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Sindu D, Razia D, Bay C, Padiyar J, Grief K, Buddhdev B, Arjuna A, Abdelrazek H, Mohamed H, McAnally K, Omar A, Walia R, Schaheen L, Tokman S. Evolving impact of the COVID-19 pandemic on lung transplant recipients: A single-center experience. J Heart Lung Transplant 2024; 43:442-452. [PMID: 37852512 DOI: 10.1016/j.healun.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 09/19/2023] [Accepted: 10/10/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Lung transplant recipients (LTRs) are at increased risk of morbidity and mortality from coronavirus disease 2019 (COVID-19); however, the disease course has changed as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) variants have mutated. We compared COVID-19-related clinical outcomes in LTRs at different stages of the pandemic. We also identified risk factors for developing severe COVID-19 independent of the dominant SARS-CoV-2 variant. METHODS This single-center, retrospective cohort study of LTRs with COVID-19 used Cox regression analyses and bootstrapping to identify factors affecting COVID-19 severity. RESULTS Between March 2020 and August 2022, 195 LTRs were diagnosed with COVID-19, almost half (89 [45.6%]) during the Omicron period. A total of 113 (58.5%) LTRs were hospitalized and 47 (24.1%) died. Age >65 years increased the risk of hospitalization and death. Although infection with the Omicron variant was associated with a lower risk of hospitalization, the median length of hospital stay (10 days, [interquartile range, 5-19]) was similar between the variants. Intensive care unit (ICU) admission and death were more common with the Delta variant but comparable between the original, Alpha, and Omicron variants. Remdesivir and molnupiravir reduced the risk of hospitalization, and monoclonal antibody therapy reduced the risk of ICU admission, intubation, and death. Vaccination and pre-exposure prophylaxis (PrEP) with tixagevimab-cilgavimab did not significantly reduce COVID-19-related ICU admission, intubation, or mortality among LTRs. CONCLUSIONS LTRs with COVID-19 continue to have high hospitalization rates and prolonged hospital stays, despite the reduced virulence of the Omicron variant. More effective PrEP and therapeutic interventions for COVID-19 among vulnerable patient groups are needed.
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Affiliation(s)
- Devika Sindu
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Deepika Razia
- Department of Medicine, Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, Arizona
| | - Curt Bay
- Department of Interdisciplinary Health Sciences, A. T. Still University, Phoenix, Arizona
| | - Josna Padiyar
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; Department of Medicine, Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, Arizona
| | - Katherine Grief
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Bhuvin Buddhdev
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; Department of Medicine, Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, Arizona
| | - Ashwini Arjuna
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; Department of Medicine, Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, Arizona
| | - Hesham Abdelrazek
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; Department of Medicine, Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, Arizona
| | - Hesham Mohamed
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; Department of Medicine, Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, Arizona
| | - Kendra McAnally
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; Department of Medicine, Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, Arizona
| | - Ashraf Omar
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; Department of Medicine, Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, Arizona
| | - Rajat Walia
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; Department of Medicine, Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, Arizona
| | - Lara Schaheen
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; Department of Surgery, Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, Arizona
| | - Sofya Tokman
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; Department of Medicine, Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, Arizona.
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Sindu D, Bansal S, Buddhdev B, McAnally K, Mohamed H, Walia R, Mohanakumar T, Tokman S. Late-Onset Exudative Pleural Effusions Without Concomitant Airway Obstruction or Lung Parenchymal Abnormalities: A Novel Presentation of Chronic Lung Allograft Dysfunction. Transpl Int 2024; 37:12395. [PMID: 38357217 PMCID: PMC10866027 DOI: 10.3389/ti.2024.12395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/10/2024] [Indexed: 02/16/2024]
Abstract
Restrictive allograft syndrome (RAS) is an aggressive variant of CLAD characterized by progressive restrictive ventilatory decline and persistent pleuro-parenchymal changes that can be seen on chest CT. We identified four lung transplant recipients with a progressive restrictive ventilatory defect due to lymphocyte-predominant exudative pleural effusions, but no pleuro-parenchymal abnormalities typical of RAS. Using molecular analysis, we also found increased levels of previously described immune markers of RAS, including NFkB, 20S proteasome, lipocalin, TNFα, and TGFβ, within the circulating small extracellular vesicles of the remaining living lung transplant recipient. Despite the absence of lung parenchymal changes, these patients had a poor prognosis with rapid deterioration in allograft function and no response to pleural-based interventions such as thoracentesis, decortication, and pleurodesis. We hypothesize that these cases represent a distinct CLAD phenotype characterized by progressive restriction due to pleural inflammation, lymphocyte-predominant pleural effusion, resultant compressive atelectasis, and eventual respiratory failure in the absence of lung parenchymal involvement.
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Affiliation(s)
- Devika Sindu
- Norton Thoracic Institute, Phoenix, AZ, United States
| | | | - Bhuvin Buddhdev
- Norton Thoracic Institute, Phoenix, AZ, United States
- School of Medicine, Creighton University, Phoenix, AZ, United States
| | - Kendra McAnally
- Norton Thoracic Institute, Phoenix, AZ, United States
- School of Medicine, Creighton University, Phoenix, AZ, United States
| | - Hesham Mohamed
- Norton Thoracic Institute, Phoenix, AZ, United States
- School of Medicine, Creighton University, Phoenix, AZ, United States
| | - Rajat Walia
- Norton Thoracic Institute, Phoenix, AZ, United States
- School of Medicine, Creighton University, Phoenix, AZ, United States
| | | | - Sofya Tokman
- Norton Thoracic Institute, Phoenix, AZ, United States
- School of Medicine, Creighton University, Phoenix, AZ, United States
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Bansal S, Fleming T, Canez J, Maine GN, Bharat A, Walia R, Tokman S, Smith MA, Tiffany B, Bremner RM, Mohanakumar T. Immune responses of lung transplant recipients against SARS-CoV-2 and common respiratory coronaviruses: Evidence for pre-existing cross-reactive immunity. Transpl Immunol 2023; 81:101940. [PMID: 37866672 PMCID: PMC11019873 DOI: 10.1016/j.trim.2023.101940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/09/2023] [Accepted: 10/19/2023] [Indexed: 10/24/2023]
Abstract
Humoral and cellular immune responses to SARS-CoV-2 and other coronaviruses in lung transplant recipients are unknown. We measured antibodies and T cell responses against the SARS-CoV-2 spike S2 and nucleocapsid antigens and spike antigens from common respiratory coronaviruses (229E, NL63, OC43, and HKU1) after vaccination or infection of LTxRs. 148 LTxRs from single center were included in this study: 98 after vaccination and 50 following SARS-CoV-2 infection. Antibodies were quantified by enzyme-linked immunosorbent assay. The frequency of T cells secreting IL2, IL4, IL10, IL17, TNFα, and IFNγ were enumerated by enzyme-linked immunospot assay. Our results have shown the development of antibodies to SARS-CoV-2 spike protein in infected LTxRs (39/50) and vaccinated LTxRs (52/98). Vaccinated LTxRs had higher number of T cells producing TNFα but less cells producing IFNγ than infected LTxRs in response to the nucleocapsid antigen and other coronavirus spike antigens. We didn't find correlation between the development of antibodies and cellular immune responses against the SARS-CoV-2 spike protein after vaccination. Instead, LTxRs have pre-existing cellular immunity to common respiratory coronaviruses, leading to cross-reactive immunity against SARS-CoV-2 which likely will provide protection against SARS-Cov-2 infection.
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Affiliation(s)
- Sandhya Bansal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Timothy Fleming
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Jesse Canez
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Gabriel N Maine
- Department of Pathology and Laboratory Medicine, Royal Oak, Beaumont Health, MI, USA
| | | | - Rajat Walia
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Sofya Tokman
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Michael A Smith
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Brian Tiffany
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - T Mohanakumar
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.
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Sindu D, Razia D, Grief K, Cherrier L, Omar A, Walia R, McAnally K, Buddhdev B, Tokman S. Prior SARS-CoV-2 infection may not alter the clinical course of COVID-19 in lung transplant recipients: A single-center experience. Clin Transplant 2023; 37:e15071. [PMID: 37405931 DOI: 10.1111/ctr.15071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/01/2023] [Accepted: 06/26/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND In the general population, prior infection with SARS-CoV-2 reduces the risk of severe COVID-19; however, studies in lung transplant recipients (LTRs) are lacking. We sought to describe the clinical course of COVID-19 recurrence and compare outcomes between the first and second episodes of COVID-19 in LTRs. METHODS We conducted a retrospective, single-center cohort study of LTRs with COVID-19 between January 1, 2022, and September 30, 2022, during the Omicron wave. We compared the clinical course of a second episode of COVID-19 to that of the patients' own first episode and to that of LTRs who developed a first episode during the study period. RESULTS During the study period, we identified 24 LTRs with COVID-19 recurrence and another 75 LTRs with a first episode of COVID-19. LTRs who survived the initial episode of COVID-19 had a similar disease course with recurrence, with a trend toward reduced hospitalization (10 (41.6%) vs. 4 (16.7%), p = .114). Furthermore, compared to LTRs with a primary infection during the Omicron wave, those with a reinfection had a non-statistically significant trend toward reduced hospitalizations (aOR .391, 95% CI [.115-1.321], p = .131), shorter lengths-of-stay (median, 4 vs. 9 days, p = .181), and reduced intensive care unit admissions, intubations, and COVID-19-related mortality. CONCLUSIONS LTRs who survive the first episode of COVID-19 are likely to have a similar clinical course with recurrent episodes. Although recurrent COVID-19 may be milder, larger, well-powered studies are needed to confirm this observation. Ongoing precautions are warranted.
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Affiliation(s)
- Devika Sindu
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Deepika Razia
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, Arizona, USA
| | - Katherine Grief
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Lauren Cherrier
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ashraf Omar
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, Arizona, USA
| | - Rajat Walia
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, Arizona, USA
| | - Kendra McAnally
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, Arizona, USA
| | - Bhuvin Buddhdev
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, Arizona, USA
| | - Sofya Tokman
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, Arizona, USA
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Sindu D, Razia D, Grief K, Cherrier L, Omar A, Walia R, Tokman S. Pre-exposure Prophylaxis with Tixagevimab-cilgavimab did not Reduce Severity of COVID-19 in Lung Transplant Recipients with Breakthrough Infection. Transplant Direct 2023; 9:e1485. [PMID: 37197016 PMCID: PMC10184979 DOI: 10.1097/txd.0000000000001485] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/22/2023] [Indexed: 05/19/2023] Open
Abstract
Lung transplant recipients (LTRs) have an increased risk of COVID-19-related morbidity and mortality. Tixagevimab-cilgavimab (tix-cil) is a long-acting monoclonal antibody combination granted Emergency Use Authorization approval by the US Food and Drug Administration for COVID-19 pre-exposure prophylaxis (PrEP) in immunocompromised patients. We sought to determine whether tix-cil 300-300 mg reduced the incidence and disease severity of severe acute respiratory syndrome coronavirus 2 infection in LTRs during the Omicron wave. Methods We performed a retrospective, single-center cohort study of LTRs who had received a COVID-19 diagnosis between December 2021 and August 2022. We compared baseline characteristics and clinical outcomes after COVID-19 between LTRs who received tix-cil PrEP and those who did not. We then conducted propensity-score matching based on baseline characteristics and therapeutic interventions and compared clinical outcomes between the 2 groups. Results Of 203 LTRs who received tix-cil PrEP and 343 who did not, 24 (11.8%) and 57 (16.6%), respectively, developed symptomatic COVID-19 (hazard ratio [HR], 0.669; 95% confidence interval [CI], 0.415-1.079; P = 0.099). The hospitalization rate of LTRs with COVID-19 during the Omicron wave trended lower in the tix-cil group than in the non-tix-cil group (20.8% versus 43.1%; HR, 0.430; 95% CI, 0.165-1.118; P = 0.083). In propensity-matched analyses, 17 LTRs who received tix-cil and 17 LTRs who did not had similar rates of hospitalization (HR, 0.468; 95% CI, 0.156-1.402; P = 0.175), intensive care unit admission (HR, 3.096; 95% CI, 0.322-29.771; P = 0.328), mechanical ventilation (HR, 1.958; 95% CI, 0.177-21.596; P = 0.583), and survival (HR, 1.015; 95% CI, 0.143-7.209; P = 0.988). COVID-19-related mortality was high in both propensity-score-matched groups (11.8%). Conclusions Breakthrough COVID-19 was common among LTRs despite tix-cil PrEP, possibly due to reduced efficacy of monoclonal antibodies against the Omicron variant. Tix-cil PrEP may reduce the incidence of COVID-19 in LTRs, but it did not reduce disease severity during the Omicron wave.
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Affiliation(s)
- Devika Sindu
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ
| | - Deepika Razia
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ
| | - Katherine Grief
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ
| | - Lauren Cherrier
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ
| | - Ashraf Omar
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ
| | - Rajat Walia
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ
| | - Sofya Tokman
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ
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Padiyar J, Tokman S, Sindu D, Buddhdev B, Omar A, Brady K, Ashton K, Hashimi S, Huang J, Smith M, Walia R, Bremner R, Schaheen L. Combined Lung Transplantation and Coronary Artery Bypass Grafting: To Graft or Not to Graft? J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Sindu D, Tokman S, Mcanally K, Walia R, Mohamed H, Abdelrazek H, Omar A, Buddhdev B, Arjuna A. Thoracic Capnocytophaga Infection in a Lung Transplant Recipient. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Sindu D, Arjuna A, Mcannaly K, Buddhdev B, Mohamed H, Abdelrazek H, Walia R, Omar A, Tokman S. A Novel Phenotype of Chronic Lung Allograft Dysfunction (CLAD). J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.1426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Jacob J, Razia D, Omar A, Walia R, Smith M, Bremner R, Tokman S. Long-Term Survival Among Single Lung Transplant Recipients is Shorter Than That of Matched Bilateral Lung Transplant Recipients. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.1041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Sindu D, Tokman S, Arjuna A, Mcanally K, Walia R, Mohamed H, Abdelrazek H, Omar A, Buddhdev B. Treatment Refractory CMV Viremia in a Lung Transplant Recipient. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Latorre-Rodríguez A, Sindu D, Tokman S, Arjuna A, Mittal S. The Presence of Activated Pepsin in Bronchoalveolar Lavage is Associated with Acute Cellular Rejection in Lung Transplant Recipients. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.1405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Sindu D, Tokman S, Mcanally K, Buddhdev B, Walia R, Mohamed H, Abdelrazek H, Smith M, Omar A, Arjuna A. West Nile Virus Meningoencephalitis in a Bilateral Lung Transplant Recipient. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Chin C, Ravichandran R, Sanborn K, Fleming T, Wheatcroft SB, Kearney MT, Tokman S, Walia R, Smith MA, Flint DJ, Mohanakumar T, Bremner RM, Sureshbabu A. Loss of IGFBP2 mediates alveolar type 2 cell senescence and promotes lung fibrosis. Cell Rep Med 2023; 4:100945. [PMID: 36787736 PMCID: PMC10040381 DOI: 10.1016/j.xcrm.2023.100945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 06/01/2022] [Accepted: 01/23/2023] [Indexed: 02/15/2023]
Abstract
Accumulation of senescent cells contributes to age-related diseases including idiopathic pulmonary fibrosis (IPF). Insulin-like growth factor binding proteins (IGFBPs) regulate many biological processes; however, the functional contributions of IGFBP2 in lung fibrosis remain largely unclear. Here, we report that intranasal delivery of recombinant IGFBP2 protects aged mice from weight loss and demonstrated antifibrotic effects after bleomycin lung injury. Notably, aged human-Igfbp2 transgenic mice reveal reduced senescence and senescent-associated secretory phenotype factors in alveolar epithelial type 2 (AEC2) cells and they ameliorated bleomycin-induced lung fibrosis. Finally, we demonstrate that IGFBP2 expression is significantly suppressed in AEC2 cells isolated from fibrotic lung regions of patients with IPF and/or pulmonary hypertension compared with patients with hypersensitivity pneumonitis and/or chronic obstructive pulmonary disease. Altogether, our study provides insights into how IGFBP2 regulates AEC2-cell-specific senescence and that restoring IGFBP2 levels in fibrotic lungs can prove effective for patients with IPF.
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Affiliation(s)
- Chiahsuan Chin
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 124 W. Thomas Road, Ste. 100, Phoenix, AZ 85013, USA; Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | - Ranjithkumar Ravichandran
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 124 W. Thomas Road, Ste. 100, Phoenix, AZ 85013, USA; Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | - Kristina Sanborn
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 124 W. Thomas Road, Ste. 100, Phoenix, AZ 85013, USA; Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | - Timothy Fleming
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 124 W. Thomas Road, Ste. 100, Phoenix, AZ 85013, USA; Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | - Stephen B Wheatcroft
- Leeds Institute of Cardiovascular & Metabolic Medicine, University of Leeds, Leeds, UK
| | - Mark T Kearney
- Leeds Institute of Cardiovascular & Metabolic Medicine, University of Leeds, Leeds, UK
| | - Sofya Tokman
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 124 W. Thomas Road, Ste. 100, Phoenix, AZ 85013, USA; Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | - Rajat Walia
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 124 W. Thomas Road, Ste. 100, Phoenix, AZ 85013, USA; Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | - Michael A Smith
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 124 W. Thomas Road, Ste. 100, Phoenix, AZ 85013, USA; Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | - David J Flint
- Strathclyde Institute of Pharmacy & Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Thalachallour Mohanakumar
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 124 W. Thomas Road, Ste. 100, Phoenix, AZ 85013, USA; Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 124 W. Thomas Road, Ste. 100, Phoenix, AZ 85013, USA; Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | - Angara Sureshbabu
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 124 W. Thomas Road, Ste. 100, Phoenix, AZ 85013, USA; Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA.
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Razia D, Olson MT, Grief K, Walia R, Bremner RM, Smith MA, Tokman S. Hospitalized patients with irreversible lung injury from COVID-19 have higher morbidity but similar 1-year survival after lung transplant compared to hospitalized patients transplanted for restrictive lung disease. J Heart Lung Transplant 2023; 42:255-263. [PMID: 36272894 PMCID: PMC9492395 DOI: 10.1016/j.healun.2022.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 08/22/2022] [Accepted: 09/08/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Hospitalized lung transplant (LT) recipients (LTRs) have higher post-LT morbidity and mortality than those who are well enough to wait for transplant at home. Outcomes after LT for COVID-19-associated acute respiratory distress syndrome (CARDS) may be even worse; thus, we compared post-LT outcomes between hospitalized LTRs transplanted for CARDS and those transplanted for restrictive lung disease (RLD). METHODS Between 2014 and 2021, hospitalized LTRs ≥18 years old with CARDS or RLD were included. Primary and secondary outcomes were 1-year post-LT survival and postoperative morbidity. For each patient in the CARDS group, an analysis of 1-to-1 matched patients from the RLD group was performed using logistic regression modeling. RESULTS Of 764 LTRs, 163 (21.3%) were hospitalized at the time of LT; 132 met the inclusion criteria: 11 (8.3%) were transplanted for CARDS and 121 (91.7%) for RLD. LTRs with CARDS were younger with longer pre-LT hospitalization stays and higher rates of pretransplant mechanical ventilation, dialysis, and ECMO as a bridge to transplant. A propensity-matched analysis demonstrated comparable rates of intrathoracic adhesions, posttransplant duration of mechanical ventilation, PGD3 at 72 hours, and delayed chest closure. Compared to LTRs with RLD, those with CARDS had significantly longer posttransplant hospital stays and a higher prevalence of ACR ≥A2 and DSA >2000 MFI, but comparable 1-year survival rates. CONCLUSION Even with careful selection, LT for patients with CARDS was associated with significant morbidity; however, 1-year survival of recipients with CARDS was comparable to that of matched hospitalized recipients with RLD.
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Affiliation(s)
- Deepika Razia
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael T. Olson
- University of Arizona College of Medicine – Phoenix Campus, Phoenix, Arizona, USA
| | - Katherine Grief
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Rajat Walia
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona,Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, Arizona
| | - Ross M. Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona,Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, Arizona
| | - Michael A. Smith
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona,Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, Arizona
| | - Sofya Tokman
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, Arizona.
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15
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Razia D, Mittal SK, Walia R, Tokman S, Huang JL, Smith MA, Bremner RM. Morbidity of antireflux surgery in lung transplant and matched nontransplant cohorts is comparable. Surg Endosc 2023; 37:1114-1122. [PMID: 36131161 PMCID: PMC9491650 DOI: 10.1007/s00464-022-09598-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/25/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Safety data on perioperative outcomes of laparoscopic antireflux surgery (LARS) after lung transplantation (LT) are lacking. We compared the 30-day readmission rate and short-term morbidity after LARS between LT recipients and matched nontransplant (NT) controls. METHODS Adult patients who underwent LARS between January 1, 2015, and October 31, 2021, were included. The participants were divided into two groups: LT recipients and NT controls. First, we compared 30-day readmission rates after LARS between the LT and NT cohorts. Next, we compared 30-day morbidity after LARS between the LT cohort and a 1-to-2 propensity score-matched NT cohort. RESULTS A total of 1328 patients (55 LT recipients and 1273 NT controls) were included. The post-LARS 30-day readmission rate was higher in LT recipients than in the overall NT controls (14.5% vs. 2.8%, p < 0.001). Compared to matched NT controls, LT recipients had a lower prevalence of paraesophageal hernia, a smaller median hernia size, and higher peristaltic vigor. Also compared to the matched NT controls, the LT recipients had a lower median operative time but a longer median length of hospital stay. The proportion of patients with a post-LARS event within 30 postoperative days was comparable between the LT and matched NT cohorts (21.8% vs 14.5%, p = 0.24). CONCLUSIONS Despite a higher perceived risk of comorbidity burden, LT recipients and matched NT controls had similar rates of post-LARS 30-day morbidity at our large-volume center with expertise in transplant and foregut surgery. LARS after LT is safe.
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Affiliation(s)
- Deepika Razia
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ 85013 USA ,Creighton University School of Medicine – Phoenix Regional Campus, Phoenix, AZ USA
| | - Sumeet K. Mittal
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ 85013 USA ,Creighton University School of Medicine – Phoenix Regional Campus, Phoenix, AZ USA
| | - Rajat Walia
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ 85013 USA ,Creighton University School of Medicine – Phoenix Regional Campus, Phoenix, AZ USA
| | - Sofya Tokman
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ 85013 USA ,Creighton University School of Medicine – Phoenix Regional Campus, Phoenix, AZ USA
| | - Jasmine L. Huang
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ 85013 USA ,Creighton University School of Medicine – Phoenix Regional Campus, Phoenix, AZ USA
| | - Michael A. Smith
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ 85013 USA ,Creighton University School of Medicine – Phoenix Regional Campus, Phoenix, AZ USA
| | - Ross M. Bremner
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ 85013 USA ,Creighton University School of Medicine – Phoenix Regional Campus, Phoenix, AZ USA
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16
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Razia D, Arjuna A, Trahan A, Hahn MF, Abdelrazek H, Omar A, Tokman S, Hashimi AS, Huang J, Smith MA, Bremner RM, Walia R. Incidentally Detected Malignancies in Lung Explants. Prog Transplant 2022; 32:332-339. [PMID: 36069063 DOI: 10.1177/15269248221122876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 12/29/2022]
Abstract
Introduction: Incidentally detected malignancies in lung explants portend risk of early cancer recurrence and metastases with posttransplant immunosuppression. We present a series of lung transplant recipients with previously unverified malignancies in native lung explants. Design: We reviewed the histopathology, radiographic imaging, and management of lung explant malignancies at our institution over 10 years (2011-2020). Endpoints were survival and allograft rejection. Results: An explant malignancy was found in 1.3% (11/855) of lung transplant recipients (6 [55%] men; median age 68 years; 6 [55%] ex-smokers [median pack-years, 25]). Nine (82%) were adenocarcinoma, 1 (9%) was squamous cell carcinoma (SCC), and 1 (9%) was follicular lymphoma. Three patients (27%) had multifocal involvement (≥3 lobes), 4 (36%) had nodal involvement, and the median (range) tumor size was 2.7 (0.4-19) cm. The median interval between last imaging and transplant was 58 (29-144) days. Mycophenolate mofetil was discontinued or reduced in all; everolimus was used in 2 patients, and cisplatin-pemetrexed chemotherapy was used in 2 patients. The prevalence of acute cellular rejection and chronic rejection was 27% and 9%, respectively. Lung recipients with cancer had significantly lower survival than those without (36.4% vs 67.3%, p = 0.002); median survival was 27 (17, 65) months in 4 recipients who were alive and cancer-free at the end of the study period. Conclusions: Unidentified malignancies, commonly adenocarcinoma, can be detected in explanted native lungs. Pneumonectomy may be curative in SCC, lymphoproliferative disorders, and stage I adenocarcinoma. Modulating immunosuppression to prevent allograft rejection and tumor proliferation is warranted.
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Affiliation(s)
- Deepika Razia
- Pulmonary and Lung Transplantation Division, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.,Creighton University School of Medicine- Phoenix Campus, Phoenix, Arizona, USA
| | - Ashwini Arjuna
- Pulmonary and Lung Transplantation Division, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.,Creighton University School of Medicine- Phoenix Campus, Phoenix, Arizona, USA
| | - Amy Trahan
- Creighton University School of Medicine- Phoenix Campus, Phoenix, Arizona, USA.,Radiology Division, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Mary F Hahn
- Creighton University School of Medicine- Phoenix Campus, Phoenix, Arizona, USA.,Pathology Division, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Hesham Abdelrazek
- Pulmonary and Lung Transplantation Division, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.,Creighton University School of Medicine- Phoenix Campus, Phoenix, Arizona, USA
| | - Ashraf Omar
- Pulmonary and Lung Transplantation Division, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.,Creighton University School of Medicine- Phoenix Campus, Phoenix, Arizona, USA
| | - Sofya Tokman
- Pulmonary and Lung Transplantation Division, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.,Creighton University School of Medicine- Phoenix Campus, Phoenix, Arizona, USA
| | - Abdul Samad Hashimi
- Creighton University School of Medicine- Phoenix Campus, Phoenix, Arizona, USA.,Thoracic Surgery and Lung Transplantation Division, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jasmine Huang
- Creighton University School of Medicine- Phoenix Campus, Phoenix, Arizona, USA.,Thoracic Surgery and Lung Transplantation Division, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael A Smith
- Creighton University School of Medicine- Phoenix Campus, Phoenix, Arizona, USA.,Thoracic Surgery and Lung Transplantation Division, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ross M Bremner
- Creighton University School of Medicine- Phoenix Campus, Phoenix, Arizona, USA.,Thoracic Surgery and Lung Transplantation Division, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Rajat Walia
- Pulmonary and Lung Transplantation Division, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.,Creighton University School of Medicine- Phoenix Campus, Phoenix, Arizona, USA
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Razia D, Bremner R, Omar A, Walia R, Tokman S. Lung Transplantation for COVID-19-Induced Respiratory Failure: Single-Center Case Series. J Heart Lung Transplant 2022. [PMCID: PMC8988707 DOI: 10.1016/j.healun.2022.01.1215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose Prior to the COVID-19 (C19) pandemic, adult respiratory distress syndrome (ARDS) was an unusual indication for lung transplant (LT); thus, short- and long-term outcomes data are lacking. As the pandemic continues, there is an increased need for post-LT data. Thus, we report our single-center experience transplanting 11 patients for C19 ARDS. Methods We conducted a chart review of LT recipients (LTRs) transplanted for C19 ARDS between 8/1/21 and 7/31/21. Descriptive statistics were used. Results Most LTRs were male (82%, n=9). The median age at LT, body mass index, and lung allocation score were 47 (43, 54) years, 28.9 (26, 30) kg/m2, and 84.5 (60, 88), respectively. The median interval from initial hospitalization to listing and listing to LT was 119 (97, 124) and 5 (4, 11) days, respectively. Pretransplant COVID-related morbidities included venous thromboembolism (55%, n=6), hemorrhage requiring transfusion (36%, n=4), pneumothorax (55%, n=6), bacterial pneumonia (82%, n=9), bacteremia (45%, n=5), fungemia (36%, n=4), renal failure requiring renal replacement therapy (RRT; 9%, n=1), cerebrovascular event (9%, n=1), and musculoskeletal weakness (100%, n=11). Most patients required mechanical ventilation (91%, n=10), and 55% (n=6) were intubated at the time of LT. Furthermore, most patients required ECMO support (73%, n=8) and 36% (n=4) were on ECMO at the time of LT. Intraoperatively, 64% (n=7) of patients required cardiopulmonary bypass, 73% (n=8) had severe intrathoracic adhesions, 73% (n=8) had delayed chest closure, and 18% (n=2) had an unexpected return to the operating room. Prevalence of primary graft dysfunction grade 2 or 3 at 72 hours was high (91%, n=10), median duration of mechanical ventilation after LT was 10 (6, 19) days, but no one required ECMO rescue. To date, 10 (91%) LTRs have been discharged, and 2 (20%) have been readmitted within 30 days; the median post-LT hospital stay was 18 (14, 24) days; all discharged LTRs required acute rehabilitation for a median of 17.5 (14, 23) days. Ten LTRs (91%) at a median of 208 (167, 245) days post-LT; 1 LTR died 344 days post-LT of treatment-refractory allograft failure due to aspiration and antibody-mediated rejection. Conclusion Despite pre-LT critical illness, intraoperative challenges, and prolonged post-LT recovery, LT appears feasible for carefully selected patients with irreversible C19 ARDS.
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Razia D, Olson M, Walia R, Bremner R, Smith M, Tokman S. A Comparison of Short-Term Morbidity and Mortality Among Inpatient Lung Transplant Recipients Transplanted for COVID-19 and Other Restrictive Lung Diseases. J Heart Lung Transplant 2022. [PMCID: PMC8988557 DOI: 10.1016/j.healun.2022.01.310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Purpose Patients with respiratory failure (RF) who are hospitalized at the time of lung transplant (LTx) have higher post-LTx morbidity and mortality than those who are well enough to remain at home. Complications may be even worse in patients transplanted for COVID-19 (C19), as they are commonly critically ill having endured prolonged mechanical ventilation, ECMO support, myopathy, malnutrition, and superimposed infections. In a retrospective cohort study, we compared inpatient lung transplant recipients (LTxRs) transplanted for C19 vs. other underlying restrictive lung diseases (RLDs) Methods After IRB approval, patients who underwent inpatient LTx between 1/1/2014 and 8/31/2021 were categorized by indication: C19 or RLD. We excluded LTxRs <18 years old, a primary indication for LTx other than UNOS disease group D, and redo LTx. Primary outcomes were postoperative morbidity and 90-day survival. Results Out of 163 inpatient LTxRs, 141 met inclusion criteria: 11 (7.8%) with C19 and 130 (92.2%) with RLD. LTxRs with C19 were younger, had a longer pre-LTx hospital stay, and more likely needed pre-LTx mechanical ventilation and ECMO support. LTxRs with C19 were also more likely to have severe adhesions intraoperatively and their chest was more commonly left open after LTx due to a perceived risk of ongoing bleeding. In addition, LTxRs with C19 had a higher prevalence of PGD3 at 72 hours and longer post-LTx hospital stays and trended toward longer post-LTx mechanical ventilation and need for inpatient rehabilitation. The 2 groups had similar 90-day survival (C19, 100% vs. RLD, 95.4%, p=0.472), however, LTxRs with C19 had a higher incidence of acute cellular rejection and DSA production (>2,000 MFI) within 6 months of transplant. Conclusion LTxRs with C19 are typically sicker and have more post-LTx complications than LTxRs with RLD hospitalized at the time of LTx. However, 90-day survival is comparable and high in both groups. Long-term follow-up is needed.
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19
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Razia D, McAnally K, Schaheen L, Abdelrazek H, Smith M, Tokman S. Persistent Subclinical SARS-CoV-2 Isolation After Redo Lung Transplant for COVID-19-Induced Lung Injury. J Heart Lung Transplant 2022. [PMCID: PMC8988632 DOI: 10.1016/j.healun.2022.01.1095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Introduction Lung transplantation (LTx) is lifesaving for patients with irreversible lung injury due to COVID-19; however, all viable virus must be cleared before transplant. Prolonged viral shedding is common, particularly among immunosuppressed patients. Thus, ongoing detection of SARS-CoV-2 RNA may delay transplant and prolong hospitalization. We report a case of an LTx recipient who developed COVID-19-associated lung injury with prolonged viral shedding that persisted following redo LTx. Case Report A 48-year-old man developed COVID-19 17 months after bilateral LTx. His illness rapidly progressed to hypoxemic respiratory failure requiring bilevel ventilation and prone positioning. He was treated with corticosteroids, remdesevir, convalescent plasma, anticoagulation, and reduced immunosuppression. Tocilizumab was not administered as data supporting its use was unavailable. Despite aggressive therapy, he remained hypoxemic and developed radiographic evidence of pulmonary fibrosis. SARS-CoV-2 was persistently isolated between November 2020 and April 2021; the PCR cycle threshold in March 2021 was 32, indicating a low level of viral RNA. There was no evidence of antibodies to SARS-CoV-2. Finally, after 2 negative nasopharyngeal swabs in April, he underwent redo bilateral LTx in May 2021, 163 days after his initial diagnosis. Postoperative critical illness myopathy required prolonged mechanical ventilation, nutrition via a feeding tube, and 19 days at an acute rehabilitation center. Routine surveillance bronchoscopy 40 days after retransplant revealed SARS-CoV-2 in bronchoalveolar lavage fluid and again in a nasal wash sample. He had no COVID-19 symptoms at the time of viral isolation, and inflammatory markers were normal. He was empirically treated with casirivimab and imdevimab, with resolution of SARS-CoV-2 isolation 8 days later. Summary Prolonged viral shedding is common in immunocompromised patients with COVID-19; however, ongoing viral isolation is not a reliable indicator of active viral replication and transmissibility. Our patient had persistent SARS-CoV-2 isolation after redo LTx with no evidence of COVID-19 or allograft injury. Thus, persistent viral shedding alone may not be an absolute contraindication to LTx and additional factors such as PCR cycle threshold and time from original infection should be considered.
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Jacob J, Buddhdev B, Hashimi S, Swanson K, Oklu R, Mayer J, Smith M, D'Cunha J, Tokman S, Schaheen L. Never Say Never: A 3D Anatomic Model Creates a Surgical Roadmap for Ultra-Complex Lung Transplant Recipient. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Razia D, Jacob J, Mohamed H, Tokman S. Parvovirus B19: A Potential Cause of Refractory Leukopenia in Lung Transplant Recipients. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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22
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Razia D, Omar A, Tokman S. Relapsed Nocardiosis Presenting as Acute Vision Loss. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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23
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Meza L, Walia R, Buddhdev B, Muley S, Tokman S. Progressive Multifocal Leukoencephalopathy Presenting as Expressive Aphasia in a Lung Transplant Recipient. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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24
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Razia D, Mittal SK, Bansal S, Ravichandran R, Smith MA, Walia R, Bremner RM, Mohanakumar T, Tokman S. Lung Transplant Candidates With Pretransplant Gastroesophageal Reflux and Antibodies to Lung Self-antigens Have Shorter CLAD-free Survival After Transplant. Transplant Direct 2022; 8:e1294. [PMID: 35187218 PMCID: PMC8845115 DOI: 10.1097/txd.0000000000001294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 12/03/2022] Open
Abstract
Pre–lung transplant (LTx) gastroesophageal reflux (GER) and circulating antibodies against the lung self-antigens (SAbs) collagen V and K-alpha-1 tubulin may predispose recipients to chronic lung allograft dysfunction (CLAD). We aimed to study the association of pre-LTx GER or pre-LTx SAbs with CLAD.
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25
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Bansal S, Arjuna A, Perincheri S, Poulson C, Bremner RM, Smith MA, Tokman S, Mohanakumar T. Restrictive allograft syndrome vs bronchiolitis obliterans syndrome: Immunological and molecular characterization of circulating exosomes. J Heart Lung Transplant 2022; 41:24-33. [PMID: 34602310 PMCID: PMC11019888 DOI: 10.1016/j.healun.2021.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 08/16/2021] [Accepted: 09/02/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Chronic lung allograft dysfunction in lung transplant recipients (LTxRs) has 2 phenotypes: obstructive bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS). Our goal was to define distinct immunologic markers of exosomes from LTxRs with BOS or RAS. METHODS Plasma was collected from LTxRs with BOS (n = 18), RAS (n = 13), and from stable LTxRs (n = 5). Antibodies to lung self-antigens (SAgs) were determined by ELISA. Exosomes were isolated by ultracentrifugation. Donor specific antibodies to HLA were quantified using Luminex. Exosomes were characterized for lung SAgs, transcription factors, 20S proteasome, HLA class I and II, and polymeric immunoglobulin receptor protein using western blot. Exosome miRNA was analyzed using NanoString. The exosome-induced immune response was determined in mice. RESULTS LTxRs with RAS, but not BOS, had donor specific antibodies at diagnosis. CIITA, NFkB, polymeric immunoglobulin receptor protein, 20S proteasome, HLA-DQ, and HLA-DR were significantly higher in RAS exosomes than in BOS exosomes. RAS plasma had high levels of proinflammatory cytokines and distinct exosomal miRNA. Immunization of C57BL/6 mice with RAS exosomes showed severe inflammation and peribronchial fibrosis, whereas BOS exosomes induced patchy inflammation and fibrosis. CONCLUSION LTxRs with BOS or RAS had exosomes with distinct molecular and immunologic profiles. RAS samples had a higher concentration of proinflammatory factors, HLA class II, lung SAgs, and antibodies to HLA class II molecules, indicating severe allograft injury. Mice immunized with RAS exosomes developed lesions in airways, pleura, interlobular septum, and alveoli, whereas BOS exosomes induced mild to patchy inflammation with lung fibrosis.
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Affiliation(s)
- Sandhya Bansal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ashwini Arjuna
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Sudhir Perincheri
- Department of Pathology and Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Christin Poulson
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael A Smith
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Sofya Tokman
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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26
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Bansal S, Tokman S, Fleming T, Maine GN, Sanborn K, Hachem R, Bharat A, Smith MA, Bremner RM, Mohanakumar T. SARS-CoV-2 infection in lung transplant recipients induces circulating exosomes with SARS-CoV-2 spike protein S2. Clin Transl Med 2021; 11:e576. [PMID: 34841719 PMCID: PMC8567032 DOI: 10.1002/ctm2.576] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/31/2021] [Accepted: 09/06/2021] [Indexed: 11/18/2022] Open
Affiliation(s)
- Sandhya Bansal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Sofya Tokman
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Timothy Fleming
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Gabriel N Maine
- Department of Pathology and Laboratory Medicine, Beaumont Health, Royal Oak, Michigan
| | - Kristina Sanborn
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ramsey Hachem
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Ankit Bharat
- Department of Surgery, Northwestern University, Chicago, Illinois
| | - Michael A Smith
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - T Mohanakumar
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Crespo MM, Lease ED, Sole A, Sandorfi N, Snyder LD, Berry GJ, Pavec JL, Venado AE, Cifrian JM, Goldberg H, Dilling DF, Gries C, Nair A, Willie K, Meyer KC, Shah RJ, Tokman S, Holm A, Patterson CM, McWilliams T, Shtraichman O, Bemiss B, Salgado J, Farver C, Strah H, Wassilew K, Kaza V, Howsare M, Murray M, Bhorade S, Budev M. ISHLT consensus document on lung transplantation in patients with connective tissue disease: Part I: Epidemiology, assessment of extrapulmonary conditions, candidate evaluation, selection criteria, and pathology statements. J Heart Lung Transplant 2021; 40:1251-1266. [PMID: 34417111 DOI: 10.1016/j.healun.2021.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 12/16/2022] Open
Abstract
Patients with connective tissue disease (CTD) and advanced lung disease are often considered suboptimal candidates for lung transplantation (LTx) due to their underlying medical complexity and potential surgical risk. There is substantial variability across LTx centers regarding the evaluation and listing of these patients. The International Society for Heart and Lung Transplantation-supported consensus document on lung transplantation in patients with CTD standardization aims to clarify definitions of each disease state included under the term CTD, to describe the extrapulmonary manifestations of each disease requiring consideration before transplantation, and to outline the absolute contraindications to transplantation allowing risk stratification during the evaluation and selection of candidates for LTx.
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Affiliation(s)
- Maria M Crespo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania,.
| | - Erika D Lease
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Amparo Sole
- Lung Transplant Unit, University Hospital la Fe, Universitat de Valencia, Valencia, Spain
| | - Nora Sandorfi
- Division of Rheumatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laurie D Snyder
- Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina
| | - Gerald J Berry
- Department of Pathology, Stanford University Health Care, Stanford, California
| | - Jérôme Le Pavec
- Department of Pulmonology, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - Aida E Venado
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco Medical Center, San Francisco, California
| | - Jose M Cifrian
- Department of Pulmonary, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Hilary Goldberg
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Daniel F Dilling
- Division of Pulmonary and Critical Care Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | | | - Arun Nair
- Institute of Transplantation,Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Keith Willie
- Department of Pulmonology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Keith C Meyer
- Division of Pulmonary, University of Wisconsin, Madison, Wisconsin
| | - Rupal J Shah
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco Medical Center, San Francisco, California
| | - Sofya Tokman
- Division of Pulmonary and Critical Care, St Joseph Hospital, Phoenix, Arizona
| | - Are Holm
- Oslo University Hospital, Oslo, Norway
| | | | | | | | - Brad Bemiss
- Division of Pulmonary and Critical Care Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Juan Salgado
- Division of Pulmonary, Allergy, and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Carol Farver
- Department of Pathology, University of Michigan Health System, Ann Arbor, Michigan
| | - Heather Strah
- Division of Pulmonary and Critical Care, University of Nebraska Medical Center, Omaha, Nebraska
| | | | | | - Molly Howsare
- Division of Pulmonary and Critical Care, Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | | | - Marie Budev
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
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Bansal S, Tokman S, Arjuna A, Sanborn K, Bremner R, Smith M, Mohanakumar T. A Comparison of Serological Markers and Exosome Content between Lung Transplant Recipients with BOS and RAS. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Razia D, Arjuna A, Omar A, Buddhdev B, Abdelrazek H, Walia R, Tokman S. Carfilzomib-Induced Pneumotoxicity in a Lung Transplant Recipient. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.2052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Olson M, Omar A, Tokman S, Carigo J, Walia R, Arjuna A. Two Cases of Spontaneous Bleeding in Lung Transplant Recipients Treated with Systemic Anticoagulation for COVID-19. J Heart Lung Transplant 2021. [PMCID: PMC7979401 DOI: 10.1016/j.healun.2021.01.2038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction COVID-19 promotes inflammation and a hypercoagulable state. Antithrombotic therapies may be administered for thromboprophylaxis in those with severe infection requiring hospitalization. Spontaneous bleeding is an infrequent, yet life-threatening complication in patients receiving systemic anticoagulation. Case Report Two bilateral lung transplant recipients - 77-year-old female with idiopathic pulmonary fibrosis (patient A) and 69-year-old male with chronic obstructive pulmonary disease (patient B) - each presented with several days’ history of dyspnea, cough, and fatigue at 29-months and 11-months post-transplant, respectively; RT-PCR was positive for SARS-CoV-2 infection in both. Over the course of the next few days, patient A rapidly deteriorated with need for intubation despite initial treatment with antibiotics and corticotherapy. Patient B experienced gradual worsening of respiratory symptoms, which required high-flow oxygen supplementation and IV antibiotics. Inflammatory markers were elevated in both patients, and CT of the chest was consistent with atypical pneumonia in each. Patient A received convalescent plasma as a rescue therapy, and patient B received remdesivir with convalescent plasma. Given the hypercoagulable state in each, patient A and B received enoxaparin and IV heparin, respectively. Slowly, hemoglobin and platelet counts dropped in both patients, with need for transfusion and hemodynamic support. CT of the abdomen revealed a left gluteal intramuscular hematoma in patient A; CT of the chest, abdomen, and pelvis revealed a spontaneous chest wall hematoma and small area of retroperitoneal bleeding in patient B (Figure 1A and B). Summary These cases raise awareness for the viral-induced hypercoagulable state observed during the disease course. Clinicians should be cautious to avoid any hemorrhagic complications associated with thromboprophylaxis in selected cases, particularly in at-risk immunosuppressed patients.
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Razia D, Tokman S, Omar A, Buddhdev B, Abdelrazek H, Walia R, Arjuna A. Coronary Thrombosis after Rabbit-ATG in LTx Recipient. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.2050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Razia D, Mittal S, Bremner R, Bansal S, Ravichandran R, Smith M, Walia R, Mohanakumar T, Tokman S. Pretransplant GERD-Induced Immune Response Predisposes to CLAD. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.1884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Buddhdev B, McAnally K, Tokman S. SARS-CoV-2 Re-Infection in a Lung Transplant Recipient. J Heart Lung Transplant 2021. [PMCID: PMC7979389 DOI: 10.1016/j.healun.2021.01.2037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introduction Since the onset of the SARS-CoV-2 pandemic, increasing evidence has shown waning immunity after initial SARS-CoV-2 infection, and re-infection in patients with a prior history of COVID-19 has been reported. We report a case of SARS-CoV-2 re-infection in a lung transplant recipient 3 months after initial illness. Case Report The patient is a 56-year-old man with a history of bilateral lung transplant in August 2018 for idiopathic pulmonary fibrosis. His post-transplant course was complicated by insulin-dependent diabetes mellitus (HbA1c 5.8%), chronic renal insufficiency (eGFR nadir 48 mL/min/1.73m2), and peripheral arterial disease requiring bilateral below-knee amputations. At the time of transplant, he was induced with basiliximab and remained on standard 3-drug immunosuppression with mycophenolate mofetil (500 mg BID), prednisone (5 mg daily), and tacrolimus. He contracted SARS-CoV-2 from his wife and tested positive for the virus on July 2, 2020 after presenting to the emergency department (ED) with headache, chills, nausea, body aches, shortness of breath, and generalized weakness. His oxygen saturation and chest X-ray were normal, and he was therefore discharged from the ED to recover at home. His symptoms resolved 17 days after diagnosis and serial SARS-CoV-2 testing via nasal washing were positive on July 16, 2020 and negative on July 30, 2020 and August 11, 2020. In addition, on October 21, 2020, he tested positive for SARS-CoV-2 antibodies (3.41, positive: index ≥1.4). On October 23, 2020, he presented to the ED with generalized chest pain, low-grade fever (100.1F), dyspnea, and weakness. His nasal swab was positive for SARS-CoV-2 and CT of the chest showed bibasilar ground-glass opacities consistent with atypical infection vs. atelectasis. His labs were notable for a CRP of 132 mg/L, ferritin of 2,307 ng/mL, LDH 304 units/L, D-dimer 240 ng/mL, and procalcitonin of 0.05 ng/mL. He was admitted for monitoring and treated with remdesivir, corticosteroids, and anticoagulation. Summary We present a case of SARS-CoV-2 re-infection 3 months after initial illness in a lung transplant recipient living in a high-incidence area. Unexpectedly, recurrent infection occurred despite development of SARS-CoV-2 antibodies. This case speaks to the vulnerability of this patient population to COVID-19 and the need for ongoing precautions to prevent infection even among patients who have seroconverted.
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Goodlet KJ, Bansal S, Arjuna A, Nailor MD, Buddhdev B, Abdelrazek H, Mohamed H, Omar A, Walia R, Mohanakumar T, Tokman S. COVID-19 in a lung transplant recipient: Exploring the diagnostic role of circulating exosomes and the clinical impact of advanced immunosuppression. Transpl Infect Dis 2020; 23:e13480. [PMID: 32997881 PMCID: PMC7536938 DOI: 10.1111/tid.13480] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 09/20/2020] [Indexed: 12/05/2022]
Abstract
Exosomes isolated from plasma of lung transplant recipients with allograft injury contain donor‐derived lung self‐antigens (collagen V and Kα1 tubulin) and human leukocyte antigen (HLA) molecules. We present a case of a 76‐year‐old, female lung transplant recipient treated for acute cellular rejection with methylprednisolone and anti‐thymocyte globulin, who subsequently contracted SARS‐CoV‐2 and developed a sharp increase in the mean fluorescent intensity of anti‐HLA antibodies. Analysis of circulating exosomes during rejection, but before SARS‐CoV‐2 infection, revealed the presence of lung self‐antigens and HLA class II molecules. After the patient contracted SARS‐CoV‐2, exosomes with the SARS‐CoV‐2 spike protein were also found. After resolution of infectious symptoms, exosomes with SARS‐CoV‐2 spike protein were no longer detected; however, exosomes with lung self‐antigens and HLA class II molecules persisted, which coincided with a progressive decline in spirometric flows, suggesting chronic lung allograft dysfunction. We propose that the analysis of circulating exosomes may be used to detect allograft injury mediated by both rejection and infection. Furthermore, the detection of exosomes containing viral proteins may be helpful in identifying allograft injury driven by viral pathogens.
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Affiliation(s)
- Kellie J Goodlet
- Department of Pharmacy Practice, College of Pharmacy, Midwestern University, Glendale, AZ, USA
| | - Sandhya Bansal
- Norton Thoracic Institute, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Ashwini Arjuna
- Norton Thoracic Institute, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Michael D Nailor
- Department of Pharmacy Services, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Bhuvin Buddhdev
- Norton Thoracic Institute, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Hesham Abdelrazek
- Norton Thoracic Institute, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Hesham Mohamed
- Norton Thoracic Institute, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Ashraf Omar
- Norton Thoracic Institute, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Rajat Walia
- Norton Thoracic Institute, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Thalachallour Mohanakumar
- Norton Thoracic Institute, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Sofya Tokman
- Norton Thoracic Institute, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
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Goodlet KJ, Tokman S, Nasar A, Cherrier L, Walia R, Nailor MD. Nocardia prophylaxis, treatment, and outcomes of infection in lung transplant recipients: A matched case-control study. Transpl Infect Dis 2020; 23:e13478. [PMID: 32989873 DOI: 10.1111/tid.13478] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 09/08/2020] [Accepted: 09/20/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND Lung transplant recipients are at heightened risk for nocardiosis compared to other solid organ transplant recipients, with incidence rates as high as 9% and up to 30% associated mortality. No controlled studies assessing risk factors for nocardiosis in this high-risk population have been reported. METHODS Patients undergoing lung transplantation at a single center between 2012 and 2018 and diagnosed with nocardiosis post-transplant were matched 1:2 to uninfected control subjects on the basis of age, transplant date, and sex. RESULTS The incidence of nocardiosis in this lung transplant population was 3.4% (20/586), occurring a median of 9.4 months (range 4.4-55.2) post-transplant. In multivariable analysis, consistent use of trimethoprim/sulfamethoxazole (TMP/SMX) in the 12 weeks prior to diagnosis was independently associated with protection against nocardiosis (OR 0.038; 95% CI 0.01-0.29; P = .002). Augmented immunosuppression in the 6 months prior to diagnosis was independently associated with the development of nocardiosis (OR 9.94; 95% CI 1.62- 61.00; P = .013). Six case patients (30%) had disseminated disease; all-cause 6-month mortality was 25%. The most common species was Nocardia farcinica (7/17 isolates), which was associated with dissemination and mortality. The most active antibiotics were TMP/SMX (100%), linezolid (100%), and amikacin (76%). Imipenem was only active against 4/17 isolates (24% susceptibility), with two isolates becoming non-susceptible later in therapy. CONCLUSIONS Trimethoprim/sulfamethoxazole prophylaxis was shown to be protective against nocardiosis in lung transplant recipients, while augmented immunosuppression conferred increased risk. Institutional epidemiologic data are needed to best guide empiric therapy for Nocardia, as historical in vitro data may not predict local susceptibilities.
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Affiliation(s)
- Kellie J Goodlet
- Department of Pharmacy Practice, College of Pharmacy, Midwestern University, Glendale, AZ, USA
| | - Sofya Tokman
- Division of Transplant Pulmonology, Norton Thoracic Institute, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Aasya Nasar
- Division of Transplant Pulmonology, Norton Thoracic Institute, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.,Department of Pharmacy Services, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Lauren Cherrier
- Division of Transplant Pulmonology, Norton Thoracic Institute, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.,Department of Pharmacy Services, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Rajat Walia
- Division of Transplant Pulmonology, Norton Thoracic Institute, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Michael D Nailor
- Department of Pharmacy Services, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
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Rahman M, Sureshbabu A, Tokman S, Mohanakumar T. Chronic Lung Allograft Dysfunction: Immune Responses Induced by Circulating Exosomes with Lung-Associated Self-Antigens. Crit Rev Immunol 2020; 39:123-134. [PMID: 31679252 DOI: 10.1615/critrevimmunol.2019030635] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Exosomes, nanovesicles shown to regulate physiological processes in vivo, have been implicated in pathological conditions including cancer, autoimmune disease, infectious disease, neurodegenerative disease, and allograft rejection. Studies of lung transplant recipients with primary graft dysfunction, respiratory viral infection, and (acute) rejection have demonstrated circulating exosomes containing donor-mismatched human leukocyte antigen and lung-associated self-antigens, K-alpha 1 tubulin and collagen V, indicating that exosomes are originating from the transplanted organ. These circulating exosomes likely play a role in activating immune responses that lead to increased risk of chronic lung allograft dysfunction, as exosomes efficiently present their antigens to the immune system by all known pathways of antigen recognition (i.e., direct, indirect, and semidirect pathways). Here, we discuss exosome biogenesis, describe their contents, and address the mechanism of exosome-mediated activation of immune responses that lead to allograft rejection, especially after lung transplantation.
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Affiliation(s)
- Mohammad Rahman
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix AZ
| | - Angara Sureshbabu
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix AZ
| | - Sofya Tokman
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix AZ
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Sharma M, Gunasekaran M, Ravichandran R, Fisher CE, Limaye AP, Hu C, McDyer J, Kaza V, Bharat A, Tokman S, Omar A, Arjuna A, Walia R, Bremner RM, Smith MA, Hachem RR, Mohanakumar T. Circulating exosomes with lung self-antigens as a biomarker for chronic lung allograft dysfunction: A retrospective analysis. J Heart Lung Transplant 2020; 39:1210-1219. [PMID: 32713614 DOI: 10.1016/j.healun.2020.07.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [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: 05/07/2020] [Revised: 06/18/2020] [Accepted: 07/01/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Exosomes isolated from plasma of lung transplant recipients (LTxRs) with bronchiolitis obliterans syndrome (BOS) contain human leukocyte antigens and lung self-antigens (SAgs), K-alpha 1 tubulin (Kα1T) and collagen type V (Col-V). The aim was to determine the use of circulating exosomes with lung SAgs as a biomarker for BOS. METHODS Circulating exosomes were isolated retrospectively from plasma from LTxRs at diagnosis of BOS and at 6 and 12 months before the diagnosis (n = 41) and from stable time-matched controls (n = 30) at 2 transplant centers by ultracentrifugation. Exosomes were validated using Nanosight, and lung SAgs (Kα1T and Col-V) were detected by immunoblot and semiquantitated using ImageJ software. RESULTS Circulating exosomes from BOS and stable LTxRs demonstrated 61- to 181-nm vesicles with markers Alix and CD9. Exosomes from LTxRs with BOS (n = 21) showed increased levels of lung SAgs compared with stable (n = 10). A validation study using 2 separate cohorts of LTxRs with BOS and stable time-matched controls from 2 centers also demonstrated significantly increased lung SAgs-containing exosomes at 6 and 12 months before BOS. CONCLUSIONS Circulating exosomes isolated from LTxRs with BOS demonstrated increased levels of lung SAgs (Kα1T and Col-V) 12 months before the diagnosis (100% specificity and 90% sensitivity), indicating that circulating exosomes with lung SAgs can be used as a non-invasive biomarker for identifying LTxRs at risk for BOS.
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Affiliation(s)
- Monal Sharma
- Norton Thoracic Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | | | | | - Cynthia E Fisher
- Deparment of Medicine, University of Washington, Seattle, Washington
| | - Ajit P Limaye
- Deparment of Medicine, University of Washington, Seattle, Washington
| | - Chengcheng Hu
- Department of Epidemiology and Biostatistics, University of Arizona, Phoenix, Arizona
| | - John McDyer
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vaidehi Kaza
- Internal Medicine-Pulmonary Disease, University of Texas Southwestern, Dallas, Texas
| | - Ankit Bharat
- Department of Surgery-Thoracic, Northwestern University, Chicago, Illinois
| | - Sofya Tokman
- Norton Thoracic Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ashraf Omar
- Norton Thoracic Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ashwini Arjuna
- Norton Thoracic Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Rajat Walia
- Norton Thoracic Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ross M Bremner
- Norton Thoracic Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael A Smith
- Norton Thoracic Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ramsey R Hachem
- Department of Internal Medicine, Washington University Medical School, St Louis, Missouri
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Goodlet K, Tokman S, Nasar A, Cherrier L, Walia R, Nailor M. High Rate of Imipenem Non-Susceptibility among Clinical Nocardia spp. Isolated from Lung Transplant Recipients. J Heart Lung Transplant 2020. [DOI: 10.1016/j.healun.2020.01.841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Crow LD, Jambusaria‐Pahlajani A, Chung CL, Baran DA, Lowenstein SE, Abdelmalek M, Ahmed RL, Anadkat MJ, Arcasoy SM, Berg D, Bibee KP, Billingsley E, Black WH, Blalock TW, Bleicher M, Brennan DC, Brodland DG, Brown MR, Carroll BT, Carucci JA, Chang TW, Chaux G, Cusack CA, Dilling DF, Doyle A, Emtiazjoo AM, Ferguson NH, Fosko SW, Fox MC, Goral S, Gray AL, Griffin JR, Hachem RR, Hall SA, Hanlon AM, Hayes D, Hickey GW, Holtz J, Hopkins RS, Hu J, Huang CC, Brian Jiang SI, Kapnadak SG, Kraus ES, Lease ED, Leca N, Lee JC, Leitenberger JJ, Lim MA, Longo MI, Malik SM, Mallea JM, Menter A, Myers SA, Neuburg M, Nijhawan RI, Norman DJ, Otley CC, Paek SY, Parulekar AD, Patel MJ, Patel VA, Patton TJ, Pugliano‐Mauro M, Ranganna K, Ravichandran AK, Redenius R, Roll GR, Samie FH, Shin T, Singer JP, Singh P, Soon SL, Soriano T, Squires R, Stasko T, Stein JA, Taler SJ, Terrault NA, Thomas CP, Tokman S, Tomic R, Twigg AR, Wigger MA, Zeitouni NC, Arron ST. Initial skin cancer screening for solid organ transplant recipients in the United States: Delphi method development of expert consensus guidelines. Transpl Int 2019; 32:1268-1276. [DOI: 10.1111/tri.13520] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 03/25/2019] [Accepted: 09/02/2019] [Indexed: 12/25/2022]
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Glanville AR, Verleden GM, Todd JL, Benden C, Calabrese F, Gottlieb J, Hachem RR, Levine D, Meloni F, Palmer SM, Roman A, Sato M, Singer LG, Tokman S, Verleden SE, von der Thüsen J, Vos R, Snell G. Chronic lung allograft dysfunction: Definition and update of restrictive allograft syndrome-A consensus report from the Pulmonary Council of the ISHLT. J Heart Lung Transplant 2019; 38:483-492. [PMID: 31027539 DOI: 10.1016/j.healun.2019.03.008] [Citation(s) in RCA: 156] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 03/18/2019] [Indexed: 02/07/2023] Open
Affiliation(s)
- Allan R Glanville
- Lung Transplant Unit, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | | | - Jamie L Todd
- Division of Pulmonary, Allergy and Critical Care Medicine, Duke University, Durham, North Carolina, USA
| | | | - Fiorella Calabrese
- Department of Cardiothoracic and Vascular Sciences, University of Padova Medical School, Padova, Italy
| | - Jens Gottlieb
- Department of Respiratory Medicine, Hannover Medical School, Member of the German Center for Lung Research, Hannover, Germany
| | - Ramsey R Hachem
- Division of Pulmonary & Critical Care, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Deborah Levine
- Pulmonary Disease and Critical Care Medicine, University of Texas Health Science Center San Antonio, San Antonio, Texas, USA
| | - Federica Meloni
- Department of Respiratory Diseases Policlinico San Matteo Foundation & University of Pavia, Pavia, Italy
| | - Scott M Palmer
- Division of Pulmonary, Allergy and Critical Care Medicine, Duke University, Durham, North Carolina, USA
| | - Antonio Roman
- Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Masaaki Sato
- Department of Thoracic Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sofya Tokman
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | | | - Jan von der Thüsen
- Department of Pathology, University Medical Center, Rotterdam, The Netherlands
| | - Robin Vos
- University Hospital Gasthuisberg, Leuven, Belgium
| | - Gregory Snell
- Lung Transplant Service, The Alfred Hospital, Melbourne, Victoria, Australia
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Cherrier L, Nasar A, Goodlet KJ, Nailor MD, Tokman S, Chou S. Emergence of letermovir resistance in a lung transplant recipient with ganciclovir-resistant cytomegalovirus infection. Am J Transplant 2018; 18:3060-3064. [PMID: 30286286 PMCID: PMC6263820 DOI: 10.1111/ajt.15135] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [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: 08/16/2018] [Revised: 09/25/2018] [Accepted: 09/27/2018] [Indexed: 01/25/2023]
Abstract
Following a year of valganciclovir prophylaxis, a lung transplant recipient developed cytomegalovirus (CMV) infection that became resistant to ganciclovir, as confirmed by detection of UL97 kinase mutation M460V and a previously uncharacterized UL54 DNA polymerase mutation L516P. The latter mutation is now shown to confer ganciclovir and cidofovir resistance. As predicted from the viral genotype, foscarnet therapy was effective, but resumption of valganciclovir as secondary prophylaxis resulted in a plasma viral load rebound to 3.6 log10 copies/mL several weeks later. Valganciclovir was then replaced by letermovir, resulting in gradual viral load reduction in the first 5 weeks to below the quantitation limit (2.7 log10 copies/mL) for 1 week, followed by 10 weeks of rising viral loads reaching 4.3 log10 copies/mL while on letermovir. At this point, CMV genotypic testing revealed UL56 mutation C325Y, which confers absolute resistance to letermovir. Retreatment with foscarnet was successful. This case adds to the considerable list of proven ganciclovir resistance mutations, and provides an early experience with letermovir resistance after off-label therapeutic use. This experience is consistent with in vitro observations of rapid emergence of letermovir-resistant CMV after drug exposure.
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Affiliation(s)
- Lauren Cherrier
- Department of Pharmacy Services, Dignity Health, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, USA
| | - Aasya Nasar
- Department of Pharmacy Services, Dignity Health, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kellie J. Goodlet
- Department of Pharmacy Practice, College of Pharmacy, Midwestern University, Glendale, Arizona, USA
| | - Michael D. Nailor
- Department of Pharmacy Services, Dignity Health, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, USA
| | - Sofya Tokman
- Division of Transplant Pulmonology, Norton Thoracic Institute, Dignity Health, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, USA
| | - Sunwen Chou
- Oregon Health & Science University and Portland VA Health Care System, Oregon, USA
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Goodlet KJ, Nailor MD, Omar A, Huang JL, LiPuma JJ, Walia R, Tokman S. Successful Lung Re-transplant in a Patient with Cepacia Syndrome due to Burkholderia ambifaria. J Cyst Fibros 2018; 18:e1-e4. [PMID: 30224331 DOI: 10.1016/j.jcf.2018.08.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 07/05/2018] [Accepted: 08/27/2018] [Indexed: 11/17/2022]
Abstract
Chronic airway inflammation and infection drive morbidity and mortality among patients with cystic fibrosis (CF). While Haemophilus influenzae and Staphylococcus aureus predominate in children, the prevalence of Pseudomonas aeruginosa increases as patients age. Other bacteria, including species within the Burkholderia cepacia complex (Bcc), are also more prevalent among adults with CF. Species within the Bcc accelerate lung function decline and can trigger development of "cepacia syndrome," both before and after lung transplantation. As a result, some centers advise against lung transplantation for Bcc-infected patients; however, little is known about the relative virulence of uncommon Bcc species. We describe a successful lung re-transplant in a patient with CF, chronic Burkholderia ambifaria airway infection, and cepacia syndrome.
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Affiliation(s)
- Kellie J Goodlet
- Department of Pharmacy Practice, College of Pharmacy, Midwestern University, Glendale, AZ, United States
| | - Michael D Nailor
- Deparment of Pharmacy Services, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Ashraf Omar
- Division of Transplant Pulmonology, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Jasmine L Huang
- Division of Transplant Surgery, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - John J LiPuma
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Rajat Walia
- Division of Transplant Pulmonology, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Sofya Tokman
- Division of Transplant Pulmonology, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States.
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Tokman S, Smith MA, Hashimi AS, Omar A. A 46-Year-Old Man With Dyspnea, Hypoxemia, and Radiographic Asymmetry After Redo Bilateral Lung Transplantation. Chest 2017; 151:e91-e94. [PMID: 28390643 DOI: 10.1016/j.chest.2016.09.013] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 08/23/2016] [Accepted: 09/21/2016] [Indexed: 10/19/2022] Open
Abstract
CASE PRESENTATION A 46-year-old man underwent redo bilateral sequential lung transplantation for rapidly progressive bronchiolitis obliterans syndrome that developed 3.5 years after initial transplantation. In the operating room, he was sedated and intubated with a dual lumen endotracheal tube with subsequent single right-lung ventilation and left allograft implantation. His pulmonary arterial pressure became elevated with reperfusion of the newly implanted left lung, which required initiation of cardiopulmonary bypass to facilitate implantation of the right lung. After implantation and reperfusion of the right lung, the patient was weaned from cardiopulmonary bypass. His chest was closed and he was transferred to the thoracic intensive care unit. On arrival to the intensive care unit, the patient was intubated, sedated, and had an oxygen saturation of 92% on a fraction of inspired oxygen of 100%, positive end-expiratory pressure of 10 cm H2O, and 20 parts per million of inhaled nitric oxide. He had a Swan-Ganz catheter in the right internal jugular vein that measured a mean pulmonary arterial pressure of 33 mm Hg and a pulmonary arterial systolic pressure of 63 mm Hg, which remained persistently elevated and prompted further diagnostic evaluation.
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Affiliation(s)
- Sofya Tokman
- Division of Pulmonary and Critical Care Medicine, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ.
| | - Michael A Smith
- Division of Thoracic Surgery, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - A Samad Hashimi
- Division of Thoracic Surgery, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Ashraf Omar
- Division of Pulmonary and Critical Care Medicine, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
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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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Singer JP, Diamond JM, Gries CJ, McDonnough J, Blanc PD, Shah R, Dean MY, Hersh B, Wolters PJ, Tokman S, Arcasoy SM, Ramphal K, Greenland JR, Smith N, Heffernan P, Shah L, Shrestha P, Golden JA, Blumenthal NP, Huang D, Sonett J, Hays S, Oyster M, Katz PP, Robbins H, Brown M, Leard LE, Kukreja J, Bacchetta M, Bush E, D'Ovidio F, Rushefski M, Raza K, Christie JD, Lederer DJ. Frailty Phenotypes, Disability, and Outcomes in Adult Candidates for Lung Transplantation. Am J Respir Crit Care Med 2016; 192:1325-34. [PMID: 26258797 DOI: 10.1164/rccm.201506-1150oc] [Citation(s) in RCA: 160] [Impact Index Per Article: 20.0] [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: 12/11/2022] Open
Abstract
RATIONALE Frailty is associated with morbidity and mortality in abdominal organ transplantation but has not been examined in lung transplantation. OBJECTIVES To examine the construct and predictive validity of frailty phenotypes in lung transplant candidates. METHODS In a multicenter prospective cohort, we measured frailty with the Fried Frailty Phenotype (FFP) and Short Physical Performance Battery (SPPB). We evaluated construct validity through comparisons with conceptually related factors. In a nested case-control study of frail and nonfrail subjects, we measured serum IL-6, tumor necrosis factor receptor 1, insulin-like growth factor I, and leptin. We estimated the association between frailty and disability using the Lung Transplant Valued Life Activities disability scale. We estimated the association between frailty and risk of delisting or death before transplant using multivariate logistic and Cox models, respectively. MEASUREMENTS AND MAIN RESULTS Of 395 subjects, 354 completed FFP assessments and 262 completed SPPB assessments; 28% were frail by FFP (95% confidence interval [CI], 24-33%) and 10% based on the SPPB (95% CI, 7-14%). By either measure, frailty correlated more strongly with exercise capacity and grip strength than with lung function. Frail subjects tended to have higher plasma IL-6 and tumor necrosis factor receptor 1 and lower insulin-like growth factor I and leptin. Frailty by either measure was associated with greater disability. After adjusting for age, sex, diagnosis, and transplant center, both FFP and SPPB were associated with increased risk of delisting or death before lung transplant. For every 1-point worsening in score, hazard ratios were 1.30 (95% CI, 1.01-1.67) for FFP and 1.53 (95% CI, 1.19-1.59) for SPPB. CONCLUSIONS Frailty is prevalent among lung transplant candidates and is independently associated with greater disability and an increased risk of delisting or death.
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Affiliation(s)
| | | | - Cynthia J Gries
- 3 Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | | | | | - Beverly Hersh
- 3 Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | | | | | | | - Nancy Smith
- 5 Department of Surgery, College of Physicians and Surgeons, and
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Jasleen Kukreja
- 6 Department of Surgery, University of California, San Francisco, San Francisco, California
| | | | - Errol Bush
- 6 Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Frank D'Ovidio
- 5 Department of Surgery, College of Physicians and Surgeons, and
| | | | | | - Jason D Christie
- 2 Department of Medicine and.,7 Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - David J Lederer
- 4 Department of Medicine.,8 Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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Tokman S, Singer JP, Devine MS, Westall GP, Aubert JD, Tamm M, Snell GI, Lee JS, Goldberg HJ, Kukreja J, Golden JA, Leard LE, Garcia CK, Hays SR. Clinical outcomes of lung transplant recipients with telomerase mutations. J Heart Lung Transplant 2015; 34:1318-24. [PMID: 26169663 DOI: 10.1016/j.healun.2015.05.002] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [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: 02/06/2015] [Revised: 04/02/2015] [Accepted: 05/01/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Successful lung transplantation for patients with pulmonary fibrosis from telomerase mutations may be limited by systemic complications of telomerase dysfunction, including myelosuppression, cirrhosis, and malignancy. We describe clinical outcomes in 14 lung transplant recipients with telomerase mutations. METHODS Subjects underwent lung transplantation between February 2005 and April 2014 at 5 transplant centers. Data were abstracted from medical records, focusing on outcomes reflecting post-transplant treatment effects likely to be complicated by telomerase mutations. RESULTS The median age of subjects was 60.5 years (interquartile range = 52.0-62.0), 64.3% were male, and the mean post-transplant observation time was 3.2 years (SD ± 2.9). A mutation in telomerase reverse transcriptase was present in 11 subjects, a telomerase RNA component mutation was present in 2 subjects, and an uncharacterized mutation was present in 1 subject. After lung transplantation, 10 subjects were leukopenic and 5 did not tolerate lymphocyte anti-proliferative agents. Six subjects developed recurrent lower respiratory tract infections, 7 developed acute cellular rejection (A1), and 4 developed chronic lung allograft dysfunction. Eight subjects developed at least 1 episode of acute renal failure and 10 developed chronic renal insufficiency. In addition, 3 subjects developed cancer. No subjects had cirrhosis. At data censorship, 13 subjects were alive. CONCLUSIONS The clinical course for lung transplant recipients with telomerase mutations is complicated by renal disease, leukopenia with intolerance of lymphocyte anti-proliferative agents, and recurrent lower respiratory tract infections. In contrast, cirrhosis was absent, acute cellular rejection was mild, and development of chronic lung allograft dysfunction was comparable to other lung transplant recipients. Although it poses challenges, lung transplantation may be feasible for patients with pulmonary fibrosis from telomerase mutations.
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Affiliation(s)
- Sofya Tokman
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco Medical Center, San Francisco, California.
| | - Jonathan P Singer
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco Medical Center, San Francisco, California
| | - Megan S Devine
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Glen P Westall
- Division of Respiratory Medicine, Alfred Hospital, Melbourne, Australia
| | - John-David Aubert
- Division of Respiratory Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Michael Tamm
- Division of Respiratory Medicine, Basel University Hospital, Basel, Switzerland
| | - Gregory I Snell
- Division of Respiratory Medicine, Alfred Hospital, Melbourne, Australia
| | - Joyce S Lee
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco Medical Center, San Francisco, California
| | - Hilary J Goldberg
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jasleen Kukreja
- Division of Cardiothoracic Surgery, University of California, San Francisco Medical Center, San Francisco, California
| | - Jeffrey A Golden
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco Medical Center, San Francisco, California
| | - Lorriana E Leard
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco Medical Center, San Francisco, California
| | - Christine K Garcia
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Steven R Hays
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco Medical Center, San Francisco, California
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Tokman S, Barnett CF, Jarlsberg LG, Taub PR, den Boon S, Davis JL, Cattamanchi A, Worodria W, Maisel A, Huang L. Procalcitonin predicts mortality in HIV-infected Ugandan adults with lower respiratory tract infections. Respirology 2014; 19:382-8. [PMID: 24460728 DOI: 10.1111/resp.12237] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [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: 06/21/2013] [Revised: 07/24/2013] [Accepted: 11/03/2013] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND OBJECTIVE In low and middle-income countries where HIV infection is prevalent, identifying patients at high risk of dying from lower respiratory tract infections is challenging and validated prognostic models are lacking. Serum procalcitonin may be a useful prognostic tool in these settings. We sought to determine if elevated serum procalcitonin is associated with increased in-hospital mortality and to combine serum procalcitonin with available clinical characteristics to create a clinically useful prognostic model. METHODS We conducted a prospective, nested case-control study of 241 HIV-infected adults admitted to Mulago Hospital in Kampala, Uganda with cough ≥2 weeks in duration. We collected demographic and clinical information, baseline serum for procalcitonin analysis, and followed patients to determine in-hospital mortality. RESULTS Serum procalcitonin was a strong and independent predictor of inpatient mortality (aOR = 7.69, p = 0.01, sensitivity = 93%, negative predictive value = 97%). Best subset multivariate analysis identified 3 variables that were combined into a prognostic model to risk stratify patients; these variables included respiratory rate ≥30 breaths/minute (aOR = 2.07, p = 0.11), oxygen saturation <90% (aOR = 3.07, p = 0.02), and serum procalcitonin >0.5 ng/ml (aOR = 7.69, p = 0.01). The predicted probability of inpatient mortality ranged from 1% when no variables were present, to 42% when all variables were present. CONCLUSIONS Elevated serum procalcitonin >0.5 ng/ml is an independent predictor of in-hospital mortality. Elevated serum procalcitonin, tachypnea, and hypoxemia may be combined into a prognostic model to identify patients at high risk of dying in the hospital. This model may be used to estimate the probability of death and to guide triage and treatment decisions.
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Affiliation(s)
- Sofya Tokman
- Department of Internal Medicine, University of California, San Francisco, CA, USA; Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, CA, USA
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Tokman S, Schuetz P, Bent S. Procalcitonin-guided antibiotic therapy for chronic obstructive pulmonary disease exacerbations. Expert Rev Anti Infect Ther 2014; 9:727-35. [DOI: 10.1586/eri.11.45] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kharas GB, Crawford AL, Bernal R, Kallal L, Thomas V, Tokman S, Trnka MC, Hyland LA, Hughes P, Carney J, Trujillo AM, Hanks M, Watson K. Novel co-polymers of vinyl acetate and alkyl ring-substituted methyl 2-cyano-3-phenyl-2-propenoates. Des Monomers Polym 2012. [DOI: 10.1163/1568555053603260] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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