Pulmonary rehabilitation protocols in urgent lung transplantation patients

BACKGROUND

Prolonged invasive respiratory support and extracorporeal membrane oxygenation (ECMO) in patients requiring urgent lung transplantation (ULTx) present significant challenges to clinical practice due to severe underlying diseases and complex conditions. The aim of the study was to report the clinical outcomes of patients who received ULTx and followed the perioperative rehabilitation protocol implemented in a lung transplant center.

METHODS

A retrospective analysis was conducted in ULTx patients who required preoperative invasive mechanical ventilation (IMV) and ECMO between January 2018 and January 2023. Data were retrieved from electronic medical records at our lung transplant center.

RESULTS

Fourteen patients (mean age 57.43±10.97 years; 12 males, 2 females) underwent ULTx with bridging ECMO and IMV. The mean body mass index was 23.94±3.33 kg/m², and the mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 21.50±3.96. The Nutritional Risk Screening 2002 (NRS 2002) scores were ≥3. ULTx was performed after an 8.5-day waiting period (interquartile interval [IQR] 5.0-26.5 d). Following the surgeries, the average lengths of ECMO and IMV were 1.0 (IQR 1.0-2.0) d and 5.0 (IQR 3.0-7.3) d, respectively. The total length of hospital stay was 60.1±30.8 d, with an average intensive care unit stay of 38.3±22.9 d and post-operative hospitalization stay of 45.8±26.1 d. Two patients died within 30 d after ULTx, with a 30-day survival rate of 85.71%.

CONCLUSION

Patients receiving ULTx showed an acceptable short-term survival rate, validating the practicality and safety of the treatment protocols implemented in our center.

Hemoptysis and the Risk for Lung Transplant or Death without Transplant in Individuals with Cystic Fibrosis in the United States

Rationale: Hemoptysis is a common and important complication in persons with cystic fibrosis (PwCF). Despite this, there is limited literature on the impact of hemoptysis on contemporary cystic fibrosis (CF) outcomes. Objectives: Evaluate whether hemoptysis increases the risk of lung transplant or death without a transplant in PwCF. Methods: We reviewed a dataset of PwCF ages 12 years or older from the CFFPR (CF Foundation Patient Registry) that included 29,587 individuals. We identified hemoptysis as our predictor of interest and categorized PwCF as either no hemoptysis, any hemoptysis (submassive and/or massive), or massive hemoptysis. We subsequently evaluated whether hemoptysis, as defined above, was associated with death without transplant or receipt of lung transplant via logistic regression. We adjusted for age, sex, body mass index, forced expiratory volume in one second (FEV1), number of exacerbations, supplemental oxygen use, CF-related diabetes, and Pseudomonas aeruginosa colonization status. Subgroup analyses were performed in advanced lung disease, defined as PwCF with an FEV1 <40% predicted. Results: PwCF with any form of hemoptysis were more likely to progress to lung transplant or die without transplant than PwCF who did not have hemoptysis (odds ratio [OR], 1.3 [95% confidence interval (CI), 1.1-1.7]). The effect size of these associations was larger when hemoptysis events were classified as "massive" (massive hemoptysis OR, 2.2 [95% CI, 1.2-3.8]) or in PwCF with advanced lung disease (massive hemoptysis in advanced lung disease OR, 3.2 [95% CI 1.3-8.2]). Conclusions: Hemoptysis is associated with an increased risk of lung transplant and death without a transplant in PwCF, especially among those with massive hemoptysis or advanced lung disease. Our results suggest that hemoptysis functions as a useful predictor of serious outcomes in PwCF and may be important to incorporate into risk prediction models and/or transplant decisions in CF.

Validation of a Simple, Rapid, and Cost-Effective Method for Acute Rejection Monitoring in Lung Transplant Recipients

Despite advances in immunosuppression therapy, acute rejection remains the leading cause of graft dysfunction in lung transplant recipients. Donor-derived cell-free DNA is increasingly being considered as a valuable biomarker of acute rejection in several solid organ transplants. We present a technically improved molecular method based on digital PCR that targets the mismatch between the recipient and donor at the HLA-DRB1 locus. Blood samples collected sequentially post-transplantation from a cohort of lung recipients were used to obtain proof-of-principle for the validity of the assay, correlating results with transbronchial biopsies and lung capacity tests. The results revealed an increase in dd-cfDNA during the first 2 weeks after transplantation related to ischemia-reperfusion injury (6.36 ± 5.36%, p < 0.0001). In the absence of complications, donor DNA levels stabilized, while increasing again during acute rejection episodes (7.81 ± 12.7%, p < 0.0001). Respiratory tract infections were also involved in the release of dd-cfDNA (9.14 ± 15.59%, p = 0.0004), with a positive correlation with C-reactive protein levels. Overall, the dd-cfDNA percentages were inversely correlated with the lung function values measured by spirometry. These results confirm the value of dd-cfDNA determination during post-transplant follow-up to monitor acute rejection in lung recipients, achieved using a rapid and inexpensive approach based on the HLA mismatch between donor and recipient.

POST COVID-19 LUNG TRANSPLANTATION ITALIAN PIVOTAL PROTOCOL: SOME ETHICAL CONSIDERATIONS

SARS‑CoV‑2 mostly affects the respiratory system with clinical patterns ranging from the common cold to fatal pneumonia. During the first wave of the COVID-19 pandemic, owing to the high number of patients who were infected with SARS‑CoV‑2 and subsequently recovered, it has been shown that some patients with post–COVID-19 terminal respiratory failure need lung transplantation for survival. There is increasing evidence coming from worldwide observations that this procedure can be performed successfully in post–COVID-19 patients. However, owing to the scarcity of organs, there is a need to define the safety and efficacy of lung transplant for post–COVID-19 patients as compared to patients waiting for a lung transplant for other pre-existing conditions, in order to ensure that sound ethical criteria are applied in organ allocation. The Milan's Policlinic Lung Transplant Surgery Unit, with the revision of the National Second Opinion for Infectious Diseases and the contribution of the Italian Lung Transplant Centres and the Italian National Transplant Centre, set up a pivotal observational protocol for the lung transplant of patients infected and successively turned negative for SARS‑CoV‑2, albeit with lung consequences such as acute respiratory distress syndrome or some chronic interstitial lung disease.

The protocol was revised and approved by the Italian National Institute of Health Ethics Committee. Description of the protocol and some ethical considerations are reported in this article.

Lung transplantation for acute respiratory distress syndrome - a retrospective European Cohort Study

BACKGROUND

The published experience of lung transplantation (LTX) in acute respiratory distress syndrome (ARDS) is limited. The aim of this study was to investigate the contemporary results of LTX attempts in ARDS in major European centers.

METHODS

We conducted a retrospective multicenter cohort study of all patients listed for LTX between 2011 and 2019. We surveyed 68 centers in 22 European countries. All patients admitted to the waitlist for lung transplantation with a diagnosis of "ARDS//pneumonia" were included. Patients without extracorporeal membrane oxygenation (ECMO) or mechanical ventilation were excluded. Patients were followed until October 1st 2020 or death. Multivariable analysis for 1-year survival after listing and lung transplantation were performed.

RESULTS

Forty-eight centers (74%) with a total transplant activity of 12 438 lung transplants during the 9-year period gave feedback. Forty patients with a median age of 35 years were identified. Patients were listed for LTX in 18 different centers in 10 countries. Thirty-one-patients underwent LTX (0·25% of all indications) and 9 patients died on the waitlist. Ninety percent of transplanted patients were on ECMO in combination with mechanical ventilation before LTX. On multivariable analysis, transplantation during 2015 until 2019 was independently associated with better 1-year survival after LTX (odds ratio 10.493, 95% CI 1.977, 55.705, p=0.006). Sixteen survivors out of 23 patients with known status (70%) returned to work after LTX.

CONCLUSION

LTX in highly selected ARDS patients is feasible and outcome has improved in the modern era. The selection process remains ethically and technically challenging.

Lobar size reduction in lung transplantation: A propensity score study

OBJECTIVE

For small-sized recipients of lung transplantation, the time span for organ reception from standard donors is generally longer than for normal-sized patients. Despite its underuse, lobar reduction may be a concrete option for these patients. This study aims to assess early and long-term outcomes associated with lobar reduction in lung transplantation.

METHODS

A retrospective study was performed on 608 consecutive lung transplantations at 2 centers between January 2005 and August 2019 (559 standard lung transplantations [standard transplantation] and 49 with lobar reduction [lung transplantation group]). A propensity-score weighting approach was used to account for potential confounding related to patients' nonrandom allocation to the 2 intervention groups. The effects of the intervention on postoperative outcomes were assessed with a weighted regression approach.

RESULTS

The propensity score was estimated on 571 patients (522 in standard transplantation group and 49 in lung transplantation group). In terms of early outcomes, the lung transplantation group showed a higher percentage of severe primary graft dysfunction at 0 hours and reported longer intensive care unit stay than the standard transplantation group. No other differences in terms of morbidity, mortality, mechanical ventilation time, hospital stay, and anastomotic complications were observed. Although the lung transplantation group showed worse long-term pulmonary function, the 2 populations had comparable survival outcomes.

CONCLUSIONS

The use of lobar reduction showed early and long-term results comparable to those after standard lung transplantation. Although a higher rate of early severe primary graft dysfunction and slightly reduced respiratory function were detected in the lobar group, these did not affect patients' morbidity and survival.

The Surplus Transplant Lung Allocation System in Italy: An Evaluation of the Allocation Process via Stochastic Modeling

Background: Lung transplantation is a specialized procedure used to treat chronic end-stage respiratory diseases. Due to the scarcity of lung donors, constructing fair and equitable lung transplant allocation methods is an issue that has been addressed with different strategies worldwide. This work aims to describe how Italy’s “national protocol for the management of surplus organs in all transplant programs” functions through an online app to allocate lung transplants. We have developed two probability models to describe the allocation process among the various transplant centers. An online app was then created. The first model considers conditional probabilities based on a protocol flowchart to compute the probability for each area and transplant center to receive each n-th organ in the period considered. The second probability model is based on the generalization of the binomial distribution to correlated binary variables, which is based on Bahadur’s representation, to compute the cumulative probability for each transplant center to receive at least nth organs. Our results show that the impact of the allocation of a surplus organ depends mostly on the region where the organ was donated. The discrepancies shown by our model may be explained by a discrepancy between the northern and southern regions in relation to the number of organs donated.

The impact of the high emergency lung transplantation program in cystic fibrosis in France: insight from a comparison with Canada

INTRODUCTION

France implemented a high emergency lung transplantation (HELT) program nationally in 2007. A similar program does not exist in Canada. The objectives of our study were to compare health outcomes within France as well as between Canada and France before and after the HELT program in a population with Cystic Fibrosis (CF).

METHODS

This population-based cohort study utilised data from the French and Canadian CF registries. A cumulative incidence curve assessed time to transplant with death without transplant as competing risks. The Kaplan-Meier method was used to estimate post-transplant survival.

RESULTS

Between 2002 and 2016, there were 1075 (13.0%) people with CF in France and 555 (10.2%) people with CF in Canada who underwent lung transplantation. The proportion of lung transplant increased in France after the HELT program was initiated (4.5% versus 10.1%) whereas deaths pre-transplant decreased from 85.3% in the pre-HELT to 57.1% in the post-HELT period. Between 2008-2016, people in France were significantly more likely to receive a transplant (Hazard Ratio (HR) 1.56, 95% CI 1.37-1.77, p<0.001) than die (HR 0.55, 95% CI 0.46-0.66, p<0.001) compared to Canada. Post-transplant survival was similar between the countries and there was no difference in survival when comparing pre- and post-HELT period in France.

CONCLUSION

Following the implementation of the HELT program, people living with CF in France were more likely to receive a transplant than die. Post-transplant survival in the post-HELT period in France did not change compared to the pre-HELT period, despite potentially sicker patients being transplanted, and is comparable to Canada.

Urgently listed lung transplant patients have outcomes similar to those of electively listed patients

OBJECTIVES

To (1) determine outcomes after urgent listing compared with elective listing for lung transplant and (2) compare in-hospital morbidity and mortality, survival, and allograft function in these 2 groups.

METHODS

From January 2006 to September 2017, 201 patients were urgently and 1423 electively listed. Among urgently listed patients, 130 subsequently underwent primary lung transplant as did 995 electively listed patients. Competing-risks analysis for death and transplant after listing and weighted balancing score matching (76 pairs) were used to compare in-hospital morbidity and survival. Mixed-effect longitudinal modeling was used to compare allograft function to 8 years post-transplant.

RESULTS

At 1 month, mortality was 26% in urgently listed patients, and 58% were transplanted. Risk factors for death included older age, higher bilirubin, and transfer from an outside hospital. At transplantation, urgently listed transplant patients were younger (53 ± 13 vs 55 ± 12 years), had more ventilator and extracorporeal membrane oxygenation support (32/25% vs 20/2.0%), more restrictive lung disease (95/73% vs 509/51%), and a higher lung allocation score (82 ± 13 vs 47 ± 17). In-hospital morbidity and mortality, time-related survival, and longitudinal allograft function were similar between matched groups.

CONCLUSIONS

Urgent listing more often than not leads to transplantation. Although urgently listed patients are sicker overall, after transplant their perioperative morbidity and mortality, overall survival, and allograft function are similar to those of electively listed patients. Appropriate patient selection and aggressive supportive care allow urgently listed lung transplant patients to achieve these similar post-transplant outcomes.

Impact of donor, recipient and matching on survival after high emergency lung transplantation in France

INTRODUCTION

Since July 2007, the French high emergency lung transplantation (HELT) allocation procedure prioritises available lung grafts to waiting patients with imminent risk of death. The relative impacts of donor, recipient and matching on the outcome following HELT remain unknown. We aimed at deciphering the relative impacts of donor, recipient and matching on the outcome following HELT in an exhaustive administrative database.

METHODS

All lung transplantations performed in France were prospectively registered in an administrative database. We retrospectively reviewed the procedures performed between July 2007 and December 2015, and analysed the impact of donor, recipient and matching on overall survival after the HELT procedure by fitting marginal Cox models.

RESULTS

During the study period, 2335 patients underwent lung transplantation in 11 French centres. After exclusion of patients with chronic obstructive pulmonary disease/emphysema, 1544 patients were included: 503 HELT and 1041 standard lung transplantation allocations. HELT was associated with a hazard ratio for death of 1.41 (95% CI 1.22-1.64; p<0.0001) in univariate analysis, decreasing to 1.32 (95% CI 1.10-1.60) after inclusion of recipient characteristics in a multivariate model. A donor score computed to predict long-term survival was significantly different between the HELT and standard lung transplantation groups (p=0.014). However, the addition of donor characteristics to recipient characteristics in the multivariate model did not change the hazard ratio associated with HELT.

CONCLUSIONS

This exhaustive French national study suggests that HELT is associated with an adverse outcome compared with regular allocation. This adverse outcome is mainly related to the severity status of the recipients rather than donor or matching characteristics.

Outcomes and risk factors identification in urgent lung transplantation: a multicentric study

Background

In rapidly lung deteriorating patients, urgent lung transplantation (ULT) seems the only definitive therapy. Few publications on this topic report conflicting results, putting a word of caution about ULT programs.

Methods

A national ULT program was introduced in 2010: patients on mechanical support may be transplanted with the first available graft. We reviewed the experience of three national center, focusing on post-operative outcomes after ULT.

Results

Ten patients (17.5%) died awaiting transplantation, while 47 underwent LT with a median urgent waiting list time of 6 days. Pre-operatively, 4.3% of patients were supported only by mechanical ventilation (MV), 55.3% by extracorporeal membrane oxygenation (ECMO) and the remaining 40.4% by both. The main indication was cystic fibrosis (64%). Median recipient lung allocation score was 72. In-hospital mortality was 19%. MV and ECMO median duration of 7 and 3 days, respectively while intensive care unit (ICU) and hospital stay were 20 and 46 days, respectively. At long-term, 1- and 3-year survival rate were 74% and 70%, respectively. Highly impact risk factors for in-hospital mortality were both presence and duration of preoperative veno-arterial ECMO and pre-transplant C-reactive protein level.

Conclusions

ULT program allows transplantation in a significant percentage of patients with acceptable results. Pre-operative recipient selection is mandatory to improve clinical outcomes.

Urgent lung transplantation in acute fibrinous and organizing pneumonia: a sliding door or a new perspective?

BACKGROUND

Lung transplantation is nowadays the standard therapy for certain well-defined chronic end-stage lung diseases, even in patients on mechanical ventilation or extracorporeal life support. While these latter techniques have been used worldwide as bridging options to lung transplantation for listed patients, they are not commonly used in previously healthy patients developing acute not-reversible lung failure.

METHODS

We will discuss two patients without any relevant medical history developing acute lung failure evolving to irreversible acute fibrinous and organising pneumonia (AFOP), thus listed for urgent lung transplantation.

RESULTS

The patients recovered well, and both are still alive.

CONCLUSIONS

In the absence of clear guidelines, our approach showed, in these patients, the possible benefits of lung transplantation regarding survival in AFOP.

Extracorporeal membrane oxygenation after lung transplantation: risk factors and outcomes analysis

Background

Lung transplantation is the treatment of choice for end-stage pulmonary disease in selected patients. However, severe primary graft dysfunction is a significant complication of transplant and requires the implantation of an extracorporeal support. The aim of the study is to evaluate the impact of extracorporeal membrane oxygenation (ECMO) after transplant in our center.

Methods

From January 2008 till June 2018, 195 consecutive unselected patients receiving a lung transplant were considered. Mean age was 49±15 years. Main indications for transplant were idiopathic pulmonary fibrosis in 72 patients, chronic obstructive pulmonary disease in 60 patients, and cystic fibrosis in 40 patients. Prior to transplant, 18 patients were on mechanical ventilation and 14 were on ECMO.

Results

Twenty-five patients required venous-venous ECMO after transplant. Vascular disease as cause of transplant [relative risk (RR) 7.8, 95% CI: 1.5-41, P=0.02], donor age (RR 1.6, 95% CI: 1.03-2.3, P=0.03) and need for cardiopulmonary by-pass during transplant (RR 3.1, 95% CI: 1.02-9, P=0.04) were associated with ECMO implantation. Patients requiring post-transplant ECMO received more transfusions (P<0.01), had a longer mechanical ventilation (P<0.01) and ICU stay (P<0.01) and had a higher hospital mortality (P<0.01). Post-transplant ECMO significantly influenced one- and five-year survival [hazard ratio (HR) 5.5, 95% CI: 3-10, P<0.001 and HR 3.5, 95% CI: 2-6, P<0.001, respectively]. However, conditional survival after t months is similar for patients with or without post-transplant ECMO.

Conclusions

In our experience, although ECMO is a reliable and effective strategy to support pulmonary function, severe graft dysfunction after lung transplantation still has a significant impact on early and late results.

Mortality rate of patients with cystic fibrosis on the waiting list and within one year after lung transplantation: a survey of Italian CF centers

Background

Cystic Fibrosis (CF) Centers are involved in the decisions regarding the eligibility of CF patients with end-stage lung disease and timing for inclusion on waiting lists (WL) for lung transplantation (LT). There are currently no data on the mortality rates of Italian CF patients on WL and during the first year after LT and we aimed to assess these outcomes by surveying the CF Centers.

Methods

A survey was sent to Italian CF Centers which were requested to report the age at which all CF subjects included on the WL between 2010 and 2014 were included on the list, admitted to either standard or urgent LT, or had died either while on the WL or within the first 3 and 12 months after LT. All outcomes were recorded by December 31, 2015.

Results

Two hundred fifty-nine CF subjects were included on the WL during the 5-year study period. The mortality rate during the WL was 19.3% and was not associated with sex, age at inclusion on the WL or standard or urgent access to LT. 159 (61.4%) subjects underwent LT, 46 (28.9%) with urgent procedure. Deaths within the first 3 and 12 months after LT were significantly more prevalent in individuals who underwent urgent LT compared to those with standard LT (p < 0.01).

Conclusions

The mortality of Italian CF patients, included in our survey, was about twice that reported by the National Transplant Center for all LT indications, including CF, during the same time period and despite the introduction of urgent LT. The latter was associated with an unfavorable early outcome compared to standard LT.

Single-center experience in urgent lung transplantation program in a country with a shortage of donors: Does the end justify the means?

In rapidly deteriorating patients awaiting lung transplantation (LT), supportive strategies are only temporary and urgent lung transplant (ULT) remains the last option. The few publications on this topic report conflicting results. According to the Italian national program, patients on mechanical ventilation and/or extracorporeal membrane oxygenation (ECMO) may be included in urgent list. We reviewed our experience from January 2012 to December 2014 with ULT and elective lung transplantation (ELT), focusing on outcomes. In the study period, 16 patients received ULT, while 51 received ELT. Among ULT, 1 patient (5.8%) died in waiting list (WL) while 16 patients underwent LT with a median WL time of 6 days. ELT WL mortality was 13.5%, and median WL time 368 days. In-hospital mortality was lower in ELT group (5.8% vs 37.5%, P < .01), while the other postoperative outcomes were not significantly different. For ULT patients, the highest impact risk factors for in-hospital mortality were pretransplant plasma transfusion, recipient Pseudomonas aeruginosa colonization, and high level of reactive C-protein and lactic acid. A ULT program with an accurate recipient selection allows earlier transplantation, reducing WL mortality, with acceptable outcomes, although with a higher in-hospital mortality. Larger studies are needed to validate our results.

Twenty-years of lung transplantation in Taiwan: Effects of cumulative institutional experience on early outcomes

BACKGROUND/PURPOSE

Lung transplantation in Taiwan began in 1991, but the experience was limited and diverse in the early years. We examined the cumulative institutional experience of the largest lung transplant cohort in Taiwan.

METHODS

A retrospective review of lung transplantations performed at a single institution from December 1995 through August 2016 was conducted. For comparative purposes, the cohort was divided into halves, with an early group (undergoing lung transplantation in the first decade) vs a late group (undergoing lung transplantation in the second decade). Standardized donor selection, organ procurement, and preservation protocols for brain-dead donors were applied. The outcomes measured were 30-day mortality and actuarial survival using the Kaplan-Meier method.

RESULTS

The cohort included 50 recipients in the early group and 42 recipients in the late group. Compared with the early group, recipients in the late group were significantly older (38.8 ± 11.6 vs 44.8 ± 13.4 years, p = 0.024) and more of them required mechanical ventilation before transplant (26.0% vs 66.7%, p < 0.001). There were more female donors (12.0% vs 33.3%, p = 0.021) and gender-matched donors (34.0% vs 61.9%, p = 0.012) in the late group. A total of 87 recipients (94.6%) had cardiopulmonary bypass (CPB) or extracorporeal membrane oxygenation (ECMO) support during transplant, and CPB was used significantly less in the late group. Graft procedures (14.0% vs 47.6%, p < 0.001), delayed chest closure (0% vs 21.4%, p < 0.001), and early tracheostomy (24.0% vs 52.4%, p = 0.005) were performed more in the late group. The durations of hospital and ICU stays were comparable in both groups, but the 30-day mortality was significantly lower in the late group (30.0% vs 2.4%, p = 0.001).

CONCLUSION

Although the results were undesirable in the first decade of the transplant program, the cumulative institutional experience led to significantly improved outcomes in the second decade of the transplant program.

Extracorporeal CO2 removal as bridge to lung transplantation in life-threatening hypercapnia

In patients awaiting lung transplantation (LTX), adequate gas exchange may not be sufficiently achieved by mechanical ventilation alone if acute respiratory decompensation arises. We report on 20 patients with life-threatening hypercapnia who received extracorporeal CO2 removal (ECCO2-R) by means of the interventional lung assist (ILA®, Novalung) as bridge to LTX. The most common underlying diagnoses were bronchiolitis obliterans syndrome, cystic fibrosis, and idiopathic pulmonary fibrosis, respectively. The type of ILA was pumpless arteriovenous or pump-driven venovenous (ILA activve®, Novalung) in 10 patients each. ILA bridging was initiated in 15 invasively ventilated and five noninvasively ventilated patients, of whom one had to be intubated prior to LTX. Hypercapnia and acidosis were effectively corrected in all patients within the first 12 h of ILA therapy: PaCO2 declined from 109 (70-146) to 57 (45-64) mmHg, P < 0.0001; pH increased from 7.20 (7.06-7.28) to 7.39 (7.35-7.49), P < 0.0001. Four patients were switched to extracorporeal membrane oxygenation due to progressive hypoxia or circulatory failure. Nineteen patients (95%) were successfully transplanted. Hospital and 1-year survival was 75 and 72%, respectively. Bridging to LTX with ECCO2-R delivered by arteriovenous pumpless or venovenous pump-driven ILA is feasible and associated with high transplantation and survival rates.