen Fieuws
- Department of Public Health, Interuniversity Centre for Biostatistics and Statistical Bioinformatics, KU Leuven, Leuven, Belgium
| | - Stijn E Verleden
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Jan Van Slambrouck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Paul De Leyn
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Willy Coosemans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Philippe Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Herbert Decaluwé
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Hans Van Veer
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Lieven Depypere
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Dieter F Dauwe
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Erwin De Troy
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Catherine M Ingels
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Arne P Neyrinck
- Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium.,Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Ina Jochmans
- Transplantation Group, Lab Abdominal Transplant Surgery, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium.,Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Bart M Vanaudenaerde
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Laurent Godinas
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Geert M Verleden
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium.,Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Dirk E Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Laurens J Ceulemans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
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4
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Benissan-Messan DZ, Ganapathi AM, Guo M, Henn MC, Keller BC, Howsare M, Rosenheck JP, Kirkby SE, Mokadam NA, Nunley D, Whitson BA. Lung transplantation in the septuagenarian can be successfully performed though long-term results impacted by diseases of aging. Clin Transplant 2022; 36:e14593. [PMID: 35032351 DOI: 10.1111/ctr.14593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/31/2021] [Accepted: 01/03/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Advanced age is considered a risk factor for lung transplantation (LTX). We sought to evaluate the long-term outcomes of LTX in the septuagenarian. METHODS LTX recipients in the UNOS transplant registry (May 1, 2005 to June 12, 2020) were stratified into 18-59, 60-69, and > = 70 years of age. Recipient and transplant characteristics were evaluated for survival, cause of death (COD), length of stay (LOS), and complications. A Kaplan-Meier analysis examined long-term survival for all patients stratified by age, specifically looking at cause of death. RESULTS A total of 27632 recipients were identified. As recipients aged, we found a decrease in proportion of cystic fibrosis and an increase in restrictive disease while obstructive disease peaked in the 60-69yo cohort (p<0.001). Septuagenarians had higher rates of single LTX, male gender and white race (p<0.001). Older recipients had significantly longer donor recovery distances traveled with paradoxical shorter ischemic times, shorter hospital LOS and were transplanted at higher volume centers. There was no difference with in-hospital mortality among groups (p = 0.5). Acute rejection during initial hospitalization, rejection within 1 year, and post-transplant dialysis incidence decreased with age. Graft failure was a common COD in younger patients while malignancy and cardio/cerebrovascular diseases were common COD in > = 70yo. CONCLUSION Select septuagenarian LTX candidates may be safely transplanted with relatively few complications. Immunosenescence and conditions of the aged are likely contributing factors to the decreased rejection and graft failure observations. Septuagenarians should not be excluded from LTX consideration based solely on age. Transplantation in septuagenarians should only be done in very selected patients (screened for malignancies and atherosclerotic disease) and these recipients should be carefully followed after transplantation because of these risk factors. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Dathe Z Benissan-Messan
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Asvin M Ganapathi
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Marissa Guo
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Matthew C Henn
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Brian C Keller
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Molly Howsare
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Justin P Rosenheck
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Stephen E Kirkby
- Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, OH
| | - Nahush A Mokadam
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - David Nunley
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Bryan A Whitson
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
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5
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Kapnadak SG, Raghu G. Lung transplantation for interstitial lung disease. Eur Respir Rev 2021; 30:30/161/210017. [PMID: 34348979 DOI: 10.1183/16000617.0017-2021] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/02/2021] [Indexed: 01/18/2023] Open
Abstract
Lung transplantation (LTx) can be a life-extending treatment option for patients with advanced and/or progressive fibrotic interstitial lung disease (ILD), especially idiopathic pulmonary fibrosis (IPF), fibrotic hypersensitivity pneumonitis, sarcoidosis and connective tissue disease-associated ILD. IPF is now the most common indication for LTx worldwide. Several unique features in patients with ILD can impact optimal timing of referral or listing for LTx, pre- or post-transplant risks, candidacy and post-transplant management. As the epidemiology of LTx and community practices have evolved, recent literature describes outcomes and approaches in higher-risk candidates. In this review, we discuss the unique and important clinical findings, course, monitoring and management of patients with IPF and other progressive fibrotic ILDs during pre-LTx evaluation and up to the day of transplantation; the need for co-management with clinical experts in ILD and LTx is emphasised. Some post-LTx complications are unique in these patient cohorts, which require prompt detection and appropriate management by experts in multiple disciplines familiar with telomere biology disorders and infectious, haematological, oncological and cardiac complications to enhance the likelihood of improved outcomes and survival of LTx recipients with IPF and other ILDs.
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Affiliation(s)
- Siddhartha G Kapnadak
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, University of Washington, Seattle, WA, USA
| | - Ganesh Raghu
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, University of Washington, Seattle, WA, USA .,Dept of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
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6
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Narula T, Khouzam S, Alvarez F, Erasmus D, Li Z, Abdelmoneim Y, Elrefaei M. Antithymocyte globulin is associated with a lower incidence of de novo donor-specific antibody detection in lung transplant recipients: A single-center experience. IMMUNITY INFLAMMATION AND DISEASE 2021; 9:1418-1427. [PMID: 34310850 PMCID: PMC8589359 DOI: 10.1002/iid3.491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/09/2021] [Indexed: 11/06/2022]
Abstract
Purpose Induction immunosuppression has improved the long‐term outcomes after lung transplant. This is the first report exploring the association of induction immunosuppression with the development of de novo donor‐specific human leukocyte antigen (HLA) antibodies (DSA) in lung transplant recipients (LTR). Methods Sixty‐seven consecutive primary LTR were followed for 3 years posttransplant. A total of 41/67 (61%) LTR‐received induction immunosuppression using a single dose of rabbit Antithymocyte Globulin (rATG; 1.5 mg/kg) within 24 h of transplant. All recipients had a negative flow cytometry crossmatch on the day of transplant. Serum samples at 1, 3, 6, and 12 months posttransplant were assessed for the presence of de novo HLA DSA. Results De novo HLA DSA were detected in 22/67 (32.8%) LTR within 1‐year posttransplant. Of these, 9/41 (21.9%) occurred in the induction therapy group and 13/26 (50%) in the noninduction group. Class II DSA were detected in 3/41 (7.3%) LTR who received induction compared to 9/26 (34.6%) LTR without induction immunosuppression (p = .005). Differences in overall survival or freedom from chronic lung allograft dysfunction rates between the two groups were not statistically significant. Conclusion Induction immunosuppression utilizing a modified regimen of single‐dose rATG is associated with a significant reduction in de novo DSA production in LTR.
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Affiliation(s)
- Tathagat Narula
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida, USA
| | - Samir Khouzam
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida, USA
| | - Francisco Alvarez
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida, USA
| | - David Erasmus
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida, USA
| | - Zhuo Li
- Health Sciences Research, Mayo Clinic, Jacksonville, Florida, USA
| | - Yousif Abdelmoneim
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida, USA
| | - Mohamed Elrefaei
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida, USA
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7
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Levy L, Huszti E, Ahmed M, Ghany R, Hunter S, Moshkelgosha S, Zhang CYK, Boonstra K, Klement W, Tikkanen J, Singer LG, Keshavjee S, Juvet S, Martinu T. Bronchoalveolar lavage cytokine-based risk stratification of minimal acute rejection in clinically stable lung transplant recipients. J Heart Lung Transplant 2021; 40:1540-1549. [PMID: 34215500 DOI: 10.1016/j.healun.2021.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 05/14/2021] [Accepted: 05/24/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Acute cellular rejection (ACR) remains the most significant risk factor for chronic lung allograft dysfunction (CLAD). While clinically significant or higher-grade (≥A2) ACR is generally treated with augmented immunosuppression (IS), the management of clinically stable grade A1 ACR remains controversial. At our center, patients with clinically stable grade A1 ACR are routinely not treated with augmented IS. While the overall outcomes in this group of patients at our center are equivalent to patients with stable A0 pathology, CLAD and death rates remain overall high. We hypothesized that a distinct cytokine signature at the time of early minimal rejection state would be associated with worse outcomes. Specifically, we aimed to determine whether bronchoalveolar lavage (BAL) biomarkers at the time of first clinically stable grade A1 ACR (CSA1R) are predictive of subsequent CLAD or death. METHODS Among all adult, bilateral, first lung transplants, performed 2010-2016, transbronchial biopsies obtained within the first-year post-transplant were categorized as clinically stable or unstable based on the presence or absence of ≥10% concurrent drop in forced expiratory volume in 1 second (FEV1). We assessed BAL samples obtained at the time of CSA1R episodes, which were not preceded by another ACR (i.e., first episodes). Twenty-one proteins previously associated with ACR or CLAD were measured in the BAL using a multiplex bead assay. Association between protein levels and subsequent CLAD or death was assessed using Cox Proportional Hazards models, adjusted for relevant peri-transplant clinical covariates. RESULTS We identified 75 patients with first CSA1R occurring at a median time of 98 days (range 48.5-197) post-transplant. Median time from transplant to CLAD or death was 1247 (756.5-1921.5) and 1641 days (1024.5-2326.5), respectively. In multivariable models, levels of MCP1/CCL2, S100A8, IL10, TNF-receptor 1, and pentraxin 3 (PTX3) were associated with both CLAD development and death (p < 0.05 for all). PTX3 remained significantly associated with both CLAD and death after adjusting for multiple comparisons. CONCLUSION Our data indicate that a focused BAL protein signature, with PTX3 having the strongest association, may be useful in determining a subset of CSA1R patients at increased risk and may benefit from a more aggressive management strategy.
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Affiliation(s)
- Liran Levy
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada; Institute of Pulmonary Medicine, Sheba Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Musawir Ahmed
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Hunter
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sajad Moshkelgosha
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Chen Yang Kevin Zhang
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kristen Boonstra
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - William Klement
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jussi Tikkanen
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Stephen Juvet
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
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8
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The Impact of Inadequate ("AX") Transbronchial Biopsies on Post-lung Transplant CLAD or Death. Transplantation 2021; 105:390-395. [PMID: 32150039 DOI: 10.1097/tp.0000000000003213] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Procuring a good quality transbronchial-biopsy sample is essential for diagnosing acute cellular rejection after lung transplantation (LT). Insufficient transbronchial-biopsy samples are graded "AX." We hypothesized that AX samples may be associated with a higher risk for chronic lung allograft dysfunction (CLAD) or death/retransplant, through a potential anatomic or physiologic underlying pulmonary process or because of undiagnosed acute cellular rejection episodes. METHODS We conducted a single-center, retrospective, cohort study drawn from all consecutive adult, first, bilateral LT between 1999 and 2015. We reviewed all biopsies obtained within the first year posttransplant and compared outcomes of patients with ≥1 AX to patients with no AX. Association of any AX or percent AX with time to CLAD or death/retransplant was assessed using Cox Proportional Hazards models. RESULTS The cohort consisted of 809 patients with a median of 6 (interquartile range 5-6) biopsies and 16.7% (interquartile range 0-25) AX samples within the first year posttransplant. Four hundred thirty-nine (54.3%) subjects had ≥1 AX sample obtained within the time period. Median time to CLAD or death/retransplant, from 1 year posttransplant, was 761 (320, 1587) and 1200 (662, 2308) days, respectively. In the multivariable analysis, there was no difference in risk for CLAD (hazard ratio = 1.05, 95% confidence interval, 0.87-1.28, P = 0.60), or death/retransplant (hazard ratio = 1.14, 95% confidence interval, 0.92-1.42, P = 0.24) between patients with ≥1 AX biopsy versus none. Among subjects with ≥1 AX, having >50% AX biopsies was not associated with outcome. CONCLUSIONS This is the first study to demonstrate that AX biopsies are not associated with an increased risk of CLAD or death/retransplant after LT and may not require to repeat the biopsy.
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9
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Dako F, Hota P, Kahn M, Kumaran M, Agosto O. Post-lung transplantation abdominopelvic complications: the role of multimodal imaging. Abdom Radiol (NY) 2020; 45:1202-1213. [PMID: 31552464 DOI: 10.1007/s00261-019-02229-3] [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] [Indexed: 12/13/2022]
Abstract
Lung transplantation (LT) is an established method for treating end-stage lung disease. Although most of the post-lung transplant imaging surveillance is focused on chronic lung allograft rejection, abdominopelvic complications have been reported in 7-62% of patients. The reported wide range of post-LT abdominopelvic complications is thought to be secondary to lack of current standardized definitions. These complications encompass a heterogeneous group of disorders including upper and lower gastrointestinal (GI) disorders, inflammatory conditions of solid organs, lymphoproliferative disorders, and neoplasms; each with varying pathophysiology, timing, severity, and treatment. Clinical manifestations of these complications may overlap or be masked by immunosuppression; therefore, imaging plays a paramount role in the early management and treatment.
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Affiliation(s)
- Farouk Dako
- Department of Radiology, Temple University Hospital, 3401 North Broad Street, Philadelphia, PA, 19123, USA.
| | - Partha Hota
- Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Mansoor Kahn
- Department of Radiology, Temple University Hospital, 3401 North Broad Street, Philadelphia, PA, 19123, USA
| | - Maruti Kumaran
- Department of Radiology, Temple University Hospital, 3401 North Broad Street, Philadelphia, PA, 19123, USA
| | - Omar Agosto
- Department of Radiology, Temple University Hospital, 3401 North Broad Street, Philadelphia, PA, 19123, USA
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10
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Levy L, Huszti E, Tikkanen J, Ghany R, Klement W, Ahmed M, Husain S, Fiset PO, Hwang D, Keshavjee S, Singer LG, Juvet S, Martinu T. The impact of first untreated subclinical minimal acute rejection on risk for chronic lung allograft dysfunction or death after lung transplantation. Am J Transplant 2020; 20:241-249. [PMID: 31397939 DOI: 10.1111/ajt.15561] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 06/14/2019] [Accepted: 07/26/2019] [Indexed: 01/25/2023]
Abstract
Acute cellular rejection (ACR) is a significant risk factor for chronic lung allograft dysfunction (CLAD). Although clinically manifest and higher grade (≥A2) ACR is generally treated with augmented immunosuppression, management of minimal (grade A1) ACR remains controversial. In our program, patients with subclinical and spirometrically stable A1 rejection (StA1R) are routinely not treated with augmented immunosuppression. We hypothesized that an untreated first StA1R does not increase the risk of CLAD or death compared to episodes of spirometrically stable no ACR (StNAR). The cohort was drawn from all consecutive adult, first, bilateral lung transplantations performed between 1999 and 2017. Biopsies obtained in the first-year posttransplant were paired with (forced expiratory volume in 1 second FEV1 ). The first occurrence of StA1R was compared to a time-matched StNAR. The risk of CLAD or death was assessed using univariable and multivariable Cox proportional hazards models. The analyses demonstrated no significant difference in risk of CLAD or death in patients with a first StA1R compared to StNAR. This largest study to date shows that, in clinically stable patients, an untreated first A1 ACR in the first-year posttransplant is not significantly associated with an increased risk for CLAD or death. Watchful-waiting approach may be an acceptable tactic for stable A1 episodes in lung transplant recipients.
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Affiliation(s)
- Liran Levy
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Jussi Tikkanen
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - William Klement
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Musawir Ahmed
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Shahid Husain
- University Health Network Multi-Organ Transplant, University of Toronto, Toronto, ON
| | - Pierre O Fiset
- Department of Pathology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - David Hwang
- Department of Pathology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Stephen Juvet
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
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11
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Lung Density Analysis Using Quantitative Chest CT for Early Prediction of Chronic Lung Allograft Dysfunction. Transplantation 2019; 103:2645-2653. [DOI: 10.1097/tp.0000000000002771] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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12
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Lehr CJ, Blackstone EH, McCurry KR, Thuita L, Tsuang WM, Valapour M. Extremes of Age Decrease Survival in Adults After Lung Transplant. Chest 2019; 157:907-915. [PMID: 31419403 DOI: 10.1016/j.chest.2019.06.042] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/11/2019] [Accepted: 06/29/2019] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Age has been implicated as a factor in the plateau of long-term survival after lung transplant. METHODS We used data from the Scientific Registry of Transplant Recipients to identify all recipients of lung transplant aged ≥18 years of age between January 1, 2006, and February 19, 2015. A total of 14,253 patients were included in the analysis. Survival was estimated using a nonproportional hazard model and random-survival forest methodology was used to examine risk factors for death. Final selection of model variables was performed using bootstrap aggregation. Age was analyzed as both a continuous and categorical variable (age <30, 30-55, and >55 years). Risk factors for death were obtained for the entire cohort and additional age-specific risk factors were identified for each age category. RESULTS The median age at transplant was 59 years. There were 1,098 (7.7%) recipients <30 years, 4,201 (29.5%) 30 to 55 years, and 8,954 (62.8%) >55 years of age. Age was the most significant risk factor for death at all time-points following transplant and its impact becomes more prominent as time from transplant increases. Risk factors for death for all patients included extremes of age, higher creatinine, single lung transplant, hospitalization before transplant, and increased bilirubin. Risk factors for death differed by age with social determinants of health disproportionately affecting survival for those in the youngest age category. CONCLUSIONS The youngest and oldest adult recipients experienced the lowest posttransplant survival through divergent pathways that may present opportunities for intervention to improve survival after lung transplant.
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Affiliation(s)
- Carli J Lehr
- Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Eugene H Blackstone
- The Respiratory Institute, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Kenneth R McCurry
- The Respiratory Institute, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Lucy Thuita
- The Respiratory Institute, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
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13
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Levy L, Tigert A, Huszti E, Saito T, Mitsakakis N, Moshkelgosha S, Joe B, Boonstra KM, Tikkanen JM, Keshavjee S, Juvet SC, Martinu T. Epithelial cell death markers in bronchoalveolar lavage correlate with chronic lung allograft dysfunction subtypes and survival in lung transplant recipients—a single‐center retrospective cohort study. Transpl Int 2019; 32:965-973. [DOI: 10.1111/tri.13444] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 01/14/2019] [Accepted: 04/11/2019] [Indexed: 01/17/2023]
Affiliation(s)
- Liran Levy
- Toronto Lung Transplant Program University Health Network University of Toronto Toronto ON Canada
| | - Alexander Tigert
- Toronto Lung Transplant Program University Health Network University of Toronto Toronto ON Canada
| | - Ella Huszti
- Biostatistics Research Unit University Health Network University of Toronto Toronto ON Canada
| | - Tomohito Saito
- Department of Thoracic Surgery Kansai Medical University Hirakata Japan
| | - Nicholas Mitsakakis
- Biostatistics Research Unit University Health Network University of Toronto Toronto ON Canada
| | - Sajad Moshkelgosha
- Toronto Lung Transplant Program University Health Network University of Toronto Toronto ON Canada
| | - Betty Joe
- Toronto Lung Transplant Program University Health Network University of Toronto Toronto ON Canada
| | - Kristen M. Boonstra
- Toronto Lung Transplant Program University Health Network University of Toronto Toronto ON Canada
| | - Jussi M. Tikkanen
- Toronto Lung Transplant Program University Health Network University of Toronto Toronto ON Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program University Health Network University of Toronto Toronto ON Canada
| | - Stephen C. Juvet
- Toronto Lung Transplant Program University Health Network University of Toronto Toronto ON Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program University Health Network University of Toronto Toronto ON Canada
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14
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Falque L, Gheerbrant H, Saint-Raymond C, Quétant S, Camara B, Briault A, Porcu P, Pirvu A, Durand M, Pison C, Claustre J. [Selection of lung transplant candidates in France in 2019]. Rev Mal Respir 2019; 36:508-518. [PMID: 31006579 DOI: 10.1016/j.rmr.2018.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 03/30/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION In 2015, the International Society for Heart and Lung Transplantation (ISHLT) published a consensus document for the selection of lung transplant candidates. In the absence of recent French recommendations, this guideline is useful in order to send lung transplant candidates to the transplantation centers and to list them for lung transplantation at the right time. BACKGROUND The main indications for lung transplantation in adults are COPD and emphysema, idiopathic pulmonary fibrosis and interstitial diseases, cystic fibrosis and pulmonary arterial hypertension (PAH). The specific indications for each underlying disease as well as the general contraindications have been reviewed in 2015 by the ISHLT. For cystic fibrosis, the main factors are forced expiratory volume in one second, 6-MWD, PAH and clinical deterioration characterized by increased frequency of exacerbations; for emphysema progressive disease, the BODE score, hypercapnia and FEV1; for PAH progressive disease or the need of specific intravenous therapy and NYHA classification. Finally, the diagnosis of fibrosing interstitial lung disease is usually a sufficient indication for lung transplantation assessment. OUTLOOK AND CONCLUSION These new recommendations, close to French practices, help clinicians to find the right time for referral of patients to transplantation centers. This is crucial for the prognosis of lung transplantation.
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Affiliation(s)
- L Falque
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble-Alpes, 38000 Grenoble, France; Université Grenoble-Alpes, 38000 Grenoble, France
| | - H Gheerbrant
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble-Alpes, 38000 Grenoble, France; Université Grenoble-Alpes, 38000 Grenoble, France
| | - C Saint-Raymond
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble-Alpes, 38000 Grenoble, France
| | - S Quétant
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble-Alpes, 38000 Grenoble, France
| | - B Camara
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble-Alpes, 38000 Grenoble, France
| | - A Briault
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble-Alpes, 38000 Grenoble, France
| | - P Porcu
- Service de chirurgie cardiaque, pôle thorax et vaisseaux, CHU de Grenoble-Alpes, 38000 Grenoble, France
| | - A Pirvu
- Service de chirurgie thoracique et vasculaire, pôle thorax et vaisseaux, CHU de Grenoble-Alpes, 38000 Grenoble, France
| | - M Durand
- Service de réanimation cardio-vasculaire et thoracique, pôle anesthésie-réanimation, CHU de Grenoble-Alpes, 38000 Grenoble, France
| | - C Pison
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble-Alpes, 38000 Grenoble, France; Université Grenoble-Alpes, 38000 Grenoble, France; Inserm1055, laboratoire de bioénergétique fondamentale et appliquée, 38000 Grenoble, France
| | - J Claustre
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble-Alpes, 38000 Grenoble, France; Université Grenoble-Alpes, 38000 Grenoble, France.
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15
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Hemmersbach-Miller M, Wolfe CR, Schmader KE. Solid organ transplantation in older adults. Infectious and other age-related considerations. ACTA ACUST UNITED AC 2019; 3. [PMID: 34113803 PMCID: PMC8189398 DOI: 10.21926/obm.transplant.1901046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In the U.S., older adults aged 65 or above comprise nearly one quarter of the solid organ transplant (SOT) waitlists, and the number of transplants performed in this age group continues to increase. There are no specific guidelines for the assessment and follow up of the older SOT candidate or recipient. Older adults are at increased risk of infectious complications after SOT. Despite these complications and even with the use of suboptimal donors, overall outcomes are favorable. We provide an overview to specific consideration as they relate to the older SOT candidate and recipient.
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Affiliation(s)
- Marion Hemmersbach-Miller
- Division of Infectious Diseases, Duke University Medical Center, Durham NC, USA.,Duke Clinical Research Institute, Durham NC, USA
| | - Cameron R Wolfe
- Division of Infectious Diseases, Duke University Medical Center, Durham NC, USA
| | - Kenneth E Schmader
- Division of Geriatrics, Duke University Medical Center, Durham NC, USA.,GRECC, Durham VA, Durham NC. USA
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16
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Lung Transplantation for Idiopathic Pulmonary Fibrosis. Respir Med 2019. [DOI: 10.1007/978-3-319-99975-3_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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17
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Five-Year Mortality Hazard Is Reduced In Chronic Obstructive Pulmonary Disease Patients Receiving Double- versus Single-Lung Transplants. J Surg Res 2018; 237:118-125. [PMID: 29871764 DOI: 10.1016/j.jss.2018.04.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 02/26/2018] [Accepted: 04/19/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Previous studies suggest double-lung transplant (DLT) may be associated with superior survival compared to single-lung transplantation (SLT) in chronic obstructive pulmonary disease (COPD) recipients. The purpose of this study was to compare survival in patients with COPD undergoing DLT versus SLT since the inception of the lung allocation score. METHODS We used the United Network for Organ Sharing database to retrospectively identify adult patients with COPD who underwent isolated lung transplantation from 5/4/2005-12/31/2014. We then separated patients into DLT versus SLT. Short-term (1 y) and long-term survival (5 y) were compared between DLT and SLT cohorts by the method of Kaplan-Meier, and Cox proportional hazards modeling was used to adjust for case mix. RESULTS Four thousand eight hundred thirty-two COPD patients were listed, and 3554 underwent lung transplantation over the study period, including 1358 SLTs (38%) and 2196 DLTs (62%). Survival 1 y after listing was 93% for those remaining wait listed (n = 1892) versus 91% for SLT (n = 1093) versus 89% for DLT (n = 1847) (log-rank P < 0.01). Survival at 1 y after transplant was 88% for both SLT and DLT groups (log-rank P = 0.93); however, 5-y survival was significantly lower after SLT (51% versus 59%, log-rank P < 0.01). After risk adjustment, hazard for 1-y mortality after DLT was not significantly reduced compared to SLT (hazard ratio 0.89 [0.69-1.14], P = 0.36) but was significantly reduced 5 y after DLT (hazard ratio 0.88 [0.78-0.99], P = 0.04). CONCLUSIONS In the largest survival analysis of COPD recipients since the inception of the lung allocation score, the hazard for 5-y mortality was significantly reduced in recipients who underwent DLT as compared to SLT.
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18
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Sequential broncho-alveolar lavages reflect distinct pulmonary compartments: clinical and research implications in lung transplantation. Respir Res 2018; 19:102. [PMID: 29801490 PMCID: PMC5970521 DOI: 10.1186/s12931-018-0786-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 04/20/2018] [Indexed: 11/10/2022] Open
Abstract
Background Bronchoalveolar lavage (BAL) has proven to be very useful to monitor the lung allograft after transplantation. In addition to allowing detection of infections, multiple BAL analytes have been proposed as potential biomarkers of lung allograft rejection or dysfunction. However, BAL collection is not well standardized and differences in BAL collection represent an important source of variation. We hypothesized that there are systematic differences between sequential BALs that are relevant to BAL analysis. Methods As part of 126 consecutive bronchoscopies in lung transplant recipients, two sequential BALs (BAL1 and BAL2) were performed in one location during each bronchoscopy by instilling and suctioning 50 ml of normal saline twice into separate containers. Cell concentration, viability and differentials, Surfactant Protein-D (SP-D), Club Cell Secretory Protein (CCSP), and levels of CXCL10, IL-10, CCL2, CCL5, VEGF-C, RAGE, CXCL9, CXCL1, IL-17A, IL-21, PDGF, and GCSF were compared between BAL1 and BAL2. Results Total cell concentration did not differ between BAL1 and BAL2; however, compared to BAL2, BAL1 had more dead cells, epithelial cells, neutrophils, and higher concentrations of airway epithelium-derived CCSP and inflammatory markers. BAL2 had a higher concentration of SP-D compared to BAL1. Conclusion In this study performed in lung transplant recipients, we show that sequential BALs represent different lung compartments and have distinct compositions. BAL1 represents the airway compartment with more epithelial cells, neutrophils, and epithelium-derived CCSP. Conversely, BAL2 samples preferentially the distal bronchoalveolar space with greater cell viability and higher SP-D. Our findings illustrate how the method of BAL collection can influence analyte concentrations and further emphasize the need for a standardized approach in translational research involving BAL samples. Electronic supplementary material The online version of this article (10.1186/s12931-018-0786-z) contains supplementary material, which is available to authorized users.
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19
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White donor, younger donor and double lung transplant are associated with better survival in sarcoidosis patients. Sci Rep 2018; 8:6968. [PMID: 29725035 PMCID: PMC5934355 DOI: 10.1038/s41598-018-25144-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 04/11/2018] [Indexed: 01/03/2023] Open
Abstract
Sarcoidosis commonly affects the lung. Lung transplantation (LT) is required when there is a severe and refractory involvement. We compared post-transplant survival rates of sarcoidosis patients with chronic obstructive pulmonary disease (COPD) and idiopathic pulmonary fibrosis (IPF). We also explored whether the race and age of the donor, and double lung transplant have any effect on the survival in the post transplant setting. We analyzed 9,727 adult patients with sarcoidosis, COPD, and IPF who underwent LT worldwide between 2005–2015 based on United Network for Organ Sharing (UNOS) database. Survival rates were compared with Kaplan-Meier, and risk factors were investigated by Cox-regression analysis. 469 (5%) were transplanted because of sarcoidosis, 3,688 (38%) for COPD and 5,570 (57%) for IPF. Unadjusted survival analysis showed a better post-transplant survival rate for patients with sarcoidosis (p < 0.001, Log-rank test). In Cox-regression analysis, double lung transplant and white race of the lung donor showed to have a significant survival advantage. Since double lung transplant, those who are younger and have lower Lung Allocation Score (LAS) at the time of transplant have a survival advantage, we suggest double lung transplant as the procedure of choice, especially in younger sarcoidosis subjects and with lower LAS scores.
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20
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Ambrosi N, Guerrieri D, Caro F, Sanchez F, Haeublein G, Casadei D, Incardona C, Chuluyan E. Alpha Lipoic Acid: A Therapeutic Strategy that Tend to Limit the Action of Free Radicals in Transplantation. Int J Mol Sci 2018; 19:ijms19010102. [PMID: 29300330 PMCID: PMC5796052 DOI: 10.3390/ijms19010102] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 12/18/2017] [Accepted: 12/27/2017] [Indexed: 12/15/2022] Open
Abstract
Organ replacement is an option to mitigate irreversible organ damage. This procedure has achieved a considerable degree of acceptance. However, several factors significantly limit its effectiveness. Among them, the initial inflammatory graft reaction due to ischemia-reperfusion injury (IRI) has a fundamental influence on the short and long term organ function. The reactive oxygen species (ROS) produced during the IRI actively participates in these adverse events. Therapeutic strategies that tend to limit the action of free radicals could result in beneficial effects in transplantation outcome. Accordingly, the anti-oxidant α-lipoic acid (ALA) have been proved to be protective in several animal experimental models and humans. In a clinical trial, ALA was found to decrease hepatic IRI after hepatic occlusion and resection. Furthermore, the treatment of cadaveric donor and recipient with ALA had a protective effect in the short-term outcome in simultaneous kidney and pancreas transplanted patients. These studies support ALA as a drug to mitigate the damage caused by IRI and reinforce the knowledge about the deleterious consequences of ROS on graft injury in transplantation. The goal of this review is to overview the current knowledge about ROS in transplantation and the use of ALA to mitigate it.
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Affiliation(s)
- Nella Ambrosi
- CEFYBO-CONICET, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires C1199ABB, Argentina.
| | - Diego Guerrieri
- CEFYBO-CONICET, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires C1199ABB, Argentina.
| | - Fiorella Caro
- CEFYBO-CONICET, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires C1199ABB, Argentina.
| | - Francisco Sanchez
- CEFYBO-CONICET, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires C1199ABB, Argentina.
| | - Geraldine Haeublein
- CEFYBO-CONICET, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires C1199ABB, Argentina.
| | - Domingo Casadei
- Instituto de Nefrología de Buenos Aires, Nephrology, Buenos Aires C1199ABB, Argentina.
| | - Claudio Incardona
- GADOR SA, Buenos Aires C1199ABB, Argentina.
- Hospital Italiano, Buenos Aires C1199ABB, Argentina.
| | - Eduardo Chuluyan
- CEFYBO-CONICET, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires C1199ABB, Argentina.
- Instituto de Nefrología de Buenos Aires, Nephrology, Buenos Aires C1199ABB, Argentina.
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21
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Ambur V, Taghavi S, Jayarajan S, Kadakia S, Zhao H, Gomez-Abraham J, Toyoda Y. The impact of lungs from diabetic donors on lung transplant recipients†. Eur J Cardiothorac Surg 2017; 51:285-290. [PMID: 28186285 DOI: 10.1093/ejcts/ezw314] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Revised: 07/09/2016] [Accepted: 07/18/2016] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES We attempted to determine if transplants of lungs from diabetic donors (DDs) is associated with increased mortality of recipients in the modern era of the lung allocation score (LAS). METHODS The United Network for Organ Sharing (UNOS) database was queried for all adult lung transplant recipients from 2006 to 2014. Patients receiving a lung from a DD were compared to those receiving a transplant from a non-DD. Multivariate Cox regression analysis using variables associated with mortality was used to examine survival. RESULTS A total of 13 159 adult lung transplants were performed between January 2006 and June 2014: 4278 (32.5%) were single-lung transplants (SLT) and 8881 (67.5%) were double-lung transplants (DLT). The log-rank test demonstrated a lower median survival in the DD group (5.6 vs 5.0 years, P = 0.003). We performed additional analysis by dividing this initial cohort into two cohorts by transplant type. On multivariate analysis, receiving an SLT from a DD was associated with increased mortality (HR 1.28, 95% CI 1.07–1.54, P = 0.011). Interestingly, multivariate analysis demonstrated no difference in mortality rates for patients receiving a DLT from a DD (HR 1.12, 95% CI 0.97–1.30, P = 0.14). CONCLUSIONS DLT with DDs can be performed safely without increased mortality, but SLT using DDs results in worse survival and post-transplant outcomes. Preference should be given to DLT when using lungs from donors with diabetes.
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Affiliation(s)
- Vishnu Ambur
- Department of Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Sharven Taghavi
- Department of Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Senthil Jayarajan
- Department of Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Sagar Kadakia
- Department of Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Huaqing Zhao
- Department of Biostatistics, Temple University School of Medicine, Philadelphia, PA, USA
| | - Jesus Gomez-Abraham
- Department of Cardiovascular Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Yoshiya Toyoda
- Department of Cardiovascular Surgery, Temple University Hospital, Philadelphia, PA, USA
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22
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Crawford TC, Magruder JT, Grimm JC, Suarez-Pierre A, Zhou X, Ha JS, Higgins RS, Broderick SR, Orens JB, Shah P, Merlo CA, Kim BS, Bush EL. Impaired Renal Function Should Not Be a Barrier to Transplantation in Patients With Cystic Fibrosis. Ann Thorac Surg 2017; 104:1231-1236. [PMID: 28822537 DOI: 10.1016/j.athoracsur.2017.05.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 05/10/2017] [Accepted: 05/11/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Previous studies have demonstrated an association between pretransplantation renal dysfunction (PRD) and increased mortality after lung transplantation (LT). The purpose of this study was to determine whether PRD impacts survival after LT in patients with cystic fibrosis (CF). METHODS We queried the United Network for Organ Sharing (UNOS) database to identify all adult (≥18 years) recipients with CF who underwent isolated LT from May 4, 2005 to December 31, 2014. We separated recipients into those with and those without PRD (glomerular filtration rate [GFR] ≤60 mL/min). We excluded patients who required dialysis before transplantation. Kaplan-Meier analysis was used to assess unadjusted survival differences. Cox proportional hazards modeling was then performed across 26 variables to assess the risk-adjusted impact of PRD on 1-, 3-, and 5-year mortality. RESULTS Isolated LT was performed on 1,830 patients with CF; 17 patients were excluded because of pretransplantation dialysis. Eighty-two of 1,813 patients (4.5%) had PRD (GFR ≤60 mL/min). Kaplan-Meier analysis revealed no survival differences between PRD and non-PRD groups at 1 year (85.3% versus 89.5%; log-rank p = 0.23), 3 years (71.0% versus 72.5%; p = 0.57), or 5 years (63.3% versus 59.8%; p = 0.95). After risk adjustment, PRD was not independently associated with an increased hazard for mortality at 1 year (hazard ratio [HR], 1.38 [95% confidence interval [CI], 0.74-2.58]; p = 0.31), 3 years (HR, 1.44 [95% CI, 0.92-2.24]; p = 0.11), or 5 years (HR, 1.30 [95% CI, 0.86-1.94]; p = 0.29). CONCLUSIONS Although PRD has historically served as a relative contraindication to LT, our study is the first to suggest that among CF recipients, PRD was not associated with increased hazard for mortality out to 5 years after LT.
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Affiliation(s)
- Todd C Crawford
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - J Trent Magruder
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joshua C Grimm
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alejandro Suarez-Pierre
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Xun Zhou
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jinny S Ha
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Robert S Higgins
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stephen R Broderick
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan B Orens
- Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pali Shah
- Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christian A Merlo
- Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bo S Kim
- Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Errol L Bush
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Abstract
Consensus statements on the selection of lung transplant candidates have consistently identified older age as a relative contraindication to transplantation. A combination of population-level demographic changes, revision of the lung allocation score (LAS), and clearer data on outcomes in elderly transplant recipients has, however, driven a steady increase in the threshold at which age is taken into consideration. This article reviews the current state of lung transplantation in elderly patients with an emphasis on the factors that have increased lung transplantation in older age groups, their expected outcomes including survival and health-related quality of life, and the factors that go in to appropriate candidate and procedure selection in this population.
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Affiliation(s)
- Andrew Courtwright
- Division of Pulmonary and Critical Care Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Edward Cantu
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Lung transplantation in the elderly: Influence of age, comorbidities, underlying disease, and extended criteria donor lungs. J Thorac Cardiovasc Surg 2017; 154:2135-2141. [PMID: 28823801 DOI: 10.1016/j.jtcvs.2017.07.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 06/15/2017] [Accepted: 07/21/2017] [Indexed: 01/15/2023]
Abstract
OBJECTIVE As large registries show an increased risk for lung transplant recipients aged 60 years or more, few single centers report favorable outcomes for carefully selected older recipients without providing essential details. The purpose of our study was to determine variables that influence survival in the elderly. METHODS All adult bilateral first lung transplants between January 2000 and December 2014 were divided in 2 groups: those aged less than 60 years (N = 223) and those aged 60 years or more (N = 83). The Charlson-Deyo Index determined recipient comorbidities. The Oto Donor Score assessed donor lung quality. RESULTS Recipients aged 60 years or more had a significant lower median survival compared with their younger counterparts (48 vs 112 months, respectively, P < .001). Recipient age was as an exponentially increasing univariate risk factor for mortality. By adjusting for variables in multivariate analysis, this trend was nonsignificant. The displacing variables were idiopathic pulmonary fibrosis (hazard ratio [HR], 1.5; 95% confidence interval [CI], 1.0-2.2), Charlson-Deyo Index 2 or greater (HR, 1.3; 95% CI, 1.0-1.8), systemic hypertension (HR, 1.7; 95% CI, 1.2-2.6), gastroesophageal reflux (HR, 1.9; 95% CI, 1.1-3.1), diverticulosis (HR, 1.7; 95% CI, 1.0-2.7), and an Oto Donor Score 8 or greater (HR, 1.5; 95% CI, 1.1-2.0). All of these risk factors were significantly more likely to occur in recipients aged 60 years or more, except for a tendency for high Charlson-Deyo Index. CONCLUSIONS The comorbidity profile, underlying disease, and donor lung quality appear to be more important than age in reducing long-term survival. Older age serves as a marker for a complex constellation of factors that might be considered the relative or absolute contraindication to lung transplantation rather than age, per se.
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Yeung JC, Krueger T, Yasufuku K, de Perrot M, Pierre AF, Waddell TK, Singer LG, Keshavjee S, Cypel M. Outcomes after transplantation of lungs preserved for more than 12 h: a retrospective study. THE LANCET RESPIRATORY MEDICINE 2017; 5:119-124. [DOI: 10.1016/s2213-2600(16)30323-x] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 09/29/2016] [Accepted: 09/30/2016] [Indexed: 10/20/2022]
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26
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How important is coronary artery disease when considering lung transplant candidates? J Heart Lung Transplant 2016; 35:1453-1461. [DOI: 10.1016/j.healun.2016.03.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 03/01/2016] [Accepted: 03/27/2016] [Indexed: 12/30/2022] Open
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Age-Dependent Gender Disparities in Post Lung Transplant Survival Among Patients With Idiopathic Pulmonary Fibrosis. Ann Thorac Surg 2016; 103:441-446. [PMID: 28341270 DOI: 10.1016/j.athoracsur.2016.08.083] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND The influence of age and gender on survival after lung transplant in patients with idiopathic pulmonary fibrosis (IPF) is not well defined. METHODS The United Network for Organ Sharing database was queried to identify IPF patients receiving lung transplant between 2005 and 2015. RESULTS There were 6,677 patients receiving lung transplant between May 2015 and June 2015 who met the inclusion criteria, predominantly males (n = 4,769, 71%). Within 1 year posttransplant, the survival curves of male and female recipients diverged, with male recipients having significantly worse survival (log-rank test p = 0.008). Univariate Cox proportional hazards regressions demonstrated no gender difference in survival below age 65 years (HR = 1.051; 95% CI = 0.945, 1.168; p = 0.362) but a significant increase in mortality hazard associated with male gender among patients age 65 years and older (HR = 1.161; 95% CI = 1.000, 1.347; p = 0.049). Multivariable Cox regression accounting for age modulation of the gender effect further demonstrated the emergence of a male disadvantage in post-transplant survival above age 65 years at transplantation. CONCLUSIONS In patients with IPF receiving lung transplant at greater than 65 years of age, male gender is associated with significantly increased risk for death, so referral for lung transplant in IPF should be considered early in the disease course.
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Wigfield CH, Buie V, Onsager D. "Age" in lung transplantation: factors related to outcomes and other considerations. CURRENT PULMONOLOGY REPORTS 2016; 5:152-158. [PMID: 27610336 PMCID: PMC4992499 DOI: 10.1007/s13665-016-0151-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The age of lung transplant recipients is steadily increasing. Older donors are more frequently considered. The risk factors associated with advanced age in lung transplantation warrant discussion to ensure optimal outcomes in this complex endeavor. This report provides a summary of the pertinent topics and available evidence.
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Singer LG, Chowdhury NA, Faughnan ME, Granton J, Keshavjee S, Marras TK, Tullis DE, Waddell TK, Tomlinson G. Effects of Recipient Age and Diagnosis on Health-related Quality-of-Life Benefit of Lung Transplantation. Am J Respir Crit Care Med 2016; 192:965-73. [PMID: 26131729 DOI: 10.1164/rccm.201501-0126oc] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
RATIONALE The average age of lung transplant recipients is increasing, and the mix of recipient indications for transplantation is changing. OBJECTIVES To determine whether the health-related quality-of-life (HRQL) benefit of lung transplantation differs by recipient age and diagnosis. METHODS In this prospective cohort study, we obtained serial HRQL measurements in adults with advanced lung disease who subsequently underwent lung transplantation (2004-2012). HRQL assessments included the St. George's Respiratory Questionnaire, 36-Item Short-Form Health Survey (SF-36), EQ-5D, Standard Gamble, and Visual Analog Scale for current health. We used linear mixed effects models for associations between age or diagnosis and changes in HRQL with transplantation. To address potential survivorship bias, we fitted Markov models to the distribution of discrete post-transplant health states (HRQL better than pretransplant, not better, or dead) and estimated quality-adjusted life-years post-transplant. MEASUREMENTS AND MAIN RESULTS A total of 430 subjects were listed, 387 were transplanted, and 326 provided both pretransplant and post-transplant data. Transplantation conferred large improvements in all HRQL measures: St. George's change of -47 units (95% confidence interval, -48 to -44), 36-Item Short-Form Health Survey physical component summary score of 17.7 (16.5-18.9), EQ-5D of 0.27 (0.24-0.30), Standard Gamble of 0.48 (0.44-0.51), and Visual Analog of 44 (42-47). Age was not associated with meaningful differences in the HRQL benefits of transplantation. There was less HRQL benefit in interstitial lung disease than in cystic fibrosis. CONCLUSIONS Lung transplantation confers large HRQL benefits, which vary by recipient diagnosis, but do not differ substantially in older recipients.
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Affiliation(s)
- Lianne G Singer
- 1 Department of Medicine and.,2 University Health Network, Toronto, Ontario, Canada
| | | | - Marie E Faughnan
- 1 Department of Medicine and.,3 St. Michael's Hospital, Toronto, Ontario, Canada; and.,4 Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - John Granton
- 1 Department of Medicine and.,2 University Health Network, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- 5 Department of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada.,2 University Health Network, Toronto, Ontario, Canada
| | - Theodore K Marras
- 1 Department of Medicine and.,2 University Health Network, Toronto, Ontario, Canada
| | - D Elizabeth Tullis
- 1 Department of Medicine and.,3 St. Michael's Hospital, Toronto, Ontario, Canada; and
| | - Thomas K Waddell
- 5 Department of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada.,2 University Health Network, Toronto, Ontario, Canada
| | - George Tomlinson
- 1 Department of Medicine and.,2 University Health Network, Toronto, Ontario, Canada
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Abstract
PURPOSE OF REVIEW Scientific and technical developments in the field of lung transplantation have allowed it to become a successful treatment option for various end-stage lung diseases. As the demand for lung allografts increases and waitlists expand, it is vital that lung transplant centers optimize use of this limited resource by selecting recipients who have the best prospects of positive long-term outcomes. Recipient selection criteria vary across transplant selection committees. We review the most recent body of literature for recipient consideration and describe potential effects on morbidity and mortality posttransplantation. RECENT FINDINGS Although prior guidelines for contraindications to lung transplantation have been described, the benchmarks for recipient selection are constantly being challenged. Age, weight, and psychologic condition of recipients pretransplant have more recently been shown to have significant influence on posttransplant outcomes. Advancements in human leukocyte antigen antibody testing and use of extracorporeal membrane oxygenation as a bridge to lung transplantation have additionally impacted recipient selection standards. SUMMARY Recipient selection criteria continue to evolve because of advances in mechanical bridging to transplant and postoperative management. This review will cover some of the new concepts in lung transplant recipient selection and their potential effect on posttransplant outcomes.
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Biswas Roy S, Alarcon D, Walia R, Chapple KM, Bremner RM, Smith MA. Is There an Age Limit to Lung Transplantation? Ann Thorac Surg 2015; 100:443-51. [DOI: 10.1016/j.athoracsur.2015.02.092] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 02/16/2015] [Accepted: 02/18/2015] [Indexed: 12/14/2022]
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Grimm JC, Valero V, Magruder JT, Kilic A, Dungan SP, Silhan LL, Shah PD, Kim BS, Merlo CA, Sciortino CM, Shah AS. A novel risk score that incorporates recipient and donor variables to predict 1-year mortality in the current era of lung transplantation. J Heart Lung Transplant 2015; 34:1449-54. [PMID: 26275639 DOI: 10.1016/j.healun.2015.07.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 06/10/2015] [Accepted: 07/13/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND In this study we sought to construct a novel scoring system to pre-operatively stratify a patient's risk of 1-year mortality after lung transplantation (LTx) based on recipient- and donor-specific characteristics. METHODS The UNOS database was queried for adult (≥18 years) patients undergoing LTx between May 1, 2005 and December 31, 2012. The population was randomly divided in a 4:1 fashion into derivation and validation cohorts. A multivariable logistic regression model for 1-year mortality was constructed within the derivation cohort. Points were then assigned to independent predictors (p < 0.05) based on relative odds ratios. Risk groups were established based on score ranges. RESULTS During the study period, 9,185 patients underwent LTx and the 1-year mortality was 18.0% (n = 1,654). There was a similar distribution of variables between the derivation (n = 7,336) and validation (n = 1,849) cohorts. Of the 14 covariates included in the final model, 9 were ultimately allotted point values (maximum score = 70). The model exhibited good predictive strength (c = 0.65) in the derivation cohort and demonstrated a strong correlation between the observed and expected rates of 1-year mortality in the validation cohort (r = 0.87). The low-risk (score 0 to 11), intermediate-risk (score 12 to 21) and high-risk (score ≥22) groups had a 10.8%, 17.1% and 32.0% risk of mortality (p < 0.001), respectively. CONCLUSIONS This is the first scoring system that incorporates both recipient- and donor-related factors to predict 1-year mortality after LTx. Its use could assist providers in the identification of patients at highest risk for poor post-transplant outcomes.
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Affiliation(s)
- Joshua C Grimm
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Vicente Valero
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - J Trent Magruder
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Arman Kilic
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Samuel P Dungan
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Leann L Silhan
- Division of Pulmonary and Critical Care, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Pali D Shah
- Division of Pulmonary and Critical Care, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Bo S Kim
- Division of Pulmonary and Critical Care, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Christian A Merlo
- Division of Pulmonary and Critical Care, The Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Ashish S Shah
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland.
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De novo donor HLA-specific antibodies predict development of bronchiolitis obliterans syndrome after lung transplantation. J Heart Lung Transplant 2014; 33:1273-81. [DOI: 10.1016/j.healun.2014.07.012] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 07/15/2014] [Accepted: 07/16/2014] [Indexed: 11/22/2022] Open
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Smith JD, Ibrahim MW, Newell H, Danskine AJ, Soresi S, Burke MM, Rose ML, Carby M. Pre-transplant donor HLA-specific antibodies: Characteristics causing detrimental effects on survival after lung transplantation. J Heart Lung Transplant 2014; 33:1074-82. [DOI: 10.1016/j.healun.2014.02.033] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 02/07/2014] [Accepted: 02/28/2014] [Indexed: 12/01/2022] Open
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35
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Suwara MI, Vanaudenaerde BM, Verleden SE, Vos R, Green NJ, Ward C, Borthwick LA, Vandermeulen E, Lordan J, Van Raemdonck DE, Corris PA, Verleden GM, Fisher AJ. Mechanistic differences between phenotypes of chronic lung allograft dysfunction after lung transplantation. Transpl Int 2014; 27:857-67. [PMID: 24750386 PMCID: PMC4282071 DOI: 10.1111/tri.12341] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 01/14/2014] [Accepted: 04/14/2014] [Indexed: 12/12/2022]
Abstract
Distinct phenotypes of chronic lung allograft dysfunction (CLAD) after lung transplantation are emerging with lymphocytic bronchiolitis (LB)/azithromycin reversible allograft dysfunction (ARAD), classical or fibrotic bronchiolitis obliterans syndrome (BOS), and restrictive allograft syndrome (RAS) proposed as separate entities. We have additionally identified lung transplant recipients with prior LB, demonstrating persistent airway neutrophilia (PAN) despite azithromycin treatment. The aim of this study was to evaluate differences in the airway microenvironment in different phenotypes of CLAD. Bronchoalveolar lavage (BAL) from recipients identified as stable (control), LB/ARAD, PAN, BOS, and RAS were evaluated for differential cell counts and concentrations of IL-1α, IL-1β, IL-6, IL-8, and TNF-α. Primary human bronchial epithelial cells were exposed to BAL supernatants from different phenotypes and their viability measured. BOS and RAS showed increased BAL neutrophilia but no change in cytokine concentrations compared with prediagnosis. In both LB/ARAD and PAN, significant increases in IL-1α, IL-1β, and IL-8 were present. BAL IL-6 and TNF-α concentrations were increased in PAN and only this phenotype demonstrated decreased epithelial cell viability after exposure to BAL fluid. This study demonstrates clear differences in the airway microenvironment between different CLAD phenotypes. Systematic phenotyping of CLAD may help the development of more personalized approaches to treatment.
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Affiliation(s)
- Monika I Suwara
- Fibrosis Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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Meyer KC, Nathan SD. Lung Transplantation for Idiopathic Pulmonary Fibrosis. IDIOPATHIC PULMONARY FIBROSIS 2013. [PMCID: PMC7121325 DOI: 10.1007/978-1-62703-682-5_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Despite advances in the development of novel pharmaceutical agents to treat idiopathic pulmonary fibrosis (IPF), there are no medical therapies known to resolve fibrosis or improve lung function in IPF. Therefore, lung transplantation remains the only life-saving therapy available to treat patients with IPF. However, a shortage of suitable donor organs limits the number of affected individuals who can undergo this procedure, and this shortage highlights the need to allocate donor lungs to those who are in the greatest need of a life-saving therapy yet ensure that those who undergo transplantation will have a reasonable expectation of long-term survival. Still, outcomes remain relatively poor for many patients after lung transplantation, although a sizable minority of patients can enjoy long-term survival after lung transplantation.
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Affiliation(s)
- Keith C. Meyer
- Dept. Internal Medicine, Sect. Allergy Pulmonary & Critical Care Med., University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin USA
| | - Steven D. Nathan
- Advanced Lung Disease and Lung Transplant Program, Inova Fairfax Hospital, Falls Church, Virginia USA
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Abecassis M, Bridges N, Clancy C, Dew M, Eldadah B, Englesbe M, Flessner M, Frank J, Friedewald J, Gill J, Gries C, Halter J, Hartmann E, Hazzard W, Horne F, Hosenpud J, Jacobson P, Kasiske B, Lake J, Loomba R, Malani P, Moore T, Murray A, Nguyen MH, Powe N, Reese P, Reynolds H, Samaniego M, Schmader K, Segev D, Shah A, Singer L, Sosa J, Stewart Z, Tan J, Williams W, Zaas D, High K. Solid-organ transplantation in older adults: current status and future research. Am J Transplant 2012; 12:2608-22. [PMID: 22958872 PMCID: PMC3459231 DOI: 10.1111/j.1600-6143.2012.04245.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
An increasing number of patients older than 65 years are referred for and have access to organ transplantation, and an increasing number of older adults are donating organs. Although short-term outcomes are similar in older versus younger transplant recipients, older donor or recipient age is associated with inferior long-term outcomes. However, age is often a proxy for other factors that might predict poor outcomes more strongly and better identify patients at risk for adverse events. Approaches to transplantation in older adults vary across programs, but despite recent gains in access and the increased use of marginal organs, older patients remain less likely than other groups to receive a transplant, and those who do are highly selected. Moreover, few studies have addressed geriatric issues in transplant patient selection or management, or the implications on health span and disability when patients age to late life with a transplanted organ. This paper summarizes a recent trans-disciplinary workshop held by ASP, in collaboration with NHLBI, NIA, NIAID, NIDDK and AGS, to address issues related to kidney, liver, lung, or heart transplantation in older adults and to propose a research agenda in these areas.
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Affiliation(s)
- M. Abecassis
- Departments of Surgery and Microbiology-Immunology, Northwestern University Feinberg School of Medicine
| | - N.D. Bridges
- Transplantation Immunobiology Branch and Clinical Transplantation Section, National Institute of Allergy and Infectious Diseases
| | | | - M.A. Dew
- Department of Psychiatry, University of Pittsburgh
| | - B. Eldadah
- Division of Geriatrics and Clinical Gerontology, National Institute on Aging
| | - M.J. Englesbe
- Division of Transplantation, Department of Surgery, University of Michigan Medical School
| | - M.F. Flessner
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases
| | - J.C. Frank
- Geffen School of Medicine at the University of California, Los Angeles
| | - J. Friedewald
- Departments of Medicine and Surgery, Northwestern University
| | - J Gill
- Division of Nephrology, University of British Columbia
| | - C. Gries
- University of Pittsburgh School of Medicine
| | - J.B. Halter
- Division of Geriatric and Palliative Medicine, University of Michigan Medical School
| | | | - W.R. Hazzard
- Division of Gerontology and Geriatric Medicine, University of Washington, VA Puget Sound Health Care System
| | | | | | - P. Jacobson
- Department of Experimental and Clinical Pharmacology, University of Minnesota
| | | | - J. Lake
- Liver Transplant Program, University of Minnesota
| | - R. Loomba
- University of California, San Diego School of Medicine
| | - P.N. Malani
- Department of Internal Medicine, University of Michigan Medical School
| | - T.M. Moore
- National Heart, Lung, and Blood Institute
| | - A. Murray
- Division of Geriatrics, University of Minnesota
| | | | - N.R. Powe
- University of California, San Francisco
| | | | | | | | - K.E. Schmader
- GRECC, Durham VA Medical Center and Division of Geriatric Medicine, Duke University School of Medicine
| | - D.L. Segev
- Division of Transplant Surgery, Johns Hopkins University School of Medicine
| | - A.S. Shah
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine
| | - L.G. Singer
- Toronto Lung Transplant Program, University of Toronto
| | - J.A. Sosa
- Divisions of Endocrine Surgery and Surgical Oncology, Department of Surgery, Yale University School of Medicine
| | | | - J.C. Tan
- Adult Kidney and Pancreas Transplant Program, Stanford University
| | - W.W. Williams
- Harvard University and Massachusetts General Hospital
| | - D.W. Zaas
- Department of Medicine, Duke University School of Medicine
| | - K.P. High
- Wake Forest School of Medicine,To Whom Correspondence Should be Sent: Kevin P. High, M.D., M.S., Professor of Medicine and Translational Science, Chief, Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC 27157-1042, Phone: (336) 716-4584, Fax: (336) 716-3825,
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Lanuza DM, Lefaiver CA, Brown R, Muehrer R, Murray M, Yelle M, Bhorade S. A longitudinal study of patients' symptoms before and during the first year after lung transplantation. Clin Transplant 2012; 26:E576-89. [PMID: 22988999 DOI: 10.1111/ctr.12002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2012] [Indexed: 12/28/2022]
Abstract
BACKGROUND Lung transplantation provides a viable option for survival of end-stage respiratory disease. In addition to prolonging survival, there is considerable interest in improving patient-related outcomes such as transplant recipients' symptom experiences. METHODS A prospective, repeated measures design was used to describe the symptom experience of 85 lung transplant recipients between 2000 and 2005. The transplant symptom inventory was administered before and at one, three, six, nine, and 12 months post-transplant. Ridit analysis provided a unique method for describing symptom experiences and changes. RESULTS After lung transplantation, significant (p<0.05) improvements were reported for the most frequently occurring and most distressing pre-transplant symptoms (e.g., shortness of breath with activity). Marked increases in the frequency and distress of new symptoms such as tremors were also reported. Patterns of symptom frequency and distress varied with time since transplant. CONCLUSION The findings provide data-based information that can be used to inform pre- and post-transplant patient education and also help caregivers anticipate a general time frame for symptom changes to prevent or minimize symptoms and their associated distress. In addition, symptoms are described, using an innovative method of illustration which shows "at-a-glance" change or lack of change in patients' symptoms from pre- to post-lung transplant.
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Affiliation(s)
- Dorothy M Lanuza
- University of Wisconsin-Madison, School of Nursing, and Hospital and Clinics, Madison, WI 53792-2455, USA.
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Hook JL, Lederer DJ. Selecting lung transplant candidates: where do current guidelines fall short? Expert Rev Respir Med 2012; 6:51-61. [PMID: 22283579 DOI: 10.1586/ers.11.83] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
In 2010, 1770 lung transplant procedures were performed in the USA, yet 2469 new candidates were added to the waiting list the same year. The shortage of suitable donor lungs requires that transplant professionals select patients for lung transplantation only if they are likely to sustain a survival benefit from the procedure. However, 20% of lung transplant recipients die within the first year of transplantation, suggesting that we are failing to identify those at high risk for severe early complications. In this perspective, we review the current guidelines for the selection of lung transplant candidates, which are based largely on expert opinion and small case series. We also propose the study of new extrapulmonary factors, such as frailty and sarcopenia, that might help improve the prediction of complications and early death after lung transplantation, leading to an improved candidate selection process.
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Affiliation(s)
- Jaime L Hook
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY, USA
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Kniepeiss D, Wagner D, Pienaar S, Thaler HW, Porubsky C, Tscheliessnigg KH, Roller RE. Solid organ transplantation: technical progress meets human dignity: a review of the literature considering elderly patients' health related quality of life following transplantation. Ageing Res Rev 2012; 11:181-7. [PMID: 21745600 DOI: 10.1016/j.arr.2011.06.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Revised: 06/09/2011] [Accepted: 06/15/2011] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Many transplant studies in elderly patients focus on survival and mortality rates. It was the aim of this review to evaluate publications dealing with individual patient performance and independence. METHODS The literature search included all articles retrievable for the hit "transplantation in elderly recipients" between 1960 and 2010. For quality search the inclusion criteria were as follows: older than 60 years and transplanted kidney, liver, heart, lung or pancreas from a deceased or living donor. We focussed on parameters concerning quality of life, frailty, nutritional status/weight loss, drugs/interactions/polypharmacy, gait/osteoporosis/fracture, delirium/dementia and geriatric assessment to address physical and psychosocial functionality of elderly recipients. RESULTS The initial hit list contained 1427 citations from electronic databases. 249 abstracts thereof were selected for full review. A total of 60 articles met final inclusion criteria. Finally, only five studies met the qualitative inclusion criteria as listed above. CONCLUSION The number of elderly patients placed on waiting lists has increased dramatically and will further grow. Interdisciplinary collaboration and distinct patient selection is recommended in most of the studies. However, data concerning quality of life and related parameters in elderly transplant recipients are rare.
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Affiliation(s)
- Daniela Kniepeiss
- Department of Surgery, Division of Transplantation, Medical University Graz, Austria.
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Lordan JL, Corris PA. Pulmonary arterial hypertension and lung transplantation. Expert Rev Respir Med 2011; 5:441-54. [PMID: 21702664 DOI: 10.1586/ers.11.21] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Transplantation remains the only therapeutic option for selected patients with advanced pulmonary arterial hypertension (PAH) who continue to deteriorate despite optimal pulmonary vasodilator therapy - including intravenous prostanoids and combination therapy. Identification of poor prognostic markers in PAH, including persistence in the New York Heart Association functional class III and IV, and adverse pulmonary hemodynamics at right heart catheterization should prompt early referral for transplantation. There is a need for inclusion of more discriminatory markers of PAH prognosis in donor-lung allocation scores to identify patients at risk and optimize survival to transplantation, given the current shortage of donor organ availability worldwide. Double-lung transplantation is the recommended operation for idiopathic PAH. Heart-lung transplantation is reserved for selected patients with idiopathic PAH with severe right ventricular dysfunction, or congenital heart disease with complex or ventricular septal defect-associated PAH. Novel surgical strategies, including atrial septostomy or the pumpless Novalung® lung assist device with conduits, from the pulmonary artery to the left atrium, can be considered as a bridge to transplant for patients with rapid clinical decline, despite maximal medical therapy. Recent transplant outcomes for PAH are encouraging, albeit with early postoperative risks, a requirement for long-term surveillance, immunosuppression and transplant immunosuppression-specific morbidity.
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Affiliation(s)
- James L Lordan
- Applied Immunobiology and Transplantation Group, Institute of Cellular Medicine, Medical School, University of Newcastle upon Tyne, Freeman Hospital, High Heaton, NE7 7DN, UK.
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Miñambres E, Zurbano F, Naranjo S, González-Castro A, Mons R, González-Fernández C, Fernández-Rozas S, Ballesteros M. Trasplante pulmonar con donantes de edad marginal (≥ 55 años). Med Intensiva 2011; 35:403-9. [DOI: 10.1016/j.medin.2010.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Revised: 12/23/2010] [Accepted: 12/23/2010] [Indexed: 11/30/2022]
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Eriksson M, Lemström K, Suojaranta-Ylinen R, Martelius T, Harjula A, Sipponen J, Halme M, Piilonen A, Salmenkivi K, Anttila VJ, Hämmäinen P. Control of early Aspergillus mortality after lung transplantation: outcome and risk factors. Transplant Proc 2011; 42:4459-64. [PMID: 21168718 DOI: 10.1016/j.transproceed.2010.09.116] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Historic treatment strategies in our institute had resulted in 10% Aspergillus mortality within the first posttransplant year. Despite nebulized amphotericin B (nAmB) prophylaxis, a significant incidence of Aspergillus infection, usually with poor outcome, is still reported. The aim of this single-center retrospective study was to evaluate the outcomes of patients receiving either standard nAmB or additional systemic caspofungin prophylaxis for selected high-risk patients. We also tried to define independent risk factors for either fungal infection or death. We followed 76 consecutive lung transplant patients performed at our center between 2002 and 2010 from the day of transplantation. The median follow-up duration was 953 days (2.6 years; range, 16-2,751 days). The endpoints were postoperative Aspergillus colonization or disease or death due to any cause. All patients received either nAmB deoxycholate (nAmBd, 15 patients) or nAmB lipid complex (nAmBLC, 61 patients). In addition, 33 patients also received short-term caspofungin prophylaxis. The overall cumulative mortality during the entire follow up was 14.5%. No clinically confirmed invasive Aspergillus infections (IPA) occurred during the first 2 postoperative years; however, there was 1 possible and 1 probable IPA. One patient died of bronchiolitis obliterans and IPA at 2 years 3 months. Twelve patients showed transient Aspergillus colonization. The antifungal prophylactic regimens were well tolerated. The risk factors for death were age >55 years and postoperative Aspergillus detection (P = .011 and P = .015, respectively). Preoperative Aspergillus colonization/disease was not a risk factor for death (P = 1.000). The strongest predictor of death was age >55 years, due to the elder probably being more susceptible to the adverse effects of immunosuppressants. Postoperative detection of Aspergillus still seems to be an indicator of a poorer outcome. Preoperative Aspergillus colonization is not necessarily a threat with prompt institution of antifungal prophylaxis.
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Affiliation(s)
- M Eriksson
- Division of Infectious Diseases, Department of Medicine, Helsinki University Hospital, Helsinki, Finland
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Vadnerkar A, Toyoda Y, Crespo M, Pilewski J, Mitsani D, Kwak EJ, Silveira FP, Bhama J, Shields R, Bermudez C, Clancy CJ, Nguyen MH. Age-specific complications among lung transplant recipients 60 years and older. J Heart Lung Transplant 2011; 30:273-81. [DOI: 10.1016/j.healun.2010.08.032] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2010] [Revised: 08/09/2010] [Accepted: 08/25/2010] [Indexed: 11/26/2022] Open
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Raman SM, Cahill BC. Lung transplantation in older adults: How old is too old? J Heart Lung Transplant 2011; 30:270-2. [DOI: 10.1016/j.healun.2010.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Revised: 10/26/2010] [Accepted: 11/09/2010] [Indexed: 11/27/2022] Open
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Machuca T, Camargo S, Schio S, Lobato V, Sanchez L, Perin F, Felicetti J, Camargo J. Lung Transplantation for Patients Older Than 65 Years: Is It a Feasible Option? Transplant Proc 2011; 43:233-5. [DOI: 10.1016/j.transproceed.2010.12.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Quétant S, Rochat T, Pison C. Résultats de la transplantation pulmonaire. Rev Mal Respir 2010; 27:921-38. [DOI: 10.1016/j.rmr.2010.08.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Accepted: 04/07/2010] [Indexed: 11/30/2022]
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Yusen RD, Shearon TH, Qian Y, Kotloff R, Barr ML, Sweet S, Dyke DB, Murray S. Lung transplantation in the United States, 1999-2008. Am J Transplant 2010; 10:1047-68. [PMID: 20420652 DOI: 10.1111/j.1600-6143.2010.03055.x] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
This article highlights trends and changes in lung and heart-lung transplantation in the United States from 1999 to 2008. While adult lung transplantation grew significantly over the past decade, rates of heart-lung and pediatric lung transplantation have remained low. Since implementation of the lung allocation score (LAS) donor allocation system in 2005, decreases in the number of active waiting list patients, waiting times for lung transplantation and death rates on the waiting list have occurred. However, characteristics of recipients transplanted in the LAS era differed from those transplanted earlier. The proportion of candidates undergoing lung transplantation for chronic obstructive pulmonary disease decreased, while increasing for those with pulmonary fibrosis. In the LAS era, older, sicker and previously transplanted candidates underwent transplantation more frequently compared with the previous era. Despite these changes, when compared with the pre-LAS era, 1-year survival after lung transplantation did not significantly change after LAS inception. The long-term effects of the change in the characteristics of lung transplant recipients on overall outcomes for lung transplantation remain unknown. Continued surveillance and refinements to the LAS system will affect the distribution and types of candidates transplanted and hopefully lead to improved system efficiency and outcomes.
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Affiliation(s)
- R D Yusen
- Washington University School of Medicine, St. Louis, MO, USA.
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Kuypers DRJ. Immunotherapy in elderly transplant recipients: a guide to clinically significant drug interactions. Drugs Aging 2009; 26:715-37. [PMID: 19728747 DOI: 10.2165/11316480-000000000-00000] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Currently, >50% of candidates for solid organ transplantation in Europe and the US are aged >50 years while approximately 15% of potential recipients are aged >or=65 years. Elderly transplant candidates are characterized by specific co-morbidity profiles that compromise graft and patient outcome after transplantation. The presence of coronary artery or peripheral vascular disease, cerebrovascular disease, history of malignancy, chronic obstructive lung disease or diabetes mellitus further increases the early post-transplant mortality risk in elderly recipients, with infections and cardiovascular complications as the leading causes of death. Not only are elderly patients more prone to developing drug-related adverse effects, but they are also more susceptible to pharmacokinetic and pharmacodynamic drug interactions because of polypharmacy. The majority of currently used immunosuppressant drugs in organ transplantation are metabolized by cytochrome P450 (CYP) or uridine diphosphate-glucuronosyltransferases and are substrates of the multidrug resistance (MDR)-1 transporter P-glycoprotein, the MDR-associated protein 2 or the canalicular multispecific organic anion transporter, which predisposes these immunosuppressant compounds to specific interactions with commonly prescribed drugs. In addition, important drug interactions between immunosuppressant drugs have been identified and require attention when choosing an appropriate immunosuppressant drug regimen for the frail elderly organ recipient. An age-related 34% decrease in total body clearance of the calcineurin inhibitor ciclosporin was observed in elderly renal recipients (aged >65 years) compared with younger patients, while older recipients also had 44% higher intracellular lymphocyte ciclosporin concentrations. Similarly, using a Bayesian approach, an inverse relationship was noted between sirolimus clearance and age in stable kidney recipients. Ciclosporin and tacrolimus have distinct pharmacokinetics, but both are metabolized by intestinal and hepatic CYP3A4/3A5 and transported across the cell membrane by P-glycoprotein. The most common drug interactions with ciclosporin are therefore also observed with tacrolimus, but the two drugs do not interact identically when administered with CYP3A inhibitors or inducers. The strongest effects on calcineurin-inhibitor disposition are observed with azole antifungals, macrolide antibacterials, rifampicin, calcium channel antagonists, grapefruit juice, St John's wort and protease inhibitors. Drug interactions with mycophenolic acids occur mainly through inhibition of their enterohepatic recirculation, either by interference with the intestinal flora (antibacterials) or by limiting drug absorption (resins and binders). Rifampicin causes a reduction in mycophenolic acid exposure probably through induction of uridine diphosphate-glucuronosyltransferases. Proliferation signal inhibitors (PSIs) such as sirolimus and everolimus are substrates of CYP3A4 and P-glycoprotein and have a macrolide structure very similar to tacrolimus, which explains why common drug interactions with PSIs are comparable to those with calcineurin inhibitors. Ciclosporin, in contrast to tacrolimus, inhibits the enterohepatic recirculation of mycophenolic acids, resulting in significantly lower concentrations and hence risk of underexposure. Therefore, when switching from tacrolimus to ciclosporin and vice versa or when reducing or withdrawing ciclosporin, this interaction needs to be taken into account. The combination of ciclosporin with PSIs requires dose reductions of both drugs because of a synergistic interaction that causes nephrotoxicity when left uncorrected. Conversely, when switching between calcineurin inhibitors, intensified monitoring of PSI concentrations is mandatory. Increasing age is associated with structural and functional changes in body compartments and tissues that alter absorptive capacity, volume of distribution, hepatic metabolic function and renal function and ultimately drug disposition. While these age-related changes are well-known, few specific effects of the latter on immunosuppressant drug metabolism have been reported. Therefore, more clinical data from elderly organ recipients are urgently required.
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Affiliation(s)
- Dirk R J Kuypers
- Department of Nephrology and Renal Transplantation, University Hospitals of Leuven, Leuven, Belgium.
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