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Ehrsam JP, Meier Adamenko O, Pannu M, Markus Schöb O, Inci I. Lung transplantation in children. TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2024; 32:S119-S133. [PMID: 38584780 PMCID: PMC10995684 DOI: 10.5606/tgkdc.dergisi.2024.25806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 12/05/2023] [Indexed: 04/09/2024]
Abstract
Lung transplantation is a well-established treatment for children facing advanced lung disease and pulmonary vascular disorders. However, organ shortage remains highest in children. For fitting the small chest of children, transplantation of downsized adult lungs, lobes, or even segments were successfully established. The worldwide median survival after pediatric lung transplantation is currently 5.7 years, while under consideration of age, underlying disease, and peri- and posttransplant center experience, median survival of more than 10 years is reported. Timing of referral for transplantation, ischemia-reperfusion injury, primary graft dysfunction, and acute and chronic rejection after transplantation remain the main challenges.
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Affiliation(s)
- Jonas Peter Ehrsam
- School of Medicine, University of Zurich, Zurich, Switzerland
- Department of Thoracic Surgery, Klinik Hirslanden Zurich, Zurich, Switzerland
- Klinik Hirslanden Zurich, Centre for Surgery, Zurich, Switzerland
| | | | | | - Othmar Markus Schöb
- School of Medicine, University of Zurich, Zurich, Switzerland
- Department of Thoracic Surgery, Klinik Hirslanden Zurich, Zurich, Switzerland
- Klinik Hirslanden Zurich, Centre for Surgery, Zurich, Switzerland
| | - Ilhan Inci
- School of Medicine, University of Zurich, Zurich, Switzerland
- Department of Thoracic Surgery, Klinik Hirslanden Zurich, Zurich, Switzerland
- Klinik Hirslanden Zurich, Centre for Surgery, Zurich, Switzerland
- University of Nicosia Medical School, Nicosia, Cyprus
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2
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Guzman-Gomez A, Ahmed HF, Dani A, Zafar F, Lehenbauer DG, Potter AS, Morales DLS, Ziady AG, Hayes D. Center volume effect on acute cellular rejection and outcomes in pediatric lung transplant recipients. J Heart Lung Transplant 2023; 42:1030-1039. [PMID: 37088340 PMCID: PMC10524259 DOI: 10.1016/j.healun.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 03/31/2023] [Accepted: 04/10/2023] [Indexed: 04/25/2023] Open
Abstract
BACKGROUND Acute cellular rejection (ACR) is common after lung transplant (LTx). We sought to determine if transplant center volume affected ACR-related outcomes in children after LTx. METHODS The United Network for Organ Sharing (UNOS) Registry was queried for patients <18-years-of-age who underwent LTx 1987-2020. Cohorts were children who survived the first-year post transplant and were treated for ACR within that first year (ACR group) and those not treated for ACR (non-ACR). LTx center volume was defined as: high volume center (HVC) (>5LTxs/year), medium volume center (MVC) (>1≤5 LTxs/year), and low volume center (LVC) (≤1LTxs/year). RESULTS 1320 patients were enrolled into the study; 269 (20.4%) did not experience ACR. The ACR cohort was older (median 14 [11-16] vs 13 [7-16] years, p < 0.001), female (65.3% vs 57.3%, p = 0.016), had cystic fibrosis (62.3% vs 45.5%, p < 0.001), and had a higher lung allocation score (37.3 [34.6-47.8] vs 35.8 [33-42.6], p = 0.029). The ACR cohort trended (p = 0.06) towards lower survival at 5-year (37% vs 47%) and 10-year (25% vs 34%) post-LTx. Among children at HVCs, ACR occurred in 17% of recipients (n = 98/574), compared to 18.5% (n = 73/395) at MVCs and 27% (n = 100/369) at LVCs. Children treated for ACR at HVCs had higher survival than LVCs at 5-years (52% vs 29%) and 10-years (36% vs 15%) (p < 0.001) but similar survival to MVCs at 5-years (52% vs 43%) and 10-years (36% vs 24%) (p = 0.081). No survival differences were detected in MVCs vs LVCs (p = 0.14). CONCLUSIONS ACR treated within the first post-LTx year influence survival of children. ACR incidence was lowest at higher volume centers whereas post-ACR treatment survival outcomes were also superior.
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Affiliation(s)
- Amalia Guzman-Gomez
- Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Hosam F Ahmed
- Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Alia Dani
- Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Farhan Zafar
- Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David G Lehenbauer
- Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Andrew S Potter
- Division of Developmental Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David L S Morales
- Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Assem G Ziady
- Cancer and Blood Disorder Institute, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Don Hayes
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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Abstract
BACKGROUND Donor-specific antibodies (DSAs) have been associated with antibody-mediated rejection, chronic lung allograft dysfunction (CLAD), and increased mortality in lung transplant recipients. Our center performs transplants in the presence of DSA, and we sought to evaluate the safety of this practice with respect to graft loss, CLAD onset, and primary graft dysfunction (PGD). METHODS We reviewed recipients transplanted from 2010 to 2017, classifying them as DSA positive (DSA+) or negative. We used Kaplan-Meier estimation to test the association between DSA status and time to death or retransplant and time to CLAD onset. We further tested associations with severe PGD and rejection in the first year using logistic regression and Fisher exact testing. RESULTS Three hundred thirteen patients met inclusion criteria, 30 (10%) of whom were DSA+. DSA+ patients were more likely to be female, bridged to transplant, and receive induction therapy. There was no association between DSA status and time to death or retransplant (log rank P = 0.581) nor death-censored time to CLAD onset (log rank P = 0.278), but DSA+ patients were at increased risk of severe PGD (odds ratio 2.88; 95% confidence interval, 1.10-7.29; P = 0.031) and more frequent antibody-mediated rejection in the first posttransplant year. CONCLUSIONS Crossing DSA at time of lung transplant was not associated with an increased risk of death or CLAD in our cohort, but patients developed severe PGD and antibody-mediated rejection more frequently. However, these risks are likely manageable when balanced against the benefits of expanded access for sensitized candidates.
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Shagabayeva L, Osho AA, Moonsamy P, Mohan N, Li SSY, Wolfe S, Langer NB, Funamoto M, Villavicencio MA. Induction therapy in lung transplantation: A contemporary analysis of trends and outcomes. Clin Transplant 2022; 36:e14782. [PMID: 35848518 DOI: 10.1111/ctr.14782] [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: 12/19/2021] [Revised: 07/08/2022] [Accepted: 07/15/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES We provide a contemporary consideration of long-term outcomes and trends of induction therapy use following lung transplantation in the United States. METHODS We reviewed the United Network for Organ Sharing registry from 2006 to 2018 for first-time, adult, lung-only transplant recipients. Long-term survival was compared between induction classes (Interleukin-2 inhibitors, monoclonal or polyclonal cell-depleting agents, and no induction therapy). A 1:1 propensity score match was performed, pairing patients who received basiliximab with similar risk recipients who did not receive induction therapy. Outcomes in matched populations were compared using Cox, Kaplan-Meier and Logistic regression modeling. MEASUREMENTS AND MAIN RESULTS 22 025 recipients were identified; 8003 (36.34%) were treated with no induction therapy, 11 045 (50.15%) with basiliximab, 1556 (7.06%) with alemtuzumab and 1421 (6.45%) with anti-thymocyte globulin. Compared with those who received no induction, patients receiving basiliximab, alemtuzumab or anti-thymocyte globulin were found on multivariable Cox-regression analyses to have lower long-term mortality (all p < .05). Following propensity score matching of basiliximab and no induction populations, analyses demonstrated a statistically significant association between basiliximab use and long- term survival (p < .001). Basiliximab was also associated with a lower risk of acute rejection (p < .001) and renal failure (p = .002). CONCLUSION Induction therapy for lung transplant recipients-specifically basiliximab-is associated with improved long-term survival and a lower risk of renal failure or acute rejection.
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Affiliation(s)
- Larisa Shagabayeva
- DeWitt Daughtry Family Department of Surgery, University of Miami Health System, Miami, Florida, USA
| | - Asishana A Osho
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Philicia Moonsamy
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Navyatha Mohan
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Selena Shi-Yao Li
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Stanley Wolfe
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nathaniel B Langer
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Masaki Funamoto
- Department of Cardiothoracic Surgery, Methodist Hospital, San Antonio, Texas, USA
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5
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Furukawa M, Chan EG, Ryan JP, Hyzny EJ, Sacha LM, Coster JN, Pilewski JM, Lendermon EA, Kilaru SD, McDyer JF, Sanchez PG. Induction Strategies in Lung Transplantation: Alemtuzumab vs. Basiliximab a Single-Center Experience. Front Immunol 2022; 13:864545. [PMID: 35720296 PMCID: PMC9199390 DOI: 10.3389/fimmu.2022.864545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
Background Induction therapy is used in about 80% of lung transplant centers and is increasing globally. Currently, there are no standards or guidelines for the use of induction therapy. At our institution, we have two induction strategies, basiliximab, and alemtuzumab. The goal of this manuscript is to share our experience and practice since this is an area of controversy. Methods We retrospectively reviewed 807 lung transplants performed at our institution between 2011 and 2020. Indications for the use of the basiliximab protocol were as follows: patients over the age of 70 years, history of cancer, hepatitis C virus or human immunodeficiency virus infection history, and cytomegalovirus or Epstein-Barr virus (donor positive/ recipient negative). In the absence of these clinical factors, the alemtuzumab protocol was used. Results 453 patients underwent alemtuzumab induction and 354 patients underwent basiliximab. There were significant differences in delayed chest closure (24.7% alemtuzumab vs 31.4% basiliximab, p = 0.037), grade 3 primary graft dysfunction observed within 72 hours (19.9% alemtuzumab vs 29.9% basiliximab, p = 0.002), postoperative hepatic dysfunction (8.8% alemtuzumab vs 14.7% basiliximab, p = 0.009), acute cellular rejection in first year (39.1% alemtuzumab vs 53.4% basiliximab, p < 0.001). The overall survival rate of the patients with alemtuzumab induction was significantly higher than those of the patients with basiliximab induction (5 years survival rate: 64.1% alemtuzumab vs 52.3%, basiliximab, p < 0.001). Multivariate Cox regression analysis confirmed lower 5-year survival for basiliximab induction (HR = 1.41, p = 0.02), recipient cytomegalovirus positive (HR = 1.49, p = 0.01), postoperative hepatic dysfunction (HR = 2.20, p < 0.001), and acute kidney injury requiring renal replacement therapy (HR = 2.27, p < 0.001). Conclusions In this single center retrospective review, there was a significant difference in survival rates between induction strategies. This outcome may be attributable to differences in recipient characteristics between the groups. However, the Alemtuzumab group experienced less episodes of acute cellular rejection within the first year.
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Affiliation(s)
- Masashi Furukawa
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Ernest G Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - John P Ryan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Eric J Hyzny
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Lauren M Sacha
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Jenalee N Coster
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Joseph M Pilewski
- Department of Pulmonology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Elizabeth A Lendermon
- Department of Pulmonology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Silpa D Kilaru
- Department of Pulmonology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - John F McDyer
- Department of Pulmonology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Pablo G Sanchez
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
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6
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Matsubayashi T, Yamamoto M, Takayama S, Otsuki Y, Yamadori I, Honda Y, Izawa K, Nishikomori R, Oto T. Allograft Dysfunction After Lung Transplantation for COPA Syndrome: A Case Report and Literature Review. Mod Rheumatol Case Rep 2022; 6:314-318. [PMID: 35079820 DOI: 10.1093/mrcr/rxac004] [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: 11/01/2021] [Revised: 12/18/2021] [Accepted: 01/04/2022] [Indexed: 11/14/2022]
Abstract
COPA syndrome is an autoinflammatory disease with autoimmune and autoinflammatory manifestations affecting lungs, joints, and kidneys. COPA syndrome is caused by heterozygous loss-of-function mutations in the coatmer subunit alpha (COPA) gene, encoding α subunit of coatmer protein complex I (COP-I) coated vesicles. Mutant COPA induces constitutive activation of stimulator of interferon (IFN) genes (STING), leading to systemic inflammation and elevated type I interferon response. We have previously reported a Japanese family of COPA syndrome with a novel V242G mutation. Two out of 4 patients required lung transplantation due to intractable interstitial lung disease (ILD) and respiratory failure. Both of them deceased after lung transplantation, one due to sepsis and the other due to allograft dysfunction possibly caused by the reccurent ILD. The literature review indentified unfavorable outcome of the solid organ transplant in COPA syndrome and its related disease, however, precise clinico-pathological description of these cases has been scarce. Here, we report in detail the clinical course of our cases to clarify the pathophysiology of allograft dysfunction in COPA syndrome and propose potential therapeutic approaches to improve post-transplant graft survival.
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Affiliation(s)
| | - Masaki Yamamoto
- Department of Pediatrics, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Saki Takayama
- Department of Pediatrics, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Yoshiro Otsuki
- Department of Pathology, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Ichiro Yamadori
- Department of Pathology, Fukuyama Medical Association Health Support Center, Hiroshima, Japan
| | - Yoshitaka Honda
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kazushi Izawa
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ryuta Nishikomori
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Fukuoka, Japan
| | - Takahiro Oto
- Department of Thoracic Surgery, HGH, Hamad Medical Corporation, Doha, Qatar
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7
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Abstract
The number of lung transplantations is progressively increasing worldwide, providing new challenges to interprofessional teams and the intensive care units. The outcome of lung transplantation recipients is critically affected by a complex interplay of particular pathophysiologic conditions and risk factors, knowledge of which is fundamental to appropriately manage these patients during the early postoperative course. As high-grade evidence-based guidelines are not available, the authors aimed to provide an updated review of the postoperative management of lung transplantation recipients in the intensive care unit, which addresses six main areas: (1) management of mechanical ventilation, (2) fluid and hemodynamic management, (3) immunosuppressive therapies, (4) prevention and management of neurologic complications, (5) antimicrobial therapy, and (6) management of nutritional support and abdominal complications. The integrated care provided by a dedicated multidisciplinary team is key to optimize the complex postoperative management of lung transplantation recipients in the intensive care unit.
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8
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Induction and maintenance immunosuppression in lung transplantation. Indian J Thorac Cardiovasc Surg 2021; 38:300-317. [DOI: 10.1007/s12055-021-01225-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 06/04/2021] [Accepted: 06/13/2021] [Indexed: 10/20/2022] Open
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Pilch NA, Bowman LJ, Taber DJ. Immunosuppression trends in solid organ transplantation: The future of individualization, monitoring, and management. Pharmacotherapy 2020; 41:119-131. [PMID: 33131123 DOI: 10.1002/phar.2481] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/07/2020] [Accepted: 08/09/2020] [Indexed: 12/20/2022]
Abstract
Immunosuppression regimens used in solid organ transplant have evolved significantly over the past 70 years in the United States. Early immunosuppression and targets for allograft success were measured by incidence and severity of allograft rejection and 1-year patient survival. The limited number of agents, infancy of human leukocyte antigen (HLA) matching techniques and lack of understanding of immunoreactivity limited the early development of effective regimens. The 1980s and 1990s saw incredible advancements in these areas, with acute rejection rates halving in a short span of time. However, the constant struggle to achieve the optimal balance between under- and overimmunosuppression is weaved throughout the history of transplant immunosuppression. The aim of this paper is to discuss the different eras of immunosuppression and highlight the important milestones that were achieved while also discussing this in the context of rational agent selection and regimen design. This discussion sets the stage for how we can achieve optimal long-term outcomes during the next era of immunosuppression, which will move from universal protocols to patient-specific optimization.
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Affiliation(s)
- Nicole A Pilch
- Department of Pharmacy Practice and Outcomes Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Lyndsey J Bowman
- Department of Pharmacy, Tampa General Hospital, Tampa, Florida, USA
| | - David J Taber
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.,Department of Pharmacy Services, Ralph H. Johnson VAMC, Charleston, South Carolina, USA
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10
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Werner R, Benden C. Pediatric lung transplantation as standard of care. Clin Transplant 2020; 35:e14126. [PMID: 33098188 DOI: 10.1111/ctr.14126] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/12/2020] [Accepted: 10/16/2020] [Indexed: 01/13/2023]
Abstract
For infants, children, and adolescents with progressive advanced lung disease, lung transplantation represents the ultimate therapy option. Fortunately, outcomes after pediatric lung transplantation have improved in recent years now producing good long-term outcomes, no less than comparable to adult lung transplantation. The field of pediatric lung transplantation has rapidly advanced; thus, this review aims to update on important issues such as transplant referral and assessment, and extra-corporal life support as "bridge to transplantation". In view of the ongoing lack of donor organs limiting the success of pediatric lung transplantation, donor acceptability criteria and surgical options of lung allograft size reduction are discussed. Post-transplant, immunosuppression is vital for prevention of allograft rejection; however, evidence-based data on immunosuppression are scarce. Drug-related side effects are frequent, close therapeutic drug monitoring is highly advised with an individually tailored patient approach. Chronic lung allograft dysfunction (CLAD) remains the Achilles' heel of pediatric lung transplant limiting its long-term success. Unfortunately, therapy options for CLAD are still restricted. The last option for progressive CLAD would be consideration for lung re-transplant; however, numbers of pediatric patients undergoing lung re-transplantation are very small and its success depends highly on the optimal selection of the most suitable candidate.
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Affiliation(s)
- Raphael Werner
- Division of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Christian Benden
- Swisstransplant, Berne, Switzerland.,University of Zurich Medical Faculty, Zurich, Switzerland
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11
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Li D, Duan Q, Weinkauf J, Kapasi A, Varughese R, Hirji A, Lien D, Meyer S, Laing B, Nagendran J, Halloran K. Azithromycin prophylaxis after lung transplantation is associated with improved overall survival. J Heart Lung Transplant 2020; 39:1426-1434. [PMID: 33041181 DOI: 10.1016/j.healun.2020.09.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/25/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Azithromycin prophylaxis (AP) in lung transplant recipients has been shown to reduce the composite end-point of death or chronic lung allograft dysfunction (CLAD) onset but without a clear effect on overall survival. Our program began using AP in 2010. We sought to evaluate the association between AP and survival and the risk of CLAD and baseline lung allograft dysfunction (BLAD). METHODS We studied double lung recipients transplanted between 2004 and 2016. We defined AP as chronic use of azithromycin initiated before CLAD onset. We analyzed the association between AP and death or retransplant using Cox regression with adjustment for potential confounders. We further used Cox and logistic models to assess the relationship between AP and post-transplant CLAD onset and BLAD, respectively. RESULTS A total of 445 patients were included, and 344 (77%) received AP (median time from transplant: 51 days). Patients receiving AP were more likely to receive induction with interleukin-2 receptor antagonists (57% vs 35%; p < 0.001). AP was associated with improved survival (hazard ratio [HR]: 0.59; 95% confidence interval [CI]: 0.42-0.82; p = 0.0020) in our fully adjusted model, with a reduced adjusted risk of BLAD (odds ratio: 0.53; 95% CI: 0.33-0.85; p = 0.0460) but no clear reduction in the adjusted risk of CLAD (HR: 0.69; 95% CI: 0.47-1.03; p = 0.0697). CONCLUSIONS AP is associated with improved survival after lung transplantation, potentially through improved baseline function. These findings build on prior trial results and suggest that AP is beneficial for lung transplant recipients.
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Affiliation(s)
- David Li
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Qiuli Duan
- Health Services Statistical & Analytical Methods, Alberta Health Services, Edmonton, Alberta, Canada
| | - Justin Weinkauf
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ali Kapasi
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Rhea Varughese
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Alim Hirji
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Dale Lien
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Steven Meyer
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Bryce Laing
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Jayan Nagendran
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Kieran Halloran
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
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12
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Linder KA, Kauffman CA, Patel TS, Fitzgerald LJ, Richards BJ, Miceli MH. Evaluation of targeted versus universal prophylaxis for the prevention of invasive fungal infections following lung transplantation. Transpl Infect Dis 2020; 23:e13448. [PMID: 33448560 DOI: 10.1111/tid.13448] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 07/11/2020] [Accepted: 08/01/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Antifungal prophylaxis to prevent invasive fungal infections (IFI) is widely used following lung transplantation, but the optimal strategy remains unclear. We compared universal with targeted antifungal prophylaxis for effectiveness in preventing IFI. METHODS Adult patients who underwent lung transplantation at the University of Michigan from /1 July 2014-31 December 2017 were studied for 18 months post-transplant. Universal prophylaxis consisted of itraconazole with or without inhaled liposomal amphotericin B. Using specific criteria, targeted prophylaxis was given with voriconazole for patients at risk for invasive pulmonary aspergillosis (IPA) and with fluconazole or micafungin for patients at risk for invasive candidiasis. Risk factors, occurrence of proven/probable IFI, and mortality were analyzed for the two prophylaxis cohorts. RESULTS Of 105 lung transplant recipients, 84 (80%) received a double lung transplant, and 38 (36%) of patients underwent transplant for pulmonary fibrosis. Fifty-nine (56%) patients received universal antifungal prophylaxis, and 46 (44%), targeted antifungal prophylaxis. Among 20 proven/probable IFI, there were 14 IPA, 4 invasive candidiasis, 1 cryptococcosis, and 1 deep sternal mold infection. Six (10%) IFI occurred in the universal prophylaxis cohort and 14 (30%) in the targeted prophylaxis cohort. Five of 6 (83%) IFI in the universal prophylaxis cohort, compared with 9/14 (64%) in the targeted prophylaxis cohort, were IPA Candida infections occurred only in the targeted prophylaxis cohort. The development of IFI was more likely in the targeted prophylaxis cohort than the universal prophylaxis cohort, HR = 4.32 (1.51-12.38), P = .0064. CONCLUSIONS Universal antifungal prophylaxis appears to be more effective than targeted antifungal prophylaxis for prevention of IFI after lung transplant.
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Affiliation(s)
- Kathleen A Linder
- Division of Infectious Diseases, University of Michigan Health System, Ann Arbor, MI, USA.,Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Carol A Kauffman
- Division of Infectious Diseases, University of Michigan Health System, Ann Arbor, MI, USA.,Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Twisha S Patel
- Department of Pharmacy, University of Michigan Health System, Ann Arbor, MI, USA
| | - Linda J Fitzgerald
- Department of Pharmacy, University of Michigan Health System, Ann Arbor, MI, USA
| | - Blair J Richards
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, MI, USA
| | - Marisa H Miceli
- Division of Infectious Diseases, University of Michigan Health System, Ann Arbor, MI, USA
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13
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Abstract
Lung transplantation is a viable option for those with end-stage lung disease which is evidenced by the continued increase in the number of lung transplantations worldwide. However, patients and clinicians are constantly faced with acute and chronic rejection, infectious complications, drug toxicities, and malignancies throughout the lifetime of the lung transplant recipient. Conventional maintenance immunosuppression therapy consisting of a calcineurin inhibitor (CNI), anti-metabolite, and corticosteroids have become the standard regimen but newer agents and modalities continue to be developed. Here we will review induction agents, maintenance immunosuppressives, adjunctive therapies and other strategies to improve long-term outcomes.
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Affiliation(s)
- Paul A Chung
- Division of Pulmonary and Critical Care, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
| | - Daniel F Dilling
- Division of Pulmonary and Critical Care, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
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14
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[Clinical analysis of lung transplantation in eight patients with obstructive bronchiolitis syndrome after hematopoietic stem cell transplantation]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 38:977-980. [PMID: 29224324 PMCID: PMC7342779 DOI: 10.3760/cma.j.issn.0253-2727.2017.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
目的 探讨肺移植治疗异基因造血干细胞移植(allo-HSCT)后闭塞性细支气管炎综合征(BOS)终末期的疗效。 方法 回顾性分析8例肺移植治疗allo-HSCT后BOS终末期病例的临床资料。 结果 8例患者均因血液系统恶性肿瘤行allo-HSCT,allo-HSCT时中位年龄为23(12~40)岁,供者为父母或同胞兄弟姐妹。8例患者allo-HSCT后发生严重BOS,行肺移植时的中位年龄为27.5(13~47)岁。allo-HSCT和肺移植的中位间隔时间是69(21~132)个月。中位随访时间为15(6~63)个月,7例存活,1例患者肺移植术后15个月死于肺出血。存活患者中有3例再发BOS,其中1例再次行肺移植术并获得成功。 结论 肺移植术是治疗allo-HSCT后BOS终末期患者的一种有效手段。
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Lay C, Law N, Holm AM, Benden C, Aslam S. Outcomes in cystic fibrosis lung transplant recipients infected with organisms labeled as pan-resistant: An ISHLT Registry‒based analysis. J Heart Lung Transplant 2019; 38:545-552. [PMID: 30733155 DOI: 10.1016/j.healun.2019.01.1306] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 01/09/2019] [Accepted: 01/22/2019] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The presence of pan-resistant organisms in patients with cystic fibrosis (CF) potentially impacts mortality after lung transplant (LT). In this study we aimed to study LT mortality in CF patients with and without pan-resistant infection. METHODS The International Society for Heart and Lung Transplantation (ISHLT) Thoracic Transplant Registry was used to identify adults with CF, first-time, bilateral LT from 1991 to 2015. Extracted data included demographics, clinical characteristics, post-transplant outcomes, and mortality (infection-related, overall). Multivariate binary logistic regression models were created with 90-day and 1-year mortality as primary outcomes. RESULTS Among 3,256 LT recipients with CF, 697 were labeled as having pan-resistant infection, the others were included as controls (n = 2,649). Pre-transplant, those labeled as pan-resistant were more likely to require ventilator support, have an infection requiring intravenous antibiotics, and have had ≥2 pneumonia episodes within 1 year. Ninety-day and 1-year mortality was similar between groups, but infection-related mortality at 90days (3.3% vs 1.88%, p = 0.01) and 1 year (6.6% vs 4.6%, p < 0.001) was higher in those labeled as pan-resistant. In multivariate analysis, presence of organisms labeled as pan-resistant was not associated with 90-day (odds ratio [OR] 1.5, 95% confidence interval [CI] 0.93 to 2.42, p = 0.09) or 1-year mortality (OR 1.32, 95% CI 0.95 to 1.83, p = 0.097). CONCLUSIONS CF patients with pre-transplant infection from organisms labeled as pan-resistant had similar 90-day and 1-year mortality as those without. Despite increased infection-related mortality in these patients, it was not predictive of mortality in multivariate analysis. The higher occurrence of post-transplant infections in these patients warrants diligent follow-up. A multicenter cohort study will be required to validate the findings of our study.
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Affiliation(s)
- Cecilia Lay
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, USA
| | - Nancy Law
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, USA
| | - Are Martin Holm
- Department of Respiratory Medicine, University of Oslo, Oslo, Norway
| | - Christian Benden
- Division of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Saima Aslam
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, USA.
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Abstract
Immunosuppressive therapy is arguably the most important component of medical care after lung transplantation. The goal of immunosuppression is to prevent acute and chronic rejection while maximizing patient survival and long-term allograft function. However, the benefits of immunosuppressive therapy must be balanced against the side effects and major toxicities of these medications. Immunosuppressive agents can be classified as induction agents, maintenance therapies, treatments for acute rejection and chronic rejection and antibody directed therapies. Although induction therapy remains an area of controversy in lung transplantation, it is still used in the majority of transplant centers. On the other hand, maintenance immunosuppression is less contentious; but, unfortunately, since the creation of three-drug combination therapy, including a glucocorticoid, calcineurin inhibitor and anti-metabolite, there have been relatively modest improvements in chronic maintenance immunosuppressive regimens. The presence of HLA antibodies in transplant candidates and development of de novo antibodies after transplantation remain a major therapeutic challenge before and after lung transplantation. In this chapter we review the medications used for induction and maintenance immunosuppression along with their efficacy and side effect profiles. We also review strategies and evidence for HLA desensitization prior to lung transplantation and management of de novo antibody formation after transplant. Finally, we review immune tolerance and the future of lung transplantation to limit the toxicities of conventional immunosuppressive therapy.
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Affiliation(s)
- Luke J Benvenuto
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Michaela R Anderson
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Selim M Arcasoy
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, USA
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Ivulich S, Dooley M, Kirkpatrick C, Snell G. Clinical Challenges of Tacrolimus for Maintenance Immunosuppression Post–Lung Transplantation. Transplant Proc 2017; 49:2153-2160. [DOI: 10.1016/j.transproceed.2017.07.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 07/30/2017] [Indexed: 12/25/2022]
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Ensor CR, Rihtarchik LC, Morrell MR, Hayanga JWA, Lichvar AB, Pilewski JM, Wisniewski S, Johnson BA, D'Cunha J, Zeevi A, McDyer JF. Rescue alemtuzumab for refractory acute cellular rejection and bronchiolitis obliterans syndrome after lung transplantation. Clin Transplant 2017; 31. [PMID: 28008661 DOI: 10.1111/ctr.12899] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2016] [Indexed: 11/30/2022]
Abstract
Refractory acute cellular rejection (rACR) is associated with death and bronchiolitis obliterans syndrome (BOS) post-lung transplantation. We report the largest cohort of lung transplant recipients (LTRs) treated with rescue alemtuzumab for rACR or BOS. RACR outcomes included burden of ACR 30 days before and 180 days after rescue assessed by a novel composite rejection standardized score (CRSS, range 0-6) and freedom from ≥A2 ACR. BOS outcomes included freedom from BOS progression and FEV1 decline >10%. Univariate parametric and nonparametric statistical approaches were used to assess treatment response. Kaplan-Meier method with log rank conversion was used to assess freedom from events. Fifty-seven alemtuzumab doses (ACR 40 and BOS 17) given to 51 patients were included. Median time to rescue was 722 (IQR 42-1403) days. CRSS declined significantly (3 vs 0.67, P<0.001) after rescue. Freedom from ≥A2 was 62.5% in rACR. Freedom from BOS progression was 52.9% at 180 days in the BOS cohort. Freedom from FEV1 decline >10% was 70% in BOS grade 1 and 14.3% in advanced BOS grades 2-3. Infections developed in 72.5% and 76.5% of rACR and BOS groups. Rescue alemtuzumab appears useful for rACR. Patients with BOS 1 may have transient benefit, and patients with advanced BOS seem not to respond to alemtuzumab.
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Affiliation(s)
- Christopher R Ensor
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA.,Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Matthew R Morrell
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - J W Awori Hayanga
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alicia B Lichvar
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Joseph M Pilewski
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Stephen Wisniewski
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bruce A Johnson
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jonathan D'Cunha
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Adriana Zeevi
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John F McDyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Hayes D, McConnell PI, Yates AR, Tobias JD, Galantowicz M, Mansour HM, Tumin D. Induction immunosuppression for combined heart-lung transplantation. Clin Transplant 2016; 30:1332-1339. [DOI: 10.1111/ctr.12827] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2016] [Indexed: 01/26/2023]
Affiliation(s)
- Don Hayes
- Department of Pediatrics; The Ohio State University College of Medicine; Columbus OH USA
- Department of Internal Medicine; The Ohio State University College of Medicine; Columbus OH USA
- Department of Surgery; The Ohio State University College of Medicine; Columbus OH USA
- Center for Pediatric Transplant Research; Nationwide Children's Hospital; Columbus OH USA
- Section of Pulmonary Medicine; Nationwide Children's Hospital; Columbus OH USA
| | - Patrick I. McConnell
- Department of Surgery; The Ohio State University College of Medicine; Columbus OH USA
- Center for Pediatric Transplant Research; Nationwide Children's Hospital; Columbus OH USA
- Department of Cardiothoracic Surgery; Nationwide Children's Hospital; Columbus OH USA
| | - Andrew R. Yates
- Department of Pediatrics; The Ohio State University College of Medicine; Columbus OH USA
- Center for Pediatric Transplant Research; Nationwide Children's Hospital; Columbus OH USA
- Section of Cardiology; Nationwide Children's Hospital; Columbus OH USA
| | - Joseph D. Tobias
- Department of Anesthesiology; The Ohio State University College of Medicine; Columbus OH USA
- Center for Pediatric Transplant Research; Nationwide Children's Hospital; Columbus OH USA
- Department of Anesthesiology & Pain Medicine; Nationwide Children's Hospital; Columbus OH USA
| | - Mark Galantowicz
- Department of Surgery; The Ohio State University College of Medicine; Columbus OH USA
- Center for Pediatric Transplant Research; Nationwide Children's Hospital; Columbus OH USA
- Department of Cardiothoracic Surgery; Nationwide Children's Hospital; Columbus OH USA
| | - Heidi M. Mansour
- Center for Pediatric Transplant Research; Nationwide Children's Hospital; Columbus OH USA
- The University of Arizona Colleges of Pharmacy and Medicine; Tucson AZ USA
| | - Dmitry Tumin
- Department of Pediatrics; The Ohio State University College of Medicine; Columbus OH USA
- Center for Pediatric Transplant Research; Nationwide Children's Hospital; Columbus OH USA
- Department of Anesthesiology & Pain Medicine; Nationwide Children's Hospital; Columbus OH USA
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Högerle BA, Kohli N, Habibi-Parker K, Lyster H, Reed A, Carby M, Zeriouh M, Weymann A, Simon AR, Sabashnikov A, Popov AF, Soresi S. Challenging immunosuppression treatment in lung transplant recipients with kidney failure. Transpl Immunol 2016; 35:18-22. [PMID: 26892232 DOI: 10.1016/j.trim.2016.02.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 02/11/2016] [Accepted: 02/12/2016] [Indexed: 12/12/2022]
Abstract
Kidney failure after lung transplantation is a risk factor for chronic kidney disease. Calcineurin inhibitors are immunosuppressants which play a major role in terms of postoperative kidney failure after lung transplantation. We report our preliminary experience with the anti-interleukin-2 monoclonal antibody Basiliximab utilized as a "calcineurin inhibitor-free window" in the setting of early postoperative kidney failure after lung transplantation. Between 2012 and 2015 nine lung transplant patients who developed kidney failure for more than 14 days were included. Basiliximab was administrated in three doses (Day 0, 4, and 20) whilst Tacrolimus was discontinued or reduced to maintain a serum level between 2 and 4 ng/mL. Baseline glomerular filtration rate pre transplant was normal for all patients. Seven patients completely recovered from kidney failure (67%, mean eGFR pre and post Basiliximab: 42.3 mL/min/1.73 m(2) and 69 mL/min/1.73 m(2)) and were switched back on Tacrolimus. Only one of these patients still needs ongoing renal replacement therapy. Two patients showed no recovery from kidney failure and did not survive. Basiliximab might be a safe and feasible therapeutical option in patients which are affected by calcineurin inhibitor-related kidney failure in the early post lung transplant period. Further studies are necessary to confirm our preliminary results.
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Affiliation(s)
- Benjamin A Högerle
- Department of Respiratory and Transplant Medicine, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Hill End Road, Harefield, Middlesex UB9 6JH, United Kingdom
| | - Neeraj Kohli
- Department of Respiratory and Transplant Medicine, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Hill End Road, Harefield, Middlesex UB9 6JH, United Kingdom
| | - Kirsty Habibi-Parker
- Department of Respiratory and Transplant Medicine, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Hill End Road, Harefield, Middlesex UB9 6JH, United Kingdom
| | - Haifa Lyster
- Department of Respiratory and Transplant Medicine, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Hill End Road, Harefield, Middlesex UB9 6JH, United Kingdom
| | - Anna Reed
- Department of Respiratory and Transplant Medicine, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Hill End Road, Harefield, Middlesex UB9 6JH, United Kingdom
| | - Martin Carby
- Department of Respiratory and Transplant Medicine, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Hill End Road, Harefield, Middlesex UB9 6JH, United Kingdom
| | - Mohamed Zeriouh
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Hill End Road, Harefield, Middlesex UB9 6JH, United Kingdom
| | - Alexander Weymann
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Hill End Road, Harefield, Middlesex UB9 6JH, United Kingdom
| | - André R Simon
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Hill End Road, Harefield, Middlesex UB9 6JH, United Kingdom
| | - Anton Sabashnikov
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Hill End Road, Harefield, Middlesex UB9 6JH, United Kingdom.
| | - Aron-Frederik Popov
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Hill End Road, Harefield, Middlesex UB9 6JH, United Kingdom
| | - Simona Soresi
- Department of Respiratory and Transplant Medicine, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Hill End Road, Harefield, Middlesex UB9 6JH, United Kingdom
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Duffy JS, Tumin D, Pope-Harman A, Whitson BA, Higgins RSD, Hayes, Jr. D. Induction Therapy for Lung Transplantation in COPD: Analysis of the UNOS Registry. COPD 2016; 13:647-52. [DOI: 10.3109/15412555.2015.1127340] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Joseph S. Duffy
- Department of Internal Medicine, The Ohio State University School of Medicine, Columbus, Ohio, USA
| | - Dmitry Tumin
- Departement of Pediatrics, The Ohio State University School of Medicine, Columbus, Ohio, USA
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Amy Pope-Harman
- Department of Internal Medicine, The Ohio State University School of Medicine, Columbus, Ohio, USA
| | - Bryan A. Whitson
- Department of Surgery, The Ohio State University School of Medicine, Columbus, Ohio, USA
| | - Robert S. D. Higgins
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Don Hayes, Jr.
- Department of Internal Medicine, The Ohio State University School of Medicine, Columbus, Ohio, USA
- Department of Surgery, The Ohio State University School of Medicine, Columbus, Ohio, USA
- Departement of Pediatrics, The Ohio State University School of Medicine, Columbus, Ohio, USA
- Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, OH, USA
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Abstract
Cardiothoracic transplantation has significantly impacted the lives of pediatric patients with advanced cardiopulmonary failure. The current state of lung transplantation in children as well as its ongoing and future challenges are discussed.
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Hayes D, Whitson BA, Ghadiali SN, Tobias JD, Mansour HM, Black SM. Influence of HLA Mismatching on Survival in Lung Transplantation. Lung 2015. [DOI: 10.1007/s00408-015-9768-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Whitson BA, Kilic A, Lehman A, Wehr A, Hasan A, Haas G, Hayes D, Sai-Sudhakar CB, Higgins RSD. Impact of induction immunosuppression on survival in heart transplant recipients: a contemporary analysis of agents. Clin Transplant 2014; 29:9-17. [PMID: 25284138 DOI: 10.1111/ctr.12469] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2014] [Indexed: 01/23/2023]
Abstract
INTRODUCTION The impact of induction immunosuppression on long-term survival in heart transplant recipients is unclear. Over the past three decades, practices have varied as induction agents have changed and experiences grew. We sought to evaluate the effect of contemporary induction immunosuppression agents in heart transplant recipients with the primary endpoint of survival, utilizing national registry data. METHODS We queried the United Network for Organ Sharing (UNOS) data registry for all heart transplants from 1987 to 2012. We restricted our analysis to adult (≥18 yr) recipients performed from 2001-2011 (to allow for the potential for a minimum of 12 months post-transplant follow-up) who received either: no antibody based induction (NONE) or the contemporary agents (INDUCED) of either: basiliximab/daclizumab (IL-2Rab), alemtuzumab, or ATG/ALG/thymoglobulin. Kaplan-Meier estimates of the survival function as well as Cox proportional hazards models were utilized. RESULTS Of the 17 857 heart transplants that met the inclusion criteria, there were 4635 (26%) reported deaths during the follow-up period. There were 8216 (46%) patients who were INDUCED. Of the INDUCED agents, 55% were IL-2Rab, 4% alemtuzumab, and 40% ALG/ATG/thymoglobulin. Donor and recipient characteristics were evaluated. Overall, being INDUCED did not significantly affect survival in univariable (p = 0.522) and multivariable (p = 0.130) Cox models as well as a propensity score adjusted model (p = 0.733). Among those induced, ATG/ALG/thymoglobulin appeared to have superior survival as compared with IL-2Rab (log-rank p = 0.007, univariable hazard ratio [HR] = 0.886; 95% CI: 0.811-0.968; p = 0.522). However, in a multivariable Cox model that adjusted for recipient age, VAD, BMI, steroid use, CMV match, and ischemic time, the hazard ratio for ALG/ATG/thymoglobulin vs. IL-2Rab was no longer statistically significant (HR = 0.948; 95% CI: 0.850-1.058; p = 0.341). CONCLUSION In a contemporary analysis of heart transplant recipients, an overall analysis of induction agents does not appear to impact survival, as compared to no induction immunosuppression. While ALG/ATG/thymoglobulin appeared to have a beneficial effect on survival compared to IL-2Rab in the univariable model, this difference was no longer statistically significant once we adjusted for clinically relevant covariates.
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Affiliation(s)
- Bryan A Whitson
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Whitson BA, Hayes D. Indications and outcomes in adult lung transplantation. J Thorac Dis 2014; 6:1018-23. [PMID: 25132968 DOI: 10.3978/j.issn.2072-1439.2014.07.04] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Accepted: 06/23/2014] [Indexed: 11/14/2022]
Abstract
Lung transplantation (LTx) is a treatment option for end-stage lung disease that would be otherwise fatal for specific patient populations. The most common indications for LTx in adults remain to be chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis, cystic fibrosis, alpha-1 antitrypsin deficiency, and idiopathic pulmonary arterial hypertension. Recent trends include performing re-transplantation while more patients over the age of 65 years are undergoing LTx. Even with these tendencies, slight improvements in survival have occurred. This article briefly reviews recent developments in adults undergoing LTx.
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Affiliation(s)
- Bryan A Whitson
- 1 Department of Surgery, 2 Department of Pediatrics, 3 Department of Internal Medicine, The Ohio State University, Columbus, OH, USA ; 4 Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Don Hayes
- 1 Department of Surgery, 2 Department of Pediatrics, 3 Department of Internal Medicine, The Ohio State University, Columbus, OH, USA ; 4 Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, OH, USA
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