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Saleem F, Liang H, Martin AK. Year in Review 2023: Noteworthy Literature in Cardiothoracic Transplantation. Semin Cardiothorac Vasc Anesth 2024; 28:106-112. [PMID: 38548478 DOI: 10.1177/10892532241242973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
This review highlights key studies examining perioperative management of cardiothoracic transplantation published in 2023. Articles were manually screened after searching Scopus, PubMed, and Google Scholar databases for manuscripts related to cardiothoracic transplantation, which yielded 343 papers with 15 qualitatively selected as the most salient for readers. Overarching themes include differences in outcomes across the various etiologies of end-stage lung disease, novel developments to expand the donor pool, and multi-organ transplantation.
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Affiliation(s)
- Faiz Saleem
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Hong Liang
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Archer Kilbourne Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
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2
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Paraskeva MA, Snell GI. Advances in lung transplantation: 60 years on. Respirology 2024; 29:458-470. [PMID: 38648859 DOI: 10.1111/resp.14721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 04/03/2024] [Indexed: 04/25/2024]
Abstract
Lung transplantation is a well-established treatment for advanced lung disease, improving survival and quality of life. Over the last 60 years all aspects of lung transplantation have evolved significantly and exponential growth in transplant volume. This has been particularly evident over the last decade with a substantial increase in lung transplant numbers as a result of innovations in donor utilization procurement, including the use donation after circulatory death and ex-vivo lung perfusion organs. Donor lungs have proved to be surprisingly robust, and therefore the donor pool is actually larger than previously thought. Parallel to this, lung transplant outcomes have continued to improve with improved acute management as well as microbiological and immunological insights and innovations. The management of lung transplant recipients continues to be complex and heavily dependent on a tertiary care multidisciplinary paradigm. Whilst long term outcomes continue to be limited by chronic lung allograft dysfunction improvements in diagnostics, mechanistic understanding and evolutions in treatment paradigms have all contributed to a median survival that in some centres approaches 10 years. As ongoing studies build on developing novel approaches to diagnosis and treatment of transplant complications and improvements in donor utilization more individuals will have the opportunity to benefit from lung transplantation. As has always been the case, early referral for transplant consideration is important to achieve best results.
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Affiliation(s)
- Miranda A Paraskeva
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Gregory I Snell
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
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3
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Corrao F, Kelly-Aubert M, Sermet-Gaudelus I, Semeraro M. Unmet challenges in cystic fibrosis treatment with modulators. Expert Rev Respir Med 2024:1-13. [PMID: 38755109 DOI: 10.1080/17476348.2024.2357210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 05/15/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION 'Highly effective' modulator therapies (HEMTs) have radically changed the Cystic Fibrosis (CF) therapeutic landscape. AREAS COVERED A comprehensive search strategy was undertaken to assess impact of HEMT in life of pwCF, treatment challenges in specific populations such as very young children, and current knowledge gaps. EXPERT OPINION HEMTs are prescribed for pwCF with definite genotypes. The heterogeneity of variants complicates treatment possibilities and around 10% of pwCF worldwide remains ineligible. Genotype-specific treatments are prompting theratyping and personalized medicine strategies. Improvement in lung function and quality of life increase survival rates, shifting CF from a pediatric to an adult disease. This implies new studies addressing long-term efficacy, side effects, emergence of adult co-morbidities and possible drug-drug interactions. More sensitive and predictive biomarkers for both efficacy and toxicity are warranted. As HEMTs cross the placenta and are found in breast milk, studies addressing the potential consequences of treatment during pregnancy and breastfeeding are urgently needed. Finally, although the treatment and expected outcomes of CF have improved dramatically in high- and middle-income countries, lack of access in low-income countries to these life-changing medicines highlights inequity of care worldwide.
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Affiliation(s)
- Federica Corrao
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies, University of Palermo, Palermo, Italy
- INSERM, Institut Necker Enfants Malades, Paris, France
| | | | - Isabelle Sermet-Gaudelus
- INSERM, Institut Necker Enfants Malades, Paris, France
- Centre de Référence Maladies Rares Mucoviscidose et maladies apparentées. Site constitutif, Université de Paris, Paris, France
- European Reference Lung Center, Frankfurt, Germany
- Université Paris Cité, Paris, France
| | - Michaela Semeraro
- Université Paris Cité, Paris, France
- Centre Investigation Clinique, Hôpital Necker Enfants Malades, Paris, France
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van der Meer R, Wilms EB, Eggermont MN, Paalvast HM, van Luin M, van Rossen RCJM, Heijerman HGM. Elexacaftor/tezacaftor/ivacaftor in liver or kidney transplanted people with cystic fibrosis using tacrolimus, a drug-drug interaction study. J Cyst Fibros 2024:S1569-1993(24)00007-9. [PMID: 38290918 DOI: 10.1016/j.jcf.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 01/14/2024] [Accepted: 01/15/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND The use of elexacaftor/tezacaftor/ivacaftor (ETI) in people with cystic fibrosis (pwCF) after solid organ transplantation is controversial because of potential drug-drug interactions (DDI) with tacrolimus. We aimed to improve insight into the safety and clinical benefits of co-administration of ETI and tacrolimus in liver or kidney transplanted adult pwCF. METHODS In 5 pwCF, tacrolimus concentrations were monitored during 2 weeks before and 4 weeks after starting ETI treatment. Trough levels, area under the curve (AUC) and clinical effect of ETI were investigated. During the study (6 weeks in total) adverse events were monitored. RESULTS The DDI between tacrolimus and ETI resulted in an increased exposure of tacrolimus in all subjects, the dose adjusted AUC0-24h was 1.79 (median) times higher at the end of the study. Five dose adjustments were performed in 4 subjects in order to attain tacrolimus target range. No adverse events were reported and all subjects showed clinical improvement during ETI treatment. CONCLUSION The clinical value of ETI treatment in kidney and liver transplanted pwCF is clear. The use of ETI may increase tacrolimus levels moderately. Therefore, we recommend close monitoring of tacrolimus trough levels in patients who start ETI.
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Affiliation(s)
- Renske van der Meer
- Department of Pulmonology and Adult CF Centre, Haga Hospital, Els Borst-Eilersplein 275, The Hague 2545 AA, The Netherlands.
| | - Erik B Wilms
- Central Hospital Pharmacy (Laboratory AHZ), Charlotte Jacobslaan 70, The Hague 2545 AB, The Netherlands
| | - Margot N Eggermont
- Department of Pulmonology and Adult CF Centre, Haga Hospital, Els Borst-Eilersplein 275, The Hague 2545 AA, The Netherlands
| | - Helena M Paalvast
- Department of Pulmonology and Adult CF Centre, Haga Hospital, Els Borst-Eilersplein 275, The Hague 2545 AA, The Netherlands
| | - Matthijs van Luin
- Department of Clinical Pharmacy, University Medical Centre Utrecht, Heidelberglaan 100, Utrecht 3584 CX, The Netherlands
| | - Richard C J M van Rossen
- Central Hospital Pharmacy (Laboratory AHZ), Charlotte Jacobslaan 70, The Hague 2545 AB, The Netherlands
| | - Harry G M Heijerman
- Department of Pulmonology and Adult CF Centre, University Medical Centre Utrecht, Heidelberglaan 100, Utrecht 3584 CX, The Netherlands
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Kadouh NK, Elijah J, Fitzgerald LJ, Phan H. Use of CFTR modulators in special populations, part 3: Solid organ transplant. Pediatr Pulmonol 2023; 58:3393-3402. [PMID: 37067449 DOI: 10.1002/ppul.26396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 02/19/2023] [Accepted: 03/15/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Solid organ transplant (SOT) recipients with cystic fibrosis (CF) may benefit from the pulmonary and extrapulmonary benefits associated with CF transmembrane conductance regulator modulators. Nevertheless, evolution of modulator safety and efficacy data prompts consideration. METHODS The search terms "transplant" AND "ivacaftor"(IVA) OR "lumacaftor"(LUM) OR "tezacaftor" (TEZ) OR "elexacaftor" (ELX) were utilized to conduct a scoping review of English articles from the period of January 1, 2012 to December 31, 2022. Search results from PubMed and Embase databases were reviewed by title and abstract for relevance. Included studies reported efficacy and safety outcomes of modulators in SOT recipients. RESULTS One hundred thirty-six patients from one cohort study (90 lung transplant recipients) and eight case reports and series (29 lung transplant recipients, 16 liver transplant recipients and one lung/liver transplant patient) were included. Post-modulator initiation, 33 patients did not necessitate tacrolimus dose adjustments, 10 required dose uptitration, and 43 required dose reductions. Moreover, LUM/IVA use with azole antifungals may lead to subtherapeutic levels but opposing effects sustained tacrolimus levels. Liver transplant recipients were more likely to experience elevations in transaminases requiring pharmacologic or medical interventions. Majority of patients experienced improvements in pulmonary function, fasting blood glucose, hemoglobin, body mass index, and rhinosinusitis symptoms. However, intolerance or lack of benefit prompted discontinuation of ELX/TEZ/IVA in over 40% of lung-transplant recipients in one study. CONCLUSION Modulator therapy has been reported to produce pulmonary and extra-pulmonary benefits in the CF population with SOT. Considerations for modulator therapy initiation ought to include modulator pharmacokinetics, concomitant medications, and transplant type due to the complex nature of SOT recipients.
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Affiliation(s)
- Nour K Kadouh
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Joseph Elijah
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Linda J Fitzgerald
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
- Sanofi Medical Affairs, Bridgewater, New Jersey, USA
| | - Hanna Phan
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
- Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, University of Michigan, Ann Arbor, Michigan, USA
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6
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Young D, Bartlett LE, Guimbellot J, Milinic T, Burdis N, Gill ER, Lease ED, Goss CH, Kapnadak SG, Ramos KJ. Patient perspectives on elexacaftor/tezacaftor/ivacaftor after lung transplant. J Cyst Fibros 2023:S1569-1993(23)00921-9. [PMID: 37798159 PMCID: PMC10987391 DOI: 10.1016/j.jcf.2023.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 09/19/2023] [Accepted: 09/25/2023] [Indexed: 10/07/2023]
Abstract
Cystic fibrosis transmembrane conductance regulator (CFTR) modulators, including elexacaftor/tezacaftor/ivacaftor (ETI), significantly improve outcomes and quality of life for people with cystic fibrosis (CF). However, little is known about how lung transplant recipients (LTRs) perceive the use of ETI. We conducted a survey to assess perspectives on ETI among LTRs with CF at our lung transplant program. Of 81 CF LTRs, 46 participants (58 %) responded. The majority of respondents (88 %) were aware of ETI. Over 80 % considered treating non-lung symptoms of CF to be very important. Concerns regarding ETI included potential drug interactions with transplant medications (77 %), side effects (53 %), cost of medication (49 %), and lack of clinical trial data for LTRs (43 %). Half reported they would only consider taking ETI if their CF or transplant doctor recommended it. The findings suggest that CF LTRs seek informational support and shared decision-making about ETI from their clinicians.
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Affiliation(s)
- Dave Young
- Department of Biology, University of Washington, Seattle, WA 98195, United States
| | - Lauren E Bartlett
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA 98195, United States
| | - Jennifer Guimbellot
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA 98195, United States
| | - Tijana Milinic
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA 98195, United States
| | - Nora Burdis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA 98195, United States
| | - Eliana R Gill
- Division of Biobehavioral Nursing and Health Informatics, Department of Nursing, University of Washington, Seattle, WA 98195, United States
| | - Erika D Lease
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA 98195, United States
| | - Christopher H Goss
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA 98195, United States; Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, WA 98195, United States; Seattle Children's Research Institute, Seattle, WA 98195, United States
| | - Siddhartha G Kapnadak
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA 98195, United States
| | - Kathleen J Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA 98195, United States.
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Huang W, Smith AT, Korotun M, Iacono A, Wang J. Lung Transplantation in a New Era in the Field of Cystic Fibrosis. Life (Basel) 2023; 13:1600. [PMID: 37511977 PMCID: PMC10381966 DOI: 10.3390/life13071600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/08/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
Lung transplantation for people with cystic fibrosis (PwCF) is a critical therapeutic option, in a disease without a cure to this day, and its overall success in this population is evident. The medical advancements in knowledge, treatment, and clinical care in the field of cystic fibrosis (CF) rapidly expanded and improved over the last several decades, starting from early pathology reports of CF organ involvement in 1938, to the identification of the CF gene in 1989. Lung transplantation for CF has been performed since 1983, and CF now accounts for about 17% of pre-transplantation diagnoses in lung transplantation recipients. Cystic fibrosis transmembrane conductance regulator (CFTR) modulators have been the latest new therapeutic modality addressing the underlying CF protein defect with the first modulator, ivacaftor, approved in 2012. Fast forward to today, and we now have a growing CF population. More than half of PwCF are now adults, and younger patients face a better life expectancy than they ever did before. Unfortunately, CFTR modulator therapy is not effective in all patients, and efficacy varies among patients; it is not a cure, and CF remains a progressive disease that leads predominantly to respiratory failure. Lung transplantation remains a lifesaving treatment for this disease. Here, we reviewed the current knowledge of lung transplantation in PwCF, the challenges associated with its implementation, and the ongoing changes to the field as we enter a new era in the care of PwCF. Improved life expectancy in PwCF will surely influence the role of transplantation in patient care and may even lead to a change in the demographics of which people benefit most from transplantation.
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Affiliation(s)
- Wei Huang
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
| | - Alexander T Smith
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
| | - Maksim Korotun
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
| | - Aldo Iacono
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
| | - Janice Wang
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
- Institute of Health System Science, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY 11030, USA
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8
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Salazar-Barragan M, Taub DR. The Effects of Elexacaftor, Tezacaftor, and Ivacaftor (ETI) on Blood Glucose in Patients With Cystic Fibrosis: A Systematic Review. Cureus 2023; 15:e41697. [PMID: 37575762 PMCID: PMC10413995 DOI: 10.7759/cureus.41697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2023] [Indexed: 08/15/2023] Open
Abstract
Cystic fibrosis (CF) is an autosomal recessive genetic disorder resulting from defects in the cystic fibrosis transmembrane conductance regulator (CFTR) protein, which in turn results in a multi-systemic disorder. There are numerous known CF alleles associated with different mutations of the CFTR gene, with the most common CF allele being a three-base-pair deletion known as ΔF508. One common manifestation of CF is glycemic dysregulation associated with decreased insulin secretion, often progressing into a distinct form of diabetes known as cystic fibrosis-related diabetes (CFRD). In the past decade, a class of drugs known as CFTR modulators has entered clinical practice. These drugs interact with the CFTR protein to restore its function, with different modulators (or combinations of modulators) suitable for patients with different CFTR mutations. Previous research has established that the modulator ivacaftor is effective in decreasing blood glucose and sometimes resolving CFRD in patients with certain CFTR mutations (class III mutations). However, early modulator therapies for individuals with the common ΔF508 mutation (e.g., a combination of the modulators lumacaftor and ivacaftor) have largely proven ineffective in improving glucose regulation. More recently, a combination therapy of three modulators, namely elexacaftor, tezacaftor, and ivacaftor (ETI), has entered clinical practice for patients with the ΔF508 mutation. However, it is not clear whether this therapy is effective in treating dysglycemia. We searched for studies of any design that examined the effects of ETI on measures of blood glucose. All available studies were observational studies comparing patients before and after initiating ETI therapy. Measures of daily-life blood glucose (those obtained with continuous glucose monitoring systems or by measuring glycated hemoglobin (HbA1c)) and post-prandial glucose spikes from oral glucose tolerance tests showed significant improvements in at least some studies. The majority of studies showed significant improvements from pre- to post-ETI in one or more blood glucose measures. While the interpretation of this evidence is complicated by the lack of randomized controlled trials, it appears that ETI therapy is associated with improved glucose regulation for at least some patients with the ΔF508 mutation.
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Affiliation(s)
| | - Daniel R Taub
- Biology, Southwestern University, Georgetown, TX, USA
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9
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Hong E, Carmanov E, Shi A, Chung PS, Rao AP, Forrester K, Beringer PM. Application of Physiologically Based Pharmacokinetic Modeling to Predict Drug-Drug Interactions between Elexacaftor/Tezacaftor/Ivacaftor and Tacrolimus in Lung Transplant Recipients. Pharmaceutics 2023; 15:pharmaceutics15051438. [PMID: 37242680 DOI: 10.3390/pharmaceutics15051438] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 04/28/2023] [Accepted: 05/06/2023] [Indexed: 05/28/2023] Open
Abstract
Elexacaftor/tezacaftor/ivacaftor (ETI) treatment has potential benefits in lung transplant recipients, including improvements in extrapulmonary manifestations, such as gastrointestinal and sinus disease; however, ivacaftor is an inhibitor of cytochrome P450 3A (CYP3A) and may, therefore, pose a risk for elevated systemic exposure to tacrolimus. The aim of this investigation is to determine the impact of ETI on tacrolimus exposure and devise an appropriate dosing regimen to manage the risk of this drug-drug interaction (DDI). The CYP3A-mediated DDI of ivacaftor-tacrolimus was evaluated using a physiologically based pharmacokinetic (PBPK) modeling approach, incorporating CYP3A4 inhibition parameters of ivacaftor and in vitro enzyme kinetic parameters of tacrolimus. To further support the findings in PBPK modeling, we present a case series of lung transplant patients who received both ETI and tacrolimus. We predicted a 2.36-fold increase in tacrolimus exposure when co-administered with ivacaftor, which would require a 50% dose reduction of tacrolimus upon initiation of ETI treatment to avoid the risk of elevated systemic exposure. Clinical cases (N = 13) indicate a median 32% (IQR: -14.30, 63.80) increase in the dose-normalized tacrolimus trough level (trough concentration/weight-normalized daily dose) after starting ETI. These results indicate that the concomitant administration of tacrolimus and ETI may lead to a clinically significant DDI, requiring the dose adjustment of tacrolimus.
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Affiliation(s)
- Eunjin Hong
- Department of Clinical Pharmacy, Mann School of Pharmacy and Pharmaceutical Sciences, University of Southern California, 1985 Zonal Ave, Los Angeles, CA 90033, USA
| | - Eugeniu Carmanov
- Department of Clinical Pharmacy, Mann School of Pharmacy and Pharmaceutical Sciences, University of Southern California, 1985 Zonal Ave, Los Angeles, CA 90033, USA
| | - Alan Shi
- Department of Clinical Pharmacy, Mann School of Pharmacy and Pharmaceutical Sciences, University of Southern California, 1985 Zonal Ave, Los Angeles, CA 90033, USA
| | - Peter S Chung
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Keck School of Medicine, University of Southern California, 1975 Zonal Ave, Los Angeles, CA 90033, USA
- USC Anton Yelchin CF Clinic, 1510 San Pablo St, Los Angeles, CA 90033, USA
| | - Adupa P Rao
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Keck School of Medicine, University of Southern California, 1975 Zonal Ave, Los Angeles, CA 90033, USA
- USC Anton Yelchin CF Clinic, 1510 San Pablo St, Los Angeles, CA 90033, USA
| | - Kevin Forrester
- Department of Clinical Pharmacy, Mann School of Pharmacy and Pharmaceutical Sciences, University of Southern California, 1985 Zonal Ave, Los Angeles, CA 90033, USA
| | - Paul M Beringer
- Department of Clinical Pharmacy, Mann School of Pharmacy and Pharmaceutical Sciences, University of Southern California, 1985 Zonal Ave, Los Angeles, CA 90033, USA
- USC Anton Yelchin CF Clinic, 1510 San Pablo St, Los Angeles, CA 90033, USA
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10
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McKone E, Ramos KJ, Chaparro C, Blatter J, Hachem R, Anstead M, Vlahos F, Thaxton A, Hempstead S, Daniels T, Murray M, Sole A, Vos R, Tallarico E, Faro A, Pilewski JM. Position paper: Models of post-transplant care for individuals with cystic fibrosis. J Cyst Fibros 2023; 22:374-380. [PMID: 36882349 DOI: 10.1016/j.jcf.2023.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 02/06/2023] [Accepted: 02/20/2023] [Indexed: 03/07/2023]
Abstract
There is no consensus on the best model of care for individuals with CF to manage the non-pulmonary complications that persist after lung transplant. The CF Foundation virtually convened a group of international experts in CF and lung-transplant care. The committee reviewed literature and shared the post-lung transplant model of care practiced by their programs. The committee then developed a survey that was distributed internationally to both the clinical and individual with CF/family audiences to determine the strengths, weaknesses, and preferences for various models of transplant care. Discussion generated two models to accomplish optimal CF care after transplant. The first model incorporates the CF team into care and proposes delineation of responsibilities for the CF and transplant teams. This model is reliant on outstanding communication between the teams, while leveraging the expertise of the CF team for management of the non-pulmonary manifestations of CF. The transplant team manages all aspects of the transplant, including pulmonary concerns and management of immunosuppression. The second model consolidates care in one center and may be more practical for transplant programs that have expertise managing CF and have access to CF multidisciplinary care team members (e.g., located in the same institution). The best model for each program is influenced by several factors and model selection needs to be decided between the transplant and the CF center and may vary from center to center. In either model, CF lung transplant recipients require a clear delineation of the roles and responsibilities of their providers and mechanisms for effective communication.
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Affiliation(s)
- Edward McKone
- St. Vincent's University Hospital and University College Dublin School of Medicine, Dublin, Ireland
| | - Kathleen J Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Cecilia Chaparro
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Joshua Blatter
- Washington University in St. Louis, Department of Pediatrics, St. Louis, MO, USA
| | - Ramsey Hachem
- Washington University in St. Louis, Division of Pulmonary & Critical Care, St. Louis, MO, USA
| | - Michael Anstead
- Division of Pulmonary, Critical Care, and Sleep Medicine, Departments of Medicine and Pediatrics, University of Kentucky, Lexington, KY, USA
| | - Fanny Vlahos
- Community Advisor to the Cystic Fibrosis Foundation, Bethesda, MD, USA
| | | | | | - Thomas Daniels
- Adult Cystic Fibrosis Physician, University Hospital Southampton, Tremona Road, Southampton, UK
| | - Michelle Murray
- National Lung Transplant Programme, Mater Misericordiae Hospital, University College Dublin, Ireland
| | - Amparo Sole
- Lung Transplant and Adult Cystic Fibrosis Unit, Hospital Universitario La Fe, Universitat de Valencia, Valencia, Spain
| | - Robin Vos
- Division of Respiratory Diseases, Univ. Hospitals Leuven, Belgium and BREATHE, Dept. of CHROMETA, KU Leuven, Leuven, Belgium
| | | | - Albert Faro
- Cystic Fibrosis Foundation, Bethesda, MD, USA
| | - Joseph M Pilewski
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, NW 628 MUH, 3459 Fifth Avenue, Pittsburgh, PA, 15213, USA.
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11
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Bacalhau M, Camargo M, Magalhães-Ghiotto GAV, Drumond S, Castelletti CHM, Lopes-Pacheco M. Elexacaftor-Tezacaftor-Ivacaftor: A Life-Changing Triple Combination of CFTR Modulator Drugs for Cystic Fibrosis. Pharmaceuticals (Basel) 2023; 16:ph16030410. [PMID: 36986509 PMCID: PMC10053019 DOI: 10.3390/ph16030410] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/28/2023] [Accepted: 03/06/2023] [Indexed: 03/30/2023] Open
Abstract
Cystic fibrosis (CF) is a potentially fatal monogenic disease that causes a progressive multisystemic pathology. Over the last decade, the introduction of CF transmembrane conductance regulator (CFTR) modulator drugs into clinical practice has profoundly modified the lives of many people with CF (PwCF) by targeting the fundamental cause of the disease. These drugs consist of the potentiator ivacaftor (VX-770) and the correctors lumacaftor (VX-809), tezacaftor (VX-661), and elexacaftor (VX-445). In particular, the triple combination of CFTR modulators composed of elexacaftor, tezacaftor, and ivacaftor (ETI) represents a life-changing therapy for the majority of PwCF worldwide. A growing number of clinical studies have demonstrated the safety and efficacy of ETI therapy in both short- and long-term (up to two years of follow-up to date) and its ability to significantly reduce pulmonary and gastrointestinal manifestations, sweat chloride concentration, exocrine pancreatic dysfunction, and infertility/subfertility, among other disease signs and symptoms. Nevertheless, ETI therapy-related adverse effects have also been reported, and close monitoring by a multidisciplinary healthcare team remains vital. This review aims to address and discuss the major therapeutic benefits and adverse effects reported by the clinical use of ETI therapy for PwCF.
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Affiliation(s)
- Mafalda Bacalhau
- Biosystems & Integrative Sciences Institute (BioISI), Faculty of Sciences, University of Lisbon, 1749-016 Lisbon, Portugal
| | - Mariana Camargo
- Department of Surgery, Division of Urology, Sao Paulo Federal University, Sao Paulo 04039-060, SP, Brazil
| | - Grace A V Magalhães-Ghiotto
- Department of Biotechnology, Genetics, and Cell Biology, Biological Sciences Center, State University of Maringa, Maringa 87020-900, PR, Brazil
| | - Sybelle Drumond
- Center for Research in Bioethics and Social Health, School of Magistracy of the State of Rio de Janeiro, Rio de Janeiro 20010-090, RJ, Brazil
| | - Carlos Henrique M Castelletti
- Molecular Prospecting and Bioinformatics Group, Keizo Asami Institute, Federal University of Pernambuco, Recife 50670-901, PE, Brazil
| | - Miquéias Lopes-Pacheco
- Biosystems & Integrative Sciences Institute (BioISI), Faculty of Sciences, University of Lisbon, 1749-016 Lisbon, Portugal
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12
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Ørum MB, Rönsholt FF, Jeppesen M, Bendstrup E, Katzenstein TL, Ott P, Perch M, Pressler T, Qvist T, Jensen-Fangel S. Outcome of elexacaftor/tezacaftor/ivacaftor therapy in patients with cystic fibrosis and solid organ transplantation. Pediatr Pulmonol 2023; 58:602-605. [PMID: 36314653 DOI: 10.1002/ppul.26217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 09/16/2022] [Accepted: 10/22/2022] [Indexed: 11/06/2022]
Abstract
We report a case series of four patients with cystic fibrosis (CF) and previous solid organ transplantation (SOT) receiving elexacaftor/tezacaftor/ivacaftor therapy for 6 months or more. Data was collected retrospectively. The treatment was well tolerated and all patients reported subjective improvements.
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Affiliation(s)
- Matilde B Ørum
- Department of Infectious Diseases, Cystic Fibrosis Clinic, Aarhus University Hospital, Aarhus, Denmark
| | - Frederikke F Rönsholt
- Department of Cardiology, Section for Lung Transplantation, University Hospital Rigshospitalet Copenhagen, Kobenhavn, Denmark.,Department of Infectious Diseases, Cystic Fibrosis Clinic, University Hospital Rigshospitalet Copenhagen, Kobenhavn, Denmark
| | - Majbritt Jeppesen
- Department of Infectious Diseases, Cystic Fibrosis Clinic, Aarhus University Hospital, Aarhus, Denmark.,Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Elisabeth Bendstrup
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Respiratory Diseases and Allergy, Center for Rare Lung Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Terese L Katzenstein
- Department of Infectious Diseases, Cystic Fibrosis Clinic, University Hospital Rigshospitalet Copenhagen, Kobenhavn, Denmark
| | - Peter Ott
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Michael Perch
- Department of Cardiology, Section for Lung Transplantation, University Hospital Rigshospitalet Copenhagen, Kobenhavn, Denmark.,Department Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Tacjana Pressler
- Department of Infectious Diseases, Cystic Fibrosis Clinic, University Hospital Rigshospitalet Copenhagen, Kobenhavn, Denmark
| | - Tavs Qvist
- Department of Infectious Diseases, Cystic Fibrosis Clinic, University Hospital Rigshospitalet Copenhagen, Kobenhavn, Denmark
| | - Søren Jensen-Fangel
- Department of Infectious Diseases, Cystic Fibrosis Clinic, Aarhus University Hospital, Aarhus, Denmark.,Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
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13
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Bec R, Reynaud-Gaubert M, Arnaud F, Naud R, Dufeu N, Di Bisceglie M, Coiffard B, Gaubert JY, Bermudez J, Habert P. Chest computed tomography improvement in patients with cystic fibrosis treated with elexacaftor-tezacaftor-ivacaftor: Early report. Eur J Radiol 2022; 154:110421. [DOI: 10.1016/j.ejrad.2022.110421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/31/2022] [Accepted: 06/20/2022] [Indexed: 11/28/2022]
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14
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Shakir S, Echevarria C, Doe S, Brodlie M, Ward C, Bourke SJ. Elexacaftor-Tezacaftor-Ivacaftor improve Gastro-Oesophageal reflux and Sinonasal symptoms in advanced cystic fibrosis. J Cyst Fibros 2022; 21:807-810. [PMID: 35718668 DOI: 10.1016/j.jcf.2022.06.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 06/02/2022] [Accepted: 06/07/2022] [Indexed: 11/17/2022]
Abstract
Upper gastrointestinal and upper airway disease are common in cystic fibrosis (CF) and may contribute to lower airway infection and inflammation. In a longitudinal cohort study of 32 patients (23 men; median age 32.5 years) with advanced CF lung disease (median FEV1 24.8% predicted) starting elexacaftor-tezacaftor-ivacaftor, the reflux symptom index score fell from a pre-treatment median (IQR) of 15 (11-23) to 5 (2.8-7.3) (p<0.001), the Hull airway reflux score fell from a median of 26.5 (16.3-39) to 7.5 (4-12) (p<0.001), and the sinonasal outcome score from a median of 36.5 (22-24) to 20 (10-32) (p<0.001) at 6 months on treatment. Mean FEV1% predicted rose by 9.2 points, the median respiratory domain score of the CF Questionnaire-Revised rose by 27.8 points and mean body mass index rose by 2.6 kg/m2. In addition to improving lung function and weight, CFTR modulators improve upper airway and gastro-oesophageal reflux symptoms in advanced CF.
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Affiliation(s)
- Sufyan Shakir
- Cystic Fibrosis Centre, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, United Kingdom
| | - Carlos Echevarria
- Cystic Fibrosis Centre, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, United Kingdom; Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, United Kingdom
| | - Simon Doe
- Cystic Fibrosis Centre, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, United Kingdom
| | - Malcolm Brodlie
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, United Kingdom; Paediatric Respiratory Medicine, Great North Children's Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, United Kingdom
| | - Christopher Ward
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, United Kingdom
| | - Stephen J Bourke
- Cystic Fibrosis Centre, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, United Kingdom.
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15
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Current state of CFTR modulators for treatment of Cystic Fibrosis. Curr Opin Pharmacol 2022; 65:102239. [DOI: 10.1016/j.coph.2022.102239] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 03/31/2022] [Accepted: 04/13/2022] [Indexed: 12/23/2022]
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16
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Doligalski CT, McKinzie CJ, Yang A, Lobo LJ, Coakley R. Poor tolerability of cystic fibrosis transmembrane conductance regulator modulator therapy in lung transplant recipients. Pharmacotherapy 2022; 42:580-584. [DOI: 10.1002/phar.2710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/13/2022] [Accepted: 05/23/2022] [Indexed: 11/10/2022]
Affiliation(s)
| | - Cameron J. McKinzie
- Department of Pharmacy Services UNC Health Care Chapel Hill North Carolina USA
| | - Anita Yang
- Department of Pharmacy Services UNC Health Care Chapel Hill North Carolina USA
| | - L. Jason Lobo
- Department of Medicine, School of Medicine University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Raymond Coakley
- Department of Medicine, School of Medicine University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
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17
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Savant AP. Cystic fibrosis year in review 2021. Pediatr Pulmonol 2022; 57:1590-1599. [PMID: 35501666 DOI: 10.1002/ppul.25948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/13/2022] [Accepted: 04/28/2022] [Indexed: 11/06/2022]
Abstract
People with cystic fibrosis (CF) have an amazing outlook with the treatment availability of highly effective modulators. Unfortunately, not all people with CF are eligible for modulators leading to continued pulmonary exacerbations and advanced lung disease. Additionally, optimizing diagnosis and evaluation for CF in the newborn period continues to be an area of focus for research. This review article will work to cover articles published in 2021 with high clinical relevance related to the above topics; however, due to the extensive body of research published, this review will not be comprehensive.
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Affiliation(s)
- Adrienne P Savant
- Department of Pediatrics, Children's Hospital of New Orleans, New Orleans, Louisiana, USA.,Department of Pediatrics, Tulane University, New Orleans, Louisiana, USA
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18
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FitzMaurice TS, Nazareth D, Iyer K, Walshaw M, Al-Aloul M. Elexacaftor/Tezacaftor/Ivacaftor as a Bridge to Lung Retransplant in a Recipient With Cystic Fibrosis. EXP CLIN TRANSPLANT 2022; 20:433-435. [PMID: 35297329 DOI: 10.6002/ect.2021.0468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The triple-combination cystic fibrosis transmembrane conductance regulator modulator elexacaftor/- tezacaftor/ivacaftor is known to improve lung function and have extrapulmonary benefits in people with cystic fibrosis. However, there is limited evidence for its use in patients with cystic fibrosis after lung transplant, where the donor lung expresses normal levels of the cystic fibrosis transmembrane conductance regulator. We describe the use of elexacaftor/tezacaftor/ivacaftor as a bridge to potential lung retransplant in a 37-year-old man with cystic fibrosis and chronic lung allograft dysfunction. Although forced expiratory volume in 1 second did not improve, the patient had decreased sputum volume, no pulmonary exacerbations of cystic fibrosis, and no longer required continuous antibiotic therapy. Pancreatic function, revised Cystic Fibrosis Questionnaire scores, sinus symptoms, weight, and corticosteroid dependence significantly improved. There were no reported side effects attributable to elexacaftor/tezacaftor/ivacaftor. However, the patient exhibited declined renal function, which had been initially attributed to lability in cyclosporin levels but which were corrected after lithotripsy for renal calculi. Triple-combination modulators of the cystic fibrosis transmembrane conductance regulator may offer benefits to carefully selected individuals awaiting retransplant, balanced against the risk of worsened immunosuppressant level control.
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Affiliation(s)
- Thomas Simon FitzMaurice
- From the Adult CF Unit, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,From the Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
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19
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A growing trend: CFTR modulators for cystic fibrosis lung transplant recipients. J Heart Lung Transplant 2021; 41:127-128. [PMID: 34924264 DOI: 10.1016/j.healun.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/05/2021] [Accepted: 10/06/2021] [Indexed: 11/23/2022] Open
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