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Magda G. Opportunistic Infections Post-Lung Transplantation: Viral, Fungal, and Mycobacterial. Infect Dis Clin North Am 2024; 38:121-147. [PMID: 38280760 DOI: 10.1016/j.idc.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
Opportunistic infections are a leading cause of lung transplant recipient morbidity and mortality. Risk factors for infection include continuous exposure of the lung allograft to the external environment, high levels of immunosuppression, impaired mucociliary clearance and decreased cough reflex, and impact of the native lung microbiome in single lung transplant recipients. Infection risk is mitigated through careful pretransplant screening of recipients and donors, implementation of antimicrobial prophylaxis strategies, and routine surveillance posttransplant. This review describes common viral, fungal, and mycobacterial infectious after lung transplant and provides recommendations on prevention and treatment.
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Affiliation(s)
- Gabriela Magda
- Columbia University Lung Transplant Program, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street PH-14, New York, NY 10032, USA.
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2
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Sindu D, Razia D, Grief K, Cherrier L, Omar A, Walia R, McAnally K, Buddhdev B, Tokman S. Prior SARS-CoV-2 infection may not alter the clinical course of COVID-19 in lung transplant recipients: A single-center experience. Clin Transplant 2023; 37:e15071. [PMID: 37405931 DOI: 10.1111/ctr.15071] [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: 05/01/2023] [Revised: 06/01/2023] [Accepted: 06/26/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND In the general population, prior infection with SARS-CoV-2 reduces the risk of severe COVID-19; however, studies in lung transplant recipients (LTRs) are lacking. We sought to describe the clinical course of COVID-19 recurrence and compare outcomes between the first and second episodes of COVID-19 in LTRs. METHODS We conducted a retrospective, single-center cohort study of LTRs with COVID-19 between January 1, 2022, and September 30, 2022, during the Omicron wave. We compared the clinical course of a second episode of COVID-19 to that of the patients' own first episode and to that of LTRs who developed a first episode during the study period. RESULTS During the study period, we identified 24 LTRs with COVID-19 recurrence and another 75 LTRs with a first episode of COVID-19. LTRs who survived the initial episode of COVID-19 had a similar disease course with recurrence, with a trend toward reduced hospitalization (10 (41.6%) vs. 4 (16.7%), p = .114). Furthermore, compared to LTRs with a primary infection during the Omicron wave, those with a reinfection had a non-statistically significant trend toward reduced hospitalizations (aOR .391, 95% CI [.115-1.321], p = .131), shorter lengths-of-stay (median, 4 vs. 9 days, p = .181), and reduced intensive care unit admissions, intubations, and COVID-19-related mortality. CONCLUSIONS LTRs who survive the first episode of COVID-19 are likely to have a similar clinical course with recurrent episodes. Although recurrent COVID-19 may be milder, larger, well-powered studies are needed to confirm this observation. Ongoing precautions are warranted.
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Affiliation(s)
- Devika Sindu
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Deepika Razia
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, Arizona, USA
| | - Katherine Grief
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Lauren Cherrier
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ashraf Omar
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, Arizona, USA
| | - Rajat Walia
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, Arizona, USA
| | - Kendra McAnally
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, Arizona, USA
| | - Bhuvin Buddhdev
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, Arizona, USA
| | - Sofya Tokman
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, Arizona, USA
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3
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Opportunistic Infections Post-Lung Transplantation: Viral, Fungal, and Mycobacterial. Clin Chest Med 2023; 44:159-177. [PMID: 36774162 DOI: 10.1016/j.ccm.2022.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Opportunistic infections are a leading cause of lung transplant recipient morbidity and mortality. Risk factors for infection include continuous exposure of the lung allograft to the external environment, high levels of immunosuppression, impaired mucociliary clearance and decreased cough reflex, and impact of the native lung microbiome in single lung transplant recipients. Infection risk is mitigated through careful pretransplant screening of recipients and donors, implementation of antimicrobial prophylaxis strategies, and routine surveillance posttransplant. This review describes common viral, fungal, and mycobacterial infectious after lung transplant and provides recommendations on prevention and treatment.
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4
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Shah SZ, Abdelmoneim Y, Pham SM, Elrefaei M. Association between SARS-CoV-2 infection and de novo HLA donor specific antibody production in lung transplant recipients: Single-center study. Hum Immunol 2022; 83:749-754. [PMID: 35987702 PMCID: PMC9376302 DOI: 10.1016/j.humimm.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 07/08/2022] [Accepted: 07/18/2022] [Indexed: 11/04/2022]
Abstract
The COVID-19 pandemic has led to significant morbidity and mortality in lung transplant recipients. Respiratory viral infections may be associated with de-novo HLA donor-specific antibody production and impact lung transplant outcome. Since one of the immunomodulation strategies post-SARS-CoV-2 infection in lung transplant recipients include decreasing or holding anti-metabolites, concerns have been raised for higher incidence of de-novo HLA donor specific antibody production in lung transplant recipients. We performed a retrospective chart review of 24 consecutive lung transplant recipients diagnosed with COVID-19 to investigate this concern. We observed no significant differences in the CPRA or MFI levels of HLA class I and II antibodies pre- COVID-19 compared to 1 and 6 months post-COVID-19 diagnosis in 11/24 (45.8 %) LTR (p = 0.98 and p = 0.63 respectively). HLA class I and II DSA were detected in 5/24 LTR pre-COVID-19 diagnosis and persisted with no significant differences in the median MFI levels at 1 and 6 months post-COVID-19 diagnosis (p = 0.89). De-novo HLA class I and II DSA were detected in 1/24 (4.2 %) LTR at one month post-COVID-19 diagnosis and persisted with no significant differences in the median MFI levels at 1 and 6 months post-COVID-19 diagnosis (p = 0.54). Our results suggest that there was no significant association between SARS-CoV-2 infection and immunomodulation on pre-existing or de novo HLA donor specific antibodies.
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Affiliation(s)
- Sadia Z Shah
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, United States
| | - Yousif Abdelmoneim
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, FL, United States
| | - Si M Pham
- Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, FL, United States
| | - Mohamed Elrefaei
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, FL, United States.
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5
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de Zwart A, Riezebos-Brilman A, Lunter G, Vonk J, Glanville AR, Gottlieb J, Permpalung N, Kerstjens H, Alffenaar JW, Verschuuren E. Respiratory Syncytial Virus, Human Metapneumovirus, and Parainfluenza Virus Infections in Lung Transplant Recipients: A Systematic Review of Outcomes and Treatment Strategies. Clin Infect Dis 2022; 74:2252-2260. [PMID: 35022697 PMCID: PMC9258934 DOI: 10.1093/cid/ciab969] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Indexed: 12/16/2022] Open
Abstract
Background Respiratory syncytial virus (RSV), parainfluenza virus (PIV), and human metapneumovirus (hMPV) are increasingly associated with chronic lung allograft dysfunction (CLAD) in lung transplant recipients (LTR). This systematic review primarily aimed to assess outcomes of RSV/PIV/hMPV infections in LTR and secondarily to assess evidence regarding the efficacy of ribavirin. Methods Relevant databases were queried and study outcomes extracted using a standardized method and summarized. Results Nineteen retrospective and 12 prospective studies were included (total 1060 cases). Pooled 30-day mortality was low (0–3%), but CLAD progression 180–360 days postinfection was substantial (pooled incidences 19–24%) and probably associated with severe infection. Ribavirin trended toward effectiveness for CLAD prevention in exploratory meta-analysis (odds ratio [OR] 0.61, [0.27–1.18]), although results were highly variable between studies. Conclusions RSV/PIV/hMPV infection was followed by a high CLAD incidence. Treatment options, including ribavirin, are limited. There is an urgent need for high-quality studies to provide better treatment options for these infections.
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Affiliation(s)
- Auke de Zwart
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Medicine and Tuberculosis, Groningen, The Netherlands
| | | | - Gerton Lunter
- University of Groningen, University Medical Center Groningen, Department of Epidemiology, Groningen, The Netherlands
| | - Judith Vonk
- University of Groningen, University Medical Center Groningen, Department of Epidemiology, Groningen, The Netherlands
| | | | - Jens Gottlieb
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Nitipong Permpalung
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Huib Kerstjens
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Medicine and Tuberculosis, Groningen, The Netherlands
| | - Jan-Willem Alffenaar
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.,Westmead Hospital, Westmead, Australia.,Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia
| | - Erik Verschuuren
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Medicine and Tuberculosis, Groningen, The Netherlands
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6
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Chronic lung allograft dysfunction. Indian J Thorac Cardiovasc Surg 2021; 38:318-325. [DOI: 10.1007/s12055-021-01228-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 06/11/2021] [Accepted: 06/21/2021] [Indexed: 10/19/2022] Open
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7
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Sweet SC. Community-Acquired Respiratory Viruses Post-Lung Transplant. Semin Respir Crit Care Med 2021; 42:449-459. [PMID: 34030206 DOI: 10.1055/s-0041-1729172] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Survival in lung transplant recipients (LTRs) lags behind heart, liver, and kidney transplant, in part due to the direct and indirect effects of infection. LTRs have increased susceptibility to infection due to the combination of a graft continually exposed to the outside world, multiple mechanisms for impaired mucus clearance, and immunosuppression. Community-acquired respiratory viral infections (CARVs) are common in LTRs. Picornaviruses have roughly 40% cumulative incidence followed by respiratory syncytial virus and coronaviruses. Although single-center retrospective and prospective series implicate CARV in rejection and mortality, conclusive evidence for and well-defined mechanistic links to long-term outcome are lacking. Treatment of viral infections can be challenging except for influenza. Future studies are needed to develop better treatments and clarify the links between CARV and long-term outcomes.
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Affiliation(s)
- Stuart C Sweet
- Division of Allergy and Pulmonary Medicine, Washington University in St. Louis, St. Louis, Missouri
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8
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Avery L, Hoffmann C, Whalen KM. The Use of Aerosolized Ribavirin in Respiratory Syncytial Virus Lower Respiratory Tract Infections in Adult Immunocompromised Patients: A Systematic Review. Hosp Pharm 2020; 55:224-235. [PMID: 32742010 DOI: 10.1177/0018578719836646] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: Respiratory syncytial virus (RSV)-associated lower respiratory tract infection (LRTI) is a concern in immunocompromised patients. Aerosolized ribavirin (RBV AER) is used for treatment of RSV LRTI; however, adverse events and rising drug costs remain a challenge for patient management. The purpose of this systematic review is to summarize the efficacy and adverse event profile of RBV AER for the treatment of hospitalized RSV LRTI in immunocompromised adult patients. Methods: A Medline/PubMed, Embase, Google Scholar, Clinicaltrials.gov, and Cochrane Library database search was conducted from 1966 to January 2019 for the use of RBV AER. Search strategy: [(ribavirin OR ICN1229) AND ("administration, oral" OR "oral" OR "administration, inhalation" OR "inhalation)] AND ("respiratory tract infection" OR "pneumonia"). Studies were reviewed if adult patients were hospitalized, immunocompromised, had RSV LRTI, received RBV AER, and included the outcome of mortality and/or adverse reactions. Methodological quality was assessed using the Cochrane Collaboration GRADE approach. Results: A total of 1787 records were identified and 15 articles met inclusion criteria: hematopoietic stem cell transplant (HSCT)/bone marrow transplant (n = 8), other malignancy/neutropenic (n = 2), solid organ transplant (n = 5). All of the trials are observational with a low quality rating; therefore, a meta-analysis was not performed. The 30-day mortality in studies that contain >10 patients with HSCT, malignancy, and transplant range from 0 to 15.4%, 6.3%, and 0 to 27%, respectively. Improved mortality was cited in 4 studies when RBV AER started before mechanical ventilation or within 2 weeks of symptom onset. Only 3 studies had comparative mortality data with RBV AER and RBV PO. Adverse reactions were reported in 5 studies and included psychiatric manifestations (anxiety, depression, feeling of isolation; n = 14), wheezing/bronchospasm (n = 6), snowflakes/hail blowing in face (n = 6), and precipitation in ventilator tubing (n = 5). Conclusion: There is a lack of high quality, comparative trials on the use of RBV AER for the treatment of RSV LRTI in adult hospitalized immunocompromised patients. There may be a mortality benefit when RBV AER is initiated early after diagnosis or prior to mechanical ventilation, but requires further study. Patient isolation and psychological effects must be weighed against the benefit of therapy.
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Affiliation(s)
- Lisa Avery
- St. John Fisher College, Rochester, NY, USA.,St. Joseph's Health, Syracuse, NY, USA
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9
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Abstract
PURPOSE OF REVIEW Incidence of community-acquired respiratory viruses (CARVs) after lung transplantation (LTx) is 10-68 cases per 100 patient-years. Infected patients may develop graft failure and there seems to be an association between CARV infection and development of chronic lung allograft dysfunction (CLAD). This review summarizes the impact of CARV infection after LTx and potential treatment strategies. RECENT FINDINGS Detection rate of CARV depends on diagnostic methods. CARV infections after LTx are reported more frequently probably attributed to improved diagnostic methods, especially nucleic acid testing. Paramyxoviridae and picornaviridae are most frequent. For paramyxoviridae, the association with CLAD is reported in various single-center observational studies. Neuraminidase inhibitors are approved for influenza and can be safely used in flu-infected LTx patients. There is no approved treatment for paramyxoviruses, most centers use ribavirin in the infected LTx recipient. SUMMARY Antivirals against CARV in LTx recipients have not yet demonstrated reduced morbidity in randomized clinical trials. Agents against CARV under development are inhibiting viral attachment and use silencing mechanisms of viral replication. The cohort of lung transplant recipients is a focus of intense research because of the high morbidity of CARV infection and intense surveillance of LTx recipeints.
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10
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Clausen ES, Zaffiri L. Infection prophylaxis and management of viral infection. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:415. [PMID: 32355859 PMCID: PMC7186616 DOI: 10.21037/atm.2019.11.85] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Viral infections are associated with significant morbidity and mortality in lung transplant recipients. Importantly, several viral infections have been associated with the development of chronic lung allograft dysfunction (CLAD). Community-acquired respiratory viruses (CARV) such as influenza and respiratory syncytial virus (RSV), are frequently associated with acute and chronic rejection. Cytomegalovirus (CMV) remains a significant burden in regards to morbidity and mortality in lung transplant recipients. Epstein-Barr virus (EBV) is mostly involved with the development of post-transplant lymphoproliferative disorder (PTLD), a lymphoid proliferation that occurs in the setting of immunosuppression. On the other hand, the development of direct acting antivirals for hepatitis C virus (HCV) is changing the use of HCV-positive organs in transplantation. In this article we will focus on reviewing common viral infections that have a significant impact on lung transplant recipients looking at epidemiology, prevention and potential treatment.
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Affiliation(s)
- Emily S Clausen
- Department of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Lorenzo Zaffiri
- Department of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
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11
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Abstract
Respiratory syncytial virus (RSV) is the most common pathogen associated with acute lower respiratory tract infections in young children. RSV is also a major viral pathogen causing severe lung disease in the adult population, particularly among the elderly. We conducted a review of adult RSV studies published from January 1970 to February 2017 to determine the burden of disease among adults worldwide. There were no restrictions on health care setting or definition of RSV infection. A total of 1530 published studies were identified, 95 of which were included in this review. The incidence rates of hospitalised RSV acute respiratory tract infection (ARI) in adults >65 years old ranged from 7.3 to 13.0/105 population in Africa and Asia and from 190 to 254/105 population in the USA. Higher incidence rates (195–1790/105 population) were observed in adults ≥50 years old for outpatient or emergency visits in the USA. Of all ARI patients, RSV accounted for 1–10% in adults and 2–14% in patients with chronic diseases or transplantation. Given the limitations in the existing data, significant efforts should be made to generate evidence on the burden of RSV infections in adults and to estimate the potential impact of future preventive interventions.
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12
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Bailey ES, Zemke JN, Choi JY, Gray GC. A Mini-Review of Adverse Lung Transplant Outcomes Associated With Respiratory Viruses. Front Immunol 2019; 10:2861. [PMID: 31921130 PMCID: PMC6930876 DOI: 10.3389/fimmu.2019.02861] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/21/2019] [Indexed: 11/13/2022] Open
Abstract
Due to their overall immunocompromised state, lung transplant recipients (LTRs) are at increased risk for the development of viral respiratory infections compared to the general population. Such respiratory infections often lead to poor transplant outcomes. We performed a systematic review of the last 30 years of medical literature to summarize the impact of specific respiratory viruses on LTRs. After screening 2,150 articles for potential inclusion, 39 manuscripts were chosen for final review. We found evidence for an association of respiratory viruses including respiratory syncytial virus (RSV), parainfluenza virus, and influenza viruses with increased morbidity following transplant. Through the literature search, we also documented associations of RSV and adenovirus infections with increased mortality among LTRs. We posit that the medical literature supports aggressive surveillance for respiratory viruses among this population.
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Affiliation(s)
- Emily S Bailey
- Duke Global Health Institute, Duke University, Durham, NC, United States.,Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, NC, United States
| | - Juliana N Zemke
- Duke Global Health Institute, Duke University, Durham, NC, United States.,Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, NC, United States
| | - Jessica Y Choi
- Duke Global Health Institute, Duke University, Durham, NC, United States.,Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, NC, United States
| | - Gregory C Gray
- Duke Global Health Institute, Duke University, Durham, NC, United States.,Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, NC, United States.,Global Health Research Center, Duke-Kunshan University, Kunshan, China.,Emerging Infectious Diseases Program, Duke-NUS Medical School, Singapore, Singapore
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13
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Respiratory Viral Infections in Transplant Recipients. PRINCIPLES AND PRACTICE OF TRANSPLANT INFECTIOUS DISEASES 2019. [PMCID: PMC7120918 DOI: 10.1007/978-1-4939-9034-4_40] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Respiratory viral infections (RVIs) are common among the general population; however, these often mild viral illnesses can lead to serious morbidity and mortality among recipients of hematopoietic stem cell and solid organ transplantation. The disease spectrum ranges from asymptomatic or mild infections to life-threatening lower respiratory tract infection or long-term airflow obstruction syndromes. Progression to lower respiratory tract infection or to respiratory failure is determined by the intrinsic virulence of the specific viral pathogen as well as various host factors, including the type of transplantation, status of the host’s immune dysfunction, the underlying disease, and other comorbidities. This chapter focuses on the epidemiology, clinical manifestations, diagnosis, and management of RVIs in this susceptible population and includes respiratory syncytial virus, parainfluenza virus, human metapneumovirus, influenza virus, human coronavirus, and human rhinovirus. The optimal management of these infections is limited by the overall paucity of available treatment, highlighting the need for new antiviral drug or immunotherapies.
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14
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Common Infections Following Lung Transplantation. ESSENTIALS IN LUNG TRANSPLANTATION 2019. [PMCID: PMC7121478 DOI: 10.1007/978-3-319-90933-2_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The lungs are the only transplanted organ in direct contact with the ‘outside world’. Infection is a significant cause of morbidity and mortality in lung transplantation. Early accurate diagnosis and optimal management is essential to prevent short and long term complications. Bacteria, including Mycobacteria and Nocardia, viruses and fungi are common pathogens. Organisms may be present in the recipient prior to transplantation, transmitted with the donor lungs or acquired after transplantation. The degree of immunosuppression and the routine use of antimicrobial prophylaxis alters the pattern of post-transplant infections.
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15
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Respiratory Viruses and Other Relevant Viral Infections in the Lung Transplant Recipient. LUNG TRANSPLANTATION 2018. [PMCID: PMC7123387 DOI: 10.1007/978-3-319-91184-7_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
As advances occur in surgical technique, postoperative care, and immunosuppressive therapy, the rate of mortality in the early postoperative period following lung transplantation continues to decline. With the improvements in immediate and early posttransplant mortality, infections and their sequel as well as rejection and chronic allograft dysfunction are increasingly a major cause of posttransplant mortality. This chapter will focus on infections by respiratory viruses and other viral infections relevant to lung transplantation, including data regarding the link between viral infections and allograft dysfunction.
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16
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Abstract
The incidence of community-acquired respiratory viruses (CARVs) is ∼15 cases per 100 patient-years after lung transplantation (LTx). Paramyxoviruses account for almost 50% of the cases of CARV infection in LTx. Most patients will be symptomatic with a mean decline of 15 to 20% in forced expiratory volume in 1 second. The attributable death rate is low in recent years 15 to 25% CARV infected LTx patients will develop chronic lung allograft dysfunction within a year after CARV infection. This risk seems to be increased in comparison to the noninfected LTx recipient. Detection rate of CARV dependent on clinical awareness, sampling, and diagnostic method with nucleic acid testing by polymerase chain reaction in bronchoalveolar lavage is the gold standard after LTx. There is no approved treatment for paramyxoviruses, most centers use ribavirin by various routes. Toxicity of systemic ribavirin is of concern and some patients will have contraindication to this treatment modality. Treatment may reduce the risk to develop chronic lung allograft dysfunction and respiratory failure. Agents under development are inhibiting viral attachment and use silencing mechanisms of viral replication.
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Affiliation(s)
- Jens Gottlieb
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
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17
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Abstract
Human parainfluenza viruses (HPIVs) are single-stranded, enveloped RNA viruses of the Paramyoviridaie family. There are four serotypes which cause respiratory illnesses in children and adults. HPIVs bind and replicate in the ciliated epithelial cells of the upper and lower respiratory tract and the extent of the infection correlates with the location involved. Seasonal HPIV epidemics result in a significant burden of disease in children and account for 40% of pediatric hospitalizations for lower respiratory tract illnesses (LRTIs) and 75% of croup cases. Parainfluenza viruses are associated with a wide spectrum of illnesses which include otitis media, pharyngitis, conjunctivitis, croup, tracheobronchitis, and pneumonia. Uncommon respiratory manifestations include apnea, bradycardia, parotitis, and respiratory distress syndrome and rarely disseminated infection. Immunity resulting from disease in childhood is incomplete and reinfection with HPIV accounts for 15% of respiratory illnesses in adults. Severe disease and fatal pneumonia may occur in elderly and immunocompromised adults. HPIV pneumonia in recipients of hematopoietic stem cell transplant (HSCT) is associated with 50% acute mortality and 75% mortality at 6 months. Though sensitive molecular diagnostics are available to rapidly diagnose HPIV infection, effective antiviral therapies are not available. Currently, treatment for HPIV infection is supportive with the exception of croup where the use of corticosteroids has been found to be beneficial. Several novel drugs including DAS181 appear promising in efforts to treat severe disease in immunocompromised patients, and vaccines to decrease the burden of disease in young children are in development.
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Affiliation(s)
- Angela R Branche
- Department of Medicine, University of Rochester, Rochester, New York
| | - Ann R Falsey
- Department of Medicine, University of Rochester, Rochester, New York
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18
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Abstract
Major strides have been made in lung transplantation during the 1990s and it has become an established treatment option for patients with advanced lung disease. Due to improvements in organ preservation, surgical techniques, postoperative intensive care, and immunosuppression, the risk of perioperative and early mortality (less than 3 months after transplantation) has declined [1]. The transplant recipient now has a greater chance of realizing the benefits of the long and arduous waiting period.Despite these improvements, suboptimal long-term outcomes continue to be shaped by issues such as opportunistic infections and chronic rejection. Because of the wider use of lung transplantation and the longer life span of recipients, intensivists and ancillary intensive care unit (ICU) staff should be well versed with the care of lung transplant recipients.In this clinical review, issues related to organ donation will be briefly mentioned. The remaining focus will be on the critical care aspects of lung transplant recipients in the posttransplant period, particularly ICU management of frequently encountered conditions. First, the groups of patients undergoing transplantation and the types of procedures performed will be outlined. Specific issues directly related to the allograft, including early graft dysfunction from ischemia-reperfusion injury, airway anastomotic complications, and infections in the setting of immunosuppression will be emphasized. Finally nonpulmonary aspects of posttransplant care and key pharmacologic points in the ICU will be covered.
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19
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Abstract
Survival after lung transplantation is limited in large part due to the high incidence of chronic rejection, known as chronic lung allograft dysfunction (CLAD). Pulmonary infections are a frequent complication in lung transplant recipients, due both to immunosuppressive medications and constant exposure of the lung allograft to the external environment via the airways. Infection is a recognized risk factor for the development of CLAD, and both acute infection and chronic lung allograft colonization with microorganisms increase the risk for CLAD. Acute infection by community acquired respiratory viruses, and the bacteria Pseudomonas aeruginosa and Staphylococcus aureus are increasingly recognized as important risk factors for CLAD. Colonization by the fungus Aspergillus may also augment the risk of CLAD. Fostering this transition from healthy lung to CLAD in each of these infectious episodes is the persistence of an inflammatory lung allograft environment.
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Affiliation(s)
- Aric L Gregson
- Division of Infectious Diseases, Department of Medicine, University of California, Box 957119, Warren Hall 14-154, Los Angeles, CA, 90995-7119, USA.
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Fisher CE, Preiksaitis CM, Lease ED, Edelman J, Kirby KA, Leisenring WM, Raghu G, Boeckh M, Limaye AP. Symptomatic Respiratory Virus Infection and Chronic Lung Allograft Dysfunction. Clin Infect Dis 2015; 62:313-319. [PMID: 26565010 PMCID: PMC4706632 DOI: 10.1093/cid/civ871] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Accepted: 08/16/2015] [Indexed: 12/13/2022] Open
Abstract
Background. Chronic lung allograft dysfunction (CLAD) is a major cause of allograft loss post-lung transplantation. Prior studies have examined the association between respiratory virus infection (RVI) and CLAD were limited by older diagnostic techniques, study design, and case numbers. We examined the association between symptomatic RVI and CLAD using modern diagnostic techniques in a large contemporary cohort of lung transplant recipients (LTRs). Methods. We retrospectively assessed clinical variables including acute rejection, cytomegalovirus pneumonia, upper and lower RVI, and the primary endpoint of CLAD (determined by 2 independent reviewers) in 250 LTRs in a single university transplantation program. Univariate and multivariate Cox models were used to analyze the relationship between RVI and CLAD in a time-dependent manner, incorporating different periods of risk following RVI diagnosis. Results. Fifty patients (20%) were diagnosed with CLAD at a median of 95 weeks post-transplantation, and 79 (32%) had 114 episodes of RVI. In multivariate analysis, rejection and RVI were independently associated with CLAD (adjusted hazard ratio [95% confidence interval]) 2.2 (1.2–3.9), P = .01 and 1.9 (1.1–3.5), P = .03, respectively. The association of RVI with CLAD was stronger the more proximate the RVI episode: 4.8 (1.9–11.6), P < .01; 3.4 (1.5–7.5), P < .01; and 2.4 (1.2–5.0), P = .02 in multivariate analysis for 3, 6, and 12 months following RVI, respectively. Conclusions. Symptomatic RVI is independently associated with development of CLAD, with increased risk at shorter time periods following RVI. Prospective studies to characterize the virologic determinants of CLAD and define the underlying mechanisms are warranted.
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Affiliation(s)
- Cynthia E Fisher
- Department of Medicine, University of Washington.,Vaccine and Infectious Disease Division
| | | | | | | | | | - Wendy M Leisenring
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Ganesh Raghu
- Department of Medicine, University of Washington
| | - Michael Boeckh
- Department of Medicine, University of Washington.,Vaccine and Infectious Disease Division.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
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Gottlieb J, Zamora MR, Hodges T, Musk AW, Sommerwerk U, Dilling D, Arcasoy S, DeVincenzo J, Karsten V, Shah S, Bettencourt BR, Cehelsky J, Nochur S, Gollob J, Vaishnaw A, Simon AR, Glanville AR. ALN-RSV01 for prevention of bronchiolitis obliterans syndrome after respiratory syncytial virus infection in lung transplant recipients. J Heart Lung Transplant 2015; 35:213-21. [PMID: 26452996 DOI: 10.1016/j.healun.2015.08.012] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 07/20/2015] [Accepted: 08/22/2015] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Respiratory syncytial virus (RSV) infection in lung transplant (LTx) patients is associated with an increased incidence of bronchiolitis obliterans syndrome (BOS). ALN-RSV01 is a small interfering RNA targeting RSV replication that was shown in an earlier Phase 2a trial to be safe and to reduce the incidence of BOS when compared with placebo. METHODS We performed a Phase 2b randomized, double-blind, placebo-controlled trial in RSV-infected LTx patients to examine the impact of ALN-RSV01 on the incidence of new or progressive BOS. Subjects were randomized (1:1) to receive aerosolized ALN-RSV01 or placebo daily for 5 days. RESULTS Of 3,985 symptomatic patients screened, 218 were RSV-positive locally, of whom 87 were randomized to receive ALN-RSV01 or placebo (modified intention-to-treat [mITT] cohort). RSV infection was confirmed by central laboratory in 77 patients (ALN-RSV01, n = 44; placebo, n = 33), which comprised the primary analysis cohort (central mITT [mITTc]). ALN-RSV01 was found to be safe and well-tolerated. At Day 180, in ALN-RSV01-treated patients, compared with placebo, in the mITTc cohort there was a trend toward a decrease in new or progressive BOS (13.6% vs 30.3%, p = 0.058), which was significant in the per-protocol cohort (p = 0.025). Treatment effect was enhanced when ALN-RSV01 was started <5 days from symptom onset, and was observed even without ribavirin treatment. There was no significant impact on viral parameters or symptom scores. CONCLUSIONS These results confirm findings of the earlier Phase 2a trial and provide further support that ALN-RSV01 reduces the risk of BOS after RSV in LTx recipients.
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Affiliation(s)
- Jens Gottlieb
- Department of Respiratory Medicine, Hannover Medical School, Biomedical Research in End stage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Germany.
| | - Martin R Zamora
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado at Denver Health Sciences Center, Aurora, Colorado
| | - Tony Hodges
- Center for Thoracic Transplantation at the Heart & Lung Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - A W Musk
- Department of Respiratory Medicine, Royal Perth Hospital, Perth, Australia
| | - Urte Sommerwerk
- Department of Pneumology, Ruhrlandklinik, Westdeutsches Lungenzentrum am Universitaetsklinikum Essen GmbH, Essen, Germany
| | - Daniel Dilling
- Departemnt of Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Selim Arcasoy
- Department of Medicine, New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY
| | - John DeVincenzo
- Department of Pediatrics, University of Tennessee Center for Health Sciences, Memphis, Tennessee
| | | | - Shaily Shah
- Alnylam Pharmaceuticals, Cambridge, Massachusetts
| | | | | | - Sara Nochur
- Alnylam Pharmaceuticals, Cambridge, Massachusetts
| | - Jared Gollob
- Alnylam Pharmaceuticals, Cambridge, Massachusetts
| | | | - Amy R Simon
- Alnylam Pharmaceuticals, Cambridge, Massachusetts
| | - Allan R Glanville
- Lung Transplant Unit, St. Vincent's Hospital, Darlinghurst, New South Wales, Australia
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Burrows FS, Carlos LM, Benzimra M, Marriott DJ, Havryk AP, Plit ML, Malouf MA, Glanville AR. Oral ribavirin for respiratory syncytial virus infection after lung transplantation: Efficacy and cost-efficiency. J Heart Lung Transplant 2015; 34:958-62. [DOI: 10.1016/j.healun.2015.01.009] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 12/04/2014] [Accepted: 01/08/2015] [Indexed: 11/16/2022] Open
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Neemann K, Freifeld A. Respiratory Syncytial Virus in Hematopoietic Stem Cell Transplantation and Solid-Organ Transplantation. Curr Infect Dis Rep 2015; 17:490. [DOI: 10.1007/s11908-015-0490-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Kloth C, Forler S, Gatidis S, Beck R, Spira D, Nikolaou K, Horger M. Comparison of chest-CT findings of Influenza virus-associated pneumonia in immunocompetent vs. immunocompromised patients. Eur J Radiol 2015; 84:1177-83. [PMID: 25796425 DOI: 10.1016/j.ejrad.2015.02.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 02/10/2015] [Accepted: 02/11/2015] [Indexed: 01/24/2023]
Abstract
PURPOSE To retrospectively compare CT-patterns of pulmonary infiltration caused by different Influenza virus types and subtypes in immunocompetent and immunocompromised patients for possible discrimination. MATERIALS AND METHODS Retrospective database search at our institution yielded 237 patients who were tested positive for Influenza virus type A or type B by bronchoalveolar lavage between January 2009 and April 2014. Fifty-six of these patients (female 26; male 30; median age 55.8 y, range 17-86 y; SD ± 14.4 y) underwent chest-HRCT due to a more severe clinical course of pulmonary infection. We registered all CT-findings compatible with pulmonary infection classifying them as airway predominant (tree-in-bud, centrilobular nodules, bronchial wall thickening ± peribronchial ground-glass opacity and consolidation) vs. interstitial-parenchymal predominant (bilateral, symmetrical GGO, consolidation, crazy paving and/or interlobular septal thickening). Twenty-six patients (46.4%) had follow-up CT-studies (0.78 mean, SD ± 5.8 scans). RESULTS Thirty-six patients were immunocompromised (group I) whereas 20 patients were immunocompetent (group II). An airway-centric pattern of infection was found in 15 patients (group I) and 14 patients (group II) whereas an interstitial-parenchymal predominant pattern was found in 14 patients (group I) and 2 patients (group II). Eleven patients had a mixed pattern with no clear assignment to one group. At FU, 12 patients from group I and 3 from group II showed transitional infiltration patterns: in 10 patients from interstitial-parenchymal into airway predominant pattern and in five patients from airway predominant into interstitial-parenchymal. No significant differences in the pattern of pulmonary infection were found between different types and subtypes of Influenza viruses. CONCLUSION Patterns of pulmonary infiltration caused by Influenza viruses do not significantly differ between immunocompetent and immunocompromised patients or between different types and subtypes of Influenza virus. One possible explanation for this could be the temporarily interchangeable character of pulmonary infiltration in this infection.
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Affiliation(s)
- C Kloth
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany.
| | - S Forler
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
| | - S Gatidis
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
| | - R Beck
- Institute of Medical Virology and Epidemiology of Viral Diseases, Eberhard-Karls-University, Elfriede-Aulhorn-Straße 6, 72076 Tübingen, Germany
| | - D Spira
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
| | - K Nikolaou
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
| | - M Horger
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
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Meyer KC, Raghu G, Verleden GM, Corris PA, Aurora P, Wilson KC, Brozek J, Glanville AR. An international ISHLT/ATS/ERS clinical practice guideline: diagnosis and management of bronchiolitis obliterans syndrome. Eur Respir J 2014; 44:1479-503. [PMID: 25359357 DOI: 10.1183/09031936.00107514] [Citation(s) in RCA: 380] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Bronchiolitis obliterans syndrome (BOS) is a major complication of lung transplantation that is associated with poor survival. The International Society for Heart and Lung Transplantation, American Thoracic Society, and European Respiratory Society convened a committee of international experts to describe and/or provide recommendations for 1) the definition of BOS, 2) the risk factors for developing BOS, 3) the diagnosis of BOS, and 4) the management and prevention of BOS. A pragmatic evidence synthesis was performed to identify all unique citations related to BOS published from 1980 through to March, 2013. The expert committee discussed the available research evidence upon which the updated definition of BOS, identified risk factors and recommendations are based. The committee followed the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) approach to develop specific clinical recommendations. The term BOS should be used to describe a delayed allograft dysfunction with persistent decline in forced expiratory volume in 1 s that is not caused by other known and potentially reversible causes of post-transplant loss of lung function. The committee formulated specific recommendations about the use of systemic corticosteroids, cyclosporine, tacrolimus, azithromycin and about re-transplantation in patients with suspected and confirmed BOS. The diagnosis of BOS requires the careful exclusion of other post-transplant complications that can cause delayed lung allograft dysfunction, and several risk factors have been identified that have a significant association with the onset of BOS. Currently available therapies have not been proven to result in significant benefit in the prevention or treatment of BOS. Adequately designed and executed randomised controlled trials that properly measure and report all patient-important outcomes are needed to identify optimal therapies for established BOS and effective strategies for its prevention.
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Affiliation(s)
- Keith C Meyer
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Ganesh Raghu
- School of Medicine, University of Washington, Seattle, WA, USA
| | | | | | - Paul Aurora
- Great Ormond Street Hospital for Children, London, UK
| | | | - Jan Brozek
- McMaster University, Hamilton, ON, Canada
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Babady NE. The FilmArray® respiratory panel: an automated, broadly multiplexed molecular test for the rapid and accurate detection of respiratory pathogens. Expert Rev Mol Diagn 2014; 13:779-88. [PMID: 24151847 PMCID: PMC7103684 DOI: 10.1586/14737159.2013.848794] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The FilmArray Respiratory Panel (RP) (BioFire(™) Diagnostics, Inc., Salt Lake City, UT, USA) is the first multiplex molecular panel cleared by the US FDA for the detection of both bacterial and viral respiratory pathogens in nasopharygeal swabs. The FilmArray RP targets 20 pathogens including 17 viruses and subtypes and three bacteria, and is performed with minimal sample manipulation. The FilmArray RP has a fully automated sample-to-answer workflow with a turn-around-time of approximately 1 h. The reported sensitivity and specificity of the assay ranges from 80 to 100 and 100%, respectively, with the sensitivity for the adenovirus as low as 46%. A new version of the FilmArray RP assay (version 1.7) with improved sensitivity for the adenovirus was released in 2013. The performance characteristics and simplified workflow have allowed its implementation in a wide range of laboratories. The FilmArray RP has changed the diagnostic landscape and will have a significant impact on the care of patients with respiratory tract infection.
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Affiliation(s)
- N Esther Babady
- Department of Laboratory Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, S428D, New York, NY, 10044, USA
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Affiliation(s)
- Daire T O'Shea
- Transplant Infectious Diseases, Alberta Transplant Institute, University of Alberta, 6-030 Katz Center for Health Research, 11361-87 Ave, Edmonton, Alberta T6G 2E1, Canada
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Effect of hypogammaglobulinemia on the incidence of community-acquired respiratory viral infections after lung transplantation. Transplant Proc 2013; 45:2371-4. [PMID: 23747186 DOI: 10.1016/j.transproceed.2012.11.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Accepted: 11/27/2012] [Indexed: 01/18/2023]
Abstract
BACKGROUND Hypogammaglobulinemia (HGG) has been associated with an increased risk of infectious complications in lung transplant recipients, but its effect specifically on community-acquired respiratory viruses (CARVs) remains unknown. This study aimed to determine if lung transplant recipients with HGG are at an increased risk of developing CARV infection. Secondary endpoints included the effect of HGG on lung function, incidence of rejection, and mortality. METHODS A retrospective review of all lung transplant recipients from 2008 to 2011 was performed. Patients were stratified as either having HGG after transplantation or having normal IgG titers according to their nadir IgG level. HGG was defined a serum IgG level of <700 mg/dL. CARVs included human metapneumovirus, influenza A/B, respiratory syncytial virus A/B, parainfluenza 1/2/3, rhinovirus, and adenovirus isolated from bronchoalveolar lavage/wash, sputum, or nasal swab. RESULTS The cohort consisted of 263 patients with a mean follow-up time of 612 ± 356 days. The incidence of CARV infection was 27% in patients with normal IgG titers and 23.4% in patients with HGG (P = .62). No difference in rejection, mortality, or lung function was found between the groups. As expected, patients who ever had a CARV infection had a significantly lower 1-second forced expiratory volume % reference on their most recent spirometry than those who had not had a CARV infection (81.6% vs 86.9%; P = .027). CONCLUSIONS Although CARV infection has been shown to affect lung graft function, these data suggests that HGG is not associated with the incidence of CARV infection.
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Meyer KC, Glanville AR. Bronchiolitis Obliterans Syndrome and Chronic Lung Allograft Dysfunction: Evolving Concepts and Nomenclature. BRONCHIOLITIS OBLITERANS SYNDROME IN LUNG TRANSPLANTATION 2013. [PMCID: PMC7122385 DOI: 10.1007/978-1-4614-7636-8_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Bronchiolitis obliterans syndrome (BOS) eventually occurs in the majority of lung transplant recipients who survive beyond 1 year, can greatly impair quality of life, and is, directly or indirectly, the major cause of delayed allograft dysfunction and recipient death. A number of associated events or conditions are strongly associated with the risk for developing BOS; these include acute rejection, gastroesophageal reflux, infections, and autoimmune reactions that can occur in the setting of alloimmune responses to the lung allograft as recipients are given intense immunosuppression to prevent allograft rejection. The term chronic lung allograft dysfunction (CLAD) is being increasingly used to refer to recipients with late allograft dysfunction that meets the spirometric criteria for the diagnosis of BOS, but clinicians should recognize that such dysfunction can occur for a variety of reasons other than BOS. The recently identified entity of restrictive allograft syndrome, which is now recognized as a relatively distinct phenotype of CLAD, has features that differentiate it from classic obstructive BOS. A number of other entities that can also significantly affect allograft function must also be considered when significant allograft dysfunction is encountered following lung transplantation.
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Oral versus inhaled ribavirin therapy for respiratory syncytial virus infection after lung transplantation. J Heart Lung Transplant 2012; 31:839-44. [DOI: 10.1016/j.healun.2012.04.002] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Revised: 04/06/2012] [Accepted: 04/17/2012] [Indexed: 11/21/2022] Open
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Hynicka LM, Ensor CR. Prophylaxis and treatment of respiratory syncytial virus in adult immunocompromised patients. Ann Pharmacother 2012; 46:558-66. [PMID: 22395247 DOI: 10.1345/aph.1q553] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To review the literature regarding current strategies and strategies under active development for the prevention and treatment of respiratory syncytial virus (RSV) infections in immunocompromised adults. DATA SOURCES The MEDLINE/PubMed, EMBASE, and Cochrane databases were queried from January 1980 to December 2011 for articles in English using these associated search terms: respiratory syncytial virus, ribavirin, intravenous immunoglobulin, IVIG, palivizumab, motavizumab, lung, pneumonia, transplantation, bone marrow, cancer, malignancy, and vaccine. STUDY SELECTION AND DATA EXTRACTION All relevant original studies, meta-analyses, systematic reviews, and review articles were assessed for inclusion. References from pertinent articles were examined for additional content not found during the initial search. DATA SYNTHESIS RSV in the immunocompromised adult can lead to significant morbidity and mortality. Treatment of RSV-infected adults is limited to antiviral therapy with ribavirin (aerosolized, oral, intravenous) and immunomodulation with intravenous immunoglobulins, corticosteroids, and palivizumab. Existing literature is predominantly case reports, small trials, and retrospective reviews of patients infected with RSV who have undergone lung or hematopoietic stem cell transplantation (HSCT). Palivizumab may be a viable option for prophylaxis against RSV in high-risk adults. Ribavirin is the most studied treatment option and should remain the backbone of multidrug regimens. Of the routes of administration, aerosolized ribavirin carries the preponderance of evidence and, though challenging, is preferred to limit systemic toxicities in the infected patient. Addition of an immunomodulator to ribavirin may provide a survival benefit over ribavirin alone; however, this has only been studied in a subset of HSCT patients with lower respiratory tract RSV infection. CONCLUSIONS Research most strongly supports the use of aerosolized ribavirin as the treatment strategy for immunocompromised adults with RSV. Addition of an immunomodulator may provide a survival benefit over ribavirin alone. Strategies and supportive data for the prevention of RSV infection in the high-risk adult are critically needed.
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Razonable RR. Management of viral infections in solid organ transplant recipients. Expert Rev Anti Infect Ther 2011; 9:685-700. [PMID: 21692673 DOI: 10.1586/eri.11.43] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Management of viral infections after transplantation involves antiviral drug therapy (if available) and reduction in immunosuppression, which allows for development of pathogen-specific immunity to the offending virus. Prevention of viral infections is of the utmost importance, and this may be accomplished through vaccination, antiviral strategies and infection control measures. This article discusses the current management of selected viral pathogens that cause clinical illness in solid organ transplant recipients. The benefits and toxicities of antiviral therapies are discussed in the context of prevention and treatment of various viral diseases. The emerging issue of antiviral resistance is emphasized for cytomegalovirus, recurrent hepatitis B and influenza, while the importance of immunominimization is discussed in the management of BK nephropathy and virus-associated malignancies.
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Affiliation(s)
- Raymund R Razonable
- Division of Infectious Diseases, Department of Medicine, and the William J von Leibig Transplant Center, College of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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Ariza-Heredia EJ, Fishman JE, Cleary T, Smith L, Razonable RR, Abbo L. Clinical and radiological features of respiratory syncytial virus in solid organ transplant recipients: a single-center experience. Transpl Infect Dis 2011; 14:64-71. [PMID: 22093238 DOI: 10.1111/j.1399-3062.2011.00673.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Revised: 05/16/2011] [Accepted: 07/10/2011] [Indexed: 11/28/2022]
Abstract
BACKGROUND Respiratory syncytial virus (RSV) infections range from upper respiratory illness to severe lower respiratory disease. There is no universally accepted treatment for RSV in solid organ transplant (SOT) recipients. METHODS Retrospective review of adult SOT patients with RSV infections, between January 2007 and December 2009, in a single transplant center was performed. RESULTS During the 3-year period, a total of 24 adults developed RSV infection, including 12 (50%) SOT recipients (5 kidneys, 4 livers, and 3 lungs). Most cases were seen in 2009 during the influenza H1N1 pandemic, likely as a result of increased testing. In 83% of the cases, the diagnosis was based on RSV antigen detection, which was also used to follow subsequent shedding (mean duration: 20.6 days). Most of the cases presented with lower respiratory disease and required hospitalization. All the patients were on at least two classes of immunosuppressive drugs. We observed a lower lymphocyte count in patients with lower respiratory tract infection. Computed tomography was superior to chest x-ray in demonstrating pulmonary disease, with the most common findings being pulmonary nodules and ground-glass opacities. Novel radiographic findings were small cavities and pleural effusions. No co-infections were documented, and no mortality could be attributed to RSV. Inhaled or oral ribavirin was administered in 67% of the cases, with variations in the treatment regimens. CONCLUSION SOT recipients accounted for half of all adult cases of RSV at our institution. Type and length of treatment varied widely, and we cannot conclude that outcomes differed between treatments with oral or inhaled ribavirin. Current therapeutic management of RSV in SOT is empiric, and can be rather expensive and difficult, without clear evidence of effectiveness.
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Affiliation(s)
- E J Ariza-Heredia
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Crockett F, Mal H, Amazzough K, Stern M, Rivaud E, Cerf C, Matthieu E, Honderlick P, Scherrer A, Couderc LJ. [H1N1 (2009) influenza A infection in transplant recipient patients: a comparative study versus non-transplanted patients]. REVUE DE PNEUMOLOGIE CLINIQUE 2011; 67:199-208. [PMID: 21920278 PMCID: PMC7126570 DOI: 10.1016/j.pneumo.2011.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/06/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To compare H1N1 (2009) influenza A infection characteristics between transplant recipient patients and non-transplanted patients. To assess the evolution of transplanted patients up to 6 months following infection. METHODS Patients diagnosed with confirmed influenza A infection from three Parisian transplant centers between September 1st, 2009 and February 15th, 2010. Clinical symptoms, biological, and radiological findings, and management were analysed and retrospectively compared between transplanted (T) and non-transplanted patients (NT). The evolution was assessed by a follow-up questionnaire, CT results 1 to 3 months after influenza infection and FEV1 variation. RESULTS Seventy patients were included. Thirteen patients had an allograft (lung: eight, kidney: four, stem cells: one): (1) hospitalization: 100% (13 out of 13) in group T, 54% (31 out of 57) in group NT (P=0.0013); (2) pneumonia: 62% (eight out of 13) in group T, 26% (eight out of 57) in group NT (P=0.004); (3) mortality rate among hospitalized patients: 7.7% (one out of 13) in the group T, 9.7% (three out of 57) in group NT (P=NS); (4) chest CT scan abnormalities remained in four lung transplanted patients; (5) a minimum 10% decrease in FEV1 was detected in four lung transplant recipients. CONCLUSION Our results suggest that H1N1(2009) influenza A infection in transplant recipient patients compared to non-transplanted patients: (1) more often leads to hospitalization; (2) is more frequently associated with pneumonia; (3) is responsible for a persistent graft functional impairment in lung transplant recipients; (4) has a low mortality rate similar to admitted non-transplanted patients.
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Affiliation(s)
- F Crockett
- Service de Pneumologie, Hôpital Foch, 40, rue Worth, 92150 Suresnes, France.
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Weigt SS, Gregson AL, Deng JC, Lynch JP, Belperio JA. Respiratory viral infections in hematopoietic stem cell and solid organ transplant recipients. Semin Respir Crit Care Med 2011; 32:471-93. [PMID: 21858751 PMCID: PMC4209842 DOI: 10.1055/s-0031-1283286] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Respiratory viral infections (RVIs) are common causes of mild illness in immunocompetent children and adults with rare occurrences of significant morbidity or mortality. Complications are more common in the very young, very old, and those with underlying lung diseases. However, RVIs are increasingly recognized as a cause of morbidity and mortality in recipients of hematopoietic stem cell transplants (HSCT) and solid organ transplants (SOTs). Diagnostic techniques for respiratory syncytial virus (RSV), parainfluenza, influenza, and adenovirus have been clinically available for decades, and these infections are known to cause serious disease in transplant recipients. Modern molecular technology has now made it possible to detect other RVIs including human metapneumovirus, coronavirus, and bocavirus, and the role of these viruses in causing serious disease in transplant recipients is still being worked out. This article reviews the current information regarding epidemiology, pathogenesis, clinical presentation, diagnosis, and treatment of these infections, as well as the aspects of clinical significance of RVIs unique to HSCT or SOT.
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Affiliation(s)
- S Samuel Weigt
- Division of Pulmonary, Department of Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California 90095, USA.
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Vu D, Bridevaux P, Aubert J, Soccal PM, Kaiser L. Respiratory viruses in lung transplant recipients: a critical review and pooled analysis of clinical studies. Am J Transplant 2011; 11:1071-8. [PMID: 21521473 PMCID: PMC7187773 DOI: 10.1111/j.1600-6143.2011.03490.x] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Lung transplant recipients present an increased risk for severe complications associated with respiratory infections. We conducted a review of the literature examining the clinical relationship between viral respiratory infection and graft complications. Thirty-four studies describing the clinical impact of influenza, respiratory syncytial virus, parainfluenza, human metapneumovirus, rhinovirus, enterovirus, coronavirus, bocavirus or adenovirus were identified. The detection rate of respiratory viral infection ranged from 1.4% to 60%. Viruses were detected five times more frequently when respiratory symptoms were present [odds ratio (OR) = 4.97; 95% CI = 2.11-11.68]. Based on available observations, we could not observe an association between respiratory viral infection and acute rejection (OR = 1.35; 95% CI = 0.41-4.43). We found a pooled incidence of 18% (9/50) of bronchiolitis obliterans syndrome (BOS) in virus-positive cases compared to 11.6% (37/319) in virus-negative cases; however, limited number of BOS events did not allow to confirm the association. Our review confirms a causal relationship between respiratory viruses and respiratory symptoms, but cannot confirm a link between respiratory viruses and acute lung rejection. This is related in part to the heterogeneity and limitations of available studies. The link with BOS needs also to be reassessed in appropriate prospective studies.
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Affiliation(s)
- D.‐L. Vu
- Laboratory of Virology, Division of Infectious Diseases and Division of Laboratory Medicine, University Hospitals of Geneva and Medical School, University of Geneva, Geneva, Switzerland
| | - P.‐O. Bridevaux
- Division of Pulmonary Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - J.‐D. Aubert
- Division of Pulmonary Medicine, University Hospitals of Geneva, Geneva, Switzerland,Division of Pulmonary Medicine, University Hospital of Lausanne, Lausanne, Switzerland
| | - P. M. Soccal
- Division of Pulmonary Medicine, University Hospitals of Geneva, Geneva, Switzerland,Clinic of Thoracic Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - L. Kaiser
- Laboratory of Virology, Division of Infectious Diseases and Division of Laboratory Medicine, University Hospitals of Geneva and Medical School, University of Geneva, Geneva, Switzerland
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Nakajima T, Palchevsky V, Perkins DL, Belperio JA, Finn PW. Lung transplantation: infection, inflammation, and the microbiome. Semin Immunopathol 2011; 33:135-56. [DOI: 10.1007/s00281-011-0249-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2010] [Accepted: 01/12/2011] [Indexed: 12/29/2022]
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Fuehner T, Dierich M, Duesberg C, DeWall C, Welte T, Haverich A, Warnecke G, Simon AR, Gottlieb J. Single-centre experience with oral ribavirin in lung transplant recipients with paramyxovirus infections. Antivir Ther 2011; 16:733-40. [PMID: 21817195 DOI: 10.3851/imp1811] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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40
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Busi Rizzi E, Schininà V, Ferraro F, Rovighi L, Cristoforo M, Chiappetta D, Lisena F, Lauria F, Bibbolino C. Radiological findings of pneumonia in patients with swine-origin influenza A virus (H1N1). Radiol Med 2010; 115:507-15. [PMID: 20526820 PMCID: PMC7101976 DOI: 10.1007/s11547-010-0553-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2009] [Accepted: 01/13/2010] [Indexed: 01/15/2023]
Abstract
Purpose During spring 2009, a pandemic swine-origin influenza A (H1N1) virus (S-OIV) emerged and spread globally. We describe the chest X-ray and computed tomography (CT) findings of 40 patients with pneumonia due to S-OIV observed in our institution. Material and methods Among 534 patients with S-OIV, according to the US Centers for Disease Control and Prevention case definition, seen between June and November 2009, 121 underwent chest X-ray and 40 (median age 44 years, range 16–79) had pneumonia. The initial chest radiographs were evaluated for pattern, distribution and extent of lung abnormalities. Unenhanced chest CT scans were performed in two patients and were reviewed for the same findings. Underlying medical conditions were present in 42% of patients (17/40). Results Our patients had predominantly mild illness, and pneumonia was observed in 40 individuals (40/121 patients who had chest X-rays, 33%; and 40/534 patients with S-OIV, 7.5%). However, S-OIV can cause severe illness requiring admission to the intensive care unit for advanced mechanical ventilation and extracorporeal life support, including adult respiratory distress syndrome (ARDS) and death. The major radiological abnormalities observed were interstitial changes (60.0%), with (22.0%) or without patchy ground-glass appearance, mostly bilateral, and located in the lower lung zones (7.5%). Extensive disease was seen in 37.5% (15/40), and ARDS was observed in three individuals (0.30%)with underlying medical conditions. Subtle pleural effusion was noted in four patients. Conclusions In our series, the most frequent pneumonia patterns observed during S-OIV (H1N1) virus were interstitial changes and patchy ground-glass appearance, mostly bilateral, and located in the lower lung zones. CT, performed in severely ill patients, confirmed the ARDS identified with chest X-rays, better depicting the features and extent of lung abnormalities.
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Affiliation(s)
- E Busi Rizzi
- Diagnostic Department, Radiology, National Institute for Infectious Diseases L. Spallanzani, Via Portuense 292, 00149, Rome, Italy.
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Weinberg A, Lyu DM, Li S, Marquesen J, Zamora MR. Incidence and morbidity of human metapneumovirus and other community-acquired respiratory viruses in lung transplant recipients. Transpl Infect Dis 2010; 12:330-5. [PMID: 20456714 PMCID: PMC7169861 DOI: 10.1111/j.1399-3062.2010.00509.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
A. Weinberg, D.M. Lyu, S. Li, J. Marquesen, M.R. Zamora. Incidence and morbidity of human metapneumovirus and other community‐acquired respiratory viruses in lung transplant recipients
Transpl Infect Dis 2010: 12: 330–335. All rights reserved. Abstract: To determine the role of human metapneumovirus (HMPV) in respiratory tract infections (RTIs) of lung transplant recipients, 60 patients were prospectively enrolled in this study spanning from September 2005 to November 2007. Community‐acquired respiratory viruses (CARVs) were identified by polymerase chain reaction and tissue culture in respiratory secretions. Of 112 RTIs, 51 were associated with ≥1 CARV, including 7 HMPV, 13 respiratory syncytial virus (RSV), 19 parainfluenza virus 1, 2, or 3 (PIV), 16 influenza A or B (FLU), and 3 human rhinoviruses (HRV). Sixteen CARV‐RTIs had multiple pathogens. While the standard protocol was to admit all paramyxoviral RTIs for inhaled ribavirin, 16% CARV‐RTIs required hospitalization because of the severity of their respiratory compromise, including 25% of HPMV‐single‐agent RTI, 38% of RSV single‐agent RTI, 10% of PIV‐single‐agent RTI, and 19% of multiple‐agent RTIs. None of those with non‐CARV RTIs required hospitalization. The incidence of clinically diagnosed acute graft rejection in the first 2 months after an RTI varied from 0 for single‐agent HRV to 88% for single‐agent RSV (25% for single‐agent HMPV). A new diagnosis of chronic graft rejection in the first year after an RTI was made in approximately 25% of the RTIs and did not significantly vary with the etiologic agent. No deaths occurred during this study. In conclusion, HMPV was associated with 6% of the RTIs in lung transplant recipients and its morbidity was similar to the average moribidity of CARVs.
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Affiliation(s)
- A Weinberg
- Department of Pediatrics, University of Colorado Denver, Aurora, CO 80045,, USA.
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Uçkay I, Gasche-Soccal PM, Kaiser L, Stern R, Mazza-Stalder J, Aubert JD, van Delden C. Low incidence of severe respiratory syncytial virus infections in lung transplant recipients despite the absence of specific therapy. J Heart Lung Transplant 2010; 29:299-305. [PMID: 19837611 PMCID: PMC7173010 DOI: 10.1016/j.healun.2009.08.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Revised: 08/04/2009] [Accepted: 08/06/2009] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Respiratory syncytial virus (RSV) infections in lung transplant recipients (LTRs) have been associated with significant morbidity and mortality. Immunoglobulins, ribavirin, and palivizumab are suggested treatments for both pre-emptive and therapeutic purposes. However, in the absence of randomized, placebo-controlled trials, efficacy is controversial and there is toxicity as well as cost concerns. METHODS We retrospectively reviewed cases of lower respiratory tract RSV infections in adult LTRs. Diagnosis was based on clinical history, combined with a positive polymerase chain reaction (PCR) and/or viral cultures of bronchoalveolar lavage (BAL) specimens. RESULTS Ten symptomatic patients were identified (7 men and 3 women, age range 28 to 64 years). All were hospitalized for community-acquired respiratory tract infections. Two patients had a concomitant acute Grade A3 graft rejection, and 1 patient had a concomitant bacterial pneumonia. Eight patients did not receive a specific anti-RSV treatment because of clinical stability and/or improvement at the time of RSV diagnosis. Only 2 patients (1 with Grade A3 allograft rejection and 1 requiring mechanical ventilation) received ribavirin and palivizumab. All patients recovered without complications and with no persistent RSV infection. However, bronchiolitis obliterans (BOS) staging worsened in 6 patients during the mean follow-up of 45 months. CONCLUSIONS Our data suggest that mild RSV infections in LTRs might evolve favorably in the absence of specific anti-viral therapy. However, this observation needs confirmation in a large clinical trial specifically investigating the development of BOS in untreated vs treated patients.
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Affiliation(s)
- Ilker Uçkay
- Service of Infectious Diseases, University of Geneva, Geneva, Switzerland
| | - Paola M. Gasche-Soccal
- Service of Pulmonary Medicine, University of Geneva, Geneva, Switzerland
- Clinic of Thoracic Surgery, University of Geneva, Geneva, Switzerland
| | - Laurent Kaiser
- Service of Infectious Diseases, University of Geneva, Geneva, Switzerland
| | - Richard Stern
- Orthopaedic Surgery Service, University of Geneva, Geneva, Switzerland
| | - Jesica Mazza-Stalder
- Service of Pulmonary Medicine, University of Geneva, Geneva, Switzerland
- Service of Pulmonary Medicine, University Hospital of Vaud, Lausanne, Switzerland
| | - John-David Aubert
- Service of Pulmonary Medicine, University Hospital of Vaud, Lausanne, Switzerland
| | - Christian van Delden
- Service of Infectious Diseases, University of Geneva, Geneva, Switzerland
- Service of Transplantation, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Liu V, Dhillon G, Weill D. A multi-drug regimen for respiratory syncytial virus and parainfluenza virus infections in adult lung and heart-lung transplant recipients. Transpl Infect Dis 2010; 12:38-44. [DOI: 10.1111/j.1399-3062.2009.00453.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Significant advances in the treatment of pulmonary arterial hypertension have occurred in the last several years. The decision to refer a patient for transplantation requires a dynamic approach. Candidate selection and timing of referral to transplant centers is critical for success, particularly with current allocation protocols that do not take into account the severity of illness. Though long-term success is tempered by chronic allograft dysfunction and infection, considerable improvements in outcomes have established lung transplantation for pulmonary arterial hypertension as an efficacious and life-prolonging treatment. However, transplantation should be reserved for patients who have failed the best available medical therapy. Ideally, transplantation occurs when the clinically deteriorating patient has enough reserve to survive long enough to be transplanted but is not debilitated enough to jeopardize the graft. There is significant uncertainty with regard to this ideal.
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Affiliation(s)
- Edward Cantu
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - R. Duane Davis
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Adenovirus Infection in the Immunocompromised Host. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2010; 659:153-74. [DOI: 10.1007/978-1-4419-0981-7_13] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Community-acquired respiratory viral infections in lung transplant recipients: a single season cohort study. Transplantation 2009; 87:1530-7. [PMID: 19461490 DOI: 10.1097/tp.0b013e3181a4857d] [Citation(s) in RCA: 128] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The impact of community-acquired respiratory virus (CARV) infections on bronchiolitis obliterans syndrome (BOS) and outcome after lung transplantation (LTx) and diagnostic techniques were prospectively evaluated. METHODS A single-center prospective cohort study was performed in LTx-outpatients between October 31, 2005 and April 30, 2006. Symptoms of respiratory tract infections were recorded and nasopharyngeal and oropharyngeal swabs were obtained. Lower respiratory sampling was performed when indicated. Immunofluorescence testing, cultures, and polymerase chain reaction for 12 different CARV were applied. Patients were followed up until December 31, 2007. New onset and BOS-stage was recorded 1 year after presentation. RESULTS Three hundred eighty-eight LTx-recipients were screened. Fifty-one percent reported of symptoms of respiratory tract infection. Seven hundred seventy upper and 180 lower respiratory samples were obtained. Thirty-four CARV were detected in 30 patients (7.7%): 12 parainfluenza, 7 respiratory syncytial virus, 6 metapneumovirus, 5 coronavirus, 3 rhinovirus, and 1 influenza virus. At 1 year, 43 new cases of BOS developed. One-year incidence of BOS was 25.0% in CARV-positive versus 9.0% in CARV-negative patients (log-rank P=0.01). Symptomatic CARV-infection proved to be a significant covariate for 1-year BOS-free survival in multivariate analysis (P=0.002, adjusted hazard ratio 4.13). CARV-infection did not influence BOS progression in 88 patients with prior BOS (P 0.45). After paramyxovirus infection, 8 of 24 patients developed new-onset BOS, whereas no case was recorded after rhinovirus and coronavirus infection. DISCUSSION Surveillance detected CARV in LTx outpatients infrequently. Symptomatic CARV-infection increases the risk for new onset of BOS, but not progression. Risk to develop BOS was especially increased after paramyxovirus infection.
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Dierich M, Fuehner T, Welte T, Simon A, Gottlieb J. [Lung transplantation. Indications, long-term results and special impact of follow-up care]. Internist (Berl) 2009; 50:561-71. [PMID: 19436963 PMCID: PMC7095941 DOI: 10.1007/s00108-008-2271-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Die Lungentransplantation ist bei weit fortgeschrittenen Lungenerkrankungen nach Ausschöpfung aller Therapiemöglichkeiten eine Therapieoption, welche die Lebensqualität und – bei bestimmten Indikationen (zystische Fibrose, Lungenfibrose, pulmonal arterielle Hypertonie) – Lebenserwartung verbessert. Die Anzahl verfügbarer Spenderorgane ist so gering, dass jeder 6. Patient auf der Warteliste verstirbt. Bei der Auswahl geeigneter Kandidaten sind neben der ursächlichen Lungen- oder Herz-Lungenerkrankung, das Alter, vorhandene Mobilität, Ernährungs- und Muskelstatus und extrapulmonale Begleiterkrankungen entscheidende Kriterien. Postoperative Komplikationen können durch die Operation bedingt, durch eine Transplantatabstoßung (akut oder chronisch), Atemwegskomplikationen, Infektionen und extrapulmonale Folgeerkrankungen auftreten. Die Nachsorge erfolgt immer in Kooperation mit dem Transplantationszentrum und hat in großen Zentren zu einer spürbaren Verbesserung der Langzeitergebnisse geführt.
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Affiliation(s)
- M Dierich
- Klinik für Pneumologie , Medizinische Hochschule Hannover, Hannover.
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Michaels MG, Fonseca-Aten M, Green M, Charsha-May D, Friedman B, Seikaly M, Sánchez PJ. Respiratory syncytial virus prophylaxis: a survey of pediatric solid organ transplant centers. Pediatr Transplant 2009; 13:451-6. [PMID: 18785906 DOI: 10.1111/j.1399-3046.2008.01017.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
RSV can cause respiratory illness after SOT, yet preventive recommendations are lacking for this population. To ascertain current preventive practices against RSV disease in pediatric SOT candidates and recipients, a survey was developed. The survey was mailed to 108 SOT programs in the United States (liver, 42; heart, 28; lung, 11; intestinal, 25; and heart-lung, 2). Results were tabulated and analyzed using standard methods. Sixty-two percent (67/108) of surveys were completed. Forty-nine percent (33/67) of programs reported using RSV prophylaxis; palivizumab was used at 97% (32/33) of centers with 26 giving palivizumab to candidates and 27 to recipients. Prophylaxis was provided to infants aged 0-12 months by 27/29 (93%) of responding centers; 23/29 of centers extended its use to infants aged 0-24 months. Three centers gave prophylaxis to children between ages two and four yr and two centers for those over four yr. RSV prophylactic strategies, and in particular the use of palivizumab, are employed by almost 50% of responding pediatric SOT centers. Strategies varied at centers based on age and organ type. Data on RSV hospitalization and outcome are needed to refine approaches to RSV immunoprophylaxis in these high-risk patients.
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Affiliation(s)
- Marian G Michaels
- Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, PA 15217, USA.
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Pelaez A, Lyon GM, Force SD, Ramirez AM, Neujahr DC, Foster M, Naik PM, Gal AA, Mitchell PO, Lawrence EC. Efficacy of oral ribavirin in lung transplant patients with respiratory syncytial virus lower respiratory tract infection. J Heart Lung Transplant 2009; 28:67-71. [PMID: 19134533 DOI: 10.1016/j.healun.2008.10.008] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2008] [Revised: 10/02/2008] [Accepted: 10/16/2008] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Respiratory syncytial virus (RSV) can cause severe lower respiratory tract infection (LRI) and is a risk factor for the development of bronchiolitis obliterans syndrome (BOS) after lung transplantation (LTx). Currently, the most widely used therapy for RSV is inhaled ribavirin. However, this therapy is costly and cumbersome. We investigated the utility of using oral ribavirin for the treatment of RSV infection after LTx. METHODS RSV was identified in nasopharyngeal swabs (NPS) or bronchoalveolar lavage (BAL) using direct fluorescent antibody (DFA) in 5 symptomatic LTx patients diagnosed with LRI. Data were collected from December 2005 and August 2007 and included: age; gender; type of LTx; underlying disease; date of RSV; pulmonary function prior to, during and up to 565 days post-RSV infection; need for mechanical ventilation; concurrent infections; and radiographic features. Patients received oral ribavirin for 10 days with solumedrol (10 to 15 mg/kg/day intravenously) for 3 days, until repeat NPS were negative. RESULTS Five patients had their RSV-LRI diagnosis made at a median of 300 days post-LTx. Mean forced expiratory volume in 1 second (FEV(1)) fell 21% (p < 0.012) during infection. After treatment, FEV(1) returned to baseline and was maintained at follow-up of 565 days. There were no complications and no deaths with oral therapy. A 10-day course of oral ribavirin cost $700 compared with $14,000 for nebulized ribavirin at 6 g/day. CONCLUSIONS Treatment of RSV after LTx with oral ribavirin and corticosteroids is well tolerated, effective and less costly than inhaled ribavirin. Further studies are needed to directly compare the long-term efficacy of oral vs nebulized therapy for RSV.
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Affiliation(s)
- Andres Pelaez
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia 30322, USA.
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Hopkins P, McNeil K, Kermeen F, Musk M, McQueen E, Mackay I, Sloots T, Nissen M. Human metapneumovirus in lung transplant recipients and comparison to respiratory syncytial virus. Am J Respir Crit Care Med 2008; 178:876-81. [PMID: 18658110 DOI: 10.1164/rccm.200711-1657oc] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Human metapneumovirus is a newly described virus isolated in 2001 from children with acute respiratory viral infection. It has subsequently been reported globally, although there are limited data in lung transplant recipients. OBJECTIVES To prospectively analyze whether human metapneumovirus was circulating in our adult lung transplant community and assess the morbidity of this infection and to compare the clinical presentation and outcome after intravenous ribavirin of human metapneumovirus with that of respiratory syncytial virus (RSV). METHODS Lung transplant patients with clinical features of respiratory viral infection underwent nasopharyngeal aspirates. Patients with a positive specimen for RSV or human metapneumovirus by reverse transcriptase-polymerase chain reaction analysis and graft dysfunction received intravenous ribavirin and pulse steroid therapy. MEASUREMENTS AND MAIN RESULTS Eighty-nine patients had 199 visits for aspirate studies. A viral cause was determined for 62 visits in 47 patients (19 human metapneumovirus, 18 RSV, 13 parainfluenza, 9 influenza A, 2 adenovirus, and 1 influenza B). A significant percentage of patients with metapneumovirus (63%) and RSV (72%) developed graft dysfunction, with average declines in FEV(1) of 30 +/- 12.4% and 25.9 +/- 11.2%, respectively. In these patients, bronchiolitis obliterans syndrome onset or progression occurred in no patients with human metapneumovirus compared with 5 of 13 (38%) patients with RSV at 6 months. CONCLUSIONS Human metapneumovirus is a leading cause of acute respiratory tract illness in lung transplant recipients. The incidence and clinical spectrum at presentation are similar to RSV, although the latter seems to be associated with a higher risk of chronic rejection. We recommend testing of nasopharyngeal aspirates for human metapneumovirus with polymerase chain reaction to assess local epidemiologic patterns.
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Affiliation(s)
- Peter Hopkins
- Department of Respiratory Medicine, The Prince Charles Hospital, Rode Road, Chermside, Brisbane, Australia 4032.
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