Exogenous lipid pneumonia related to smoking weed oil following cadaveric renal transplantation

Substance use and abuse in pediatric transplant recipients: What the transplant provider needs to know

Substance abuse is infrequently addressed during pre- and post-transplant care. However, the significant increase in the use of nicotine- and marijuana-containing products in the general and transplant adolescent population is concerning. In addition, alcohol use/abuse remains prevalent in the US population as it is highly accessible. Pediatric transplant providers should be prepared to screen for the use of any of these substances (eg, alcohol, nicotine, marijuana, cocaine, opiates, amphetamines) and to counsel them about the dangers of substance use and abuse including the unique dangers of the substances as a transplant recipient. Formal screening tools (in children as young as 9 years) should always be used as casual assessment of substance abuse has a high failure rate. This review summarizes the substances most commonly used in adolescent transplant recipients and the approach that transplant providers should take in order to prevent, decrease, or halt use in this patient population.

Cannabis Dependence or Abuse in Kidney Transplantation: Implications for Posttransplant Outcomes

BACKGROUND

Cannabis is categorized as an illicit drug in most US states, but legalization for medical indications is increasing. Policies and guidance on cannabis use in transplant patients remain controversial.

METHODS

We examined a database linking national kidney transplant records (n = 52 689) with Medicare claims to identify diagnoses of cannabis dependence or abuse (CDOA) and associations [adjusted hazard ratio (aHR) with 95% upper and lower confidence limits (CLs)] with graft, patient, and other clinical outcomes.

RESULTS

CDOA was diagnosed in only 0.5% (n = 254) and 0.3% (n = 163) of kidney transplant recipients in the years before and after transplant, respectively. Patients with pretransplant CDOA were more likely to be 19 to 30 years of age and of black race, and less likely to be obese, college-educated, and employed. After multivariate and propensity adjustment, CDOA in the year before transplant was not associated with death or graft failure in the year after transplant, but was associated with posttransplant psychosocial problems such as alcohol abuse, other drug abuse, noncompliance, schizophrenia, and depression. Furthermore, CDOA in the first year posttransplant was associated with an approximately 2-fold increased risk of death-censored graft failure (aHR, 2.29; 95% CL, 1.59-3.32), all-cause graft loss (aHR, 2.09; 95% CL, 1.50-2.91), and death (aHR, 1.79; 95% CL, 1.06-3.04) in the subsequent 2 years. Posttransplant CDOA was also associated with cardiovascular, pulmonary, and psychosocial problems, and with events such as accidents and fractures.

CONCLUSIONS

Although associations likely, in part, reflect associated conditions or behaviors, clinical diagnosis of CDOA in the year after transplant appears to have prognostic implications for allograft and patient outcomes. Recipients with posttransplant CDOA warrant focused monitoring and support.

The nephrologist's guide to cannabis and cannabinoids

PURPOSE OF REVIEW

Cannabis (marijuana, weed, pot, ganja, Mary Jane) is the most commonly used federally illicit drug in the United States. The present review provides an overview of cannabis and cannabinoids with relevance to the practice of nephrology so that clinicians can best take care of patients.

RECENT FINDINGS

Cannabis may have medicinal benefits for treating symptoms of advanced chronic kidney disease (CKD) and end-stage renal disease including as a pain adjuvant potentially reducing the need for opioids. Cannabis does not seem to affect kidney function in healthy individuals. However, renal function should be closely monitored in those with CKD, the lowest effective dose should be used, and smoking should be avoided. Cannabis use may delay transplant candidate listing or contribute to ineligibility. Cannabidiol (CBD) has recently exploded in popularity. Although generally well tolerated, safe without significant side effects, and effective for a variety of neurological and psychiatric conditions, consumers have easy access to a wide range of unregulated CBD products, some with inaccurate labeling and false health claims. Importantly, CBD may raise tacrolimus levels.

SUMMARY

Patients and healthcare professionals have little guidance or evidence regarding the impact of cannabis use on people with kidney disease. This knowledge gap will remain as long as federal regulations remain prohibitively restrictive towards prospective research.

Denying renal transplantation to an adolescent medical cannabis user: An ethical case study

Medical cannabis is now legal in over half of the United States. As more patients adopt this unconventional therapy, it is inevitable that potential transplant recipients will disclose their cannabis use during transplant evaluation. Transplant teams are tasked with the decision to utilize a pressure resource, often with little guidance from international and national professional organizations. Many healthcare providers remain uniformed or misinformed about the risks of cannabis use and organ transplantation. In order to illustrate the multifaceted and complex evaluation of transplant patients using medical cannabis, this article presents the case of a 20-year-old woman recommended for renal transplant who was originally denied active listing due to her medical cannabis use. A review of the literature explores the perceived and actual risks of cannabis use in the immunocompromised patient. Furthermore, a discussion of the ethics of medical cannabis use and organ transplantation is included with recommendations for multidisciplinary transplant teams.

Marijuana use in transplantation: A call for clarity

Transplant centers have varying policies for marijuana (MJ) use in donors, transplant candidates, and recipients. Rationales for these differences range from concerns for fungal complications, impaired adherence, and drug interactions. This paper reviews the current status of MJ policies and practices in transplant centers and results of a survey sent to the American Society of Transplantation (AST) membership by the Executive Committee of the AST Infectious Diseases Community of Practice.The purpose of the survey was to compare policies and concerns of MJ use to actual observed complications. Of the 3321 surveys sent, 225 members (8%) responded. Transplant centers varied in their approval processes, differing even in organ types within the same institutions. Furthermore, there was discordance among transplant centers in their perceived risks of marijuana use as opposed to complications actually observed. An increasing number of states continue to legalize medical and recreational MJ resulting in widespread availability. Further research is needed to assess the validity of concerns for complications of MJ use in potential donors and recipients. Ultimately, standardized guidelines should be established based on studies and evidence-based criteria to assist transplant programs in their policies around the use of cannabis in their donors and recipients.

Marijuana medusa: The many pulmonary faces of marijuana inhalation in adolescent males

Marijuana use has risen dramatically over the past decade. Over this same time period, pediatric hospitals have seen an increase in presentation of adolescents with acute respiratory symptoms after recent marijuana inhalation. We report a case series of three adolescent males with significant findings of bilateral pulmonary nodules and ground glass opacities on chest imaging associated with recent marijuana inhalation. Lung biopsies in two of the three patients confirmed silica-induced pneumoconiosis. The third patient was diagnosed with acute hypersensitivity pneumonitis without lung biopsy. Improvement in clinical symptoms and lung function testing were noted in two of three patients after marijuana inhalation cessation. This case series highlights the variety of severe pulmonary presentations in adolescents following recent marijuana inhalation. Future studies are required to assess whether these presenting pulmonary complications are from direct marijuana exposure or indirect associations with marijuana inhalation injuries.

Contemporary Policies Regarding Alcohol and Marijuana Use Among Liver Transplant Programs in the United States

BACKGROUND

Alcoholic liver disease is a common indication for orthotopic liver transplantation (OLT). Although OLT has been shown to confer survival benefit to patients with acute alcoholic hepatitis (AAH), historically most programs require a 6-month abstinence period before OLT which excludes patients with AAH. Marijuana has become legal in more than half the states in the United States. This survey of liver transplant programs was conducted to evaluate current policies regarding alcohol, marijuana and methadone use.

METHODS

A questionnaire was distributed to 100 United Network for Organ Sharing-approved liver transplant programs in North America that have performed at least 30 liver transplants/year in the last 5 years.

RESULTS

Forty-nine programs responded. Only 43% of the programs required a specific period of abstinence before transplant for alcoholic liver disease and only 26% enforced 6-month abstinence policy. For patients with AAH, 71% programs waived the 6-month abstinence requirement and considered psychosocial factors, such as family support, patient's motivation, or commitment to rehabilitate. Few programs used validated instruments to assess risk of relapse in AAH patients. Fourteen percent of programs transplant patients actively using marijuana and an additional 28% of programs listed patients using marijuana provided they discontinue by the time of OLT. Active methadone users were accepted in 45% of the programs.

CONCLUSIONS

Policies regarding alcohol use have become more flexible particularly toward patients with AAH. Marijuana use is also more accepted. Although policies regarding alcohol and marijuana have changed significantly in the last decade, they remain highly variable among programs.

Marijuana Use and Organ Transplantation: a Review and Implications for Clinical Practice

PURPOSE OF REVIEW

Physicians of all disciplines must rapidly adjust their clinical practices following the expansion of marijuana legalization across the country. Organ transplantation teams are uniquely struggling in this gray zone with eight states having passed laws explicitly banning the denial of transplant listing based on a patient's use of medical marijuana. In this review, we examine the clinical evidence of marijuana use in transplant patients to enable psychiatric providers to meaningfully contribute to the relevant medical and psychiatric aspects of this issue in a unique patient population.

RECENT FINDINGS

There is no consensus among experts regarding marijuana use in transplantation patients. There are extant case reports of post-transplant complications attributed to marijuana use including membranous glomerulonephritis, ventricular tachycardia, and tacrolimus toxicity. However, recent studies suggest that the overall survival rates in kidney, liver, lung, and heart transplant patients using marijuana are equivalent to non-users. Transplant teams should not de facto exclude marijuana users from transplant listing but instead holistically evaluate a patient's candidacy, integrating meaningful medical, psychiatric, and social variables into the complex decision-making process. Psychiatric providers can play a key role in this process. Appropriate stewardship over donor organs, a limited and precious resource, will require a balance of high-clinical standards with inclusive efforts to treat as many patients as possible.

Shopping for a Transplant: When Noncompliant Patients Seek Wait Listing at Multiple Hospitals

United Network for Organ Sharing policy allows patients to be listed for a transplant at multiple hospitals. This strategy can sometimes lessen the transplant waiting time for patients because waiting times vary geographically. We explore the ethical dilemma of “shopping for a transplant” by presenting the case of a patient with an addictive disorder who was listed for liver transplantation at one hospital on the east coast of the United States and was seeking listing at 2 additional hospitals in midwestern United States, when marijuana use was suspected by 1 of the latter 2 facilities. Although the transplant team at this facility deferred listing the patient, the team's bioethicist posed the concept of a duty to notify the facility where the patient was already listed for transplantation about any confirmed substance abuse, in an effort to prevent a scarce resource from being allocated to an individual who is noncompliant.

Marijuana and Listing for Heart Transplant

Background—

There is no consensus within the heart transplant community about whether patients who use marijuana should be eligible for transplant listing, but several states have passed legislation prohibiting marijuana-using patients from being denied transplant listing based on their use of the substance.

Methods and Results—

We conducted an independent, voluntary, web-based survey of heart and lung transplant providers to assess current practice patterns and attitudes toward marijuana use in patients with advanced heart failure being considered for transplant. A total of 360 heart transplant providers responded from 26 countries. Nearly two thirds of respondents (n=222, 64.4%) supported listing patients with advanced, end-stage heart failure for transplant who use legal medical marijuana. Significantly, fewer respondents (n=96, 27.5%) supported transplant listing for patients using legal recreational marijuana. The majority of providers currently make patients eligible for transplantation after a period of abstinence from marijuana (n=241, 68.3%). There were no differences between the proportion of respondents supporting transplant listing after stratification by profession or country/region. Most (78.4%) survey respondents from states with laws prohibiting marijuana-using patients from being denied transplant listing reported denying all marijuana-using patients or mandating abstinence before transplant listing.

Conclusions—

The majority of heart and lung transplant providers in our study sample supports the listing of patients who use medical marijuana for transplant after a period of abstinence. Communication and collaboration between the medical community and legislative groups about marijuana use in transplant candidates is needed to ensure the best patient outcomes with the use of scarce donor organs.

Effects on the immune system

Marijuana and other exogenous cannabinoids alter immune function and decrease host resistance to microbial infections in experimental animal models and in vitro. Two modes of action by which delta9-tetrahydrocannabinol (THC) and other cannabinoids affect immune responses have been proposed. First, cannabinoids may signal through the cannabinoid receptors CB1 and CB2. Second, at sites of direct exposure to high concentrations of cannabinoids, such as the lung, membrane perturbation may be involved. In addition, endogenous cannabinoids or endocannabinoids have been identified and have been proposed as native modulators of immune functions through cannabinoid receptors. Exogenously introduced cannabinoids may disturb this homoeostatic immune balance. A mode by which cannabinoids may affect immune responses and host resistance maybe by perturbing the balance of T helper (Th)1 pro-inflammatory versus Th2 anti-inflammatory cytokines. While marijuana and various cannabinoids have been documented to alter immune functions in vitro and in experimental animals, no controlled longitudinal epidemiological studies have yet definitively correlated immunosuppressive effects with increased incidence of infections or immune disorders in humans. However, cannabinoids by virtue of their immunomodulatory properties have the potential to serve as therapeutic agents for ablation of untoward immune responses.

Pulmonary alveolar proteinosis: progress in the first 44 years

Pulmonary alveolar proteinosis is a rare clinical syndrome that was first described in 1958. Subsequently, over 240 case reports and small series have described at least 410 cases in the literature. Characterized by the alveolar accumulation of surfactant components with minimal interstitial inflammation or fibrosis, pulmonary alveolar proteinosis has a variable clinical course ranging from spontaneous resolution to death with pneumonia or respiratory failure. The most effective proven treatment--whole lung lavage--was described soon after the first recognition of this disease. In the last 8 years, there has been rapid progress toward elucidation of the molecular mechanisms underlying both the congenital and acquired forms of pulmonary alveolar proteinosis, following serendipitous discoveries in gene-targeted mice lacking granulocyte-macrophage colony-stimulating factor (GM-CSF). Impairment of surfactant clearance by alveolar macrophages as a result of inhibition of the action of GM-CSF by blocking autoantibodies may underlie many acquired cases, whereas congenital disease is most commonly attributable to mutations in surfactant protein genes but may also be caused by GM-CSF receptor defects. Therapy with GM-CSF has shown promise in approximately half of those acquired cases treated, but it is unsuccessful in congenital forms of the disease, consistent with the known differences in disease pathogenesis.