Cyclosporine C2 monitoring improves renal dysfunction after lung transplantation

A review of landmark studies on maintenance immunosuppressive regimens in kidney transplantation

Immunosuppressive medications play a pivotal role in kidney transplantation, and the calcineurin inhibitors (CNIs), including cyclosporine A (CsA) and tacrolimus (TAC), are considered as the backbone of maintenance immunosuppressive regimens. Since the introduction of CNIs in kidney transplantation, the incidence of acute rejection has decreased, and allograft survival has improved significantly. However, CNI nephrotoxicity has been a major concern, believed to heavily impact long-term allograft survival and function. To address this concern, several CNI-sparing regimens were developed and studied in randomized, controlled, clinical trials, aiming to reduce CNI exposure and preserve long-term allograft function. However, more recent information has revealed that CNI nephrotoxicity is not the primary cause of late allograft failure, and its histopathology is neither specific nor pathognomonic. In this review, we discuss the historical development of maintenance immunosuppressive regimens in kidney transplantation, covering the early era of transplantation, the CNI-sparing era, and the current era where the alloimmune response, rather than CNI nephrotoxicity, appears to be the major contributor to late allograft failure. Our goal is to provide a chronological overview of the development of maintenance immunosuppressive regimens and summarize the most recent information for clinicians caring for kidney transplant recipients (KTRs).

Everolimus Versus Mycophenolate Mofetil De Novo After Lung Transplantation: A Prospective, Randomized, Open-Label Trial

The role of mammalian target of rapamycin (mTOR) inhibitors in de novo immunosuppression after lung transplantation is not well defined. We compared Everolimus versus mycophenolate mofetil in an investigator-initiated single-center trial in Hannover, Germany. A total of 190 patients were randomly assigned 1:1 on day 28 posttransplantation to mycophenolate mofetil (MMF) or Everolimus combined with cyclosporine A (CsA) and steroids. Patients were followed up for 2 years. The primary endpoint was freedom from bronchiolitis obliterans syndrome (BOS). The secondary endpoints were incidence of acute rejections, infections, treatment failure and kidney function. BOS-free survival in intention-to-treat (ITT) analysis was similar in both groups (p = 0.174). The study protocol was completed by 51% of enrolled patients. The per-protocol analysis shows incidence of bronchiolitis obliterans syndrome (BOS): 1/43 in the Everolimus group and 8/54 in the MMF group (p = 0.041). Less biopsy-proven acute rejection (AR) (p = 0.005), cytomegalovirus (CMV) antigenemia (p = 0.005) and lower respiratory tract infection (p = 0.003) and no leucopenia were seen in the Everolimus group. The glomerular filtration rate (GFR) decreased in both groups about 50% within 6 months. Due to a high withdrawal rate, the study was underpowered to prove a difference in BOS-free survival. The dropout rate was more pronounced in the Everolimus group. Secondary endpoints indicate potential advantages of Everolimus-based protocols but also a potentially higher rate of drug-related serious adverse events.

Renal complications following lung and heart-lung transplantation

As survival improves after lung and heart-lung transplants, the long term detrimental impact of current management on renal function becomes more apparent as the number of non-renal solid organ transplant recipients on renal transplant waiting lists increases. Progressive chronic kidney disease (CKD) is a significant cause of morbidity and mortality in the transplant population. In this review we discuss the specific problems prior to lung or heart-lung transplant that predispose to CKD, as well as potential renal complications encountered during the peri- and post-transplant period. Significant acute and chronic nephrotoxicity is caused by calcineurin inhibitors (CNI). Mechanisms to decrease CNI exposure exist but have yet to be adopted in routine clinical care. Modifiable risk factors and the current screening and management approach taken at our institution are described. Pediatric nephrologists should be involved from an early stage. Future work will need to focus on identifying more accurate measures of renal function, given the limitations of current glomerular filtration rate estimation equations in a population where nutritional status may rapidly change post transplant. Multicentre studies of CNI minimisation strategies are required to guide future therapy that aims to minimise CKD development and progression in this vulnerable population.

Monitoring of nonsteroidal immunosuppressive drugs in patients with lung disease and lung transplant recipients: American College of Chest Physicians evidence-based clinical practice guidelines

OBJECTIVES

Immunosuppressive pharmacologic agents prescribed to patients with diffuse interstitial and inflammatory lung disease and lung transplant recipients are associated with potential risks for adverse reactions. Strategies for minimizing such risks include administering these drugs according to established, safe protocols; monitoring to detect manifestations of toxicity; and patient education. Hence, an evidence-based guideline for physicians can improve safety and optimize the likelihood of a successful outcome. To maximize the likelihood that these agents will be used safely, the American College of Chest Physicians established a committee to examine the clinical evidence for the administration and monitoring of immunosuppressive drugs (with the exception of corticosteroids) to identify associated toxicities associated with each drug and appropriate protocols for monitoring these agents.

METHODS

Committee members developed and refined a series of questions about toxicities of immunosuppressives and current approaches to administration and monitoring. A systematic review was carried out by the American College of Chest Physicians. Committee members were supplied with this information and created this evidence-based guideline.

CONCLUSIONS

It is hoped that these guidelines will improve patient safety when immunosuppressive drugs are given to lung transplant recipients and to patients with diffuse interstitial lung disease.

Pharmacokinetic optimization of immunosuppressive therapy in thoracic transplantation: part II

Part I of this article, which appeared in the previous issue of the Journal, reviewed calcineurin inhibitors--ciclosporin and tacrolimus. In part II, we review the pharmacokinetics and therapeutic drug monitoring of mycophenolate and mammalian target of rapamycin inhibitors--sirolimus and everolimus--in thoracic transplantation, and we provide an overall discussion and suggest various areas for future study.

Pharmacokinetic optimization of immunosuppressive therapy in thoracic transplantation: part I

Although immunosuppressive treatments and therapeutic drug monitoring (TDM) have significantly contributed to the increased success of thoracic transplantation, there is currently no consensus on the best immunosuppressive strategies. Maintenance therapy typically consists of a triple-drug regimen including corticosteroids, a calcineurin inhibitor (ciclosporin or tacrolimus) and either a purine synthesis antagonist (mycophenolate mofetil or azathioprine) or a mammalian target of rapamycin inhibitor (sirolimus or everolimus). The incidence of acute and chronic rejection and of mortality after thoracic transplantation is still high compared with other types of solid organ transplantation. The high allogenicity and immunogenicity of the lungs justify the use of higher doses of immunosuppressants, putting lung transplant recipients at a higher risk of drug-induced toxicities. All immunosuppressants are characterized by large intra- and interindividual variability of their pharmacokinetics and by a narrow therapeutic index. It is essential to know their pharmacokinetic properties and to use them for treatment individualization through TDM in order to improve the treatment outcome. Unlike the kidneys and the liver, the heart and the lungs are not directly involved in drug metabolism and elimination, which may be the cause of pharmacokinetic differences between patients from all of these transplant groups. TDM is mandatory for most immunosuppressants and has become an integral part of immunosuppressive drug therapy. It is usually based on trough concentration (C(0)) monitoring, but other TDM tools include the area under the concentration-time curve (AUC) over the (12-hour) dosage interval or the AUC over the first 4 hours post-dose, as well as other single concentration-time points such as the concentration at 2 hours. Given the peculiarities of thoracic transplantation, a review of the pharmacokinetics and TDM of the main immunosuppressants used in thoracic transplantation is presented in this article. Even more so than in other solid organ transplant populations, their pharmacokinetics are characterized by wide intra- and interindividual variability in thoracic transplant recipients. The pharmacokinetics of ciclosporin in heart and lung transplant recipients have been explored in a number of studies, but less is known about the pharmacokinetics of mycophenolate mofetil and tacrolimus in these populations, and there are hardly any studies on the pharmacokinetics of sirolimus and everolimus. Given the increased use of these molecules in thoracic transplant recipients, their pharmacokinetics deserve to be explored in depth. There are very few data, some of which are conflicting, on the practices and outcomes of TDM of immunosuppressants after thoracic transplantation. The development of sophisticated TDM tools dedicated to thoracic transplantation are awaited in order to accurately evaluate the patients' exposure to drugs in general and, in particular, to immunosuppressants. Finally, large cohort TDM studies need to be conducted in thoracic transplant patients in order to identify the most predictive exposure indices and their target values, and to validate the clinical usefulness of improved TDM in these conditions. In part I of the article, we review the pharmacokinetics and TDM of calcineurin inhibitors. In part II, we will review the pharmacokinetics and TDM of mycophenolate and mammalian target of rapamycin inhibitors, and provide an overall discussion along with perspectives.

Chronic kidney disease in children following lung and heart-lung transplantation

CKD is a major co-morbidity in pediatric lung transplant recipients. We report the prevalence of renal impairment post-lung transplant at a single center, using a modified, age-adjusted eGFR for the best approximation of true GFR, and investigated associations and possible predictors of decline in renal function post-transplant. Renal function was assessed by eGFR pre-transplant, three and 12 months post-transplant, and at last follow-up. Decline in renal function was analyzed as percentage fall in eGFR in two phases (0-3 and 3-12). Furthermore, we investigated impact of gender, age, pre-transplant diagnosis and renal function, transplant type, early post-transplant dialysis, and tacrolimus trough levels on decline in eGFR using multivariate analysis. Over a five-yr period, 30 transplants were performed. Mean eGFR pretransplant was 117 mL/min/1.73 m(2) (s.d. 35) with mean decline in eGFR during the first three months post-transplant of 33% (s.d. 31, p < 0.001). Thereafter, mean decline in eGFR was 8% (s.d. 18, p = 0.02). None of the factors assessed were significantly associated with decline in eGFR post-transplant. In conclusion, many children have decline in renal function following lung transplantation, particularly early post-transplant. Unlike in adults, we were unable to detect any predictors of renal impairment in pediatric lung transplant recipients.

Single time point measurement by C2 or C3 is highly predictive in cyclosporine area under the curve estimation immediately after lung transplantation

BACKGROUND

The two h post-dose cyclosporine (CsA) concentration has been advocated as the optimal time point measurement for CsA area under the curve (AUC) estimation after solid organ transplantation. The aim of the study was to investigate whether intensified CsA monitoring is necessary, or if a single time point measurement is accurate to estimate the AUC in the very early period following lung transplantation (LuTX).

METHODS

Within the first two wk following transplantation, daily AUCs were calculated by serial CsA measurements at zero, one, two, three, four, and six h (C0-C6) in 12 consecutive lung transplant recipients. Correlation of single CsA measurements and AUC as well as linear regression analysis was performed to evaluate the most predictive single CsA blood level regarding the AUC.

RESULTS

A total of 606 CsA concentration measurements were performed and the 101 corresponding AUCs were calculated for each patient. Mean AUC was 3443 +/- 1451 microg/L. C0: 361 +/- 118 microg/L, C1: 481 +/- 231 microg/L, C2: 682 +/- 314 microg/L, C3: 715 +/- 347 microg/L, C4: 658 +/- 271 microg/L, C6: 571 +/- 260 microg/L. The correlation of CsA serum levels with AUC was the lowest at trough levels (C0) with a correlation coefficient (r = 0.31) and highest at three h (C3: r = 0.89) and two h (C2: r = 0.88).

CONCLUSIONS

Similar to a stable post-transplant period, CsA trough levels turned out to have poor correlation with the corresponding AUC early after LuTX. The highest correlation of C3 with the AUC may be explained by delayed intestinal resorption immediately post-operative, however C2 is a peer parameter. Optimum AUCs and corresponding C2 or C3 levels in the immediate post-operative phase however remain to be determined.

Severity of lymphocytic bronchiolitis predicts long-term outcome after lung transplantation

RATIONALE

Severe and recurrent acute vascular rejection of the pulmonary allograft is an accepted major risk factor for obliterative bronchiolitis.

OBJECTIVES

We assessed the role of lymphocytic bronchiolitis as a risk factor for bronchiolitis obliterans syndrome (BOS) and death after lung transplantation.

METHODS

Retrospective analysis of 341 90-day survivors of lung transplant performed in 1995-2005 who underwent 1,770 transbronchial lung biopsy procedures.

MEASUREMENTS AND MAIN RESULTS

Transbronchial biopsies showed grade B0 (normal) (n = 501), B1 (minimal) (n = 762), B2 (mild) (n = 176), B3 (moderate) (n = 70), B4 (severe) (n = 4) lymphocytic bronchiolitis, and Bx (no bronchiolar tissue) (n = 75). A total of 182 transbronchial biopsies were ungraded (8 inadequate, 142 cytomegalovirus, 32 other diagnoses). Lung transplant recipients were grouped by highest B grade before diagnosis of BOS: B0 (n = 12), B1 (n = 166), B2 (n = 89), and B3-B4 (n = 51). Twenty-three were unclassifiable. Cumulative incidence of BOS and death were dependent on highest B grade (Kaplan-Meier, P < 0.001, log-rank). Multivariable Cox proportional hazards analysis showed significant risks for BOS were highest B grade (relative risk [RR], 1.62; 95% confidence interval [CI], 1.31-2.00) (P < 0.001), longer ischemic time (RR, 1.00; CI, 1.00-1.00) (P < 0.05), and recent year of transplant (RR, 0.93; CI, 0.87-1.00) (P < 0.05), whereas risks for death were BOS as a time-dependent covariable (RR, 19.10; CI, 11.07-32.96) (P < 0.001) and highest B grade (RR, 1.36; CI, 1.07-1.72) (P < 0.05). Acute vascular rejection was not a significant risk factor in either model.

CONCLUSIONS

Severity of lymphocytic bronchiolitis is associated with increased risk of BOS and death after lung transplantation independent of acute vascular rejection.

Successful lung transplantation for adolescents at a hospital for adults

OBJECTIVE

To describe the results of lung transplantation (LTx) in adolescents at a hospital for adults.

DESIGN AND SETTING

Prospective cohort study set in an LTx unit at an adult tertiary referral hospital from 1991 to 2006.

PATIENTS

37 consecutive adolescent lung transplant recipients including 13 males and 24 females (mean age, 16.7+/-2.0 [SD] years; range 12-19 years) who received heart-lung (six patients) or bilateral LTx (31 patients) for cystic fibrosis (29), congenital heart disease (four), acute respiratory failure (two), or another disorder (two). Two patients were transplanted after invasive ventilation, five after non-invasive ventilation and two after extracorporeal membrane oxygenation.

MAIN OUTCOME MEASURES

Overall survival compared with an adult cohort; survival free of bronchiolitis obliterans syndrome (BOS); overall and BOS-free survival in those transplanted before and after January 2000.

RESULTS

Mean waiting time was 273 days (range, 5-964 days; median, 163 days), mean donor age was 28 years (range, 9-53 years). Median inpatient stay was 11 days (range, 7-94 days). Mean follow-up was 1540+/-1357 days (range, 35-5163 days). The 5-year survival rate for the 16 patients transplanted before January 2000 was 38%, versus 74% for the 21 transplanted since January 2000 (P=0.05; Mantel-Cox). Overall, 18 of 35 evaluable patients developed BOS. Only BOS was associated with an increased mortality risk (P<0.01).

CONCLUSION

LTx may be performed successfully in adolescents at a hospital for adults.

The Clinical Benefits of Cyclosporine C2-Level Monitoring: A Systematic Review

BACKGROUND

Monitoring of cyclosporine microemulsion (Neoral) using 2-hour postdose (C2) levels is alleged to improve clinical outcomes, but the efficacy of this strategy is uncertain.

METHODS

A systematic literature search was performed for trials directly comparing patients monitored with C2 levels with those monitored by trough (C0) levels. Primary outcomes assessed were renal function and acute rejection.

RESULTS

A total of 29 studies met the inclusion criteria. Only 10 of these were randomized controlled trials. Overall quality was poor and this precluded meta-analysis. The most consistent finding in de novo renal, hepatic, and cardiac transplant recipients is a higher mean cyclosporine dose in the early postoperative period in C2 monitored patients. There is no clear evidence that this leads to impaired renal function. In the majority of studies, the monitoring strategy had no significant effect on the rate of acute rejection. In stable transplant recipients, the majority of studies show a reduction in mean cyclosporine dose with adoption of C2 monitoring. No obvious clinical benefit was derived from this reduction in dose.

CONCLUSION

In de novo transplant patients, there is little evidence from prospective studies to support the theoretical benefits of C2 monitoring. Potential dose reductions in stable patients may reduce costs, but no short-term clinical benefit is seen. Quality of studies in this area is poor, and the practical limitations of C2 monitoring mean that further evidence is required before a strategy for the administration of cyclosporine based on C2 levels can be recommended.

Therapeutic monitoring of calcineurin inhibitors for the nephrologist

The calcineurin inhibitors (CNI) cyclosporine and tacrolimus remain the backbone of immunosuppression for most kidney transplant recipients. Despite many years of experience, protocols that optimize efficacy with minimal toxicity remain a subject of debate. Nevertheless, studies of the pharmacokinetic properties of the CNI, particularly cyclosporine, have led to improved dosing strategies. The purpose of this article is to review the current understanding of CNI pharmacokinetics and its relevance to proper dosing and monitoring of these medications. This article also reviews the trials that have helped to define the optimal dosages and discusses the effect of adjunctive immunosuppressive agents on CNI pharmacokinetics and dosing.

Cyclosporine C2 Target Levels and Acute Cellular Rejection After Lung Transplantation

BACKGROUND

Acute pulmonary allograft rejection (AR) is the most important risk factor for bronchiolitis obliterans syndrome (BOS), which is associated with reduced quality of life and decreased survival after lung transplantation (LTx). Trough (C0) cyclosporine (CyA) levels have a poor correlation with area-under-the-curve (AUC) measurements of cyclosporine exposure compared with 2-hour post-dose (C2) levels, but there are no published guidelines for C2 levels after LTx. Hence, we assessed the utility of C2 target levels to prevent AR.

METHODS

Fifty consecutive de novo LTx patients (bilateral, 44; single, 3; heart-lung, 3; cystic fibrosis, 20; non-cystic fibrosis, 30) managed with CyA were assigned target C2 levels as follows: >800 microg/liter within 48 hours; >1,200 microg/liter from Week 1 to Month 1; >1,000 microg/liter in Month 2; >800 microg/liter in Month 3; >700 in microg/liter in Months 3 to 6; and >600 microg/liter thereafter. Surveillance transbronchial biopsies (TBBxs) were performed at 3, 6, 9 and 12 weeks. An intention-to-treat analysis was performed and results compared with our historic controls managed by C0 monitoring.

RESULTS

Fifteen of 50 (30%) LTx recipients developed AR on 23 of 171 TBBxs (Grade A2:A3 = 21:2) during follow-up (mean +/- SD) of 1,185 +/- 426 days (range, 16 to 1,790 days). Eighteen of 23 AR episodes occurred after sub-target C2 levels. The 30-day, 1-, 3- and 5-year actuarial survival rates were 98%, 94%, 82% and 77%, respectively. Thirteen of 48 (27%) evaluable LTx recipients developed BOS with 1-, 3- and 5-year freedom-from-BOS rates of 96%, 79% and 59%, respectively. Only 1 patient developed severe renal dysfunction.

CONCLUSIONS

Achieving and maintaining target C2 levels after LTx is associated with reduced rates of AR and BOS, preservation of renal function, and excellent short-term survival rates when compared with historic controls.

Everolimus versus azathioprine in maintenance lung transplant recipients: an international, randomized, double-blind clinical trial

Everolimus is a proliferation signal inhibitor with immunosuppressive activity that may reduce the rate of progression of chronic rejection, bronchiolitis obliterans syndrome (BOS), after lung transplantation. In a randomized, double-blind clinical trial, 213 BOS-free maintenance patients received everolimus (3 mg/day) or azathioprine (AZA, 1-3 mg/kg/day) in combination with cyclosporine and corticosteroids. The prospectively defined primary endpoint was the incidence of efficacy failure (decline in FEV1 >15%[deltaFEV1 >15%], graft loss, death or loss to follow-up) at 12 months. Incidence of efficacy failure at 12 months was significantly lower in the everolimus group than AZA (21.8% vs. 33.9%; p = 0.046); at 24 months, rates of efficacy failure became similar between the groups. At 12 months, the everolimus group had significantly reduced incidences of deltaFEV1 >15%, deltaFEV1 >15% with BOS, and acute rejection. At 24 months, only incidence of acute rejection remained significantly less in the everolimus group. Treatment discontinuations (particularly due to adverse events), serious adverse events and high serum creatinine values were more common with everolimus. For the first time, a drug has demonstrated significant slowing of loss in lung function, suggesting that patients kept on prolonged maintenance treatment with everolimus may benefit from replacing AZA with everolimus 3 months after lung transplantation.

Association Between Cyclosporine Concentrations at 2 Hours Post-dose and Clinical Outcomes in De Novo Lung Transplant Recipients

BACKGROUND

The objective of this study was to investigate the relationship between cyclosporine (CsA) pharmacokinetic parameters and clinical outcomes after lung transplantation.

METHODS

Data from 48 lung or heart/lung transplant recipients originally recruited to a randomized, prospective clinical trial of Sandimmune vs Neoral and followed for 12 months were included in this study. CsA dosing was based on the trough concentration. CsA concentrations at 0 (C0), 2 (C2), and 6 (C6) hours post-dosing were obtained at 1, 2, 3, 4, 13, 26, 39, and 52 post-operative weeks. Based on their average C2 levels in the first post-transplant month, patients were stratified retrospectively into Low C2 (<1,000 microg/liter, n = 18), Intermediate C2 (1,000-1,500 microg/liter, n = 16) and High C2 (>1,500 microg/liter, n = 14) Groups.

RESULTS

Cyclosporine C2 was the best single-point determinant (r2 = 0.934) for area-under-the-concentration-time curve (AUC(0-6 hours)) compared with C0 (r2 = 0.267) or C6 (r2 = 0.304). The mean +/- SD values of CsA C2 and AUC(0 to 6 hours) in the first year post-transplant were significantly lower in patients with >2 rejection episodes compared with those with < or =2 rejection episodes (C2: 875 +/- 546 microg/liter vs 1,114 +/- 633 microg/liter, p = 0.01; AUC(0-6 hours): 4,036 +/- 1,904 microg x hour/liter vs 4,870 +/- 2,182 microg x hour/liter; p = 0.01) whereas C0 and C6 did not differ. Patients in the Intermediate C2 Group were free from rejection episodes for a significantly longer duration (p < 0.001) and had significantly higher predicted forced expiratory volume in 1 second (%) values (p < 0.001) compared with the Low and High C2 Groups. The percentage of increase in serum creatinine concentration by the end of first month post-transplant was significantly higher in the Intermediate C2 Group (p < 0.003).

CONCLUSIONS

CsA C2 concentrations correlated better with the incidence of multiple rejections after lung transplantation than did C0 or C6. C2 concentrations between 1,000 and 1,500 microg/liter within the first post-operative month may be associated with better graft outcomes and improved pulmonary function and worsened renal function.

Intravenous Ribavirin Is a Safe and Cost-effective Treatment for Respiratory Syncytial Virus Infection After Lung Transplantation

BACKGROUND

Community-acquired viral infections, such as respiratory syncytial virus (RSV), represent a risk factor for bronchiolitis obliterans syndrome (BOS), the major limiting factor for long-term survival after lung transplantation (LTx). RSV often presents with acute bronchiolitis and may be fatal in 10% to 20% of patients. Standard therapies for RSV include nebulized ribavirin with or without steroids, but are costly and inconvenient. We investigated the utility of intravenous (IV) ribavirin with steroids for the treatment of RSV infection after LTx.

METHODS

RSV was identified in nasopharyngeal and throat swabs (NPS) using indirect fluorescent antibody (IFA) testing in 18 symptomatic patients, which was confirmed by viral culture in 14. Data were collected for the period between April 2002 and October 2004. The study included 10 men and 8 women, mean age 42 +/- 15 (range 18 to 63) years. Transplant procedures were 5 single LTx and 13 bilateral LTx. RSV diagnosis was made on Day 1,374 +/- 1,270 (range 61 to 4,598, median 935) post-operatively. Underlying diagnoses included cystic fibrosis (n = 9), emphysema (n = 7) and pulmonary fibrosis (n = 2). All 18 patients received intravenous (IV) ribavirin (33 mg/kg on Day 1 and 20 mg/kg/day thereafter in 3 divided doses) with oral prednisolone (1 mg/kg) until repeat NPS were negative for RSV on IFA. Median therapy was 8 days (6 to 15).

RESULTS

The mortality rate was 0%. Mean FEV1 fell from 2.1 +/- 1.0 liter (0.7 to 3.7 liters) to 1.8 +/- 0.9 liter (0.5 to 3.6 liters) (p < 0.001), but recovered to 2.1 +/- 0.9 (0.7 to 3.7 liters) within 3 months and was maintained at follow-up of 521 +/- 328 days (141 to 1,023 days, median 302). Only 1 patient developed bronchiolitis obliterans syndrome (BOS). Complications included mild hemolytic anemia (blood hemoglobin fell from 122 +/- 22 [84 to 154] g/liter to 107 +/- 18 [75 to 138] g/liter, p = 0.02). Cost savings per 8-day course were $US15,913 when compared with nebulized therapy at 6 g/day (p < 0.001).

CONCLUSIONS

This is the largest reported series of treated RSV cases after LTx and the first to show that therapy with IV ribavirin and oral corticosteroids is well tolerated and effective. Cost utility vs nebulized therapy has been established. Early diagnosis and management are essential to prevent airway epithelial injury and subsequent BOS.