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Midyat L, Muise ED, Visner GA. Pediatric Lung Transplantation for Pulmonary Vascular Diseases: Recent Advances and Challenges. Clin Chest Med 2024; 45:761-769. [PMID: 39069336 DOI: 10.1016/j.ccm.2024.02.023] [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] [Indexed: 07/30/2024]
Abstract
Pediatric lung transplantation for pulmonary vascular diseases has seen notable advancements and trends. Medical therapies, surgical options, and bridging techniques like extracorporeal membrane oxygenation and different forms of transplants have expanded treatment possibilities. Current challenges include ensuring patient adherence to post-transplant therapies, addressing complications like primary graft dysfunction and rejection, and conducting further research in less common conditions like pulmonary veno-occlusive disease and pulmonary vein stenosis. In this review article, the authors will explore the advancements, emerging trends, and persistent challenges in pediatric lung transplantation for pulmonary vascular diseases.
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Affiliation(s)
- Levent Midyat
- Division of Pulmonary Medicine, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, 4401 Penn Avenue, AOB Suite 3300, Pittsburgh, PA 15224, USA.
| | - Eleanor D Muise
- Division of Pulmonary Medicine, NYU Grossman School of Medicine, Hassenfeld Children's Hospital, 240 East 38th Street, 14th Floor, New York, NY 10016, USA
| | - Gary A Visner
- Division of Pulmonary Medicine, Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, BCH 3121, Boston, MA 02115, USA
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2
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Qin J, Hu C, Cao X, Gao J, Chen Y, Yan M, Chen J. Development and validation of a nomogram model to predict primary graft dysfunction in patients after lung transplantation based on the clinical factors. Clin Transplant 2023; 37:e15039. [PMID: 37256785 DOI: 10.1111/ctr.15039] [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: 03/11/2023] [Revised: 05/16/2023] [Accepted: 05/18/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Primary graft dysfunction (PGD), a significant complication that can affect patients' prognosis and quality of life, develops within 72 h post lung transplantation (LTx). Early detection and prevention of PGD should be given special consideration. The purpose of this study was to create a clinical prediction model to forecast the occurrence of PGD. METHODS We collected information on 622 LTx patients from Wuxi People's Hospital from 2016 to 2020 and used the data to construct the prediction model. Information on 224 patients from 2021 to June 2022 was used for external validation. We used LASSO regression for variable screening. A nomogram was developed for model presentation. Distinctness, fit, and calibration were used to evaluate the performance of the model. RESULTS Subjects with respiratory failure, who received fresh frozen plasma, donor age, donor gender, donor mechanism of death, donor smoking, donor ventilator use time, and donor PaO 2/FiO 2 ratio were independent predictor variables for the occurrence of PGD. The area under the curve of the nomogram was .779. The Hosmer-Lemeshow test showed a good model fit (P = .158). The calibration curve of the nomogram is fairly close to the ideal diagonal. Moreover, the decision curve analysis revealed a positive net benefit of the model. External validation also confirmed the reliability of the model. CONCLUSIONS The nomogram of PGD based on clinical risk factors in postoperative LTx patients was established with high reliability. It provides clinicians and nurses with a new and effective tool for early prediction of PGD and early intervention.
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Affiliation(s)
- Jianan Qin
- School of Nursing, Fudan University, Shanghai, China
- Operation Department, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Chunxiao Hu
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Xiaodong Cao
- Department of Nursing, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Jian Gao
- Department of Nutrition, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuan Chen
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Meiqiong Yan
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jingyu Chen
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
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Wong W, Johnson B, Cheng PC, Josephson MB, Maeda K, Berg RA, Kawut SM, Harhay MO, Goldfarb SB, Yehya N, Himebauch AS. Primary graft dysfunction grade 3 following pediatric lung transplantation is associated with chronic lung allograft dysfunction. J Heart Lung Transplant 2023; 42:669-678. [PMID: 36639317 PMCID: PMC10811698 DOI: 10.1016/j.healun.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 12/01/2022] [Accepted: 12/15/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Severe primary graft dysfunction (PGD) is associated with the development of bronchiolitis obliterans syndrome (BOS), the most common form of chronic lung allograft dysfunction (CLAD), in adults. However, PGD associations with long-term outcomes following pediatric lung transplantation are unknown. We hypothesized that PGD grade 3 (PGD 3) at 48- or 72-hours would be associated with shorter CLAD-free survival following pediatric lung transplantation. METHODS This was a single center retrospective cohort study of patients ≤ 21 years of age who underwent bilateral lung transplantation between 2005 and 2019 with ≥ 1 year of follow-up. PGD and CLAD were defined by published criteria. We evaluated the association of PGD 3 at 48- or 72-hours with CLAD-free survival by using time-to-event analyses. RESULTS Fifty-one patients were included (median age 12.7 years; 51% female). The most common transplant indications were cystic fibrosis (29%) and pulmonary hypertension (20%). Seventeen patients (33%) had PGD 3 at either 48- or 72-hours. In unadjusted analysis, PGD 3 was associated with an increased risk of CLAD or mortality (HR 2.10, 95% CI 1.01-4.37, p=0.047). This association remained when adjusting individually for multiple potential confounders. There was evidence of effect modification by sex (interaction p = 0.055) with the association of PGD 3 and shorter CLAD-free survival driven predominantly by males (HR 4.73, 95% CI 1.44-15.6) rather than females (HR 1.23, 95% CI 0.47-3.20). CONCLUSIONS PGD 3 at 48- or 72-hours following pediatric lung transplantation was associated with shorter CLAD-free survival. Sex may be a modifier of this association.
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Affiliation(s)
- Wai Wong
- Department of Pediatrics, Division of Pulmonary Medicine and Respiratory Diseases, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Brandy Johnson
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Pi Chun Cheng
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana
| | - Maureen B Josephson
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Katsuhide Maeda
- Department of Surgery, Division of Cardiothoracic Surgery, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Steven M Kawut
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael O Harhay
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Samuel B Goldfarb
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, University of Minnesota, Masonic Children's Hospital, Minneapolis, Minnesota
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Adam S Himebauch
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Memaran N, Onnen M, Müller C, Schwerk N, Carlens J, Borchert-Mörlins B, Bauer E, Blöte R, Sugianto RI, Zürn K, Wühl E, Warnecke G, Tudorache I, Hansen G, Gjertson DW, Schmidt BMW, Melk A. Cardiovascular Burden Is High in Pediatric Lung Transplant Recipients. Transplantation 2022; 106:1465-1472. [PMID: 34982755 DOI: 10.1097/tp.0000000000004025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cardiovascular morbidity is common in adults after lung transplantation (LTx) but has not been described for pediatric LTx recipients. Early subclinical cardiovascular damage is reflected by increases in pulse wave velocity (PWV; indicating arteriosclerosis), intima-media thickness (IMT; indicating atherosclerosis), and left ventricular mass index (LVMI; indicating left ventricular hypertrophy). METHODS We annually assessed 47 pediatric LTx recipients in a prospective longitudinal study (144 observations, mean 3.1 visits/patient, range of 1-4 visits, mean follow-up 2.2 y). RESULTS At inclusion, increased PWV and IMT were detected in 13% and 30%, respectively, and elevated LVMI was detected in 33%. Higher PWV was associated with male sex, longer time since LTx, higher diastolic blood pressure, and lower glomerular filtration rate. Male sex and lower hemoglobin levels were associated with higher IMT, and the presence of diabetes was associated with higher LVMI. CONCLUSIONS Pediatric LTx recipients suffer from a high and sustained burden of subclinical cardiovascular damage. In light of improving long-term outcomes, cardiovascular morbidity needs to be addressed. Our analysis identified classical and nonclassical risk factors to be associated with the measures for cardiovascular damage, which could serve as targets for intervention.
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Affiliation(s)
- Nima Memaran
- Department of Pediatric Kidney, Liver, and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Mareike Onnen
- Department of Pediatric Kidney, Liver, and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Carsten Müller
- Clinic for Pediatric Pneumology, Allergology, and Neonatology, Hannover Medical School, Hannover, Germany
| | - Nicolaus Schwerk
- Clinic for Pediatric Pneumology, Allergology, and Neonatology, Hannover Medical School, Hannover, Germany
| | - Julia Carlens
- Clinic for Pediatric Pneumology, Allergology, and Neonatology, Hannover Medical School, Hannover, Germany
| | - Bianca Borchert-Mörlins
- Department of Pediatric Kidney, Liver, and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Elena Bauer
- Department of Pediatric Kidney, Liver, and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Ricarda Blöte
- Department of Pediatric Kidney, Liver, and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Rizky I Sugianto
- Department of Pediatric Kidney, Liver, and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Katharina Zürn
- Department of Pediatric Kidney, Liver, and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Elke Wühl
- Division of Pediatric Nephrology, University Children's Hospital, University of Heidelberg, Heidelberg, Germany
| | - Gregor Warnecke
- Department of Cardiothoracic Surgery, Hannover Medical School, Hannover, Germany
| | - Igor Tudorache
- Department of Cardiothoracic Surgery, Hannover Medical School, Hannover, Germany
| | - Gesine Hansen
- Clinic for Pediatric Pneumology, Allergology, and Neonatology, Hannover Medical School, Hannover, Germany
| | - David W Gjertson
- Division of Biostatistics, University of California, Los Angeles School of Public Health, Los Angeles, CA
| | | | - Anette Melk
- Department of Pediatric Kidney, Liver, and Metabolic Diseases, Hannover Medical School, Hannover, Germany
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Koh W, Rao SB, Yasechko SM, Hayes D. Postoperative management of children after lung transplantation. Semin Pediatr Surg 2022; 31:151179. [PMID: 35725051 DOI: 10.1016/j.sempedsurg.2022.151179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Pediatric lung transplantation is a highly specialized treatment option at a select few hospitals caring for children. Advancements in surgical and medical approaches in the care of these children have improved their care with only minimal improvement in outcomes which remain the lowest of all solid organ transplants. A crucial time period in the management of these children is in the perioperative period after performance of the lung transplant. Supporting allograft function, preventing infection, maintaining fluid balance, achieving pain control, and providing optimal respiratory support are all key factors required for this highly complex pediatric patient population. We review commonly encountered complications that these patients often experience and provide strategies for management.
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Affiliation(s)
- Wonshill Koh
- Heart Institute; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Sangeetha B Rao
- Division of Critical Care Medicine, Boston Children's Hospital, Boston, MA; of Pediatrics, Harvard Medical School, Boston, MA
| | | | - Don Hayes
- Heart Institute; Division of Pulmonary Medicine Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
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Critser PJ, Boyer D, Visner GA, Collins SL, Fynn-Thompson F, Mullen MP. Recovery of right ventricular function after bilateral lung transplantation for pediatric pulmonary hypertension. Pediatr Transplant 2022; 26:e14236. [PMID: 35098627 DOI: 10.1111/petr.14236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 12/04/2021] [Accepted: 01/01/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Lung transplantation is a therapeutic option for end-stage pediatric pulmonary hypertension (PH). Right ventricular (RV) recovery post-lung transplant in children with PH has not been well-described, and questions persist about the peri-operative course and post-transplant cardiac function after lung transplantation in medically refractory PH patients with baseline RV dysfunction. METHODS A single-center chart review identified patients with childhood PH who subsequently underwent bilateral orthotopic lung transplantation between 2000 and 2020. Twenty-six patients met criteria; three were excluded due to echocardiograms not available for digital review. RV fractional area change (FAC) and left ventricular eccentricity index (LVEI) were determined prior to transplantation, and at 1, 3, 6, and 12-month post-transplantation. RESULTS Fourteen of 23 patients had baseline RV dysfunction. The median age at transplantation was 16.5 years and 13.9 years for those with and without baseline RV dysfunction, respectively. Of the 14 with baseline RV dysfunction, 12 (86%) were alive 1-year post-transplantation. All patients with baseline RV dysfunction had increased RV-FAC post-transplantation with normalization of RV-FAC in 70% at 3 months and 100% of patients by 12-month post-transplantation. Duration of ventilation (p = .4), intensive care unit (p = .5), or hospital stay (p = .9) was not associated with pre-transplant RV function. CONCLUSIONS Among pediatric patients with PH and RV dysfunction, pre-transplantation RV function was not associated with short-term outcomes. All patients with baseline RV dysfunction had improvement in RV function, justifying consideration of lung transplantation among pediatric patients with end-stage PH and RV dysfunction.
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Affiliation(s)
- Paul J Critser
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Debra Boyer
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Gary A Visner
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Shane L Collins
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Francis Fynn-Thompson
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mary P Mullen
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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