Estudio comparativo de dos soluciones de preservación en la función inicial del trasplante bipulmonar en humanos

[Primary graft dysfunction after lung transplantation]

Lung transplantation is a therapeutic option for pulmonary diseases in which the other treatment options have failed or in cases of rapid disease progression. However, transplantation is not free from complications, and primary graft dysfunction is one of them. Primary graft dysfunction is a form of acute lung injury. It characteristically develops during the immediate postoperative period, being associated to high morbidity and mortality, and increased risk of bronchiolitis obliterans. Different terms have been used in reference to primary graft dysfunction, leading to a consensus document to clarify the definition in 2005. This consensus document regards primary graft dysfunction as non-cardiogenic pulmonary edema developing within 72 hours of reperfusion and intrinsically attributable to alteration of the lung parenchyma. A number of studies have attempted to identify risk factors and to establish the underlying physiopathology, with a view to developing potential therapeutic options. Such options include nitric oxide and pulmonary surfactant together with supportive measures such as mechanical ventilation or oxygenation bypass.

Early outcome after single vs bilateral lung transplantation in older recipients

BACKGROUND

Lung transplantation (LT) has been increasingly performed in patients older than 60 years. The outcome of LT in this recipient age group has not been extensively analyzed. The purpose of this study was to evaluate the early death (30 days) in LT recipients older than 60 years according to the type of procedure, that is, single vs bilateral LT.

METHODS

We retrospectively reviewed our experience with older recipients between January 1999 and August 2007. Probability of survival was compared using the two-tailed Fisher exact test. The odds ratio for death at 30 days was estimated using multiple logistic regression.

RESULTS

During the study, 167 LT procedures were performed in 164 patients, of whom 51 (30.5%) were aged 60 years or older (age range, 60-70 years; mean [SD], 63.3 [2.4] years). Thirty-seven recipients aged 60 years or older underwent single LT, and 14 underwent bilateral LT. The 30-day survival was 81% (95% confidence interval [CI], 65%-92%) in patients who underwent single LT, and 92% (95% CI, 64%-100%) in patients who underwent bilateral LT. No differences were observed in the survival probability between the two groups (P = .42). Logistic regression analysis for death at 30 days showed an odds ratio of 1.10 (95% CI, 0.08-14.5; P = .94) in the unilateral LT group.

CONCLUSIONS

Early survival in LT recipients aged 60 years or older who underwent bilateral LT was comparable with that in who underwent single LT. The type of procedure is not a predictor of death in this age group. Recipients older than 60 years should not be excluded from consideration for bilateral LT.

Evaluation of the Oxygenation Ratio as Long-Term Prognostic Marker After Lung Transplantation

OBJECTIVE

We hypothesized that the arterial blood gas oxygen tension/fraction of inspired oxygen ratio (PaO2/FiO2) would prove to be useful as a mortality marker after lung transplantation (LT). The aims of this study were to define the prevalence of various ranges of PaO2/FiO2 during the first 24 hours after LT and to evaluate which measurement using the PaO2/FiO2 best correlates with mortality.

METHODS

A retrospective study was performed that included all patients who underwent LT from 1997 to 2005. We collected PaO2/FiO2 ratios at 0, 12, and 24 hours after admission to the intensive care unit (ICU). We classified the 132 patients in 5 groups, based on PaO2/FiO2 (Group 1, PaO2/FiO2 <100; Group 2, PaO2/FiO2 100-199; Group 3, PaO2/FiO2 200-299; Group 4, PaO2/FiO2 300-399; Group 5, PaO2/FiO2 >or=400). The correlation between PaO2/FiO2 and mortality was studied using Cox regression.

RESULTS

Cox regression analysis showed that PaO2/FiO2 at 0 and 12 hours after admission to the ICU were not useful mortality markers. However, the PaO2/FiO2 at 24 hours after admission to the ICU was a useful long-term prognostic marker. PaO2/FiO2 >100 (groups 2, 3, 4, and 5) at 24 hours was significantly associated with less mortality when a lower PaO2/FiO2 was the reference (hazard Ratio: 0.08, 0.02, 0.05, and 0.02, respectively). On multivariate analysis PaO2/FiO2 >or=100 (groups 2, 3, 4, and 5) at 24 hours was significantly associated with less mortality when a lower PaO2/FiO2 was the reference (hazard ratio: 0.07, 0.003, 0.01, and 0.005, respectively).

CONCLUSIONS

A value of PaO2/FiO2 >100 mm Hg 24 hours after admission to the ICU is associated with a lower mortality.

Prognosis Factors in Lung Transplant Recipients Readmitted to the Intensive Care Unit

OBJECTIVE

To identify outcome predictors and prognostic factors for survival among lung transplant recipients on readmission to the intensive care unit (ICU).

METHODS

This was a retrospective study of all lung transplant recipients during a 10-year period from 1997 to 2006. Data collection included age, gender, reason, and type of lung transplantation. Variables specific to individual ICU admissions included admission diagnosis, length of stay, duration of mechanical ventilation, interval from transplantation, Acute Physiology and Chronic Health Evaluation (APACHE) II score on ICU admission, and the identification of systemic organ dysfunction. We used Student t test (or where appropriate, its nonparametric equivalent) or the chi(2) test for comparisons among the patients who died and those who survived their ICU readmissions.

RESULTS

Among 144 lung transplant patients 28 were later readmitted to the ICU after at least 1 week. The admission diagnosis was sepsis in 20 cases (71.4%). Seventeen patients died during their ICU stay (60.7%). A higher APACHE II score (P = .008), the presence of three or more dysfunctional organs upon readmission (P = .016), and the need for mechanical ventilation (P = .022) were risk factors for mortality. The mortality risk was also higher among the group with a longer delay to ICU readmission (P = .003).

DISCUSSION

Readmission to the ICU, which is common among lung transplant recipients, was associated with a high mortality. Sepsis was the main cause of ICU readmission and the most frequent cause of death. APACHE II score, need for mechanical ventilation, number of dysfunctional organs, and delay in ICU readmission were important prognostic factors.