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Magruder JT, Shah AS, Crawford TC, Grimm JC, Kim B, Orens JB, Bush EL, Higgins RS, Merlo CA. Simulated Regionalization of Heart and Lung Transplantation in the United States. Am J Transplant 2017; 17:485-495. [PMID: 27618731 DOI: 10.1111/ajt.13967] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 06/29/2016] [Accepted: 07/06/2016] [Indexed: 01/25/2023]
Abstract
We simulated the impact of regionalization of isolated heart and lung transplantation within United Network for Organ Sharing (UNOS) regions. Overall, 12 594 orthotopic heart transplantation (OHT) patients across 135 centers and 12 300 orthotopic lung transplantation (OLT) patients across 67 centers were included in the study. An algorithm was constructed that "closed" the lowest volume center in a region and referred its patients to the highest volume center. In the unadjusted analysis, referred patients were assigned the highest volume center's 1-year mortality rate, and the difference in deaths per region before and after closure was computed. An adjusted analysis was performed using multivariable logistic regression using recipient and donor variables. The primary outcome was the potential number of lives saved at 1 year after transplant. In adjusted OHT analysis, 10 lives were saved (95% confidence interval [CI] 9-11) after one center closure and 240 lives were saved (95% CI 209-272) after up to five center closures per region, with the latter resulting in 1624 total patient referrals (13.2% of OHT patients). For OLT, lives saved ranged from 29 (95% CI 26-32) after one center closure per region to 240 (95% CI 224-256) after up to five regional closures, but the latter resulted in 2999 referrals (24.4% of OLT patients). Increased referral distances would severely limit access to care for rural and resource-limited populations.
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Affiliation(s)
- J T Magruder
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A S Shah
- Department of Cardiac Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - T C Crawford
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J C Grimm
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - B Kim
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J B Orens
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - E L Bush
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - R S Higgins
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C A Merlo
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, MD
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Magruder JT, Crawford TC, Grimm JC, Kim B, Shah AS, Bush EL, Higgins RS, Merlo CA. Risk Factors for De Novo Malignancy Following Lung Transplantation. Am J Transplant 2017; 17:227-238. [PMID: 27321167 DOI: 10.1111/ajt.13925] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 05/16/2016] [Accepted: 06/12/2016] [Indexed: 01/25/2023]
Abstract
Risk factors for non-skin cancer de novo malignancy (DNM) after lung transplantation have yet to be identified. We queried the United Network for Organ Sharing database for all adult lung transplant patients between 1989 and 2012. Standardized incidence ratios (SIRs) were computed by comparing the data to Surveillance, Epidemiology, and End Results Program data after excluding skin squamous/basal cell carcinomas. We identified 18 093 adult lung transplant patients; median follow-up time was 1086 days (interquartile range 436-2070). DNMs occurred in 1306 patients, with incidences of 1.4%, 4.6%, and 7.9% at 1, 3, and 5 years, respectively. The overall cancer incidence was elevated compared with that of the general US population (SIR 3.26, 95% confidence interval [CI]: 2.95-3.60). The most common cancer types were lung cancer (26.2% of all malignancies, SIR 6.49, 95% CI: 5.04-8.45) and lymphoproliferative disease (20.0%, SIR 14.14, 95% CI: 9.45-22.04). Predictors of DNM following lung transplantation were age (hazard ratio [HR] 1.03, 95% CI: 1.02-1.05, p < 0.001), male gender (HR 1.20, 95% CI: 1.02-1.42, p = 0.03), disease etiology (not cystic fibrosis, idiopathic pulmonary fibrosis or interstitial lung disease, HR 0.59, 95% CI 0.37-0.97, p = 0.04) and single-lung transplantation (HR 1.64, 95% CI: 1.34-2.01, p < 0.001). Significant interactions between donor or recipient smoking and single-lung transplantation were noted. On multivariable survival analysis, DNMs were associated with an increased risk of mortality (HR 1.44, 95% CI: 1.10-1.88, p = 0.009).
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Affiliation(s)
- J T Magruder
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - T C Crawford
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J C Grimm
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - B Kim
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A S Shah
- Department of Cardiac Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - E L Bush
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - R S Higgins
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C A Merlo
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Tokman S, Hays SR, Leard LE, Bush EL, Kukreja J, Kleinhenz ME, Golden JA, Singer JP. Prolonged Barium-Impaction Ileus in Two Lung Transplant Recipients With Systemic Sclerosis: Case Report. Transplant Proc 2016; 47:2965-7. [PMID: 26707322 DOI: 10.1016/j.transproceed.2015.10.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 10/20/2015] [Indexed: 11/15/2022]
Abstract
Lung transplantation can be a life-saving measure for people with end-stage lung disease from systemic sclerosis. However, outcomes of lung transplantation may be compromised by gastrointestinal manifestations of systemic sclerosis, which can involve any part of the gastrointestinal tract. Esophageal and gastric disease can be managed by enteral feeding with the use of a gastrojejunal feeding tube. In this report, we describe the clinical courses of 2 lung transplant recipients with systemic sclerosis who experienced severe and prolonged barium-impaction ileus after insertion of a percutaneous gastrojejunal feeding tube.
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Affiliation(s)
- S Tokman
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of California, San Francisco, California; Advanced Lung Disease and Lung Transplant Program, Norton Thoracic Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona.
| | - S R Hays
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of California, San Francisco, California
| | - L E Leard
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of California, San Francisco, California
| | - E L Bush
- Division of Cardiothoracic Surgery, Department of Surgery, University of California, San Francisco, California
| | - J Kukreja
- Division of Cardiothoracic Surgery, Department of Surgery, University of California, San Francisco, California
| | - M E Kleinhenz
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of California, San Francisco, California
| | - J A Golden
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of California, San Francisco, California
| | - J P Singer
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of California, San Francisco, California
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Li B, Hartwig MG, Appel JZ, Bush EL, Balsara KR, Holzknecht ZE, Collins BH, Howell DN, Parker W, Lin SS, Davis RD. Chronic aspiration of gastric fluid induces the development of obliterative bronchiolitis in rat lung transplants. Am J Transplant 2008; 8:1614-21. [PMID: 18557728 PMCID: PMC5485647 DOI: 10.1111/j.1600-6143.2008.02298.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Long-term survival of a pulmonary allograft is currently hampered by obliterative bronchiolitis (OB), a form of chronic rejection that is unique to lung transplantation. While tracheobronchial aspiration from gastroesophageal reflux disease (GERD) has clinically been associated with OB, no experimental model exists to investigate this problem. Using a WKY-to-F344 rat orthotopic left lung transplant model, the effects of chronic aspiration on pulmonary allograft were evaluated. Recipients received cyclosporine with or without 8 weekly aspirations of gastric fluid into the allograft. Six (66.7%) of 9 allografts with aspiration demonstrated bronchioles with surrounding monocytic infiltrates, fibrosis and loss of normal lumen anatomy, consistent with the development of OB. In contrast, none of the allografts without aspiration (n = 10) demonstrated these findings (p = 0.002). Of the grafts examined grossly, 83% of the allografts with chronic aspiration but only 20% without aspiration appeared consolidated (p = 0.013). Aspiration was associated with increased levels of IL-1 alpha, IL-1 beta, IL-6, IL-10, TNF-alpha and TGF-beta in BAL and of IL-1 alpha, IL-4 and GM-CSF in serum. This study provides experimental evidence linking chronic aspiration to the development of OB and suggests that strategies aimed at preventing aspiration-related injuries might improve outcomes in clinical lung transplantation.
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Affiliation(s)
- B. Li
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - M. G. Hartwig
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - J. Z. Appel
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - E. L. Bush
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - K. R. Balsara
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Z. E. Holzknecht
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - B. H. Collins
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - D. N. Howell
- Department of Pathology, Duke University Medical Center, Durham, NC
| | - W. Parker
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - S. S. Lin
- Department of Surgery, Duke University Medical Center, Durham, NC,Department of Immunology, Duke University Medical Center, Durham, NC
| | - R. D. Davis
- Department of Surgery, Duke University Medical Center, Durham, NC,Corresponding author: R. Duane Davis,
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Li B, Hartwig MG, Appel JZ, Bush EL, Balsara KR, Holzknecht ZE, Collins BH, Howell DN, Parker W, Lin SS, Davis RD. Chronic aspiration of gastric fluid induces the development of obliterative bronchiolitis in rat lung transplants. Am J Transplant 2008. [PMID: 18557728 DOI: 10.111/j.1600-6143.2008.02298.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Long-term survival of a pulmonary allograft is currently hampered by obliterative bronchiolitis (OB), a form of chronic rejection that is unique to lung transplantation. While tracheobronchial aspiration from gastroesophageal reflux disease (GERD) has clinically been associated with OB, no experimental model exists to investigate this problem. Using a WKY-to-F344 rat orthotopic left lung transplant model, the effects of chronic aspiration on pulmonary allograft were evaluated. Recipients received cyclosporine with or without 8 weekly aspirations of gastric fluid into the allograft. Six (66.7%) of 9 allografts with aspiration demonstrated bronchioles with surrounding monocytic infiltrates, fibrosis and loss of normal lumen anatomy, consistent with the development of OB. In contrast, none of the allografts without aspiration (n = 10) demonstrated these findings (p = 0.002). Of the grafts examined grossly, 83% of the allografts with chronic aspiration but only 20% without aspiration appeared consolidated (p = 0.013). Aspiration was associated with increased levels of IL-1 alpha, IL-1 beta, IL-6, IL-10, TNF-alpha and TGF-beta in BAL and of IL-1 alpha, IL-4 and GM-CSF in serum. This study provides experimental evidence linking chronic aspiration to the development of OB and suggests that strategies aimed at preventing aspiration-related injuries might improve outcomes in clinical lung transplantation.
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Affiliation(s)
- B Li
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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