Impact of lung transplantation on recipient quality of life: a serial, prospective, multicenter analysis through the first posttransplant year

Telehealth interventions to improve outcomes in lung transplant recipients: Primary results of the INSPIRE-III randomized clinical trial

BACKGROUND

There is growing evidence that many patients undergoing lung transplantation report significant distress and low physical activity (PA), which might not improve despite lung transplantation and may be associated with worse clinical outcomes. Few studies have attempted to improve psychological outcomes and functional capacity and PA after transplant.

METHODS

Investigational Study of Psychological Interventions in Recipients of Lung Transplant-III is a single-site, randomized clinical trial in which 180 post lung transplant patients, recruited between November 2019 and October 2023, completed a psychometric test battery to assess distress and functional capacity measured by the 6-Minute Walk Test and PA assessed by 7 consecutive days of continuous activity monitoring. Participants were then randomly assigned to either a 12-week Coping Skills Training and Exercise intervention (CSTEX) or a Standard of Care plus Education (SoC-ED) program delivered via telephone. Participants were then retested after completion of the telehealth interventions.

RESULTS

After 12 weeks, both intervention groups achieved small but similar improvements in distress and functional capacity. Although there were no between-group differences overall, patients who were considered clinically depressed at baseline and received CSTEX achieved greater improvements in depression compared to depressed patients who received SoC-ED.

CONCLUSIONS

Although patients in both CSTEX and SoC-ED showed only modest benefit from their respective interventions, a subgroup of patients in CSTEX who were depressed at study entry had greater reductions in depressive symptoms compared to SoC-ED. Depressive symptoms should be carefully monitored post-transplant and referred for treatment if symptoms persist.

TRIAL REGISTRY

NCT04093869.

Health-related Quality of Life and Exercise Capacity in Double Lung Transplant Recipients With Baseline Lung Allograft Dysfunction

Background

Baseline lung allograft dysfunction (BLAD) after lung transplant is associated with an increased risk of dying, but the association with health-related quality of life (HRQL) and exercise capacity is not known. We hypothesized that BLAD would be associated with reduced HRQL and 6-min walk distance (6MWD) at 1 y post-lung transplant.

Methods

We analyzed patients who underwent lung transplants in our program from 2004 to 2018 who completed 1-y 36-item Short Form (SF-36) questionnaire and 6MWD testing. We secondarily analyzed the Beck Depression Inventory and Borg dyspnea scores in patients using the available data. We defined BLAD as a failure of both forced expiratory volume in 1 s and forced vital capacity to reach ≥80% predicted of a healthy reference population's lung function on 2 consecutive tests ≥3 wk apart at any time point posttransplant. We tested the relationship between BLAD status and SF-36 physical component summaries and 6MWD using least squares regression, adjusting for age at transplant, sex at birth, and primary lung disease.

Results

Two hundred sixty-four patients were included, 96 (36%) of whom met the criteria for BLAD. Patients with interstitial lung disease as an indication for transplant and those who received older, female, and heavy smoking donors were at increased risk of BLAD. SF-36 physical component summary scores were lower in patients with BLAD (75 versus 85; P = 0.0076), as were 6MWD values (528 versus 572 m; P = 0.0053). BLAD was associated with lower SF-36 scores (P = 0.0025) and 6MWD (P = 0.0008) in adjusted regression models at 1 y posttransplant. We did not observe differences in Beck Depression Inventory or Borg scores.

Conclusions

BLAD was associated with reduced HRQL and 6MWD scores at 1 y posttransplant in adjusted models. This suggests that poor posttransplant lung function could contribute to lower HRQL and exercise capacity in lung recipients and is worthy of further exploration in terms of causes, prevention, and treatment.

Health-related quality of life following lung transplantation for cystic fibrosis: A systematic review

BACKGROUND

Lung transplantation represents the definite treatment for CF patients with advanced-stage pulmonary disease. Recent major developments in the treatment of CF indicate the need for an evaluation of lung transplantation as the current best practice in end-stage disease. This systematic review was performed to evaluate the impact of lung transplantation on health-related quality of life in patients with CF.

METHODS

PubMed was searched for studies matching the eligibility criteria between January 2000 and January 2022. OVID (MEDLINE), Google Scholar, and EBSCOhost (EMBASE) as well as bibliographies of included studies were also reviewed. Applying predetermined eligibility criteria, the included studies were selected. Predetermined forms were used to conduct a quality appraisal and implement data tabulation. Results were synthesized by narrative review. This systematic review was prospectively registered in the PROSPERO register (CRD 42022341942).

RESULTS

Ten studies (1494 patients) were included. Lung transplantation results in improvements in HRQoL in CF patients relative to their baseline waitlisted state. Up to five years postoperatively CF patients retain their HRQoL at levels similar to the general population. There are several modulating factors that impact HRQoL outcomes in CF patients post-LTx. Compared to lung recipients with other diagnoses CF patients achieve either greater or equal levels of HRQoL.

CONCLUSION

Lung transplantation conveys improved HRQoL to CF patients with the advanced-stage pulmonary disease for up to five years, and to levels comparable to the general population and non-waitlisted CF patients. This systematic review quantifies, using current evidence, the improvements in HRQoL gained by CF patients following lung transplantation.

Lung Transplant Procedure of Choice: Bilateral Transplantation Versus Single Transplantation Complications, Quality of Life, and Survival

This article examines the existing literature regarding single (SLT) and bilateral lung transplantation (BLT) to help answer the question of which approach is preferable. Specifically, this review highlights the following subjects: disease-specific indications for SLT versus BLT; the impact of procedure type on posttransplantation functional status; the impact of procedure type on posttransplantation quality of life; chronic rejection after lung transplantation; ethical challenges facing the choice between single and bilateral transplants; and, novel strategies in this arena.

Clinical impact of a modified lung allocation score that mitigates selection bias

BACKGROUND

The Lung Allocation Score (LAS) is used in the U.S. to prioritize lung transplant candidates. Selection bias, induced by dependent censoring of waitlisted candidates and prediction of posttransplant survival among surviving, transplanted patients only, is only partially addressed by the LAS. Recently, a modified LAS (mLAS) was designed to mitigate such bias. Here, we estimate the clinical impact of replacing the LAS with the mLAS.

METHODS

We considered lung transplant candidates waitlisted during 2016 and 2017. LAS and mLAS scores were computed for each registrant at each observed organ offer date; individuals were ranked accordingly. Patient characteristics associated with better priority under the mLAS were investigated via logistic regression and generalized linear mixed models. We also determined whether differences in rank were explained more by changes in predicted pre- or posttransplant survival. Simulations examined how 1-year waitlist, posttransplant, and overall survival might change under the mLAS.

RESULTS

Diagnosis group, 6-minute walk distance, continuous mechanical ventilation, functional status, and age demonstrated the highest impact on differential allocation. Differences in rank were explained more by changes in predicted pretransplant survival than changes in predicted posttransplant survival, suggesting that selection bias has more impact on estimates of waitlist urgency. Simulations suggest that for every 1000 waitlisted individuals, 12.8 (interquartile range: 5.2-24.3) fewer waitlist deaths per year would occur under the mLAS, without compromising posttransplant and overall survival.

CONCLUSIONS

Implementing a mLAS that mitigates selection bias into clinical practice can lead to important differences in allocation and possibly modest improvement in waitlist survival.

Feasibility and acceptability of a physical activity behavioural modification tele-coaching intervention in lung transplant recipients

BACKGROUND

Despite improvements in pulmonary function following lung transplantation (LTx), physical activity levels remain significantly lower than the general population. To date, there is little research investigating interventions to improve daily physical activity in LTx recipients. This study assessed the feasibility and acceptability of a novel, 12-weeks physical activity tele-coaching (TC) intervention in LTx recipients.

METHODS

Lung transplant recipients within 2 months of hospital discharge were recruited and randomised (1:1) to TC or usual care (UC). TC consists of a pedometer and smartphone app, allowing transmission of activity data to a platform that provides feedback, activity goals, education, and contact with the researcher as required. Recruitment and retention, occurrence of adverse events, intervention acceptability and usage were used to assess feasibility.

RESULTS

Key criteria for progressing to a larger study were met. Of the 15 patients eligible, 14 were recruited and randomised to TC or UC and 12 completed (67% male; mean ± SD age; 58 ± 7 years; COPD n = 4, ILD n = 6, CF n = 1, PH n = 1): TC (n = 7) and UC (n = 5). TC was well accepted by patients, with 86% indicating that they enjoyed taking part. Usage of the pedometer was excellent, with all patients wearing it for over 90% of days and rating the pedometer and telephone contact as the most vital aspects. There were no adverse events related to the intervention. After 12 weeks, only TC displayed improvements in accelerometry steps/day (by 3475 ± 3422; p = .036) and movement intensity (by 153 ± 166 VMU; p = .019), whereas both TC and UC groups exhibited clinically important changes in physical SF-36 scores (by 11 ± 14 and 7 ± 9 points, respectively).

CONCLUSION

TC appears to be a feasible, safe, and well-accepted intervention in LTx.

Health-Related Quality of Life Outcomes Following Single or Bilateral Lung Transplantation: A Systematic Review

BACKGROUND

Lung transplantation is the definitive treatment for end-stage lung disease. There has been uncertainty regarding whether single or bilateral lung transplantation confers patients' greater health-related quality of life. This systematic review was performed to evaluate the impact of single lung transplantation (SLTx) against bilateral lung transplantation on short- and long-term health-related quality of life.

METHODS

A literature search was conducted on PubMed for studies matching the eligibility criteria between January 2000 and January 2022. OVID (MEDLINE), Google Scholar, EBSCOhost (EMBASE), and bibliographies of included studies were reviewed. Inclusion of studies was based on predetermined eligibility criteria. Quality appraisal and data tabulation were performed using predetermined forms. Results were synthesized by narrative review. The structure of this systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This systematic review was prospectively registered in the PROSPERO register (CRD42022344389).

RESULTS

Ten studies (1916 patients) were included. Within 12 mo posttransplantation, there was no evidence of the improved health-related quality of life with respect to the type of lung transplantation procedure. Bilateral lung transplantation patients reported significantly greater scores in both the physical and mental health domains of health-related quality of life. Bilateral lung transplantation offered significantly better health-related quality of life outcomes at later follow-up periods. Bilateral lung transplantation showed a significantly slower reduction in health-related quality of life physical composite scores relative to SLTx.

CONCLUSION

Bilateral lung transplant (BLTx) recipients perceive the greater health-related quality of life beyond 1-y post-lung transplantation. BLTx recipients better retain their health-related quality of life long-term posttransplantation than those receiving SLTx.

Sleep quality, depressive symptoms, and transplant outcomes: Follow-up analyses from the ADAPT prospective pilot study

BACKGROUND

Previous studies suggested that depressive symptoms and sleep quality may be important for long-term clinical outcomes following cardiothoracic transplant. Few studies, however, have systematically examined objective markers of these behavioral factors among ambulatory transplant recipients, or their association with clinical outcomes.

METHODS

We examined sleep quality and depressive symptoms with subsequent clinical outcomes (hospitalizations and death) in a sample of 66 lung or heart transplant recipients using a single-center, prospective cohort study. Recipients were assessed at approximately 6 months post-transplant and completed one week of actigraphy assessment to examine sleep quality and self-report measures of mood (Centers for Epidemiologic Studies of Depression [CESD]). Recipients were followed for clinical outcomes.

RESULTS

At 6-months following transplantation, recipients spent the majority of daytime activity at a sedentary level (61% of daily activity [SD = 10]) and elevated depressive symptoms were common (subclinical = 17%, mild = 12%, or moderate = 8%). Over a median follow-up of 4.5 years (IQR = 0.9, 5.1), 51 participants (77%) had at least one unplanned hospitalization and 11 (17%) participants died. In addition, sleep efficiency measurements suggested that a subset of participants exhibited suboptimal sleep (mean efficiency = 87% [SD = 7]). Poorer sleep quality, indexed by lower sleep efficiency and greater sleep fragmentation, was associated with greater depressive symptoms (r's = 0.37-0.50, P < .01). Better sleep quality at 6-months (HR = 0.75 [0.60, 0.95], P = .015), including sleep efficiency (HR = 0.74 [0.56, 0.99], P = .041) and sleep fragmentation (HR = 0.71 [0.53, 0.95], P = .020) were associated with lower risk of hospitalization or death. Compared with individuals without elevated depressive symptoms or sleep difficulties, individuals with either factor (HR = 1.72 [1.05, 2.81], P = .031) or both factors (HR = 2.37 [1.35, 4.18], P = .003) exhibited greater risk of clinical events in adjusted analyses.

CONCLUSIONS

Sleep quality is associated with depressive symptoms among cardiothoracic transplant recipients and enhances the prognostic association between biobehavioral risk factors and clinical outcomes.

Exercise training for adult lung transplant recipients

BACKGROUND

Pulmonary transplantation is the final treatment option for people with end-stage respiratory diseases. Evidence suggests that exercise training may contribute to speeding up physical recovery in adults undergoing lung transplantation, helping to minimize or resolve impairments due to physical inactivity in both the pre- and post-transplant stages. However, there is a lack of detailed guidelines on how exercise training should be carried out in this specific sub-population.

OBJECTIVES

To determine the benefits and safety of exercise training in adult patients who have undergone lung transplantation, measuring the maximal and functional exercise capacity; health-related quality of life; adverse events; patient readmission; pulmonary function; muscular strength; pathological bone fractures; return to normal activities and death.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Specialised Register up to 6 October 2020 using relevant search terms for this review. Studies in the CKTR are identified through CENTRAL, MEDLINE, and EMBASE searches, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials (RCTs) were included comparing exercise training with usual care or no exercise training, or with another exercise training program in terms of dosage, modality, program length, or use of supporting exercise devices. The study population comprised of participants older than 18 years who underwent lung transplantation independent of their underlying respiratory pathology.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed all records identified by the search strategy and selected studies that met the eligibility criteria for inclusion in this review. In the first instance, the disagreements were resolved by consensus, and if this was not possible the decision was taken by a third reviewer. The same reviewers independently extracted outcome data from included studies and assessed risk of bias. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

Eight RCTs (438 participants) were included in this review. The median sample size was 60 participants with a range from 16 to 83 participants. The mean age of participants was 54.9 years and 51.9% of the participants were male. The median duration of the exercise training programs for the groups undergoing the intervention was 13 weeks, and the median duration of training in the active control groups was four weeks. Overall the risk of bias was considered to be high, mainly due to the inability to blind the study participants and the selective reporting of the results. Due to small number of studies included in this review, and the heterogeneity of the intervention and outcomes, we did not obtain a summary estimate of the results. Two studies comparing resistance exercise training with no exercise reported increases in muscle strength and bone mineral density (surrogate outcomes for pathological bone fractures) with exercise training (P > 0.05), but no differences in adverse events. Exercise capacity, health-related quality of life (HRQoL), pulmonary function, and death (any cause) were not reported. Three studies compared two different resistant training programs. Two studies comparing squats using a vibration platform (WBVT) compared to squats on the floor reported an improvement in 6-minute walk test (6MWT) (28.4 metres, 95% CI 3 to 53.7; P = 0.029; and 28.3 metres, 95% CI 10.0 to 46.6; P < 0.05) with the WBVT. Supervised upper limb exercise (SULP) program improved 6MWT at 6 months compared to no supervised upper limb exercise (NULP) (SULP group: 561.2 ± 83.6 metres; NULP group: 503.5 ± 115.2 metres; P = 0.01). There were no differences in HRQoL, adverse events, muscular strength, or death (any cause). Pulmonary function and pathological bone fractures were not reported. Two studies comparing multimodal exercise training with no exercise reported improvement in 6MWT at 3 months (P = 0.008) and at 12-months post-transplant (P = 0.002) and muscular strength (quadriceps force (P = 0.001); maximum leg press (P = 0.047)) with multimodal exercise, but no improvement in HRQoL, adverse events, pulmonary function, pathological bone fractures (lumbar T-score), or death (any cause). One study comparing the same multimodal exercise programs given over 7 and 14 weeks reported no differences in 6MWT, HRQoL, adverse events, pulmonary function, muscle strength, or death (any cause). Pathological bone fractures were not reported. According to GRADE criteria, we rated the certainty of the evidence as very low, mainly due to the high risk of bias and serious imprecision.

AUTHORS' CONCLUSIONS

In adults undergoing lung transplantation the evidence about the effects of exercise training is very uncertain in terms of maximal and functional exercise capacity, HRQoL and safety, due to very imprecise estimates of effects and high risk of bias.

The Lung Allocation Score and Its Relevance

Lung transplantation in the United States, under oversight by the Organ Procurement Transplantation Network (OPTN) in the 1990s, operated under a system of allocation based on location within geographic donor service areas, wait time of potential recipients, and ABO compatibility. On May 4, 2005, the lung allocation score (LAS) was implemented by the OPTN Thoracic Organ Transplantation Committee to prioritize patients on the wait list based on a balance of wait list mortality and posttransplant survival, thus eliminating time on the wait list as a factor of prioritization. Patients were categorized into four main disease categories labeled group A (obstructive lung disease), B (pulmonary hypertension), C (cystic fibrosis), and D (restrictive lung disease/interstitial lung disease) with variables within each group impacting the calculation of the LAS. Implementation of the LAS led to a decrease in the number of wait list deaths without an increase in 1-year posttransplant survival. LAS adjustments through the addition, modification or elimination of covariates to improve the estimates of patient severity of illness, have since been made in addition to establishing criteria for LAS value exceptions for pulmonary hypertension patients. Despite the success of the LAS, concerns about the prioritization, and transplantation of older, sicker individuals have made some aspects of the LAS controversial. Future changes in US lung allocation are anticipated with the current development of a continuous distribution model that incorporates the LAS, geographic distribution, and unaccounted aspects of organ allocation into an integrated score.

The Actualization of the Transplantation Complex on the Axis of Psychosomatic Totality-Results of a Qualitative Study

Although transplantation medicine is not new, there is a clinically justified gap in the existing literature with respect to the psychological processing of lung transplants. The present study aims to examine whether lung transplantation leads to an actualization of psychological, e.g., oral-sadistic fantasies. Following a qualitative approach, 38 lung transplant patients were interviewed three times within the first six months after transplantation. Data analysis focused on identifying unconscious and conscious material. The inter-rater reliability for all codes was calculated using Krippendorff’s Alpha (c-α-binary = 0.94). Direct and implicit evidence of a so-called transplantation complex was detected e.g., regarding the “incorporation” of the dead donor and his lungs. These processes occur predominantly at an imaginary level and are related to the body. Our findings emphasize that such psychological aspects should be borne in mind in the psychological treatment of lung-transplant patients in order to improve the processing of lung transplants, and that this might have a positive effect on patient adherence.

Near-normal aerobic capacity in long-term survivors after lung transplantation

The clinical course of lung transplantation (LT) is diverse: some patients present chronic lung allograft dysfunction (CLAD) and progressive decline in pulmonary function, but others maintain normal spirometric values and active lives.

This is a multicentre study reporting, for the first time, near-normal peak V′_O2 values during cardiopulmonary exercise testing and normal exercise capacity in long-term lung transplant recipients without CLADhttps://bit.ly/35ftce3

Organ Transplant Recipients' Experiences of Physical Activity: Health, Self-Care, and Transliminality

Physical activity (PA) is an important lifestyle component of long-term health management for organ transplant recipients, yet little is known about recipients' experiences of PA. The purpose of this study was to shed light on this experience and to investigate the possible implications of PA in the context of what is a complex patient journey. Phenomenological analysis was used to examine interviews with 13 organ transplant recipients who had taken part in sporting opportunities posttransplantation. Findings illuminate how participants' experiences of PA were commonly shaped by the transliminal nature of being an organ transplant recipient as well as a sense of duty to enact health, self-care, and donor-directed gratitude. This analysis underlines the potential role of PA in supporting organ transplant recipients' attempts to live well following transplantation and makes novel connections between PA and our existing knowledge about challenges related to identity, survivorship, obligation, and patient empowerment.

Exercise training for lung transplant candidates and recipients: a systematic review

Exercise intolerance and impaired quality of life (QoL) are characteristic of lung transplant candidates and recipients. This review investigated the effects of exercise training on exercise capacity, QoL and clinical outcomes in pre- and post-operative lung transplant patients.A systematic literature search of PubMed, Nursing and Allied Health, Cochrane (CENTRAL), Scopus and CINAHL databases was conducted from inception until February, 2020. The inclusion criteria were assessment of the impact of exercise training before or after lung transplantation on exercise capacity, QoL or clinical outcomes.21 studies met the inclusion criteria, comprising 1488 lung transplant candidates and 1108 recipients. Studies consisted of five RCTs, two quasi-experimental and 14 single-arm cohort or pilot studies. Exercise training improved or at least maintained exercise capacity and QoL before and after lung transplantation. The impact on clinical outcomes was less clear but suggested a survival benefit. The quality of evidence ranged from fair to excellent.Exercise training appears to be beneficial for patients before and after lung transplantation; however, the evidence for direct causation is limited by the lack of controlled trials. Well-designed RCTs are needed, as well as further research into the effect of exercise training on important post-transplant clinical outcomes, such as time to discharge, rejection, infection, survival and re-hospitalisation.

Use of a Bluetooth tablet-based technology to improve outcomes in lung transplantation: A pilot study

The impact of remote patient monitoring platforms to support the postoperative care of solid organ transplant recipients is evolving. In an observational pilot study, 28 lung transplant recipients were enrolled in a novel postdischarge home monitoring program and compared to 28 matched controls during a 2-year period. Primary endpoints included hospital readmissions and total days readmitted. Secondary endpoints were survival and inflation-adjusted hospital readmission charges. In univariate analyses, monitoring was associated with reduced readmissions (incidence rate ratio [IRR]: 0.56; 95% confidence interval [CI]: 0.41-0.76; P < .001), days readmitted (IRR: 0.46; 95% CI: 0.42-0.51; P < .001), and hospital charges (IRR: 0.52; 95% CI: 0.51-0.54; P < .001). Multivariate analyses also showed that remote monitoring was associated with lower incidence of readmission (IRR: 0.38; 95% CI: 0.23-0.63; P < .001), days readmitted (IRR: 0.14; 95% CI: 0.05-0.37; P < .001), and readmission charges (IRR: 0.11; 95% CI: 0.03-0.46; P = .002). There were 2 deaths among monitored patients compared to 6 for controls; however, this difference was not significant. This pilot study in lung transplant recipients suggests that supplementing postdischarge care with remote monitoring may be useful in preventing readmissions, reducing subsequent inpatient days, and controlling hospital charges. A multicenter, randomized control trial should be conducted to validate these findings.

Changes in Health-Related Quality of Life During the First Year in Lung Transplant Recipients

BACKGROUND

Health-related quality of life (HRQOL) has increasingly been accepted as a supplementary outcome measure for patients before and after lung transplantation (LT). This longitudinal study was conducted to recognize the tracks of HRQOL during the first year after transplantation and the main factors associated with HRQOL of LT recipients. The research was conducted in accordance with the 2000 Declaration of Helsinki and the Declaration of Istanbul 2008. The transplant organs were from volunteer donation, and next of kin provided written informed consents of their own free will. No prisoners were used, and donors were neither paid nor coerced.

METHODS

A total of 118 patients were investigated before and 3, 6, 9, and 12 months post-transplantation. The Medical Outcomes SF-36 (Chinese version) was used to measure the HRQOL. The recipients' demographic characteristics and clinical data were evaluated to determine the relative contributions to HRQOL outcomes.

RESULTS

Recipients reported a mean physical component summary of 39.62 ± 6.57, 57.90 ± 9.99, 59.15 ± 8.73, 58.79 ± 8.52, and 58.72 ± 8.99 before transplantation and at 3, 6, 9, and 12 months after LT (F = 64.960, P < .001). By 3 months after transplant, patients experienced significant improvement in physical component summary (MD = 18.27, SE = 1.52, P < .001); but between 3 and 12 months, no significant improvement was observed (MD = 0.82, SE = 1.77, P = .645). Patients reported a continuous rise with means of 44.63 ± 5.35, 51.13 ± 10.25, 51.92 ± 9.72, 53.23 ± 10.34, and 55.40 ± 8.83 for the mental component summary before LT and at 3, 6, 9, and 12 months after transplant (F = 13.059, P < .001). By 3 months after transplant, patients experienced significant improvement in mental component summary (MD = 6.50, SE = 1.50, P < .001). Between 3 and 12 months, a continuous significant improvement was observed (MD = 4.27, SE = 1.92, P = .030). The generalized estimated equation showed that age, marital status, residence, disease diagnosis, transplant type, sleep disorders, gastrointestinal complications, and BODE index (body mass index, obstruction, dyspnea, exercise) were all found to be related to HRQOL.

CONCLUSION

The HRQOL of LT patients improved significantly at 3 months after transplantation, but between 3 and 12 months after transplantation, the changes were not obvious. Health practitioners should pay more attention to elderly patients, unmarried patients, patients living in urban areas, patients diagnosed with pneumoconiosis, patients with left single-lung transplantation, patients with sleep disorders, patients with high BODE indexes, and patients with gastrointestinal complications.

Improvements in frailty contribute to substantial improvements in quality of life after lung transplantation in patients with cystic fibrosis

BACKGROUND

While lung transplantation (LTx) improves health-related quality of life (HRQL) in cystic fibrosis (CF), the determinants of this improvement are unknown. In other populations, frailty-a syndrome of vulnerability to physiologic stressors-is associated with disability and poor HRQL. We hypothesized that improvements in frailty would be associated with improved disability and HRQL in adults with CF undergoing LTx.

METHODS

In a single-center prospective cohort study from 2010 to 2017, assessments of frailty, disability, and HRQL were performed before and at 3- and 6-months after LTx. We assessed frailty by the short physical performance battery (SPPB). We assessed disability with the Lung Transplant Valued Life Activities scale (LT-VLA) and HRQL by the Medical Outcomes Study Short Form Physical and Mental Component Summary scales (SF12-PCS, -MCS), the Airway Questionnaire 20-Revised (AQ20R), and the Euroqol 5D (EQ5D). We tested the association of concurrent changes in frailty and lung function on disability and HRQL by linear mixed-effects models adjusted for sex and body mass index.

RESULTS

Among 23 participants with CF, improvements in frailty and lung function were independently associated with improved disability and some HRQL measures. For example, each 1-point improvement in SPPB or 200 mL improvement in FEV1 was associated with improved LT-VLA disability by 0.14 (95%CI: 0.08-0.20) and 0.07 (95%CI: 0.05-0.09) points and improved EQ5D by 0.05 (95%CI: 0.03 to 0.07) and 0.02 (95%CI: 0.01-0.03) points, respectively.

CONCLUSION

Improvement in frailty is a novel determinant of improved disability and HRQL in adults with CF undergoing LTx.

Diagnosis and treatment of lung disease associated with alpha one-antitrypsin deficiency: A position statement from the Thoracic Society of Australia and New Zealand

AATD is a common inherited disorder associated with an increased risk of developing pulmonary emphysema and liver disease. Many people with AATD-associated pulmonary emphysema remain undiagnosed and therefore without access to care and counselling specific to the disease. AAT augmentation therapy is available and consists of i.v. infusions of exogenous AAT protein harvested from pooled blood products. Its clinical efficacy has been the subject of some debate and the use of AAT augmentation therapy was recently permitted by regulators in Australia and New Zealand, although treatment is not presently subsidized by the government in either country. The purpose of this position statement is to review the evidence for diagnosis and treatment of AATD-related lung disease with reference to the Australian and New Zealand population. The clinical efficacy and adverse events of AAT augmentation therapy were evaluated by a systematic review, and the GRADE process was employed to move from evidence to recommendation. Other sections address the wide range of issues to be considered in the care of the individual with AATD-related lung disease: when and how to test for AATD, changing diagnostic techniques, monitoring of progression, disease in heterozygous AATD and pharmacological and non-pharmacological therapy including surgical options for severe disease. Consideration is also given to broader issues in AATD that respiratory healthcare staff may encounter: genetic counselling, patient support groups, monitoring for liver disease and the need to establish national registries for people with AATD in Australia and New Zealand.

Remote Therapy to Improve Outcomes in Lung Transplant Recipients: Design of the INSPIRE-III Randomized Clinical Trial

BACKGROUND

Impaired functional capacity and emotional distress are associated with lower quality of life (QoL) and worse clinical outcomes in post lung transplant patients. Strategies to increase physical activity and reduce distress are needed.

METHODS

The Investigational Study of Psychological Interventions in Recipients of Lung Transplant-III study is a single site, parallel group randomized clinical trial in which 150 lung transplant recipients will be randomly assigned to 3 months of telephone-delivered coping skills training combined with aerobic exercise (CSTEX) or to a Standard of Care plus Education control group. The primary endpoints are a global measure of distress and distance walked on the 6-Minute Walk Test. Secondary outcomes include measures of transplant-specific QoL, frailty, health behaviors, and chronic lung allograft dysfunction-free survival.

RESULTS

Participants will be evaluated at baseline, at the conclusion of 3 months of weekly treatment, at 1-year follow-up, and followed annually thereafter for clinical events for up to 4 years (median = 2 y). We also will determine whether functional capacity, distress, and health behaviors (eg, physical activity, medication adherence, and volume of air forcefully exhaled in 1 second (FEV1), mediate the effects of the CSTEX intervention on clinical outcomes.

CONCLUSIONS

Should the CSTEX intervention result in better outcomes compared with the standard of care plus post-transplant education, the remotely delivered CSTEX intervention can be made available to all lung transplant recipients as a way of enhancing their QoL and improving clinical outcomes.

Impact of Affect on Lung Transplant Candidate Outcomes

BACKGROUND

We examined the association of adult lung transplant candidates' self-reported affect with transplant-related outcomes, evaluating whether a positive (vs negative) frame of mind might be protective.

METHOD

Consenting waitlisted candidates from 6 centers completed the questionnaires including the Positive and Negative Affect Schedule annually and posttransplant. Univariate logistic regression analysis was performed to determine the association of baseline affect with outcomes of death or delisting. Models were subsequently adjusted for age, marital status, and education.

RESULTS

Questionnaires were completed by 169 candidates (77.9% participation). Mean positive affect, negative affect, and positive-to-negative affect ratio (positivity ratio) were similar to expected norms. The scores of the questionnaire did not change significantly over time. Fifteen (8.9%) waitlisted participants died. Candidates who died while waiting had lower positivity ratios compared to those who survived (1.82 vs 2.45; P = .02). A more negative affect was associated with increased death on the waiting list (adjusted odds ratio [OR] 1.10; P = .021). Conversely, a higher positivity ratio was associated with decreased death while waiting (adjusted OR: 0.45; P = .027).

CONCLUSION

Negative affect may represent a novel risk factor for death on the waitlist. Enhancing positive affect may represent a useful target for psychological optimization in lung transplant candidates.

Health-related quality of life and stress-related post-transplant trajectories of lung transplant recipients: a three-year follow-up of the Swiss Transplant Cohort Study

BACKGROUND Lung transplantation (LTx) provides a viable option for the survival of end-stage lung diseases. Besides survival as a clinical outcome measure, health-related quality of life (HRQoL) and psychological distress have become important outcomes in studies investigating the effectiveness of LTx in the short- and long-term. OBJECTIVE To assess and compare HRQoL trajectories of patients after LTx prior to and over a follow-up period of three years post-transplant, and to identify differences regarding distress, HRQoL and patient-related outcomes. METHODS In this longitudinal study, 27 lung transplant recipients were prospectively examined for psychological distress (Symptom Checklist short version-9; SCL-K-9), health-related quality of life (EuroQOL five dimensions questionnaire; EQ-5D), depression (HADS-Depression scale), and socio-demographic and medical outcomes at two weeks, three months, six months and three years following LTx. Additionally, potential outcome-related predictors for LTx-outcomes at three years post-transplant were assessed. Data were collected in accordance with guidelines set by the STROBE (strengthening the reporting of observational studies in epidemiology) statement. RESULTS Lung transplant recipients showed the most pronounced improvements in HRQoL and reduction in psychological distress between two weeks and three months post-transplant, with relative stable HRQoL and distress trajectories thereafter. The most important predictors of poor somatic health trajectories over time were the pre-transplant disease severity score and the pre-transplant HADS-Depression score. In addition, idiopathic pulmonary fibrosis (IPF) and pre-transplant extracorporeal membrane oxygenation (ECMO)-use predicted poorer survival, while cystic fibrosis was associated with better survival three years post-transplant. COMCLUSION Lung transplantation yields significant survival and HRQoL benefits, with its peak improvement at three months post-transplant. The majority of patients can preserve these health changes in the long-term. Patients with a worse HRQoL and higher psychological distress at six months post-transplant tended to have a poorer survival post-transplant. Other risk factors for poorer survival included IPF, pre-transplant ECMO-use, pre-transplant symptoms of depression, high pre-transplant disease severity and worse somatic disease severity trajectories. The majority of LTx-recipients were unable to work due to illness-related reasons.

c-Jun N-terminal kinase (JNK)-mediated induction of mSin1 expression and mTORC2 activation in mesenchymal cells during fibrosis

Mammalian target of rapamycin complex 2 (mTORC2) has been shown to regulate mTORC1/4E-BP1/eIF4E signaling and collagen I expression in mesenchymal cells (MCs) during fibrotic activation. Here we investigated the regulation of the mTORC2 binding partner mammalian stress-activated protein kinase-interacting protein 1 (mSin1) in MCs derived from human lung allografts and identified a novel role for mSin1 during fibrosis. mSin1 was identified as a common downstream target of key fibrotic pathways, and its expression was increased in MCs in response to pro-fibrotic mediators: lysophosphatidic acid (LPA), transforming growth factor β, and interleukin 13. Fibrotic MCs had higher mSin1 protein levels than nonfibrotic MCs, and siRNA-mediated silencing of mSIN1 inhibited collagen I expression and mTORC1/2 activity in these cells. Autocrine LPA signaling contributed to constitutive up-regulation of mSin1 in fibrotic MCs, and mSin1 was decreased because of LPA receptor 1 siRNA treatment. We identified c-Jun N-terminal kinase (JNK) as a key intermediary in mSin1 up-regulation by the pro-fibrotic mediators, as pharmacological and siRNA-mediated inhibition of JNK prevented the LPA-induced mSin1 increase. Proteasomal inhibition rescued mSin1 levels after JNK inhibition in LPA-treated MCs, and the decrease in mSin1 ubiquitination in response to LPA was counteracted by JNK inhibitors. Constitutive JNK1 overexpression induced mSin1 expression and could drive mTORC2 and mTORC1 activation and collagen I expression in nonfibrotic MCs, effects that were reversed by siRNA-mediated mSIN1 silencing. These results indicate that LPA stabilizes mSin1 protein expression via JNK signaling by blocking its proteasomal degradation and identify the LPA/JNK/mSin1/mTORC/collagen I pathway as critical for fibrotic activation of MCs.

Feasibility of Immediate in-Intensive Care Unit Pulmonary Rehabilitation after Lung Transplantation: A Single Center Experience

Background

Physical function may influence perioperative outcomes of lung transplantation. We investigated the feasibility of a pulmonary rehabilitation program initiated in the immediate postoperative period at an intensive care unit (ICU) for patients who underwent lung transplantation.

Methods

We retrospectively evaluated 22 patients who received pulmonary rehabilitation initiated in the ICU within 2 weeks after lung transplantation at our institution from March 2015 to February 2016. Levels of physical function were graded at the start of pulmonary rehabilitation and then weekly throughout rehabilitation according to criteria from our institutional pulmonary rehabilitation program: grade 1, bedside (G1); grade 2, dangling (G2); grade 3, standing (G3); and grade IV, gait (G4).

Results

The median age of patients was 53 years (range, 25 to 73 years). Fourteen patients (64%) were males. The initial level of physical function was G1 in nine patients, G2 in seven patients, G3 in four patients, and G4 in two patients. Patients started pulmonary rehabilitation at a median of 7.5 days (range, 1 to 29 days) after lung transplantation. We did not observe any rehabilitation-related complications during follow-up. The final level of physical function was G1 in six patients, G3 in two patients, and G4 in 14 patients. Fourteen of the 22 patients were able to walk with or without assistance, and 13 of them maintained G4 until discharge; the eight remaining patients never achieved G4.

Conclusions

Our results suggest the feasibility of early pulmonary rehabilitation initiated in the ICU within a few days after lung transplantation.

Bilateral versus single lung transplantation: are two lungs better than one?

There is a long-standing debate over whether single or bilateral lung transplant provides better short and long-term clinical outcomes. We performed a detailed PubMed search on relevant clinical research publications on single (SLT) and bilateral lung transplantation (BLT). We included studies that were published before and after the implementation of the lung allocation score (LAS). We reviewed disease-specific short- and long-term outcomes associated with each transplantation technique. The majority of published studies are retrospective cohort studies that use institutional data or large patient registries. Outcomes associated with transplantation technique vary by disease specific indication, age, and patient severity. Over the past decade, the relative proportion of bilateral lung transplantation has increased. Increasing adoption of bilateral lung transplant likely reflects the general acceptance of several advantages associated with the technique. However, making a clear, evidence-based decision is difficult in light of the fact that there has never been and probably never will be a randomized trial. Our institutional preference is bilateral lung transplant. However, consideration for the technique should still be made on a case-by-case basis.

Cyclophosphamide for Refractory Acute Cellular Rejection After Lung Transplantation

Background

Acute cellular rejection (ACR) is a major risk factor for chronic lung allograft dysfunction after lung transplantation. Acute cellular rejection can persist or recur despite augmentation of immunosuppression by conventional methods. There are limited therapeutic options in treating these recurrent and refractory ACRs. We describe our experience with cyclophosphamide therapy for recurrent and refractory ACR in lung transplant recipients.

Methods

Six consecutive patients who were treated with cyclophosphamide for recurrent or refractory ACR were included in the series. The primary outcome measures were improvement in ACR score and forced expiratory volume at 1 second. Secondary outcome measures included adverse drug events including bone marrow suppression, gastrointestinal side effects, and infections.

Results

Five of the 6 patients treated demonstrated complete resolution of ACR on follow-up biopsies. Acute cellular rejection score improved after cyclophosphamide treatment (P = 0.03). None of the patients had high grade (≥A3) ACR in the 3 months after cyclophosphamide administration. Cyclophosphamide had no effect on forced expiratory volume at 1 second trend or bronchiolitis obliterans score. All patients tolerated cyclophosphamide with minor gastrointestinal side effects, mild bone marrow suppression, and nonfatal infections that were amenable to treatment.

Conclusions

Cyclophosphamide therapy is an option in treating recurrent and refractory ACR in patients who have failed conventional treatments. Cyclophosphamide is tolerated well without serious adverse drug events (ADE).

Patient-reported health outcomes in long-term lung transplantation survivors: A prospective cohort study

During the last three decades lung transplantation (LTx) has become a proven modality for increasing both survival and health-related quality of life (HRQoL) in patients with various end-stage lung diseases. Most previous studies have reported improved HRQoL shortly after LTx. With regard to long-term effects on HRQoL, however, the evidence is less solid. This prospective cohort study was started with 828 patients who were on the waiting list for LTx. Then, in a longitudinal follow-up, 370 post-LTx patients were evaluated annually for up to 15 years. For all wait-listed and follow-up patients, the following four HRQoL instruments were administered: State-Trait Anxiety Inventory, Zung Self-rating Depression Scale, Nottingham Health Profile, and a visual analogue scale. Cross-sectional and generalized estimating equation (GEE) analysis for repeated measures were performed to assess changes in HRQoL during follow-up. After LTx, patients showed improvement in all HRQoL domains except pain, which remained steady throughout the long-term follow-up. The level of anxiety and depressive symptoms decreased significantly and remained constant. In conclusion, this study showed that HRQoL improves after LTx and tends to remain relatively constant for the entire life span.

Survival Benefit of Lung Transplantation in the Modern Era of Lung Allocation

RATIONALE

Lung transplantation is an accepted and increasingly employed treatment for advanced lung diseases, but the anticipated survival benefit of lung transplantation is poorly understood.

OBJECTIVES

To determine whether and for which patients lung transplantation confers a survival benefit in the modern era of U.S. lung allocation.

METHODS

Data on 13,040 adults listed for lung transplantation between May 2005 and September 2011 were obtained from the United Network for Organ Sharing. A structural nested accelerated failure time model was used to model the survival benefit of lung transplantation over time. The effects of patient, donor, and transplant center characteristics on the relative survival benefit of transplantation were examined.

MEASUREMENTS AND MAIN RESULTS

Overall, 73.8% of transplant recipients were predicted to achieve a 2-year survival benefit with lung transplantation. The survival benefit of transplantation varied by native disease group (P = 0.062), with 2-year expected benefit in 39.2 and 98.9% of transplants occurring in those with obstructive lung disease and cystic fibrosis, respectively, and by lung allocation score at the time of transplantation (P < 0.001), with net 2-year benefit in only 6.8% of transplants occurring for lung allocation score less than 32.5 and in 99.9% of transplants for lung allocation score exceeding 40.

CONCLUSIONS

A majority of adults undergoing transplantation experience a survival benefit, with the greatest potential benefit in those with higher lung allocation scores or restrictive native lung disease or cystic fibrosis. These results provide novel information to assess the expected benefit of lung transplantation at an individual level and to enhance lung allocation policy.

Outcomes after lung transplantation

With more than 50,000 procedures having been performed worldwide, lung transplantation (LT) has become the standard of care for patients with end-stage chronic respiratory failure. LT leads to dramatic improvements in both pulmonary function and health related quality of life. Survival after LTs has steadily improved, but still lags far behind that observed after other solid organ transplantations, as evidenced by a median survival rate that currently stands at 5.8 years. Because of these disappointing results, the ability of LT to expand survival has been questioned. However, the most recent studies, based on sophisticated statistical modeling suggest that LT confers a survival benefit to the vast majority of lung transplant recipients. Chronic lung allograft dysfunction (CLAD) that develops in about 50% of recipients 5 years after LT is a major impediment to lung transplant survival. A better understanding of the mechanisms underlying CLAD could allow for better post-transplant survival.

Pattern and Predictors of Hospital Readmission During the First Year After Lung Transplantation

Hospital readmission after lung transplantation negatively affects quality of life and resource utilization. A secondary analysis of data collected prospectively was conducted to identify the pattern of (incidence, count, cumulative duration), reasons for and predictors of readmission for 201 lung transplant recipients (LTRs) assessed at 2, 6, and 12 mo after discharge. The majority of LTRs (83.6%) were readmitted, and 64.2% had multiple readmissions. The median cumulative readmission duration was 19 days. The main reasons for readmission were other than infection or rejection (55.5%), infection only (25.4%), rejection only (9.9%), and infection and rejection (0.7%). LTRs who required reintubation (odds ratio [OR] 1.92; p = 0.008) or were discharged to care facilities (OR 2.78; p = 0.008) were at higher risk for readmission, with a 95.7% cumulative incidence of readmission at 12 mo. Thirty-day readmission (40.8%) was not significantly predicted by baseline characteristics. Predictors of higher readmission count were lower capacity to engage in self-care (incidence rate ratio [IRR] 0.99; p = 0.03) and discharge to care facilities (IRR 1.45; p = 0.01). Predictors of longer cumulative readmission duration were older age (arithmetic mean ratio [AMR] 1.02; p = 0.009), return to the intensive care unit (AMR 2.00; p = 0.01) and lower capacity to engage in self-care (AMR 0.99; p = 0.03). Identifying LTRs at risk may assist in optimizing predischarge care, discharge planning and long-term follow-up.

Life after a lung transplant: a balance of joy and challenges

AIM AND OBJECTIVE

To describe patients' experiences throughout the first four months post-lung transplant.

BACKGROUND

Health professionals are familiar with the fact that patients' average survival after a lung transplant is about seven years and that 74% of these patients reject new organs within the first two years. By contrast, knowledge of these patients' perspectives after lung transplantation is scant.

DESIGN/METHOD

A qualitative study was conducted between May 2013-May 2014 in which 26 interviewees participated - four months post-transplant - based on a semistructured interview guide. The data were inductively analysed using a content thematic approach within a phenomenological and hermeneutic frame.

RESULTS

The main findings in the study reveal that (1) having a lung transplant is an overwhelming experience, which for some patients includes (2) troubling physical and psychological challenges. The interviewees were happy to get another chance to live, although some of them suffered from medical side effects, postoperative complications and psychological problems. When asked about the future, interviewees stated that life could be described as (3) a balance of joy and challenges. They had received a new chance in life and were eager to fulfil their life hopes and dreams. At the same time, they were worried about the future. Having a lung transplant implies rules that have to be followed. What are the healthy choices they are supposed to make? And will there be a tomorrow?

CONCLUSIONS

Having a lung transplant is described as an overwhelming experience because of the improvement in the physical function of the body. Patients were grateful to family, friends and healthcare professionals for supporting them. The first four months post-transplantation were described as both physically and psychologically challenging. Interviewees were aware of the prognosis for patients following lung transplantation. They expressed feelings of worry and insecurity but still had hopes and dreams.

RELEVANCE TO CLINICAL PRACTICE

The patients are troubled by both physical and psychological challenges after lung transplantation. Several areas call for interventions from healthcare professionals during the early post-transplant period.

The Burden of Cost in Bronchiolitis Obliterans Syndrome: Predictions for the Next Decade

In health economics, costs can be divided into both direct and indirect categories. Direct costs tend to consist of medical costs, which are those directly attributed to health care interventions (e.g., hospitalizations, pharmaceuticals, devices), and non-medical direct costs such as monitoring and professional caregiving. Indirect costs tend to comprise those related to lost productivity due to illness (or treatment), burden on systems outside of the healthcare domain, and other costs that can sometimes outweigh the entire sum of direct healthcare costs. The most common life-threatening complication of lung and hematopoietic stem-cell transplantation (HSCT) is bronchiolitis obliterans syndrome (BOS). BOS is currently diagnosed as a 20% decline in the forced expiratory volume in one second (FEV1) from the best (baseline) post-transplantation value, and is a major cause of morbidity and mortality amongst lung and stem cell transplant patients. BOS affects half of all lung transplant patients within the first 5 years post-transplant, rising to the majority of patients (~80%) within the first decade following transplant. We estimated both direct and indirect costs for the first 10 years following BOS diagnosis, a viewpoint that highlights a tremendous imbalance between healthcare and non-healthcare costs. The lost workforce resulting from BOS-related infirmity will cost society more than $3.7 Billion over the next decade, a figure that is more than double the estimated 10-year cost of treating BOS ($1.4B), including diagnostics, immunosuppressives, and additional complications. As such, BOS is estimated to present a burden of cost that must be evaluated in a new light to include the wider societal perspective.

A global perspective of lung transplantation: Part 1 - Recipient selection and choice of procedure

Lung transplantation has grown considerably in recent years and its availability has spread to an expanding number of countries worldwide. Importantly, survival has also steadily improved, making this an increasingly viable procedure for patients with end-stage lung disease and limited life expectancy. In this first of a series of articles, recipient selection and type of transplant operation are reviewed. Pulmonary fibrotic disorders are now the most indication in the U.S., followed by chronic obstructive pulmonary disease and cystic fibrosis. Transplant centers have liberalized criteria to include older and more critically ill candidates. A careful, systematic, multi-disciplinary selection process is critical in identifying potential barriers that may increase risk and optimize long-term outcomes.

Interventional Options for COPD- LVRS, Bronchoscopic Therapies and the Future

This article serves as aCME available, enduring material summary of the following COPD9USA presentations: "Lung Volume Reduction Surgery" Presenter: William A. Bulman, MD "Bronchoscopic Approaches to Lung Volume Reduction" Presenter: Frank Sciurba, MD "Stem Cell Therapies for Advanced Emphysema" Presenter: Edward P. Ingenito, MD, PhD "Lung Transplantation for COPD" Presenter: Daniel Dilling, MD, FACP, FCCP.

Psychosocial Predictors of Mortality Following Lung Transplantation

Lung transplantation has become an increasingly common treatment for patients with end-stage lung disease. Few studies have examined psychosocial risk factors for mortality in transplant recipients, despite evidence suggesting that elevated levels of negative affect are associated with greater mortality following major cardiac surgery. We therefore examined the relationship between negative affect early after lung transplantation and long-term survival in a sample of 132 lung transplant recipients (28 cystic fibrosis, 64 chronic obstructive pulmonary disease, 26 idiopathic pulmonary fibrosis, 14 other) followed for up to 13.5 years (median 7.4 years) following transplantation. Patients underwent both medical and psychosocial assessments 6 months following transplantation, which included the Beck Depression Inventory-II (BDI-II), Spielberger Anxiety Inventory, and General Health Questionnaire (GHQ). Over the course of follow-up, 80 (61%) participants died. Controlling for demographic factors, native lung disease, disease severity, family income, education level, social support, and frequency of posttransplant rejection, elevated symptoms of depression (BDI-II: HR = 1.31, p = 0.011) and distress (GHQ: HR = 1.28, p = 0.003) were associated with increased mortality. Higher levels of depression and general distress, but not anxiety, measured 6 months following lung transplantation are associated with increased mortality, independent of background characteristics and medical predictors.

Neurocognitive changes after lung transplantation

RATIONALE

Neurocognitive impairments are associated with reduced quality of life and may adversely affect medical compliance, but their prevalence after lung transplantation has not been extensively studied.

OBJECTIVES

To examine the frequency of neurocognitive impairment after lung transplantation and to examine perioperative factors affecting post-transplant neurocognitive function.

MEASUREMENTS AND MAIN RESULTS

We performed serial assessments of neurocognitive function in a consecutive series of 47 subjects who received transplants between March 2013 and November 2013 (45% women; mean age, 53.5 ± 17.2 yr). Neurocognitive function was assessed using a composite measure including the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) total score and Trail Making Test parts A and B obtained before transplant, at hospital discharge, and 3 months after discharge. The presence of neurocognitive impairment was assessed using the Montreal Cognitive Assessment Battery (MoCA), and in-hospital delirium was assessed using the Confusion Assessment Method. Results demonstrated that neurocognitive performance initially worsened among non-cystic fibrosis patients and improved over follow-up (P = 0.002). Time effects were strongest on Trail Making Test part B (P < 0.001) and the RBANS (P = 0.054). Participants who exhibited delirium during their hospitalization showed poorer performance during follow-up assessments (P = 0.006). Examination of cognitive impairment rates demonstrated that 21 participants (45%) exhibited neurocognitive impairment (MoCA < 26) before lung transplant, whereas 27 (57%) participants exhibited impairment after transplantation, and 19 (57%) participants continued to neurocognitive impairment during a 3-month follow-up.

CONCLUSIONS

Neurocognitive impairments are prevalent among lung transplant candidates and appear to worsen in some patients after transplant. Delirium during hospitalization is associated with worse neurocognitive function after transplant among patients without cystic fibrosis.

A systematic review of health-related quality of life and psychological outcomes after lung transplantation

BACKGROUND

Lung transplantation (LTx) aims to reduce physical disability and mental distress, extend survival, and improve health-related quality of life (HRQoL). In this systematic review we aimed to: (1) augment evidence regarding measures to assess HRQoL and psychological outcomes after LTx; and (2) summarize HRQoL and psychological outcomes after LTx.

METHODS

Validated and standardized instruments with well-known psychometric properties used for assessing HRQoL and psychological outcomes after LTx were identified by means of comprehensive literature searches of PsychINFO and Medline/PubMed, up through March 2014, using the following search terms in various combinations: lung transplantation; physical functioning; symptom experience; mental health; anxiety; depression; distress; social functioning; life satisfaction; and health-related quality of life.

RESULTS

The search strategy identified 371 titles and abstracts. Of these, 279 were retrieved for further assessment and 63 articles selected for final review. Thirty-nine studies were found for HRQoL, 15 for physical functioning, 5 for mental health and 4 for social functioning. A total of 50 psychometric instruments were encountered.

CONCLUSIONS

Considerable heterogeneity exists in methodology, operational concepts and applied outcome measures in the existing literature on HRQoL and psychological outcomes after LTx. Nevertheless, the studies generally point to significant improvements in both mental health and HRQoL post-transplant. Further research is warranted utilizing consistent outcome measures, including LTx-specific measures and longitudinal study designs.

Factors affecting discharge destination following lung transplantation

BACKGROUND

Lung transplant (LT) recipients requiring additional care may be referred to inpatient rehabilitation prior to discharge home. This study seeks to describe discharge destinations following LT, compare the characteristics of patients discharged to different destinations, and identify the predictors of discharge destination.

METHODS

Retrospective study of 243 LT recipients who survived to hospital discharge between 2006 and 2009. LT recipients were compared based on discharge destination on data pertaining to demographics, clinical characteristics, and healthcare utilization.

RESULTS

Of the 243 recipients, 197 (81%) were discharged home, 42 (17%) to inpatient rehabilitation, and 4 (2%) to other medical facilities. Age, pulmonary diagnosis, most recent six-minute walk distance (6 MWD) prior to transplant, pre-transplant mechanical ventilation, priority listing status, pre- and post-transplant intensive care unit length of stay (ICU LOS), post-transplant LOS, total LOS, and participation in pre-transplant rehabilitation were statistically different between patients that were discharged home versus inpatient rehabilitation. Age, most recent 6 MWD prior to transplant, pre-transplant mechanical ventilation, and total LOS were found to be independent predictors of discharge destination.

CONCLUSION

Clinical factors can help identify patients more likely to require inpatient rehabilitation. Identification of these factors has the potential to facilitate early discharge planning and optimize continuity of care.

Development and psychometric properties of the Pulmonary-specific Quality-of-Life Scale in lung transplant patients

BACKGROUND

The Pulmonary-specific Quality-of-Life Scale (PQLS) was developed to measure quality of life (QoL) among patients awaiting lung transplant. The objective of this study was to determine the psychometric properties of the PQLS, identify empirically derived sub-scales, and examine ability to detect changes in pulmonary-specific QoL scores after lung transplantation.

METHODS

Data were derived from the INSPIRE trial, a dual-site randomized controlled trial of coping skills training in 389 lung transplant candidates (obstructive [48.3%], restrictive [24.2%], cystic fibrosis [13.6%], and other [13.9%]). Cronbach alpha was calculated to assess the internal reliability of the PQLS (n = 388). Test-retest reliability was assessed with correlation coefficients between baseline and 12-week post-baseline scores for the usual care control condition (n = 140). Convergent validity was assessed with correlation coefficients between the PQLS and established measures of QoL and emotional distress, 6-minute walk test distance, forced expiratory volume in 1 second, and use of supplemental oxygen at rest (n = 388). Change from baseline to 6 months post-transplantation was assessed with repeated measures analysis of variance (n = 133).

RESULTS

The PQLS was internally reliable and stable across 12 weeks. The PQLS correlated strongly with QoL measures (e.g., Shortness of Breath Questionnaire, r = 0.78, p < 0.0001), moderately with mood and anxiety (e.g., Beck Depression Inventory-II, r = 0.59, p < 0.0001), and modestly with lung disease severity (e.g., 6-minute walk test, r = -0.41, p < 0.0001). PQLS scores improved by nearly 2 SDs after transplant.

CONCLUSIONS

These results demonstrated the reliability, validity, and sensitivity to change of the PQLS for measuring pulmonary QoL among patients with advanced lung disease and the responsiveness of the PQLS to changes in QoL after lung transplantation.

Update in lung transplantation 2013

Research in pulmonary transplantation is actively evolving in quality and scope to meet the challenges of a growing population of lung allograft recipients. In 2013, research groups leveraged large publicly available datasets in addition to multicenter research networks and single-center studies to make significant contributions to our knowledge and clinical care in the areas of donor use, clinical transplant outcomes, mechanisms of rejection, infectious complications, and chronic allograft dysfunction.