Consensus document for the selection of lung transplant candidates: An update from the International Society for Heart and Lung Transplantation

Optimizing patient outcomes in interstitial lung disease through pre- and post-transplant management strategies

Interstitial lung diseases (ILD) encompass a diverse group of over 200 chronic pulmonary disorders characterized by varying degrees of inflammation and fibrosis, which can lead to severe respiratory impairment. Lung transplantation offers a crucial therapeutic option for patients with advanced ILD, extending survival and improving quality of life. This review explores optimal management strategies in both the pre- and post-transplant phases to enhance patient outcomes. Comprehensive pre-transplant evaluation, including pulmonary function testing, imaging, and comorbidity assessment, is critical for determining transplant eligibility and timing. Post-transplant care must focus on preventing complications such as primary graft dysfunction and chronic lung allograft dysfunction, managed through tailored immunosuppression and proactive monitoring. Recent advancements in diagnostic techniques and therapeutic approaches, including emerging technologies like ex vivo lung perfusion and precision medicine, promise to further improve outcomes. The ultimate goal is to establish an evidence-based, multidisciplinary framework for optimizing ILD management and lung transplantation.

Infections and lung transplantation: key considerations for eligibility, management, and posttransplant care

PURPOSE OF REVIEW

Lung transplantation is a critical and evolving therapy for patients with end-stage lung disease. As the need for lung transplantation increases, careful candidate selection is vital to maximizing outcomes and ensuring appropriate organ allocation. A key challenge in lung transplant candidates is the colonization or infection of the lungs by environmental and upper airway pathogens. These lung pathogens, along with other chronic infections, can lead to posttransplant complications with high mortality and an increased risk of graft failure.

RECENT FINDINGS

Major infectious considerations for lung transplantation include colonization or infection by multidrug-resistant bacteria (including Burkholderia cepacia complex), nontuberculous mycobacteria, molds, and chronic viral infections. By recognizing the epidemiology, diagnosis, and management of these infections in the peri-transplant period, transplant providers can better mitigate infectious risks and improve transplant success. Similarly, advancements in diagnostics and therapeutics offer novel approaches to managing previously challenging infections.

SUMMARY

As experience grows in treating these difficult infectious syndromes, more candidates are becoming eligible for transplantation. A thorough understanding of infectious considerations in lung transplant candidates is essential for improving candidate selection, reducing posttransplant complications, and expanding transplant eligibility.

Outcomes of single-lung retransplantation after double-lung transplantation

OBJECTIVE

To compare outcomes of single-lung retransplantation (SLRTx) and double-lung retransplantation (DLRTx) after an initial double-lung transplantation.

METHODS

The Organ Procurement and Transplantation Network/United Network for Organ Sharing database between May 2005 and December 2022 was retrospectively analyzed. Multiorgan transplantations, repeated retransplantations, and lung retransplantations when the status of the initial transplantation was unknown were excluded.

RESULTS

A total of 891 patients were included in the analysis, included 698 (78.3%) with DLRTx and 193 (21.7%) with SLRTx. The mean lung allocation score was higher in the DLRTx group (59.6 ± 20.7 vs 55.1 ± 19.3; P = .007). The use of extracorporeal membrane oxygenation (ECMO) bridge to lung transplantation was similar in the 2 groups (P = .125), as was waitlist time (P = .610). The need for mechanical ventilation (54.6% vs 35.8%; P = .005) and ECMO (17.9% vs 9.0%; P = .069) at 72 hours post-transplantation was greater in the DLRTx group. However, median post-transplantation hospital stay (21.5 [interquartile range (IQR), 12-35] days versus 20 [IQR, 12-35] days; P = .119) and in-hospital mortality (10.9% [n = 76/698] vs 12.4% [n = 24/193]; P = .547) were comparable in the 2 groups. Long-term survival was significantly better in the DLRTx group (P < .001, log-rank test). In the propensity score-weighted multivariable model, the DLRTx group had 28% lower risk of mortality at any point during follow-up compared to the SLRTx group (hazard ratio, 0.72; 95% confidence interval, 0.57-0.91; P = .006).

CONCLUSIONS

The less invasiveness of single-lung transplantation in the retransplantation setting has minimal short-term benefit and is associated with significantly worse long-term survival. Double-lung retransplantation should remain the standard for lung retransplantation after initial double-lung transplantation.

Impact of donor age ≥65 years on graft survival in large lung transplant cohorts

BACKGROUND

Although the demand for allografts continuously surpasses the supply, the majority of lungs offered for transplant are declined based on various factors, including donor age. This in turn sustains the wait-list mortality of patients with end-stage pulmonary disease.

METHODS

In this single-center, observational cohort study, we investigated the impact of donor age on graft survival. We additionally compared our center's data to data reported to the International Society for Heart and Lung Transplantation (ISHLT) Thoracic Organ Transplant Registry. Kaplan-Meier method was used to describe overall graft survival. Multivariate Cox proportional hazards regression was used to assess clinical features associated with graft loss.

RESULTS

Between January 2010 and December 2023, Alfred performed 1,101 single and double lung transplants and the combined ISHLT cohort totaled 32,200 transplants. At Alfred, grafts originating from donors ≥65 years were used in 13.3% of lung transplant cases and univariate analysis showed no impact of donor age ≥65 on graft survival (hazard ratio [HR] 0.86, p = 0.34). In the combined cohort, North America had a lower proportion of donors aged ≥65 years compared to Europe and the Alfred (2.4% vs 9.8% vs 13.3%, p < 0.001). The univariate analysis showed a negative impact of donor age ≥65 on graft survival (HR 1.16, p < 0.001). However, this did not hold in a multivariate model (HR 1.06, p = 0.298) when adjusted for center experience and recipient characteristics.

CONCLUSIONS

Donor age might impact outcomes to a lesser degree than previously suggested. Therefore, appropriately assessed age-extended lungs should be routinely considered for lung transplantation.

Timing of lung transplant evaluation: considerations, barriers and alternatives

PURPOSE OF REVIEW

Over the past decade, increased knowledge has contributed to improved medical and technical treatments across the spectrum of respiratory diseases. As a result, timing for transplant evaluation might be more challenging. In this review, the focus is on timing of lung transplant evaluation of patients from the main respiratory diseases referred. Disease-specific predictors of survival in relation to timing of transplant evaluation and alternative treatments will be reviewed.

RECENT FINDINGS

Treatment options have evolved for respiratory diseases like chronic obstructive pulmonary disease, pulmonary fibrosis, cystic fibrosis and pulmonary arterial hypertension. These treatments have led to improved quality of life, exercise tolerance, lung function and outcome. However, the effect of these alternative treatments on transplant candidacy and knowledge on timing of lung transplant evaluation are lacking.

SUMMARY

This article reviews the current best evidence to guide clinicians regarding the optimum timing for transplant referral and highlights considerations to optimize transplant candidacy and outcomes.

[Lung Volume Reduction Surgery - an Alternative or a Bridge to Transplantation]

Lung volume reduction surgery (LVRS) and lung transplantation (LuTX) are established therapeutic options for patients with advanced pulmonary emphysema. This review analyses both procedures with respect to indications, surgical techniques, outcomes, and complications. Special attention is given to the controversial sequential application as a bridge to transplantation. Evidence shows that both procedures can significantly improve lung function, quality of life, and survival when patients are carefully selected. Despite some overlap in indication criteria, most patients qualify for only one of the procedures as based on their specific clinical constellation. Recent research has challenged traditional contraindications such as pulmonary hypertension or homogeneous emphysema, and consequently, the indication spectrum for LVRS has been expanded. Contrary to earlier assumptions, current multicentre studies demonstrate that prior LVRS has no negative impact on subsequent transplantation outcomes, provided minimally invasive surgical techniques and modern perioperative management are employed. LVRS can delay the need for transplantation, which is a significant advantage given the shortage of donor organs. The key to success lies in interdisciplinary evaluation and personalized treatment planning. Both procedures should be understood as complementary rather than competing options. Future research should focus on predictive biomarkers, optimal timing, and combined patient-centred endpoints.

Management of pharmacotherapy in lung transplant candidates

PURPOSE OF REVIEW

Lung transplantation is a common treatment for end-stage lung disease (ESLD). Patients present to lung transplantation evaluation on various medications that could impact their candidacy and posttransplant course. In this review, we will discuss pretransplant optimization of pharmacotherapy to minimize complications while waiting for transplant and increase posttransplant success. We will also discuss important considerations for posttransplant immunosuppression, antimicrobial prophylaxis, and complex drug interactions.

RECENT FINDINGS

Prior to lung transplantation, several medications should be optimized to promote posttransplant success including minimization of corticosteroids, opioids, and benzodiazepines. Lung transplantation candidates should be up to date on vaccinations. Most medications for ESLD are well tolerated to continue up until the point of transplant including antifibrotics, CFTR modulators, and pulmonary vasodilators. Mammalian target of rapamycin inhibitors and other immunosuppressants may need to be stopped or minimized before lung transplantation to minimize posttransplant infection and would healing complications. Medications that increase risk of posttransplant bleeding, thrombosis, or aspiration should be stopped prior to listing.

SUMMARY

In this article, we discuss management of pharmacotherapy for lung transplantation candidates to minimize posttransplant complications. Changes in medications for ESLD should be done cautiously to prevent worsening of native disease while waiting for lung transplantation.

Recipient selection for lung transplantation: perspective in decision-making

BACKGROUND

To determine the conditions that prevented transplant in patients referred to our center due to end-stage lung disease.

STUDY DESIGN

Descriptive study.

PLACE AND DURATION OF THE STUDY

Department of lung transplant clinic, Koşuyolu High Specialization Education and Research Hospital, Istanbul, Turkey, from December 2017 to January 2022.

METHODS

Patients with end-stage lung disease referred to our clinic were retrospectively evaluated with regard to reasons for exclusion, diagnosis, and demographic data. The Karnofsky Performance Status scoring scale was used to measure the functional status of the patients.

RESULTS

A total of 311 patients were evaluated during the study period. The mean age was 44.2 (range 4-73) years. There were 207 (66.6%) male patients. The most common indications were idiopathic interstitial pneumonia in 104 (33.4%) patients, chronic obstructive pulmonary disease in 53 (17%) patients, bronchiectasis in 49 (15.7%) patients, and cystic fibrosis in 28 (9%) patients. Of the patients, 106 (34%) were not appropriate candidates for a lung transplant. The most common reasons for refusal were preventable situations such as activity limitation and poor performance in 53 (50%) patients, weight in 49 (46.2%) patients, and smoking in 10 (9.4%) patients.

CONCLUSION

Impaired performance status was the most common cause of lung transplant exclusion. Weight and smoking were preventable causes of exclusion. Implementing pulmonary rehabilitation in very few patients was the most important handicap. It is believed that providing optimal treatment with a multidisciplinary approach and timely referral to transplant centers will significantly reduce the reasons for exclusion. Key message What is already known on this topic?  Referring lung transplant candidates to clinics at the earliest stage is essential for assessing their condition and exploring treatment options. What this study adds?  Factors like smoking, obesity, and muscle loss can hinder the transplantation process; thus, timely interventions are crucial. The primary reason for excluding candidates from lung transplantation is the decline in performance status. How this study might affect research, practice or policy?  Programs focused on smoking cessation, weight management, and muscle strengthening can play a vital role in enhancing patients' health before transplantation. It is imperative to expand and enhance the accessibility of pulmonary rehabilitation programs.

Breath of change: Evaluating the healthcare impact of the race-neutral Global Lung Initiative (GLI) 2022 on adults with cystic fibrosis

This study evaluates the clinical impact of transitioning from the GLI 2012 to the race-neutral GLI 2022 spirometry equations in people with cystic fibrosis (pwCF). Spirometry data from a large adult CF centre showed an increase in average ppFEV1 (71.1 %-75 %, p < 0.01), with White patients showing the greatest change (4.56 %). Fewer patients met lung transplantation thresholds, and 1.7 % became newly eligible for clinical trials, while 7 % became ineligible. These findings suggest the need for further research on the long-term implications of GLI 2022 across respiratory conditions.

Paediatric Lung Transplantation for Childhood Interstitial Lung Disease: Indications and Outcome

BACKGROUND

Childhood interstitial lung disease (chILD) is heterogeneous, associated with significant morbidity and can cause organ failure. In these cases, lung transplantation (LuTx) is a treatment option. Data on indications and outcome after LuTx for chILD is limited. We compared characteristics of LuTx for chILD to the indications cystic fibrosis (CF) and pulmonary hypertension (PH).

METHODS

chILD-patients <18 years who underwent LuTx at our center between Jan 1st, 2011 and Sep 30th, 2023, were retrospectively analysed and divided into two groups depending on their age at disease manifestation: Children in the chILD A group predominantly became ill during the first two years of life, chILD B patients thereafter. Outcomes were compared to patients with CF and PH.

RESULTS

101 children were included (chILD A 12; chILD B 19; CF 49; PH 21). Patients in the chILD A group were younger (mean age 1.5 vs., 12.9, 15.2, 10.9 years) and frequently required mechanical ventilation before LuTx (41.7%, vs. 10.5%, 2%, 9.5%, respectively). Their median ICU stay (23 vs. 4, 2, 13 days) and median hospital stay (48 vs. 27, 30, 42 days) after LuTx was longer. Patients with chILD B had the lowest pre-transplant ICU requirement (21.1% vs. 66.7% for chILD A, 30.6% for CF and 47.6% for PH) and short median hospital stay. Five year survival was comparable in all groups (80.2%, 86.5%, 80.4%, and 81.2%).

CONCLUSION

LuTx for patients with chILD shows favourable outcome, although younger chILD A patients had a higher pre-transplant morbidity and longer ICU and hospital stay surrounding the transplantation.

Utility and bias in psychosocial evaluations for transplant listing

PURPOSE OF REVIEW

Disparities in access to transplantation are persistent and pervasive among minoritized populations, and remain incompletely explained by socioeconomic status, insurance, geography, or medical factors. Although much attention has been paid to factors contributing to disparities in organ allocation, fewer studies have focused on barriers to the transplant waitlist. Given increasing calls for equity in organ transplantation, we examine the role of nonmedical factors used in transplant listing decisions, including psychosocial factors like social support, motivation, and knowledge in improving utility in transplant listing decisions, as well as their potential for reinforcing bias.

RECENT FINDINGS

Minoritized groups are more likely to be declined from transplant listing owing to psychosocial criteria. Lack of consistent definitions, screening tools with differential subgroup validity, and insufficient evidence-base contribute to concerns about reliance on psychosocial factors in transplant listing decisions.

SUMMARY

Improving consistency and evidence-based approaches in patient evaluation and listing decisions will require greater efforts to identify which psychosocial risk factors are predictive of posttransplant outcomes. Social needs screening presents a strengths-based framework for incorporating psychosocial factors in transplant listing decisions.

Time on the waiting list is an independent risk factor for day-90 mortality after lung transplantation

BACKGROUND

The waitlist deaths of transplantation candidates based on their time on the waiting list (TWL) have already been studied, but the short-term mortality and early complications of lung transplant (LT) recipients based on their TWL have not been specifically studied. The first aim of this study was to assess the relationship between increased TWL and short-term mortality in LT recipients.

METHODS

In this observational, monocentric, retrospective study, all patients who underwent LT between January 2016 and August 2022 at Bichat Claude Bernard Hospital, Paris were analyzed. Univariate analysis (chi2 test, Mann-Whitney test, Fisher's exact test) and multivariate analysis (logistic regression) were performed. Ninety-days and one-year survival were studied (Kaplan-Meier curves, log-rank test). p < 0.05 indicated statistical significance.

RESULTS

242 LT patients were analyzed. The median TWL was 100 (43-229) days. Postoperative complications, including septic shock (36 versus 18%, p = 0.002), grade 3 primary graft dysfunction (31 versus 20%, p < 0.001), and KDIGO3 acute kidney injury (8 versus 25%, p < 0.001), were more common in the prolonged TWL (pTWL) group (>100 days) than in the short TWL group (≤100 days). The duration of hospitalization in the ICU was longer (18 [11-34] versus 13 [9-23] days, p = 0.02) in the pTWL group. According to our multivariate analysis, TWL was an independent risk factor for 90-days mortality (OR 1.02, 95% CI [1.00-1.04]; p = 0.032).

CONCLUSION

TWL was an independent risk factor for 90-days mortality after LT. Receiving LT after more than 100 days on the waitlist exposes to increased postoperative complications.

The use of mechanical ventilation in interstitial lung disease

This review explores the challenges and strategies for managing mechanical ventilation in interstitial lung disease (ILD), particularly during acute exacerbations. It highlights the unique physiological barriers posed by fibrotic, non-compliant lungs, discusses evidence-based approaches to noninvasive and invasive ventilation, and emphasises the importance of balancing life-sustaining treatments with palliative care. This review aims to provide practical insights into optimising respiratory support for ILD patients while aligning treatment goals with patient prognosis and preferences.

Acute kidney injury after lung transplantation, incidence, risk factors, and effects: A Swedish nationwide study

BACKGROUND

Acute kidney injury (AKI) is a serious complication after lung transplantation, but the reported incidence varies in the literature. No data on AKI have been published from the Swedish lung transplantation program.

METHODS

The aim of our study was to investigate the incidence, perioperative risk factors, and effects of early postoperative acute kidney injury (Kidney Disease Improving Global Outcomes [KDIGO] criteria) after lung transplantation. A retrospective, nationwide study of 568 lung-transplanted patients in Sweden between 2011 and 2020 was performed.

RESULTS

The incidence of AKI (any grade) was 42%. Renal replacement therapy was used in 5% of the patients. Preoperative factors independently associated with increased incidence of AKI were higher body mass index (odds ratio [OR]: 1.07, 95% CI: 1.02, 1.12) longer time on transplantation waiting list (OR: 1.05 [1.01, 1.09]), re-transplantation (OR: 2.24 [1.05, 4.80]) and moderate to severe tricuspid regurgitation (OR: 2.61 [1.36, 5.03]). Intraoperative factors independently associated with increased incidence of AKI were use of cardiopulmonary bypass (OR: 2.70 [1.57, 4.63]), increasing number of transfused red blood cell units, and use of immunosuppressive therapy other than routine (OR: 2,56 [1.47, 4.46]). A higher diuresis (OR: 0.70, 95% CI: 0.58-0.85) was associated with less incidence of acute kidney injury. Development of AKI was associated with increased time to extubation (median 30 h, IQR [9, 118] vs. 6 [3, 16]), length of stay in the intensive care unit (9 days [4, 25] vs. 3 [2, 5]) and increased rate of primary graft dysfunction (OR 2.33 [1.66, 3.29]) and 30-day mortality (OR: 10.8 [3.0, 69]).

CONCLUSIONS

Acute kidney injury is common after lung transplantation and affects clinical outcomes negatively. Preoperative factors may be used for risk assessment. The use of cardiopulmonary bypass is a potentially modifiable intraoperative risk factor.

EDITORIAL COMMENT

Acute kidney injury is a common complication after lung transplantation that severely influences patient outcomes. This large study of more than 500 patients treated over a decade identified potentially modifiable factors associated with the development of acute kidney injury.

Current challenges in lung transplantation

Lung transplantation remains the definitive treatment for end-stage lung disease, but several critical challenges persist. Key issues include the limited availability of donor organs, ongoing debates over optimal preservation methods, and the controversy surrounding the best intraoperative support systems. Additionally, the efficacy of bridging strategies to transplantation continues to be questioned. This review delves into these pressing topics. This includes a focus on donation after cardiac death as a potential solution to expand the donor pool and recent advancements in hypothermic preservation, including innovative portable devices, and the role of bridging strategies. By addressing these multifaceted challenges, this review highlights the importance of continued advancements in donor management, organ preservation, and perioperative care to ultimately improve outcomes for lung transplant recipients.

Approach to Lung Transplantation in Pulmonary Arterial Hypertension: A Delphi Consensus on Behalf of the Transplant Task Force of the Pulmonary Vascular Research Institute

Lung transplantation is indicated for selected patients with advanced pulmonary arterial hypertension (PAH). We used a modified Delphi process to develop recommendations on care of patients with PAH undergoing lung transplantation. This Delphi panel was recruited from the Pulmonary Vascular Research Institute's Innovative Drug Discovery Initiative - Lung Transplantation Workstream, consisting of clinical and research experts in PAH and lung transplantation. In this process, 29 panelists were given open-ended questions, querying topics related to lung transplantation in PAH. A steering group converted the responses into discrete statements. Panelists then rated agreement using a Likert scale in two further survey rounds: -5 (strongly disagree) to 5 (strongly agree). Consensus was defined as mean ≥ 2.5 or ≤ -2.5, with a standard deviation not crossing zero. Consensus was reached on 141 of 223 statements. Notable areas of consensus were for early discussions about transplantation, and agreement with previously published referral and listing criteria. There was agreement that lung transplantation could be offered in sick candidates, including those with concurrent renal or hepatic insufficiency. Bilateral lung transplantation was considered the procedure of choice for most patients, with rare indications for heart-lung transplantation. Consensus on bridging strategies included use of veno-arterial extracorporeal membrane oxygenation and preemptive awake cannulation in those with severe right ventricular dysfunction. Consensus was also achieved on intraoperative use of invasive hemodynamic monitoring, and prolonged postoperative circulatory support guided by hemodynamic response and echocardiography. Patients with PAH undergoing transplantation require specialized management, which differs somewhat from other candidates.

Association of HLA Mismatch With Adverse Cardiovascular Events Following Lung Transplantation: A Single-Center Study

AIMS

Coronary artery disease (CAD) is a frequent comorbidity in lung transplant (LuTx) candidates. The impact of allogenic organ transplantation and the corresponding alterations in immune response on the progression of CAD remains poorly understood. In this study, we sought to analyze the effect of donor-recipient overall human leukocyte antigen (HLA) and HLA-DQ mismatch on cardiovascular outcomes following LuTx.

METHODS AND RESULTS

This retrospective analysis of adult patients receiving lung transplantation at the LMU University Hospital between 2012 and 2018 included 310 patients, the majority of whom (67.4%) had undergone double lung transplantation. There were no significant differences in the incidence of the primary composite endpoint between patients with high/low HLA mismatches (22 [7.9%] vs. 4 [12.9%]; p = 0.311). Numerically higher rates of the primary endpoint, myocardial infarction, and cardiovascular death in the low HLA mismatch group can partially be explained by differences in baseline rates of CAD and coronary sclerosis. Notably, neither HLA-DQ mismatch nor the occurrence of rejection episodes or cytomegalovirus (CMV) infection was associated with the occurrence of cardiovascular events following transplantation.

CONCLUSION

In this study cohort, high HLA mismatch and HLA-DQ mismatch were not associated with increased adverse cardiovascular events. Furthermore, neither transplant rejection nor CMV infection increased the risk for cardiovascular events. The high cardiovascular event rates following LuTx necessitate meticulous cardiovascular follow-up, irrespective of immunological matching.

Single-lung Transplant in a Patient with Mycobacterium avium Pulmonary Disease Successfully Treated with Amikacin Liposome Inhalation Suspension

A 55-year-old man presented to our hospital with idiopathic pulmonary fibrosis (IPF). He was registered with the Japan Organ Transplant Network the following year due to disease progression. Treatment with clarithromycin, ethambutol, and rifampicin for complications of Mycobacterium avium pulmonary disease was initiated, but sputum conversion could not be achieved. The administration of an amikacin liposome inhalation suspension (ALIS) resulted in sputum conversion, and single-lung transplantation was performed. ALIS therapy was continued after lung transplantation, and no M. avium disease was observed for 15 months. ALIS may cause M. avium pulmonary disease with additional indications for lung transplantation.

Successful Lung Transplantation in A Patient With Pre-Existing Chronic Myeloid Leukemia Treated With Imatinib: A Case Report

Although active malignancy is a contraindication to lung transplantation, there is increasing uncertainty as to what constitutes "active" malignancy given the rapidly changing therapeutic armamentarium and overall survival of patients with malignancy. Chronic myeloid leukemia (CML) is an example of a previously fatal malignancy that has been transformed into a chronic disease with close-to-normal life expectancy since the advent of tyrosine kinase inhibitor (TKI) therapy. However, it remains relatively unknown if lung transplantation could successfully be performed in patients with CML. We describe the course of a 34-year-old woman with cystic fibrosis and advanced lung disease who was diagnosed with CML while undergoing lung transplant evaluation. She was initiated on imatinib with optimal treatment response; she achieved major molecular response (MMR) and deep molecular response (DMR) at 8 and 10 months of treatment, respectively. She developed progressive respiratory failure and underwent bilateral lung transplantation at close to 3 years after achieving MMR. At 6 years post-transplant, she has excellent graft function and remains in DMR on imatinib. Treated CML in DMR should be regarded as inactive malignancy and should not preclude patients from life-saving transplant consideration. Our case also demonstrates the feasibility of long-term immunosuppression on TKI therapy.

Idiopathic inflammatory myopathies related lung disease in adults

Interstitial lung disease (ILD) is common in idiopathic inflammatory myopathies in adults, especially in patients with antisynthetase syndrome and anti-MDA5 antibody-associated dermatomyositis. Pulmonary manifestations can range from subclinical ILD to rapidly progressive respiratory failure. Coexistent myositis, characteristic skin lesions, arthritis, and Raynaud's phenomenon are common. However, 16-65% of patients present with isolated lung disease. Detection of myositis-specific and myositis-associated antibodies can aid in diagnosis and disease characterisation. Chest imaging and pathology most commonly show non-specific interstitial pneumonia and organising pneumonia patterns. Immunosuppression is the mainstay of management with aggressive combination treatment for rapidly progressive disease and incremental escalation as needed for chronic ILD. The addition of antifibrotic agents is an option in progressive fibrotic disease, and lung transplantation can be considered in severe, end-stage disease. Most patients respond to treatment, but short-term mortality remains high for patients with rapidly progressive disease associated with anti-MDA5 antibody ILD.

Multimodal Inpatient Prehabilitation Prior to Heart or Lung Transplantation in a Latin American Transplant Reference Center

INTRODUCTION

Whether the implementation of a multimodal prehabilitation program is effective and safe for high-risk heart or lung transplantation candidates, whose condition prevents hospital discharge, is unclear.

METHODS

We conducted a retrospective study at a cardiothoracic transplant center in Chile. Two cohorts of hospitalized patients listed for heart or lung transplant were studied: the first underwent traditional (historical) and nonstructured prehabilitation, and the second underwent protocol-driven multimodal prehabilitation (MP). Adverse events and preoperative functional changes in the MP group were documented, as well as comparative postoperative outcomes between both cohorts.

RESULTS

Between 2018 and 2023, 24 transplant recipients were analyzed. During the MP phase, significant improvement was observed in Medical Research Council scale (52.0 ± 7 to 58.7 ± 3; P = .042), sit-to-stand test (7.1 ± 7 to 15.9 ± 6; P = .018), and euthymic state (from 4 to 10 patients; P .036), without reported adverse events. Postoperatively, MP group demonstrated faster standing (1.9 ± 0.7 vs 1.3 ± 0.5 days; P = .05) and sitting times (2.0 ± 0.7 vs 1.2 ± 0.5 days; P = .007), with more early extubations (3 vs 11; P = .003) in comparison to the historical prehabilitation cohort.

CONCLUSION

In this small retrospective study, MP in hospitalized patients awaiting heart or lung transplantation appears to be safe and associated with improvements in pre- and postoperative outcomes.

Prognostic Utility of the GAP Score in Interstitial Lung Disease Patients Evaluated for Lung Transplantation: A Single-Center Study

BACKGROUND

Lung transplantation (LT) is a critical option for patients with advanced respiratory diseases, especially interstitial lung diseases (ILD). The GAP score (Gender, Age, Physiology) has shown prognostic value in idiopathic pulmonary fibrosis (IPF), but its utility in other progressive fibrotic diseases and LT candidates is less well-studied.

METHODS

This retrospective study included ILD patients evaluated as LT candidates between January 2017 and December 2023 at a single center. The GAP score was calculated for each patient, and patients were classified into GAP stages I, II, or III. Outcomes evaluated included LT waiting list inclusion, LT performed, death, and active follow-up without waiting list inclusion. The prognostic utility was analyzed using survival analysis, including Cox regression and Kaplan-Meier methods.

RESULTS

Of 413 ILD patients, 119 were included on the LT waiting list. GAP stage III was an independent predictor of transplant-free survival (HR = 2.720; p = 0.011). Patients in stage II showed a transplant-free survival of 51.3% at 2 years, while stage III had 49.2% survival at 1 year. GAP stages significantly predicted transplant outcomes and survival rates (p < 0.001).

CONCLUSION

The GAP score is a reliable prognostic tool for ILD patients being evaluated for LT, aiding in decision-making regarding referral and waiting list inclusion. It may serve as a useful marker for early referral and prioritization.

Pulmonary hypertension associated with COPD: a phenotype analysis

Background

Pulmonary hypertension (PH) associated with COPD (PH-COPD) exhibits diverse phenotypes, challenging therapeutic management. This study aimed to describe the characteristics of COPD patients with distinct phenotypes, namely end-stage COPD with or without PH (group 1), other COPD patients with mild-to-moderate pre-capillary PH-COPD (group 2) and COPD patients with a pulmonary vascular phenotype (PVP) (group 3).

Methods

We performed a retrospective analysis of COPD patients who underwent right heart catheterisation from 2015 to 2022.

Results

81 patients were included in group 1, 37 in group 2 and 35 in group 3. The groups differed in terms of clinical, functional, haemodynamic and imaging characteristics. Group 1 had significantly marked lung hyperinflation with increased total lung capacity and residual volume, a feature not observed in group 3. These results were confirmed by analysis of chest CT scans, which confirmed varying degrees of emphysema, as follows: severe in group 1, moderate in group 2 and mild in group 3, with median total emphysema indices of 55% (48-62), 32% (16-49) and 16% (3.4-31), respectively, p<0.0001.

Conclusions

Our results highlight the broad spectrum of PH in COPD, from PH associated with end-stage COPD (phenotype/group 1), characterised by predominant alveolar wall damage with severe emphysema, to PVP (phenotype/group 3), mainly due to pulmonary vascular changes. Phenotype/group 2 represents an intermediate state combining features of both. In the current debate on how to distinguish PH-COPD phenotypes, it might be of interest to include quantitative thresholds for emphysema in future diagnostic and management algorithms.

If and When to Consider Prophylactic Immunoglobulin Replacement Therapy in Secondary Hypogammaglobulinemia

Secondary hypogammaglobulinemia (SHG), or decreased IgG levels due to reduced production or increased loss caused by medications or underlying conditions, can be associated with increased infection risk. Although immunoglobulin replacement therapy (IgRT) is generally accepted as a strategy to help prevent recurrent bacterial infections in SHG, controversy exists as to whether it should be initiated to prevent the first occurrence of infection. This question has been raised particularly in the setting of anti-CD20 therapy, solid organ transplant, and B-cell malignancies and their treatments once IgG levels fall below 300 to 400 mg/dL. This article reviews the evidence for and against initiating IgRT in these settings, as well as associated considerations for evaluation and monitoring. Although it is relatively clear that infection risk increases with decreasing IgG levels, the exact contribution of SHG to overall infection risk and the protective benefit of IgRT in the absence of infections remain unclear. In the absence of clear consensus, shared decision-making is often needed to determine if and when to initiate IgRT.

Prognostic value of cardiac CT-derived RV dysfunction in lung transplantation candidates: A single-center retrospective study

BACKGROUND

There are no specific criteria for listing and prioritizing lung transplantation (LTx) candidates based on the severity of right ventricular (RV) dysfunction. We evaluated the prognostic value of cardiac CT-derived right ventricular ejection fraction (RVEF) in LTx candidates.

METHODS

This retrospective study included patients who were listed for LTx and underwent cardiac computed tomography (CT) between September 2019 and December 2023. Patients were categorized into 3 groups based on CT-derived RVEF and survival analyses were performed among these groups: normal RVEF (≥45%), mild-to-moderate RV dysfunction (25%-45%), and severe RV dysfunction (<25%).

RESULTS

In the 203 patients (median age, 61 years [interquartile range [IQR], 54-64]), the most common indication for LTx was interstitial lung disease (79.3%). Patients were followed for a median duration of 297 days (IQR, 140-632), and the 1-year survival rates were 85.2% for those with normal RV, 69.3% for those with mild-to-moderate RV dysfunction, and 55.6% for those with severe RV dysfunction (p < 0.001). Severe RV dysfunction (hazard ratio [HR] 6.72, p = 0.020), age (HR 1.1, p = 0.010), and 6-minute walking distance (HR 0.62, p = 0.010) were associated with an increased risk of 1-year mortality.

CONCLUSIONS

Severe RV dysfunction identified on cardiac CT was a significant prognostic factor for 1-year mortality in LTx candidates. Patients with severe RV dysfunction should be prioritized for LTx and classified as urgent due to their elevated short-term mortality risk. Cardiac CT may provide valuable prognostic information during the pretransplant evaluation process.

Non-Pharmacological Management of Idiopathic Pulmonary Fibrosis

Idiopathic pulmonary fibrosis (IPF) is a relatively common progressive fibrotic interstitial lung disease associated with significant morbidity and mortality. The available medications for IPF only slow down the disease process, with lung transplantation the only option for a cure. Non-pharmacological therapies are significant adjuncts that can improve symptom burden and quality of life with minimal or no side effects. Supplemental oxygen can improve exercise capacity and the sensation of dyspnea in a significant portion of patients with resting or exertional hypoxemia and has been supported by several professional societies. Pulmonary rehabilitation is a comprehensive program that includes education and therapeutic exercises to improve patient stamina and strength. It is one of the few interventions that have been shown to produce a meaningful increase in a patient's exercise capacity, but its wide adoption is limited by availability, especially in rural areas. Sleep optimization with supplemental oxygen and positive airway pressure therapy should actively be investigated for all patients diagnosed with IPF. Although gastroesophageal reflux control with non-pharmacological means is still controversial as an intervention to reduce the rate of lung function decline, it can help control reflux symptoms and improve cough intensity. IPF patients should be educated on the importance of balanced nutrition and the potential benefits of screening for lung transplantation. Palliative medicine can help with symptom control and should be considered for all patients regardless severity, but especially in those in the later stages of disease.

Cold storage of human precision-cut lung slices in TiProtec preserves cellular composition and transcriptional responses and enables on-demand mechanistic studies

BACKGROUND

Human precision-cut lung slices (hPCLS) are a unique platform for functional, mechanistic, and drug discovery studies in the field of respiratory research. However, tissue availability, generation, and cultivation time represent important challenges for their usage. Therefore, the present study evaluated the efficacy of a specifically designed tissue preservation solution, TiProtec, complete or in absence (-) of iron chelators, for long-term cold storage of hPCLS.

METHODS

hPCLS were generated from peritumor control tissues and stored in DMEM/F-12, TiProtec, or TiProtec (-) for up to 28 days. Viability, metabolic activity, and tissue structure were determined. Moreover, bulk-RNA sequencing was used to study transcriptional changes, regulated signaling pathways, and cellular composition after cold storage. Induction of cold storage-associated senescence was determined by transcriptomics and immunofluorescence (IF). Finally, cold-stored hPCLS were exposed to a fibrotic cocktail and early fibrotic changes were assessed by RT-qPCR and IF.

RESULTS

Here, we found that TiProtec preserves the viability, metabolic activity, transcriptional profile, as well as cellular composition of hPCLS for up to 14 days. Cold storage did not significantly induce cellular senescence in hPCLS. Moreover, TiProtec downregulated pathways associated with cell death, inflammation, and hypoxia while activating pathways protective against oxidative stress. Cold-stored hPCLS remained responsive to fibrotic stimuli and upregulated extracellular matrix-related genes such as fibronectin and collagen 1 as well as alpha-smooth muscle actin, a marker for myofibroblasts.

CONCLUSIONS

Optimized long-term cold storage of hPCLS preserves their viability, metabolic activity, transcriptional profile, and cellular composition for up to 14 days, specifically in TiProtec. Finally, our study demonstrated that cold-stored hPCLS can be used for on-demand mechanistic studies relevant for respiratory research.

Beyond the Graft: Recurrence of Interstitial Lung Diseases Post Transplant

Interstitial lung diseases (ILDs) represent a heterogenous group of lung disorders marked by inflammation and/or fibrosis of the lung parenchyma, often leading to progressive shortness of breath and end-stage respiratory failure. In the U.S., ILDs affect approximately 650,000 individuals and cause approximately 25,000-30,000 deaths annually. Lung transplantation (LTx) offers definitive treatment for advanced ILD, with improved survival attributed to advancements in immunosuppression, organ preservation, surgical techniques, and postoperative care. However, disease recurrence in transplanted lungs remains a significant concern. Understanding the risk factors and mechanisms underlying recurrence is critical for refining recipient selection and improving outcomes. This review examines ILD recurrence post LTx and its implications for lung transplantation success.

Derivation of a simple risk calculator for predicting clinical worsening in patients with pulmonary hypertension due to interstitial lung disease

Background

Pulmonary hypertension due to interstitial lung disease (ILD-PH) portends very poor clinical outcomes, with a median survival time of 1.5 to 2 years. Currently, there is no tool to assess the risk of clinical worsening in patients with ILD-PH. Our aim was to derive a simple and practical risk calculator that could be used to predict risk of clinical worsening in patients with ILD-PH.

Methods

The INCREASE study was a 16-week study that evaluated inhaled treprostinil in patients with ILD-PH. Baseline data from patients who were randomized to the placebo arm (n=163) and thus untreated with any approved pulmonary artery vasodilators were used to derive a risk calculator. The endpoint of interest was the time to clinical worsening. Stepwise regression, Harrell's c-index, and clinician input were used to derive 2 multivariable Cox PH models from a set of candidate variables. The models were then simplified by applying a point-scoring system to the predictors and refitting with total point score as the covariate. Total point scores were grouped into 3 risk strata (lower, intermediate, and higher).

Results

Two versions of a risk calculator were derived. The first was a non-invasive risk calculator which included NT-proBNP and FVC%/DLCO%, and a second adds cardiac index, an invasive parameter, to the above two parameters. For the total point score models, the estimated c-indices were 0.703 (95% CI: 0.635, 0.783) and 0.683 (95% CI: 0.612, 0.761) for the invasive and non-invasive model, respectively.

Conclusion

These two risk calculators provide a simple way to risk stratify ILD-PH patients with clinically useful discrimination. The calculators are easy to employ in clinical practice, since they utilize assessments commonly collected in the care of patients with ILD-PH. Moreover, the calculators can provide clinicians with important prognostic information which can be used to reinforce the benefits of therapy. The risk calculators may also find utility as part of the composite allocation score of ILD-PH patients listed for lung transplant. Future research in this area could include incorporating longer-term outcomes as well as validating the risk models in a separate patient population.

Lung transplantation for pulmonary chronic graft-versus-host disease: a missed opportunity?

Chronic graft-versus-host disease is a common complication after allogeneic hematopoietic stem cell transplantation, with pulmonary chronic graft-versus-host disease (PcGvHD) particularly associated with a dismal prognosis. Lung transplantation (LuTx) is a final therapeutic option for well-selected patients affected by this condition. Nevertheless, only a small group of PcGvHD patients are referred for LuTx. This review addresses common concerns regarding referral and listing of PcGvHD patients for LuTx (such as risk of relapse of hematological malignancy, infectious complications and rejection) and survival outcomes of this specific cohort of patients. Importantly, LuTx for PcGvHD has comparable outcomes to other indications. The establishment of specific LuTx indication criteria for PcGvHD patients may improve referral rates and timing of both referral and listing of suitable candidates.

Population Pharmacokinetic and Pharmacodynamic of Atorvastatin in Chinese Lung Transplant Recipients

Atorvastatin is a widely prescribed cholesterol-lowering drug that inhibits 3-hydroxy-3-methylglutaryl coenzyme A reductase to reduce lipid levels. This study aimed to establish a population pharmacokinetic and pharmacodynamic model for atorvastatin in Chinese lung transplant recipients (LTRs), particularly those using voriconazole (VOR) and with different genotypes. It evaluated precise dosing regimens and analyzed the correlation between atorvastatin exposure and clinical outcomes. A nonlinear mixed-effects model was used for the population pharmacokinetic/pharmacodynamic (PK/PD) analysis. A one-compartment population PK model was developed, incorporating VOR, SLCO2A1 rs76906503, and SLC22A8 rs2187383 to assess apparent clearance and volume of distribution. LDL-C was modeled as a biomarker to evaluate atorvastatin efficacy. A Monte Carlo simulation was conducted to assess various dosing schemes and the effects of different covariates on achieving the target LDL concentration. The correlation between atorvastatin exposure and clinical outcomes was also evaluated. Results indicated that the average probability of target attainment for optimal dosing regimens across various covariate results exceeded 45.8%. Dosages of 10, 20, and 40 mg were deemed suitable for LTRs. A lower dose was recommended for LTRs taking VOR or with mutant-type genotypes to avoid overexposure and adverse reactions. The population PK/PD model offers valuable guidance for evaluating atorvastatin dosing regimens in clinical settings, particularly for LTRs using VOR and those with different genotypes.

CT Honeycombing and Traction Bronchiectasis Extent Independently Predict Survival across Fibrotic Interstitial Lung Disease Subtypes

Background Prognostic value of radiologic features in interstitial lung disease (ILD) has been predominantly studied in idiopathic pulmonary fibrosis, but findings vary. The relative importance of features versus guideline-defined patterns in predicting outcomes is unknown. Purpose To identify radiologic features that are independently associated with transplant-free survival beyond clinical predictive factors across all ILD subtypes, and to identify whether individual features versus patterns are more important for prognostication. Materials and Methods This is a secondary analysis of the prospective Canadian Registry for Pulmonary Fibrosis. Consecutive patients with ILD were evaluated in standardized multidisciplinary discussions between January 2021 and March 2022. Radiologic features on thin-section CT images were quantified, and guideline-defined usual interstitial pneumonia (UIP) and fibrotic hypersensitivity pneumonitis (fHP) patterns were assigned. Multivariable Cox analysis was used to assess the associations of radiologic features with transplant-free survival, and nested models were used to test the relative importance of features compared with patterns. Results A total of 1593 patients (mean age, 66 years ± 12 [SD]; 800 male) were included. The following four features were associated with transplant-free survival: extent of honeycombing (hazard ratio, 1.20; 95% CI; 1.06, 1.36 per 10% increase in lung involvement; P = .005), extent of traction bronchiectasis (hazard ratio, 1.18; 95% CI: 1.10, 1.26 per 10% increase; P < .001), pulmonary artery diameter (hazard ratio, 1.03; 95% CI: 1.01; 1.04 per 1-mm increase; P = .002), and presence of subpleural sparing (hazard ratio, 0.76; 95% CI: 0.56, 0.96; P = .03). Guideline-defined patterns were not independently associated with survival in a model that included these four radiologic features, each of which retained its prognostic value. Conclusion The extent of fibrosis was predictive of worse outcomes across all ILD subtypes in a dose-dependent fashion and independent of well-recognized clinical prognostic factors. Guideline-defined UIP and fHP patterns each helped risk-stratify patients in isolation but lost prognostic value when accounting for the extent of fibrosis, suggesting that their previous association with mortality is based on these patterns acting as surrogates for a greater extent of fibrosis. © RSNA, 2025 Supplemental material is available for this article. See also the editorial by Wells in this issue.

The association between pretransplant malignancy and post-transplant survival and cancer recurrence in bilateral lung transplantation: An analysis of 23,291 recipients

Background

Given the increasing need for lung transplants among older patients with a history of cancer, this study analyzed database registry to assess outcomes for bilateral lung transplant (BLT) recipients with pre-transplant malignancy (TM).

Methods

This study evaluated the United Network for Organ Sharing registry for adult BLT performed between 2005 and 2023. Patients with a history of previous or multiorgan transplants, and those with donors who had cancer history, were excluded. Propensity score matching was used to compare patients with or without pre-TM. Overall and post-TM-free survival were analyzed.

Results

Among the 23,291 recipients of BLT, 8.0% (1,870) had pre-TM. Compared to those without pre-TM, patients with pre-TM had worse overall (hazard ratio [HR] 1.20, 95% confidence interval [CI] 1.12-1.29, p < 0.001) and post-TM-free survival (HR 1.32, 95% CI 1.24-1.41, p < 0.001). However, after adjusting for age, sex, and race through propensity score matching, the survival difference between the groups became nonsignificant (HR 1.05, 95% CI 0.97-1.13, p = 0.229). While the pre-TM group still had worse post-TM-free survival, this difference diminished after excluding cutaneous post-TM (HR 1.06, 95% CI 0.99-1.15, p = 0.116). Additionally, the recurrence rate of pre-TM after transplant was not higher than de novo cancers in patients without pre-TM.

Conclusions

Patients with pre-TM had similar survival rates after BLT as those without pre-TM. Importantly, there was no increased risk of the primary pre-TM type recurring post-transplant compared to patients without pre-TM. If patients with pre-TM are free from recurrence or metastasis for a significant time, there could be some who can benefit from BLT. Further data regarding timeline between pre-TM and BLT would be necessary to draw conclusion in this issue.

Impact of elexacaftor-tezacaftor-ivacaftor in lung transplantation for cystic fibrosis in the United States

Background

Cystic fibrosis (CF) is an autosomal recessive condition leading to progressive lung disease and often necessitating lung transplantation. Historically, CF has been one of the leading indications for lung transplants in the United States. The advent of CF transmembrane conductance regulator (CFTR) modulators, particularly elexacaftor-tezacaftor-ivacaftor (ETI), has significantly improved clinical outcomes for people with CF (pwCF), offering potential alterations in disease progression and transplantation needs.

Methods

Data on lung transplants performed in the United States since 1988 were retrieved from the Organ Procurement & Transplantation Network. Custom reports were generated to compare the number of lung transplants and waitlist additions before and after ETI approval in 2019. The analysis focused on trends from 2009-2019 (pre-ETI) and 2021-2023 (post-ETI).

Results

The average annual lung transplants for CF decreased significantly from 243 (2009-2019) to 56.7 (2021-2023) post-ETI approval. Similarly, the average number of pwCF added to the lung transplant waitlist per year dropped from 295 to 55.6. Despite an overall increase in lung transplants and waitlist additions in the United States, the proportion involving pwCF has markedly declined post-ETI.

Conclusions

The introduction of ETI has dramatically reduced the need for lung transplants among pwCF, reflecting significant improvements in lung function and disease management. These findings underscore the transformative impact of CFTR modulators like ETI on the natural history of CF, highlighting the importance of continued advancements in precision medicine for genetic disorders. Future studies should investigate long-term outcomes and sustained trends in lung transplantation needs among pwCF.

Improved Results Over Time With Bridge-to-Lung Transplantation: A 10-Year Experience of a Single High-Volume Center

When donor scarcity limits timely lung transplantation (LTx), extracorporeal membrane oxygenation (ECMO) as a bridge to transplantation (BTT) can prolong survival and delay deconditioning until the donor lungs become available. We reviewed 10-year BTT experiences of a single high-volume center, where 99 (59%) were on ECMO BTT among 169 eligible adult LTx cases. Both 28-day and 2-year survivals did not differ between BTT and non-BTT. The BTT data was then divided into two periods, delineated by the most recent 3 years. The clinical outcomes of the earlier period ("Period 1") and the later period ("Period 2") were compared, and mortality within 28 days of LTx was significantly lower in Period 2 (n = 1, 1.7%) than in Period 1 (n = 6, 14.6%, p < 0.01). Improved survival was observed in the subgroup with BTT duration of 14 days or more. Taken together, more experiences in BTT and improved competence may contribute to better survival after LTx, especially in patients receiving ECMO for 14 days or more.

Lung Transplantation—Indications, Follow-Up Care and Long-Term Results

BACKGROUND

Lung transplantation is the treatment of choice for end-stage nonmalignant lung disease. It has become a routine procedure through advances in donor lung preservation, extracorporeal membrane oxygenation, immunosuppression, intensive care medicine, and follow-up care.

METHODS

This review is based on publications about lung transplantation that were retrieved by a selective literature search, and on the procedures and experience of two large-volume lung transplantation centers.

RESULTS

The mean survival time after lung transplantation is six years, which is the shortest after the transplantation of any solid organ. Chronic graft dysfunction is present in 41% of patients at five years and is the main cause of death after lung transplantation, followed by infection and cancer.

CONCLUSION

Despite all the advances in lung transplantation, acute and-above all-chronic graft dysfunction still pose a major challenge for large-volume transplantation centers. Immunosuppression that is individually tailored to prevent both graft rejection and infection is important for these patients' longterm survival. Xenotransplantation and so-called lung bioengineering may become available in the future as alternatives to allotransplantation.

Correlation of Coronary Calcium Measured on Conventional Computed Tomography with Coronary Angiography Findings in Lung Transplant Patients

Introduction and objective: The pre-transplant protocol for lung transplant candidates includes a chest CT scan to assess disease progression and often coronary angiography (CA) to rule out coronary artery disease (CAD). Coronary artery calcium is commonly observed in these pre-transplant CT scans. This study aims to evaluate the relationship between coronary calcium detected on CT and findings from CA to determine whether calcium presence could serve as an additional criterion for selecting patients for CA. Material and Methods: We included 252 consecutive lung transplant patients who had both a CT scan and CA within 365 days of each other. Coronary calcium quantification was performed using artery-based, segment artery-based, and visual assessment methods. CA findings were classified by stenosis severity: ≤20%, 21-70%, and >70%. Results: This study showed very high concordance (kappa = 0.896; 95% CI: 0.843-0.948) between the three methods, especially in distinguishing patients without and with coronary calcium (kappa = 1.000; 95% CI: 0.929-1.071). ROC analysis identified the absence of coronary calcium as the best cutoff to differentiate patients with ≤20% stenosis from those with >21%, with a sensitivity of 73.5%, specificity of 55.7%, PPV of 28.5%, and NPV of 90%. Only 11 patients (8.7%) without coronary calcium had stenosis of 21-70%, and only 2 (1.6%) had stenosis > 70%. Conclusions: The visual assessment method yielded results similar to the other two quantification methods. The absence of coronary calcium in pre-transplant CT may be a useful criterion for selecting patients for CA.

Lung transplantation and bone health: A narrative review

Bone health after lung transplantation has not been comprehensively reviewed in over 2 decades. This narrative review summarizes the available literature on bone health in the context of lung transplantation, including epidemiology, presentation, and postoperative management. Osteoporosis is reported in approximately 30% to 50% of lung transplant candidates, largely due to disease-related impact on bone and lifestyle, and corticosteroid-related effects during end-stage lung disease (interstitial lung diseases, chronic obstructive pulmonary disease, and historically cystic fibrosis). After lung transplantation, many patients experience steroid-induced bone loss, followed by stabilization or recovery to baseline levels with pharmacologic management. Although evidence on fracture incidence is limited, fracture risk appears to increase in the year following transplantation, with common fracture sites including the vertebrae and the ribs. Vertebral and rib fractures restrict chest expansion and affect lung function, underscoring the importance of fracture prevention in lung transplant recipients. There is limited evidence on the pharmacologic management of osteoporosis after lung transplantation. Existing randomized controlled trials have focused on parenteral bisphosphonates and calcitriol but have been underpowered to evaluate their effect on fracture outcomes. Resistance training, particularly in conjunction with antiresorptive therapy, has also been shown to improve bone health when initiated 2 months after transplantation. No studies to date have documented the effectiveness of denosumab in lung transplant recipients; more studies on pharmacotherapy are warranted to elucidate optimal medical management. Considering the high osteoporosis prevalence and fracture risk in lung transplant populations, the development of formal guidance is warranted to promote improved management after transplantation.

Novel Therapies for Right Ventricular Failure

PURPOSE OF REVIEW

Traditionally viewed as a passive player in circulation, the right ventricle (RV) has become a pivotal force in hemodynamics. RV failure (RVF) is a recognized complication of primary cardiac and pulmonary vascular disorders and is associated with a poor prognosis. Unlike treatments for left ventricular failure (LVF), strategies such as adrenoceptor signaling inhibition and renin-angiotensin system modulation have shown limited success in RVF. This review aims to reassure about the progress in RVF treatment by exploring the potential of contemporary therapies for heart failure, including angiotensin receptor and neprilysin inhibitors, sodium-glucose co-transporter 2 inhibitors, and soluble guanylate cyclase stimulators, which may be beneficial for treating RV failure, particularly when associated with left heart failure. Additionally, it examines novel therapies currently in the pipeline.

RECENT FINDINGS

Over the past decade, a new wave of RVF therapies has emerged, both pharmacological and device-centered. Novel pharmacological interventions targeting metabolism, calcium homeostasis, oxidative stress, extracellular matrix remodeling, endothelial function, and inflammation have shown significant promise in preclinical studies. There is also a burgeoning interest in the potential of epigenetic modifications as therapeutic targets for RVF. Undoubtedly, a deeper understanding of the mechanisms underlying RV failure, both with and without pulmonary hypertension, is urgently needed. This knowledge is not just a theoretical pursuit, but a crucial step that could lead to the development of pharmacological and cell-based therapeutic options that directly target the RV and pulmonary vasculature, aligning with the principles of precision medicine.

Neuroimaging Augments DCD-N Score in Predicting Time from Withdrawal of Life-Sustaining Measures to Death Among Potential Organ Donors

BACKGROUND

Controlled donation after circulatory determination of death (DCD) is feasible only if circulatory arrest occurs soon after withdrawal of life-sustaining measures (WLSM). When organ recovery cannot proceed because this time interval is too long, there are potential negative implications, including perceptions of "secondary loss" for patients' families and significant resource consumption. The DCD-N score is a validated clinical tool for predicting rapid death following WLSM. We hypothesized that neuroimaging evidence of effaced perimesencephalic cisterns improves prediction of time to death compared with the DCD-N score alone.

METHODS

In a retrospective population-based cohort study, DCD-N scores were prospectively determined in patients for whom consent for DCD had been obtained. Perimesencephalic cisterns on last available neuroimaging were assessed in duplicate and classified as normal, partially effaced, or completely effaced. Multivariable logistic regression assessed the capacity of DCD-N score and effaced cisterns to predict death within 1, 2, or 3 h of WLSM.

RESULTS

Of 164 consecutive patients, 49 (30%) progressed to death by neurologic criteria and were excluded. Of the remaining 115 patients, 81 (70%) died within 2 h of WLSM. When perimesencephalic cisterns were patent, this occurred in 48% of patients, compared with 88% and 93%, respectively, of patients with partially and completely effaced cisterns (p < 0.0001). In multivariable analysis, the odds ratio for prediction of death within 2 h was 7.2 (2.8-18.3) for each incremental DCD-N score and 15.4 (4.1-58.1) for the presence of either partially or completely effaced cisterns (c = 0.92 vs. 0.75-0.84 for univariate models). Results were comparable for prediction of death within 1 or 3 h. With patent cisterns, median time to death was 132.5 (21-420) minutes, compared with 23.5 (16-32) and 22 (19-30) minutes, respectively, with partially and completely effaced cisterns (p = 0.0002).

CONCLUSIONS

Cerebral edema with effaced perimesencephalic cisterns predicts rapid death following WLSM in potential DCD organ donors and improves on performance of the DCD-N score alone. Although originally validated for the prediction of death within 1 h, the DCD-N score remains predictive up to 3 h following WLSM.

Potential of phosphodiesterase 4B inhibition in the treatment of progressive pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is often regarded as the archetypal progressive fibrosing interstitial lung disease (ILD). The term "progressive pulmonary fibrosis" (PPF) generally describes progressive lung fibrosis in an individual with an ILD other than IPF. Both IPF and PPF are associated with loss of lung function, worsening dyspnea and quality of life, and premature death. Current treatments slow the decline in lung function but have side effects that may deter the initiation or continuation of treatment. There remains a high unmet need for additional therapies that can be used alone or in combination with current therapies to preserve lung function in patients with IPF and PPF. Phosphodiesterase-4 (PDE4) is an enzyme involved in the regulation of inflammatory processes. Pre-clinical studies have shown that preferential inhibition of PDE4B has anti-inflammatory and antifibrotic effects and a lower potential for gastrointestinal adverse events than pan-PDE4 inhibition. The preferential PDE4B inhibitor nerandomilast demonstrated efficacy in preserving lung function in a phase II trial in patients with IPF and is under investigation in phase III trials as a treatment for IPF and PPF.

ERS Congress 2024: highlights from the Thoracic Surgery and Lung Transplantation Assembly

Assembly 8, which includes groups 8.01 Thoracic surgery and 8.02 Lung transplantation, arranged many interesting sessions for #ERSCongress 2024, and we highlight some of them in this article https://bit.ly/3AgC5Yv.

Gastrointestinal cancer incidence after lung transplantation in sarcoidosis patients

Background

The risk of gastrointestinal (GI) cancer after lung transplantation (LTx) in sarcoidosis patients is not well defined. Given the cancer risks linked to sarcoidosis and organ transplantation, this study investigated the incidence of GI de novo malignancies (DNM), comparing LTx recipients with sarcoidosis or idiopathic pulmonary fibrosis (IPF).

Methods

We analyzed data from the United Network for Organ Sharing registry, including adults with sarcoidosis or IPF who underwent LTx between May 2005 and December 2018. The primary outcome was the incidence of GI DNM by March 2023.

Results

Of 7996 lung transplant recipients, 108 (1.35%) developed GI malignancies post-transplantation. Among these, 662 patients (9%) had sarcoidosis and 7334 (91%) had IPF. Sarcoidosis patients showed a non-significant trend toward a higher risk of GI malignancies compared to those with IPF (subhazard ratio 1.72, 95% confidence interval 0.90-3.29; P=0.099), with no observed difference in the risk of non-GI cancers.

Conclusions

The overall incidence of GI DNM following LTx is low, and sarcoidosis does not appear to increase the risk of GI cancers compared to IPF. This finding suggests that enhanced GI cancer screening beyond standard guidelines may not be warranted in this population, allowing for targeted surveillance of more prevalent malignancies in sarcoidosis patients post-LTx.

[Diagnosis and Treatment of Pulmonary Embolism and Pulmonary Hypertension in Patients With Interstitial Lung Disease]

Pulmonary embolism (PE) and pulmonary hypertension (PH) are common comorbidities that worsen the prognosis of patients diagnosed with interstitial lung disease (ILD). Despite advances in the diagnosis and treatment of these entities, their impact on the management and progression of ILD is not sufficiently studied. This article includes a review and update of the diagnosis and treatment of PE and PH in patients with underlying ILD.

Prognostic value of the 6-min walk test derived attributes in patients with idiopathic pulmonary fibrosis

INTRODUCTION

Idiopathic pulmonary fibrosis (IPF) is a fatal progressive fibrosing lung disease. A decreased 6-min walk distance (6MWD) and exercise-induced oxygen desaturation measured during the 6-min walk test (6MWT), are known predictors of mortality in patients with IPF. However, the use of antifibrotic drugs showed a survival benefit in IPF. Therefore, this study aimed to evaluate to what extend 6MWT-derived attributes are associated with two-year survival when antifibrotic drugs were introduced as part of standard IPF-care.

METHODS

This real-world data-study included patients with IPF with a 6MWT between 2015 and 2020, and used composite outcome: mortality or lung transplantation within 2 years of follow-up. Data were collected systematically, including demographics, pulmonary function tests, comorbidities, medications and 6MWT-derived attributes. The prediction attributes of 6MWT were studied with a Cox Proportional-Hazards model and Kaplan-Meier survival curves. The best discriminating attribute to predict mortality was added to the prediction model Gender-Age-Physiology (GAP).

RESULTS

In 216 patients, 2-year transplant-free survival cut-off points were identified for the 6MWD (≥413 m), 6MWD %predicted (≥83 %), SpO2-nadir (≥86 %) and distance-saturation-product (≥374 m%), with the best discriminative value for SpO2-nadir (area under the curve: 0.761). 2-Year survival percentage of patients with SpO2-nadir below or above threshold (86 %) was 37.1 % and 80.0 %, respectively. Exercise-induced oxygen desaturation added to the GAP model showed an improvement in its predictive power.

CONCLUSION

Patients with IPF who have an exercise-induced oxygen desaturation have worse prognosis. Addition of SpO2-nadir to the GAP model seems promising for use in clinical care of IPF patients.

The Saudi Thoracic Society Evidence-based guidelines for the diagnosis and management of chronic obstructive pulmonary disease

The Saudi Thoracic Society (STS) developed an updated evidence-based guideline for diagnosing and managing chronic obstructive pulmonary disease (COPD) in Saudi Arabia. This guideline aims to provide a comprehensive and unbiased review of current evidence for assessing, diagnosing, and treating COPD. While epidemiological data on COPD in Saudi Arabia are limited, the STS panel believes that the prevalence is increasing due to rising rates of tobacco smoking. The key objectives of the guidelines are to facilitate accurate diagnosis of COPD, identify the risk for COPD exacerbations, and provide recommendations for relieving and reducing COPD symptoms in stable patients and during exacerbations. A unique aspect of this guideline is its simplified, practical approach to classifying patients into three classes based on symptom severity using the COPD Assessment Test and the risk of exacerbations and hospitalizations. The guideline provides the reader with an executive summary of recommended COPD treatments based on the best available evidence and also addresses other major aspects of COPD management and comorbidities. This guideline is primarily intended for use by internists and general practitioners in Saudi Arabia.

[Risk analysis applied to the monitoring of immunosuppressor concentrations in lung transplant recipients]

Mastering and monitoring immunosuppressant concentrations is central to the care of lung transplant patients and involves multiple stakeholders. The objective is to conduct a risk analysis to evaluate the impact of various actions taken. The lung transplantation team was convened to carry out a failure mode effect analysis. The process was divided into stages where different risks were identified. The risk priority number (RPN) (severity, frequency, detectability) and risk level of criticality (frequency, severity) were established before implementation of actions (before 2009) and then after (in 2022) to classify risks according to four levels of criticality. The implemented actions included the establishment of a quality assurance process, computerization of monitoring, and double analysis by a physician/pharmacist pair. Thirty-two risks were identified during the four stages of the process: biological sampling (n=13), reception (n=3), analysis and treatment of levels (n=5), transmission of information/prescriptions to the patient (n=11). The total raw RPN (before 2009) was 839, with 12 major risks. The current total RPN (in 2022) was 452 (a decrease of 46.1%), with 7 major risks identified. The analysis enabled the objective evaluation of the effectiveness of the actions taken. The most secure stage of the process is the reception of residual level results. Efforts should focus on empowering and involving patients, as well as engaging local stakeholders in collaboration with the specialized transplantation team.