Beware Cold Agglutinins in Organ Donors! Ex Vivo Lung Perfusion From an Uncontrolled Donation After Circulatory-Determination-of-Death Donor With a Cold Agglutinin: A Case Report

BACKGROUND

We began to recover lungs from uncontrolled donation after circulatory determination of death to assess for transplant suitability by means of ex vivo lung perfusion (EVLP) and computerized tomographic (CT) scan. Our first case had a cold agglutinin with an interesting outcome.

CASE REPORT

A 60-year-old man collapsed at home and was pronounced dead by Emergency Medical Services personnel. Next-of-kin consented to lung retrieval, and the decedent was ventilated and transported. Lungs were flushed with cold Perfadex, removed, and stored cold. The lungs did not flush well. Medical history revealed a recent hemolytic anemia and a known cold agglutinin. Warm nonventilated ischemia time was 51 minutes. O2-ventilated ischemia time was 141 minutes. Total cold ischemia time was 6.5 hours. At cannulation for EVLP, established clots were retrieved from both pulmonary arteries. At initiation of EVLP with Steen solution, tiny red aggregates were observed initially. With warming, the aggregates disappeared and the perfusate became red. After 1 hour, EVLP was stopped because of florid pulmonary edema. The lungs were cooled to 20°C; tiny red aggregates formed again in the perfusate. Ex vivo CT scan showed areas of pulmonary edema and a pyramidal right middle lobe opacity. Dissection showed multiple pulmonary emboli-the likely cause of death. However, histology showed agglutinated red blood cells in the microvasculature in pre- and post-EVLP biopsies, which may have contributed to inadequate parenchymal preservation.

CONCLUSIONS

Organ donors with cold agglutinins may not be suitable owing to the impact of hypothermic preservation.

Factors Associated with Adherence to Treatment Regimens after Lung Transplantation

CONTEXT

The number of patients currently awaiting lung transplantation far exceeds the supply of available organs. Adherence to postoperative treatment regimens is essential for optimal posttransplant success.

OBJECTIVE

The present study was designed to examine the demographic and psychological factors associated with compliance in patients who have had lung transplants.

DESIGN

Eighteen women and 13 men participated in this study an average of 24 months after transplantation, completing a demographic form, a self-report compliance measure, a social support questionnaire, and the Multidimensional Health Locus of Control Scale. A significant other or family member and the posttransplant nurse coordinator also rated each subject's compliance with the posttransplant regimen.

RESULTS

Although patients rated themselves as being compliant with aspects of their self-care, on more subtle measures of compliance, their self-reported compliance was not as impressive. Patients who had had their transplants more recently appeared to be more compliant. Patients with cystic fibrosis used their spirometer more often than patients with other lung diseases. Family support was significantly correlated with self-reported compliance.

CONCLUSIONS

This study suggests that how patients are asked about adherence to treatment regimens influences how compliant they appear. The data also indicate that the longer after transplant, the less compliant the patient, and suggests the need for patient reeducation at some point after transplant. Longitudinal studies are needed to assess the degree to which compliance affects the number of rejection and febrile episodes as well as patient mortality after lung transplant.

Uncontrolled Donation After Circulatory Determination of Death Donors (uDCDDs) as a Source of Lungs for Transplant

In April 2014, the American Journal of Transplantation published a report on the first lung transplant in the United States recovered from an uncontrolled donation after circulatory determination of death donor (uDCDD), assessed by ex vivo lung perfusion (EVLP). The article identified logistical and ethical issues related to introduction of lung transplant from uDCDDs. In an open clinical trial, we have Food and Drug Administration and Institutional Review Board approval to transplant lungs recovered from uDCDDs judged suitable after EVLP. Through this project and other experiences with lung recovery from uDCDDs, we have identified solutions to many logistical challenges and have addressed ethical issues surrounding lung transplant from uDCDDs that were mentioned in this case report. Here, we discuss those challenges, including issues related to recovery of other solid organs from uDCDDs. Despite logistical challenges, uDCDDs could solve the critical shortage of lungs for transplant. Furthermore, by avoiding the deleterious impact of brain death and days of positive pressure ventilation, and by using opportunities to treat lungs in the decedent or during EVLP, lungs recovered from uDCDDs may ultimately prove to be better than lungs currently being transplanted from conventional brain-dead organ donors.

Nitric oxide ventilation of rat lungs from non-heart-beating donors improves posttransplant function

Lungs from non-heart-beating donors (NHBDs) would enhance the donor pool. Ex vivo perfusion and ventilation of NHBD lungs allows functional assessment and treatment. Ventilation of rat NHBD lungs with nitric oxide (NO) during ischemia, ex vivo perfusion and after transplant reduced ischemia-reperfusion injury (IRI) and improved lung function posttransplant. One hour after death, Sprague-Dawley rats were ventilated for another hour with either 60% O2 or 60% O2/40 ppm NO. Lungs were then flushed with 20-mL cold Perfadex, stored cold for 1 h, perfused in an ex vivo circuit with Steen solution and warmed to 37 degrees C, ventilated 15 min, perfusion-cooled to 20 degrees C, then flushed with cold Perfadex and stored cold. The left lung was transplanted and ventilated separately. Recipients were sacrificed after 1 h. NO-ventilation was associated with significantly reduced wet:dry weight ratio in the ex vivo circuit, better oxygenation, reduced pulmonary vascular resistance, increased lung tissue levels of cGMP, maintained endothelial NOS eNOS, and reduced increases in tumor necrosis factor alpha (TNF-alpha) and inducible nitric oxide synthase (iNOS). NO-ventilation had no effect on MAP kinases or NF-kappaB activation. NO administration to NHBDs before and after lung retrieval may improve function of lungs from NHBDs.

Development of the new lung allocation system in the United States

This article reviews the development of the new U.S. lung allocation system that took effect in spring 2005. In 1998, the Health Resources and Services Administration of the U.S. Department of Health and Human Services published the Organ Procurement and Transplantation Network (OPTN) Final Rule. Under the rule, which became effective in 2000, the OPTN had to demonstrate that existing allocation policies met certain conditions or change the policies to meet a range of criteria, including broader geographic sharing of organs, reducing the use of waiting time as an allocation criterion and creating equitable organ allocation systems using objective medical criteria and medical urgency to allocate donor organs for transplant. This mandate resulted in reviews of all organ allocation policies, and led to the creation of the Lung Allocation Subcommittee of the OPTN Thoracic Organ Transplantation Committee. This paper reviews the deliberations of the Subcommittee in identifying priorities for a new lung allocation system, the analyses undertaken by the OPTN and the Scientific Registry for Transplant Recipients and the evolution of a new lung allocation system that ranks candidates for lungs based on a Lung Allocation Score, incorporating waiting list and posttransplant survival probabilities.

Molecular characterization of the zebrafish P2X receptor subunit gene family

P2X receptors are non-selective cation channels gated by extracellular ATP and are encoded by a family of seven subunit genes in mammals. These receptors exhibit high permeabilities to calcium and in the mammalian nervous system they have been linked to modulation of neurotransmitter release. Previously, three complementary DNAs (cDNAs) encoding members of the zebrafish gene family have been described. We report here the cloning and characterization of an additional six genes of this family. Sequence analysis of all nine genes suggests that six are orthologs of mammalian genes, two are paralogs of previously described zebrafish subunits, and one remains unclassified. All nine subunits were physically mapped onto the zebrafish genome using radiation hybrid analysis. Of the nine gene products, seven give functional homo-oligomeric receptors when recombinantly expressed in human embryonic kidney cell line 293 cells. In addition, these subunits can form hetero-oligomeric receptors with phenotypes distinct from the parent subunits. Analysis of gene expression patterns was carried out using in situ hybridization, and seven of the nine genes were found to be expressed in embryos at 24 and 48 h post-fertilization. Of the seven that were expressed, six were present in the nervous system and four of these demonstrated considerable overlap in cells present in the sensory nervous system. These results suggest that P2X receptors might play a role in the early development and/or function of the sensory nervous system in vertebrates.

Long term results of lung transplantation for cystic fibrosis

OBJECTIVES

We reviewed our experience with lung transplant for cystic fibrosis (CF) over a 10-year period to identify factors influencing long-term survival.

METHODS

One hundred and twenty-three patients with CF have undergone 131 lung transplant procedures at our institution; 114 have had bilateral sequential lung transplants (DLTX) and nine have had bilateral lower lobe transplants from living donors. Three patients had retransplant for acute graft failure, and five had late retransplant for bronchiolitis obliterans syndrome (BOS). Kaplan-Meier survival was calculated for the entire cohort and for subsets at higher risk of death to determine factors predicting a better outcome.

RESULTS

Actuarial survival for the entire group of DLTX CF patients was 81% at 1 year, 59% at 5 years, and 38% at 10 years. Lobar transplant was associated with a poorer survival (37.5% at 1 and 5 years). Among DLTX patients, colonization with Burkholderia cepacia was present in 22 patients and was associated with poorer outcome (1- and 5-year survival 60 and 36% in B. cepacia patients vs. 86 and 64% in non-cepacia patients). DLTX patients younger than age 20 (n=22) had a similar survival to patients age 20 or older (n=90). Being on a ventilator at the time of transplant was not associated with poorer survival (n=8). BOS affects increasing numbers of survivors with time. Five CF patients have been retransplanted due to BOS with one operative death and 1-year survival of 60%.

CONCLUSIONS

DLTX has acceptable long term survival in CF adults and children with end stage disease. CF patients colonized with B. cepacia have a worse outcome but transplantation is still warranted.

The first transmembrane domain of the P2X receptor subunit participates in the agonist-induced gating of the channel

Based on pharmacological properties, the P2X receptor family can be subdivided into those homo-oligomers that are sensitive to the ATP analog alphabeta-methylene ATP(alphabetameATP) (P2X(1) and P2X(3)) and those that are not (P2X(2), P2X(4), P2X(5), P2X(6), and P2X(7)). We exploited this dichotomy through the construction of chimeric receptors and site-directed mutagenesis in order to identify domains responsible for these differences in the abilities of extracellular agonists to gate P2X receptors. Replacement of the extracellular domain of the alphabetameATP-sensitive rat P2X(1) subunit with that of the alphabetameATP-insensitive rat P2X(2) subunit resulted in a receptor that was still alphabetameATP-sensitive, suggesting a non-extracellular domain was responsible for the differential gating of P2X receptors by various agonists. Replacement of the first transmembrane domain of the rat P2X(2) subunit with one from an alphabetameATP-sensitive subunit (either rat P2X(1) or P2X(3) subunit) converted the resulting chimera to alphabetameATP sensitivity. This conversion did not occur when the first transmembrane domain came from a non-alphabetameATP-sensitive subunit. Site-directed mutagenesis indicated that the C-terminal portion of the first transmembrane domain was important in determining the agonist selectivity of channel gating for these chimeras. These results suggest that the first transmembrane domain plays an important role in the agonist operation of the P2X receptor.

Polar residues of the second transmembrane domain influence cation permeability of the ATP-gated P2X(2) receptor

P2X receptors are simple polypeptide channels that mediate fast purinergic depolarizations in both nerve and muscle. Although the depolarization results mainly from the influx of Na(+), these channels also conduct a significant Ca(2+) current that is large enough to evoke transmitter release from presynaptic neurons. We sought to determine the molecular basis of this Ca(2+) conductance by a mutational analysis of recombinant P2X(2) receptors. Wild type and 31 mutant P2X(2) receptors were expressed in HEK-293 cells and studied under voltage-clamp. We found that the relative Ca(2+) permeability measured from the reversal potentials of ATP-gated currents was unaffected by neutralizing fixed charge (Asp(315), Asp(349)) near the mouths of the channel pore. By contrast, mutations that changed the character or side chain volume of three polar residues (Thr(336), Thr(339), Ser(340)) within the pore led to significant changes in P(Ca)/P(Cs). The largest changes occurred when Thr(339) and Ser(340) were replaced with tyrosine; these mutations almost completely abolished Ca(2+) permeability, reduced P(Li)/P(Cs) by about one-half, and shifted the relative permeability sequence of Cs(+), Rb(+), K(+), and Na(+) to their relative mobility in water. Our results suggest that the permeability sequence of the P2X(2) receptor arises in part from interactions of permeating cations with the polar side chains of three amino acids located in a short stretch of the second transmembrane domain.

On the contribution of the first transmembrane domain to whole-cell current through an ATP-gated ionotropic P2X receptor

Scanning cysteine mutagenesis was used to identify potential pore-forming residues in and around the first transmembrane domains of ionotropic P2X(2) receptor subunits. Twenty-eight unique cysteine-substituted mutants (R28C-Y55C) were individually expressed in HEK293 cells by lipofection. Twenty-three of these were functional as assayed by application of ATP to transfected voltage-clamped cells. Individual mutants varied in their sensitivity to ATP; otherwise, currents through functional mutant receptors resembled those of the homomeric wild-type (WT) receptor. In five (H33C, R34C, I50C, K53C, and S54C) of 23 functional mutants, coapplication of 30 microm ATP and 500 nm Ag(+) irreversibly inhibited inward current evoked by subsequent applications of ATP alone. These inhibitions did not result in a lateral shift in the agonist concentration-response curve and are unlikely to involve a modification of the agonist binding site. Two (K53C and S54C) of the five residues modified by Ag(+) applied in the presence of ATP when the channels were gating were also modified by 1 mm (2-aminoethyl)methanethiosulfonate applied in the absence of ATP when the channels were closed. These data suggest that domains near either end of the first transmembrane domain influence ion conduction through the pore of the P2X(2) receptor.

Lung retrieval from non-heart beating cadavers with the use of a rat lung transplant model

BACKGROUND

Lungs retrieved from cadavers after death and circulatory arrest may alleviate the critical shortage of lungs for transplant. We report a rat lung transplantation model that allows serial measurement of arterial blood gases after left single lung transplantation from non-heart beating donors.

METHODS

Twelve Sprague-Dawley rats underwent left lung transplantation with a vascular cuff technique. Donor rats were anesthetized with intraperitoneal injection of pentobarbital, heparinized, intubated via tracheotomy, and then killed with pentobarbital. Lungs were retrieved immediately or after 2 hours of oxygen ventilation after death (tidal volume 1 mL/100 g, rate 40/min FIO2 = 1.0, positive end-expiratory pressure 5 cm H2O). Recipient rats were anesthetized, intubated, and ventilated. The carotid artery and jugular vein were cannulated for arterial blood gases and infusion of Ringer's lactate (4 mL/h). Anesthesia was maintained with halothane 0.2%, and recipient arterial blood gases were measured at 4 and 6 hours after lung transplantation after snaring the right pulmonary artery for 5 minutes. Animals were put to death 6 hours after lung transplantation, and portions of transplanted lungs were frozen in liquid nitrogen and assayed for wet/dry ratio, myeloperoxidase as a measure of neutrophil infiltration, and conjugated dienes as a measure of free radical-mediated lipid peroxidation.

RESULTS

Arterial PO2 and wet/dry ratio were not significantly different in recipients of non-heart beating donor lungs retrieved immediately after death or after 2 hours of oxygen ventilation. Significant neutrophil infiltration was observed in recipients of non-heart beating donor lungs retrieved 2 hours after death from oxygen-ventilated donors.

CONCLUSIONS

Strategies to ameliorate reperfusion injury may allow for successful lung transplantation from non-heart beating donors.

Maintenance of cAMP in non-heart-beating donor lungs reduces ischemia-reperfusion injury

Studies suggest that pulmonary vascular ischemia-reperfusion injury (IRI) can be attenuated by increasing intracellular cAMP concentrations. The purpose of this study was to determine the effect of IRI on capillary permeability, assessed by capillary filtration coeficient (Kfc), in lungs retrieved from non-heart-beating donors (NHBDs) and reperfused with the addition of the beta(2)-adrenergic receptor agonist isoproterenol (iso), and rolipram (roli), a phosphodiesterase (type IV) inhibitor. Using an in situ isolated perfused lung model, lungs were retrieved from NHBD rats at varying intervals after death and either ventilated with O(2) or not ventilated. The lungs were reperfused with Earle's solution with or without a combination of iso (10 microM) and roli (2 microM). Kfc, lung viability, and pulmonary hemodynamics were measured. Lung tissue levels of adenine nucleotides and cAMP were measured by HPLC. Combined iso and roli (iso/roli) reperfusion decreased Kfc significantly (p < 0.05) compared with non-iso/roli-reperfused groups after 2 h of postmortem ischemia. Total adenine nucleotide (TAN) levels correlated with Kfc in non-iso/roli-reperfused (r = 0.89) and iso/roli-reperfused (r = 0.97) lungs. cAMP levels correlated with Kfc (r = 0.93) in iso/roli-reperfused lungs. Pharmacologic augmentation of tissue TAN and cAMP levels might ameliorate the increased capillary permeability observed in lungs retrieved from NHBDs.

Molecular cloning and functional characterization of the zebrafish ATP-gated ionotropic receptor P2X(3) subunit

We describe a P2X subunit cloned from the zebrafish (Danio rerio) that is an orthologue of the mammalian P2X(3) subunit. Like the mammalian P2X(3), this receptor desensitizes rapidly in the presence of agonist. However, it differs in that alphabeta-meATP is a much less potent agonist than ATP and the antagonist TNP-ATP is not active at low nanomolar concentrations. Similar to the rat P2X(3) subunit, the zebrafish subunit forms hetero-oligomeric assemblies with the rat P2X(2) that possesses a phenotype distinct from either parent. This novel clone will provide an important basis for future experiments investigating the structure/function relationships of P2X subunit domains.

Factors associated with adherence to treatment regimens after lung transplantation

CONTEXT

The number of patients currently awaiting lung transplantation far exceeds the supply of available organs. Adherence to postoperative treatment regimens is essential for optimal posttransplant success.

OBJECTIVE

The present study was designed to examine the demographic and psychological factors associated with compliance in patients who have had lung transplants.

DESIGN

Eighteen women and 13 men participated in this study an average of 24 months after transplantation, completing a demographic form, a self-report compliance measure, a social support questionnaire, and the Multidimensional Health Locus of Control Scale. A significant other or family member and the posttransplant nurse coordinator also rated each subject's compliance with the posttransplant regimen.

RESULTS

Although patients rated themselves as being compliant with aspects of their self-care, on more subtle measures of compliance, their self-reported compliance was not as impressive. Patients who had had their transplants more recently appeared to be more compliant. Patients with cystic fibrosis used their spirometer more often than patients with other lung diseases. Family support was significantly correlated with self-reported compliance.

CONCLUSIONS

This study suggests that how patients are asked about adherence to treatment regimens influences how compliant they appear. The data also indicate that the longer after transplant, the less compliant the patient, and suggests the need for patient reeducation at some point after transplant. Longitudinal studies are needed to assess the degree to which compliance affects the number of rejection and febrile episodes as well as patient mortality after lung transplant.

Properties of the novel ATP-gated ionotropic receptor composed of the P2X(1) and P2X(5) isoforms

We recently reported that a novel hetero-oligomeric P2X receptor is formed from the P2X(1) and P2X(5) isoforms when coexpressed in human embryonic kidney 293 cells (). A more complete description of the pharmacology of this novel receptor is presented here. A brief application of ATP to a voltage-clamped cell transiently expressing P2X(1/5) receptors resulted in a biphasic current that rapidly reached a peak and then decayed to a sustained plateau. Washout of ATP was accompanied by generation and fade of a pronounced tail of inward current. EC(50) values were determined from concentration-response curves for a range of agonists. The rank order of agonist potency was ATP >/= 2 methylthio ATP > adenosine 5'-O-(3-thiotriphosphate) > alpha,beta-methylene ATP > ADP > CTP. alpha,beta-methylene ADP, UTP, GTP, and AMP were ineffective. Only ATP and 2 methylthio ATP were full agonists. IC(50) values were determined from concentration-response curves for three commonly used purinergic antagonists. Suramin and pyridoxal phosphate-6-azophenyl-2', 4'-disulfonic acid were equipotent at P2X(1) and P2X(1/5) receptors; however, the P2X(1/5) receptor was much less sensitive to TNP-ATP than was the P2X(1) receptor. The amplitude of peak ATP-gated current was relatively insensitive to changes in [Ca(2+)](O) (1-30 mM). Finally, plateau currents were potentiated by low concentrations of pyridoxal phosphate-6-azophenyl-2', 4'-disulfonic acid and by raising [Ca(2+)](O). These results provide additional information on the pharmacological profile of the recombinant P2X(1/5) receptor channel and provide a basis to further evaluate ATP-induced currents in native tissues.

Identification of a domain involved in ATP-gated ionotropic receptor subunit assembly

P2X receptors are ATP-gated ion channels found in a variety of tissues and cell types. Seven different subunits (P2X(1)-P2X(7)) have been molecularly cloned and are known to form homomeric, and in some cases heteromeric, channel complexes. However, the molecular determinants leading to the assembly of subunits into P2X receptors are unknown. To address this question we utilized a co-immunoprecipitation assay in which epitope-tagged deletion mutants and chimeric constructs were examined for their ability to co-associate with full-length P2X subunits. Deletion mutants of the P2X(2) receptor subunit were expressed individually and together with P2X(2) or P2X(3) receptor subunits in HEK 293 cells. Deletion of the amino terminus up to the first transmembrane domain (amino acid 28) and beyond (to amino acid 51) did not prevent subunit assembly. Analysis of the carboxyl terminus demonstrated that mutants missing the portion of the protein downstream of the second transmembrane domain could also still co-assemble. However, a mutant terminating 25 amino acids before the second transmembrane domain could not assemble with other subunits or itself, implicating the missing region of the protein in assembly. This finding was supported and extended by data utilizing a chimera strategy that indicated TMD2 is a critical determinant of P2X subunit assembly.

Hetero-oligomeric assembly of P2X receptor subunits. Specificities exist with regard to possible partners

P2X receptors are a distinct family of ligand-gated ion channels activated by extracellular ATP. Each of the seven identified subunit proteins (P2X1 through P2X7) has been reported to form functional homo-oligomeric channels when expressed in heterologous systems. Functional studies of native receptors, together with patterns of subunit gene expression, suggest that hetero-oligomeric assembly among members of this family may also occur. This prediction is supported by reports describing hetero-oligomeric assembly for three different recombinant subunit combinations. In this report, we systematically examined the ability of all members of the P2X receptor family to interact using a co-immunoprecipitation assay. The seven P2X receptor subunits were differentially epitope-tagged and expressed in various combinations in human embryonic kidney 293 cells. It was found that six of the seven subunits formed homo-oligomeric complexes, the exception being P2X6. When co-assembly between pairs of subunits was examined, all were able to form hetero-oligomeric assemblies with the exception of P2X7. Whereas P2X1, P2X2, P2X5, and P2X6 were able to assemble with most subunits, P2X3 and P2X4 presented a more restricted pattern of co-association. These results suggest that hetero-oligomeric assembly might underlie functional discrepancies observed between P2X responses seen in the native and recombinant settings, while providing for an increased diversity of signaling by ATP.

Inadequacy of computed tomography in assessing patients with esophageal carcinoma after induction chemoradiotherapy

BACKGROUND

Induction chemoradiotherapy followed by surgery may improve survival of patients with esophageal carcinoma. Computed tomography (CT) has been used to evaluate the tumor response after completing induction chemoradiotherapy. The authors examined the ability of CT to evaluate the pathologic tumor response to induction therapy and to stage the tumor correctly.

METHODS

Preinduction and postinduction chemoradiotherapy CT scans were reviewed retrospectively for 50 patients enrolled in a protocol of induction chemoradiotherapy followed by surgery. All studies were performed on third-generation or fourth-generation scanners. Radiographic response was determined using Eastern Cooperative Oncology Group solid tumor response criteria for bidimensional measurable disease. This was compared with the pathologic tumor response. CT-tumor (T) classification using the modified Tio scale was compared with the pathologic T classification.

RESULTS

CT-T classification did not correlate with the pathologic stage (P = 0.09) or the pathologic tumor response (P = 0.22). The postinduction chemoradiotherapy CT accurately staged the T classification in 42% of patients but overstaged 36% of patients and understaged 20% of patients. CT had a sensitivity of 65%, a specificity of 33%, a positive predictive value of 58%, and a negative predictive value of 41% in evaluating the pathologic tumor response.

CONCLUSIONS

CT is a poor diagnostic study tool for determining the pathologic tumor response or the pathologic disease stage after induction chemoradiotherapy in patients with esophageal carcinoma.

Reduced ischemia-reperfusion injury with rolipram in rat cadaver lung donors: effect of cyclic adenosine monophosphate

BACKGROUND

The perfusion of rat lungs retrieved from cadavers with a solution containing isoproterenol has been shown to ameliorate the ischemia-reperfusion injury seen in lungs retrieved after death, and this protective effect parallels increases in tissue cyclic adenosine monophosphate levels. In this study, we investigated the effect of rolipram, a phosphodiesterase inhibitor, on capillary permeability and lung cyclic adenosine monophosphate levels in lungs retrieved from circulation-arrested rats.

METHODS

Using an isolated perfused lung circuit, we retrieved lungs from circulation-arrested donor rats either ventilated with 100% oxygen or not ventilated for varying postmortem times. The lungs were reperfused with or without rolipram (2 micromol/L). The capillary filtration coefficient and wet to dry weight ratio, indicators of pulmonary vascular integrity, were determined, and tissue levels of adenine nucleotides and cyclic adenosine monophosphate were measured by high-performance liquid chromatography.

RESULTS

The capillary filtration coefficient was significantly reduced in nonventilated cadaver lungs reperfused with rolipram 120 minutes after death (p<0.05). Oxygen ventilation or reperfusion with rolipram had a similar effect on the capillary filtration coefficient. Cyclic adenosine monophosphate levels were significantly higher in rolipram-reperfused lungs retrieved 120 minutes after death in both oxygen-ventilated (p<0.01) and nonventilated (p<0.01) lungs.

CONCLUSIONS

In lungs from nonventilated, circulation-arrested donors, reperfusion with rolipram reduces the ischemia-reperfusion injury that may be due to intracellular cyclic adenosine monophosphate. Alteration of perfusate may have an impact on capillary leak caused by antecedent ischemia. Thus, rolipram may be a useful adjunct in the preservation of donor lungs retrieved after death.

Co-expression of P2X1 and P2X5 receptor subunits reveals a novel ATP-gated ion channel

P2X receptors are a family of ion channels gated by extracellular ATP. Each member of the family can form functional homomeric channels, but only P2X2 and P2X3 have been shown to combine to form a unique heteromeric channel. Data from in situ hybridization studies suggest that P2X1 and P2X5 may also co-assemble. In this study, we tested this hypothesis by expressing recombinant P2X1 and P2X5 receptor subunits either individually or together in human embryonic kidney 293 cells. In cells expressing the homomeric P2X1 receptor, 30 microM alpha,beta-methylene ATP (alpha,beta-me-ATP) evoked robust currents that completely desensitized in less than 1 sec, whereas alpha,beta-me-ATP failed to evoke current in cells expressing the homomeric P2X5 receptor. By contrast, alpha, beta-me-ATP evoked biphasic currents with a pronounced nondesensitizing plateau phase in cells that co-expressed both subunits. Further, the EC50 for alpha,beta-me-ATP was greater in cells expressing both P2X1 and P2X5 than in cells expressing P2X1 alone (5 and 1.6 microM, respectively). Heteromeric assembly was confirmed using a co-immunoprecipitation assay of epitope-tagged P2X1 and P2X5 subunits. In summary, this study provides biochemical and functional evidence of a novel channel formed by P2X subunit heteropolymerization. This finding suggests that heteromeric subunit assembly constitutes an important mechanism for generating functional diversity of ATP-mediated responses.

N-Linked glycosylation is essential for the functional expression of the recombinant P2X2 receptor

P2X receptors are integral membrane proteins that belong to the growing family of transmitter-gated ion channels. The extracellular domain of these receptors contains several consensus sequences for N-linked glycosylation that may contribute to the functional expression of the channel. We have previously reported the extracellular orientation of asparagine residues 182, 239, and 298 of the P2X2 receptor subunit by showing that the protein is glycosylated at each site [Torres, G. E., et al. (1998) FEBS Lett. 425, 19-23 (1)]. In this study, we focused on the consequences of removing N-linked glycosylation from the P2X2 receptor by using two different approaches, tunicamycin treatment or site-directed mutagenesis. HEK-293 cells stably transfected with the P2X2 receptor subunit showed little or no response to ATP after tunicamycin treatment. In addition, loss of function was observed with the elimination of all three N-linked glycosylation sites from P2X2. Cell surface labeling with biotin or indirect immunofluorescence revealed that the expression of the nonglycosylated receptors produced by either tunicamycin or site-directed mutagenesis is greatly reduced at the cell surface, indicating that the nonglycosylated P2X2 receptors are retained inside the cell. These data provide the first direct evidence for a critical role of N-linked glycosylation in the cell surface expression of a P2X receptor subunit.

Neuropeptide Y receptors involved in calcium channel regulation in PC12 cells

Our laboratory has previously used NGF-differentiated PC12 cells as a sympathetic neuronal model to investigate the effects of NPY on catecholamine synthesis and release. We have additionally used these cells to demonstrate the NPY-induced inhibition of Ca2+ channels which was suggested by those studies. In the present work, multiple NPY, PYY, and PP analogs are utilized to further define the receptor subtypes involved in this Ca2+ channel modulation. We find that in PC12 cells NPY and PP modulate Ca2+ channels through Y1, Y2, Y3, and Y4 receptors. In addition, we show that these receptors are differentially coupled to N, L, and non-N, non-L Ca2+ channel subtypes. The results of the present study in combination with our previous investigations demonstrate an intriguing and complex role for NPY and PP in the modulation of sympathetic neurotransmission.

Lung transplantation for cystic fibrosis: effective and durable therapy in a high-risk group

BACKGROUND

The purpose of this study was to review our experience with lung transplantation in patients with end-stage cystic fibrosis.

METHODS

Eight-two patients with cystic fibrosis have undergone bilateral lung transplantation (n=76) or bilateral lower lobe transplantation (n=6) since October 1990.

RESULTS

Actuarial survival for the entire cohort is 79% at 1 year and 57% at 5 years. The development of bronchiolitis obliterans syndrome is the leading cause of death after the first year. Freedom from bronchiolitis obliterans syndrome is 84% at 1 year and 51% at 3 years. Pulmonary function tests improve dramatically in recipients. There was no association between death within 1 year and recipient age, weight, graft ischemic time, cytomegalovirus seronegativity, or the presence of pan-resistant organisms. Similarly, there was no association between the development of bronchiolitis obliterans syndrome within 2 years and ischemic time, number of rejection episodes, cytomegalovirus seronegativity, or the presence of panresistant organisms.

CONCLUSIONS

Despite their poor nutritional status and the presence of multiply resistant organisms, patients with cystic fibrosis can undergo bilateral lung transplantation with acceptable morbidity and mortality.

Neuropeptide Y inhibition of calcium channels in PC-12 pheochromocytoma cells

We previously demonstrated, using rat PC-12 pheochromocytoma cells differentiated to a sympathetic neuronal phenotype with nerve growth factor (NGF), that neuropeptide Y (NPY) inhibits catecholamine synthesis as well as release. Inquiry into the mechanisms of these inhibitions implicated distinct pathways involving reduction of Ca2+ influx through voltage-activated Ca2+ channels. In the present investigation the effects of NPY on whole cell Ba2+ currents were examined to obtain direct evidence supporting the mechanisms suggested by those studies. NPY was found to inhibit the voltage-activated Ba2+ current in NGF-differentiated PC-12 cells in a reversible fashion with an EC50 of 13 nM. This inhibition was pertussis toxin sensitive and resulted from NPY modulation of L- and N-type Ca2+ channels. The inhibition of L-type channels was not seen with < 1 nM free intracellular Ca2+ or when protein kinase C (PKC) was inhibited by chelerythrine or PKC-(19-31). Furthermore, the effect of NPY on L-type channels was mimicked by the PKC activator phorbol 12-myristate 13-acetate. These studies demonstrate that, in addition to inhibition of N-type Ca2+ channels, in NGF-differentiated PC-12 cells NPY inhibits L-type Ca2+ channels via an intracellular Ca(2+)- and PKC-dependent pathway.

A domain contributing to the ion channel of ATP-gated P2X2 receptors identified by the substituted cysteine accessibility method

P2X receptors are a family of ATP-gated ion channels thought to have intracellular N and C termini and two transmembrane segments separating a large extracellular domain. We examined the involvement of the second putative transmembrane domain (TM2) of the P2X2 subunit in ion conduction, using the substituted cysteine accessibility method (SCAM). This method tests the ability of hydrophilic reagents such as Ag+ or the methanethiosulfonates to modify covalently the sulfhydryl side chains exposed to aqueous environments. ATP-gated current was measured in HEK293 cells transiently expressing either wild-type or functional mutant P2X2 receptors containing a cysteine substitution in or around TM2. Application of Ag+ to gating channels had no sustained effect on wild-type P2X2 (WT) but irreversibly altered whole-cell currents in 15 mutants. By contrast, bath application of (2-aminoethyl)methanethiosulfonate (MTSEA) to closed channels inhibited 8 of the 15 residues affected by Ag+ when the channel was gating. Inhibition of the closed channel was prevented in seven of eight mutants when membrane-permeant MTSEA was scavenged by 20 mM intracellular cysteine, indicating that these seven mutants lie on the intracellular side of the channel gate. Further, MTSEA inhibited current through G342C in the absence of intracellular cysteine but augmented the current when cysteine was present, suggesting that this residue may be part of the gate. Taken together, the data help to the identify a functional domain of the channel pore by mapping residues on either side of the channel gate.

Topological analysis of the ATP-gated ionotropic [correction of ionotrophic] P2X2 receptor subunit

We investigated the transmembrane topology of the P2X2 receptor subunit expressed in HEK 293 cells. Initial studies using two P2X subunits expressed in tandem indicated that the amino- and carboxy-termini are on the same side of the membrane. Immunofluorescence studies showed the cytoplasmic orientation of the amino- and carboxy-termini. Finally, N-glycosylation scanning mutagenesis revealed that reporter sites inserted into the central loop, but not those in the amino- or carboxy-terminal regions, were glycosylated, thus suggesting an extracellular placement for that domain. Our results support a two-transmembrane arrangement for P2X receptors with intracellular amino- and carboxy-termini.

Effect of perfusion pH on rat lung viability of non-heart beating donors

OBJECTIVE

Non-heart beating donors could be an important source of lungs for transplantation. In prior experiments, trypan blue exclusion was used to assess the percentage of viable lung cells after different intervals following circulatory arrest. In this study, we assessed the importance of the trypan blue perfusate pH because in liver preservation studies, pH of the perfusate appears to be very important with the presence of a 'pH paradox'.

METHODS

Forty Sprague-Dawley rats (n = 5 each group) were sacrificed, left at room temperature, and ventilated with 100% O2 (tidal volume 0.01 cc/g, rate 30/min) for 4 or 8 h after death. Lungs were then flushed with 150 cc of trypan blue in Krebs-Heinseleit buffer via the pulmonary artery, then with 150 cc of fixative (2%) paraformaldehyde + 2% gluteraldehyde). The pH of the trypan blue solution was varied from 6.5 to 7.8. Lungs were sectioned, and cell viability was quantified based on exclusion of trypan blue.

RESULTS

Longer cadaver time was associated with less viability, but pH had no effect on viability. The results were similar in groups ventilated for the same period of time and then flushed with solutions at different pH (4 h, viability 80-84%; 8 h, viability 68-72%). Over the range investigated, the pH of the trypan blue solution had no impact on lung viability in non-heart beating donors and the lungs did not show the 'pH paradox'.

CONCLUSION

Lung tissue is not susceptible to the 'pH paradox' observed in liver preservation studies. Because more than 80% of lung cells are still viable 4 h after death if the lungs are ventilated with 100% O2 during the cadaveric period, retrieval and transplantation of cadaveric lungs may be feasible and might alleviate the paucity of lung donors.

Induction chemoradiotherapy followed by esophagectomy in patients with carcinoma of the esophagus

BACKGROUND

Induction chemoradiotherapy followed by esophagectomy may provide results superior to those of single-modality treatment in patients with esophageal cancer. The purpose of this study was to review our experience with this approach for esophageal cancer.

METHODS

From 1988 to 1996, 166 consecutive patients with esophageal cancer were evaluated; 66 entered a protocol of chemotherapy (5-fluorouracil, cisplatin) concurrent with radiation (45 Gy) followed by esophagectomy. Fifty-four patients completed the protocol.

RESULTS

Toxicity associated with induction chemoradiotherapy was minimal. The actuarial survival at 12, 24, and 36 months was 59%, 42%, and 32%, respectively. The pathologic complete response (pCR) rate was 41%, with 12-, 24-, and 36-month survivals of 77%, 50%, and 45%, whereas non-pCR patients had survivals of 46%, 35%, and 23%. The difference in survival between pCR and non-pCR patients was not significant (p = 0.13), but the difference in recurrence-free survival was significant (p = 0.007).

CONCLUSIONS

This well-tolerated protocol resulted in a high pCR. Trimodality treatment for esophageal cancer may provide long-term survival in some patients regardless of their pCR status.

When does the lung die? Kfc, cell viability, and adenine nucleotide changes in the circulation-arrested rat lung

Lungs harvested from cadaveric circulation-arrested donors may increase the donor pool for lung transplantation. To determine the degree and time course of ischemia-reperfusion injury, we evaluated the effect of O2 ventilation on capillary permeability [capillary filtration coefficient (Kfc)], cell viability, and total adenine nucleotide (TAN) levels in in situ circulation-arrested rat lungs. Kfc increased with increasing postmortem ischemic time (r = 0.88). Lungs ventilated with O2 1 h postmortem had similar Kfc and wet-to-dry ratios as controls. Nonventilated lungs had threefold (P < 0.05) and sevenfold (P < 0.0001) increases in Kfc at 30 and 60 min postmortem compared with controls. Cell viability decreased in all groups except for 30-min postmortem O2-ventilated lungs. TAN levels decreased with increasing ischemic time, particularly in nonventilated lungs. Loss of adenine nucleotides correlated with increasing Kfc values (r = 0.76). This study indicates that lungs retrieved 1 h postmortem may have normal Kfc with preharvest O2 ventilation. The relationship between Kfc and TAN suggests that vascular permeability may be related to lung TAN levels.

Reduced ischemia-reperfusion injury with isoproterenol in non-heart-beating donor lungs

Transplantation of lungs retrieved from non-heart-beating donors could expand the donor pool. Recent studies suggest that the ischemia-reperfusion injury (IRI) to the lung can be attenuated by increasing intracellular cAMP concentrations. The purpose of this study was to determine the effect of IRI on capillary permeability, as measured by Kfc, in lungs retrieved from non-heart-beating donors and reperfused with or without isoproterenol (iso). Using an in situ isolated perfused lung model, lungs were retrieved from non-heart-beating donor rats ventilated with O2 or not at varying intervals after death. The lungs were reperfused with or without iso (10 microM). Kfc, lung viability, and pulmonary hemodynamics were measured, and tissue levels of adenine nucleotides and cAMP were measured by HPLC. Iso-reperfusion decreased Kfc significantly (P < 0.05) compared to non-iso-reperfused groups at all postmortem ischemic times, irrespective of preharvest ventilation status. Pulmonary arterial pressures and resistances increased and venous resistances decreased with iso-reperfusion. Total adenine nucleotide (TAN) levels correlated with Kfc in non-iso-reperfused (r = 0.65) and iso-perfused (r = 0.84) lungs. cAMP levels increased significantly with iso-reperfusion. cAMP levels correlated with Kfc (r = 0.87) in iso-reperfused lungs. Iso-reperfusion of lungs retrieved from non-heart-beating donor rats results in decreased capillary permeability and increased lung tissue cAMP levels. Pharmacologic augmentation of tissue TAN and cAMP levels may further ameliorate the increased capillary permeability seen in lungs retrieved from non-heart-beating donors.

Seizures in lung transplant recipients

PURPOSE

We wished to assess organ transplant recipients, who incur a significant risk for seizures.

METHOD

We reviewed 85 lung transplants performed in 81 patients at the University of North Carolina hospitals between 1991 and 1994. All patients were reviewed for age, reason for transplant, detailed description of seizures, neurological examination, medications, and laboratory results, including cyclosporine level, EEG, and brain imaging.

RESULTS

Eighteen of 81 (22%) patients experienced seizures. Patients aged < 25 years had the greatest risk of seizures and 15 of the 18 patients had cystic fibrosis. Sixteen of the 18 (89%) patients, by history, had partial-onset seizures. Eleven of the 18 (61%) patients had seizures < or = 10 days after initiation of intravenous methylprednisolone for allograft rejection. Two patients had seizures associated with sustained hypertension: 1 of these patients was simultaneously being treated for rejection. Four patients had strokes (1 before transplant) and seizures. Two patients were receiving imipenem. Magnetic resonance imaging (MRI) of the brain demonstrated areas of increased T2 signal in 8 of 9 patients.

CONCLUSIONS

Our findings demonstrate multiple etiologies for seizures in our transplant recipients. However, we believe that patients, especially those aged < 25 years, being treated with intravenous methylprednisolone for rejection may be at increased risk of seizures. We hypothesize that the focal loss of blood-brain barrier (BBB) may play a significant role in the development of partial seizures in lung transplant recipients.

Studies of rat lung viability and adenine nucleotide metabolism after death

BACKGROUND

Prior studies from our laboratory have supported the use of cadaveric lungs for transplantation. In this study we investigated different preservation strategies for lungs retrieved from cadavers 4 hours after circulatory arrest.

METHODS

Seventy-two Sprague-Dawley rats were sacrificed and then ventilated with 100% oxygen for 4 hours. The lungs were then flushed with modified Euro-Collins, University of Wisconsin, or Carolina rinse solution, either alone, with prostaglandin E1, or with prostaglandin E1 plus the free radical scavenger dimethylthiourea. After an additional 4-hour cold storage, the left lung was flushed with trypan blue solution to quantify cell viability, whereas the right lung was used to determine wet-to-dry weight ratios and to measure the levels of the adenine nucleotides adenosine triphosphate, adenosine diphosphate, and adenosine monophosphate by high-performance liquid chromatography.

RESULTS

Viability was consistently better in the lungs flushed with Carolina rinse solution; these differences were statistically significant compared with those in the corresponding modified Euro-Collins subgroups (p < 0.005). The addition of prostaglandin E1 to all three preservation solutions improved the total adenine nucleotide levels; this increase was statistically significant for the modified Euro-Collins subgroup (p < 0.005). The total adenine nucleotide levels for the University of Wisconsin subgroups were higher than those for the corresponding modified Euro-Collins subgroups. The highest total adenine nucleotide levels were obtained in lungs flushed with Carolina rinse plus prostaglandin E1. Wet-to-dry weight ratios were always significantly lower in the lungs preserved with University of Wisconsin solution (p < 0.05), with a value similar to that of fresh tissue.

CONCLUSIONS

The characteristics of the solution used to flush and to store rat cadaveric lungs have an impact on lung viability and adenine nucleotide metabolism. The ideal preservation strategy may allow for lung retrieval from cadavers for safe transplantation.

Canine double-lung transplantation with cadaveric donors

If lungs could be retrieved from cadavers after circulatory arrest, the critical shortage of donors for lung transplantation might be alleviated. To assess gas exchange after transplantation of lungs from cadaveric donors, we performed double-lung transplantation through sequential thoracotomies in 12 dogs. Donors were sacrificed by intravenous pentobarbital injection and then ventilated with 100% oxygen. Lungs were harvested 2 hours (n = 6) or 4 hours (n = 6) after death and flushed with 2 L modified Euro-Collins solution. Recipients underwent sequential right and left lung transplantation; they were then monitored while under anesthesia for 8 hours, with adjustments of the fraction of inspired oxygen. Nine of 12 recipients survived the 8-hour study period. Four of six dogs with cadaveric lungs retrieved 2 hours after death survived; deaths were from pulmonary embolism at 6 hours and pulmonary edema at 2 hours. Five of six dogs with cadaveric lungs retrieved 4 hours after death survived; one died of hypoxia during implantation of the left lung, while dependent on the right lung graft. Postoperative hemodynamic and gas exchange parameters were similar in both groups. Alveolar-arterial oxygen gradient rose significantly compared with baseline 1 hour after transplantation in both groups (462 +/- 60 vs 38 +/- 31 mmHg for 2-hour group, p < 0.0001, and 484 +/- 63 vs 38 +/- 14 mmHg for 4-hour group, p < 0.0002). By 8 hours after operation, the gradients had significantly decreased in both groups (105 +/- 37 mm Hg for 2-hour group and 146 +/- 53 mm Hg for 4-hour group) and were similar to baseline values. Extravascular lung water also rose significantly 1 hour after transplantation (15.7 +/- 2.8 vs 7.9 +/- 0.5 ml/kg for 2-hour group, p < 0.02, and 16.9 +/- 1.2 vs 6.6 +/- 0.4 ml/kg for 4-hour group, p < 0.0001) and decreased gradually during the 8-hour study period. Donor lungs retrieved at 2 and 4 hours postmortem afford similar recipient outcomes. Improvement in alveolar-arterial oxygen gradient and reduction in extravascular lung water during the study period imply that the ischemia-reperfusion injury induced by this model is reversible. If this approach could be safely introduced to clinical practice, substantially more transplant procedures could be performed.

One hundred consecutive thymectomies for myasthenia gravis

BACKGROUND

Between June 1997 and November 1993, 100 consecutive thymectomies for myasthenia gravis were performed at University of North Carolina Hospitals in Chapel Hill.

METHODS

A consistent, planned protocol involving preoperative, intraoperative, and postoperative care was followed. All thymectomies were performed through a median sternotomy with removal of all visible thymus and perithymic fat in the anterior mediastinum.

RESULTS

There was no perioperative mortality or longterm morbidity. Mean postoperative hospital stay was 6.3 days (range, 3 to 18 days). Ninety-six percent of the patients were extubated the day of the operation, and all patients were extubated within 24 hours. Mean postoperative intensive care unit stay was 1.2 days (range, 1 to 4 days). After a mean follow-up of 65 months (range, 1 to 199 months), 78% of all patients are improved by at least one modified Osserman classification when their current status is compared with their worst preoperative disease severity. In fact, 69% of patients with mild disease preoperatively (class I, II, or III maximal severity) are in pharmacologic remission (asymptomatic without regular medication), whereas 29% of patients with severe disease (class IV or V) are in remission (p = 0.0001).

CONCLUSIONS

Our programmatic approach to thymectomy through a sternotomy has shown minimal morbidity and mortality. It is beneficial to myasthenics at both ends of the age and severity spectrum.

Lung retrieval from cadaver donors with nonbeating hearts: optimal preservation solution

BACKGROUND

We have previously studied the time course of pulmonary cell viability, ultrastructural damage, and adenine nucleotide metabolites after circulatory arrest in a rat model to investigate the feasibility of lung retrieval for transplantation from cadavers. This study was designed to investigate the effect of hypothermic flush and subsequent 4-hour storage with either modified Euro-Collins or University of Wisconsin solution on lungs retrieved 4 hours after death.

METHODS

Ninety-six Sprague-Dawley rats were sacrificed by intraperitoneal injection of pentobarbital. Control lungs were flushed immediately after sacrifice and stored for 4 hours. Rats in the experimental groups were sacrificed, and then their lungs were either ventilated with 100% oxygen or not ventilated for 4 hours before flushing with either Euro-Collins or University of Wisconsin solution followed by 4-hour hypothermic storage. At the end of the storage period, all right lungs were maintained at -70 degrees C and used to determine wet-to-dry weight ratios and adenine nucleotide levels with high-pressure liquid chromatography. Left lungs were assessed for viability with trypan blue dye exclusion. The effect on viability of flushing with Carolina rinse solution after storage was also assessed.

RESULTS

The percentage of viable cells in the control group after 4-hour hypothermic storage was 74% +/- 2% in Euro-Collins solution-flushed lungs and 78% +/- 2% in University of Wisconsin solution-flushed lungs. This result was virtually identical to that of lungs retrieved after 4 hours of in situ oxygen ventilation followed by 4 hours of hypothermic storage. Nonventilated cadaver lungs had substantially less viability. Adenosine triphosphate levels were significantly higher in the control group than in the oxygen-ventilated group, which were higher still than those in the nonventilated group. Adenosine triphosphate levels were consistently higher in University of Wisconsin solution-flushed lungs compared with Euro-Collins solution-flushed lungs in all groups. Total adenine nucleotide levels had a similar pattern. Wet-to-dry ratios were significantly lower in the control group (Euro-Collins = 6.27 +/- 0.46, University of Wisconsin = 4.63 +/- 0.07) compared with the oxygen-ventilated (Euro-Collins = 9.80 +/- 0.44, University of Wisconsin = 10.96 +/- 0.60) and nonventilated (Euro-Collins = 9.44 +/- 0.26, University of Wisconsin = 11.54 +/- 1.16; p < 0.0001) groups.

CONCLUSIONS

Four hours of circulatory arrest before 4 hours of hypothermic storage had no additional adverse impact on lung viability compared with lungs subjected to 4 hours of hypothermic storage alone, provided nonperfused lungs were ventilated with 100% oxygen. Adenine nucleotide levels were well maintained in oxygen-ventilated cadaver lungs, more so in University of Wisconsin solution-flushed lungs compared with Euro-Collins solution-flushed lungs.

Severe osteoporosis before and after lung transplantation

STUDY OBJECTIVE

Osteoporosis and/or fractures have been reported as a complication of kidney, heart, liver, bone marrow, and, most recently, lung transplantation (LTx). We measured bone mineral density (BMD) before and after LTx to determine the frequency and severity of preoperative and postoperative osteoporosis.

PATIENTS AND METHODS

We conducted a cross-sectional study of BMD in 100 patients with various diagnoses before (n = 55) and after (n = 45) LTx.

RESULTS

Age-matched mean spine and femoral BMDs were severely depressed before and after LTx placing 45% of the pre-LTx and 73% of the post-LTx patients at or below the fracture threshold (2 SDs below the mean). As expected, patients with cystic fibrosis had lower (p < 0.05) mean spine and femoral BMD than patients with COPD or other lung diseases both before and after LTx. Nevertheless, considerable osteoporosis was present in the patients with COPD and other lung diseases before and after LTx. The best predictors of pre- and post-LTxZ scores were body mass index (r = 0.56 to 0.59, p < 0.001) and cumulative steroid dose/per kilogram (r = 0.49-0.51, p < 0.001), respectively. Osteoporosis has resulted in 3 symptomatic fractures before and 12 after LTx.

CONCLUSIONS

Osteoporosis appears to be widespread in patients with end-stage respiratory failure before LTx and LTx, while often life-saving, has an adverse impact on BMD. As patients live longer after LTx, osteoporosis-related fractures may compromise quality of life by causing pain and debilitation.

Cadaver lungs for transplantation. Effect of ventilation with alveolar gas

In an effort to increase the donor pool for lung transplantation (LTX), we have demonstrated the feasibility of LTX from circulation-arrested cadavers in a canine LTX model. We hypothesized that ventilation of the cadaver lung with alveolar gas (20% O2, 5% CO2, balance N2) (AG) would be superior to ventilation with 100% oxygen (O2) after circulatory arrest of the donor. Twelve mongrel dogs were intubated, heparinized and euthanized by pentothal injection and ventilated with AG (n=6) or O2 (n=6). Four hours later, donor animals underwent sternotomy, and the lungs were flushed with cold modified Euro-Collins solution, harvested, and stored inflated in ice slush. Left lung allotransplantation was performed, and recipients were made dependent o n the transplanted lung by occlusion of the contralateral bronchus and pulmonary artery. Recipient animals were ventilated with an FiO2 of 0.4 and followed for 8 hr. Total ischemic time was 7.9 hr for both groups. Pulmonary edema developed in all recipients of AG lungs; one recipient survived the 8-hr observation period with poor oxygenation. In contrast, three of six recipients of O2-ventilated lungs survived for 8-hr with excellent gas exchange. Specimens of donor lungs before and after transplant were evaluated histologically utilizing trypan blue exclusion as an indicator of cell viability. At the time of organ retrieval 4 hr after death, 6% of cells were nonviable in the O2-ventilated cadaver lungs. Circulation-arrested cadaver lungs ventilated with 100% O2 prior to organ retrieval have superior pulmonary function after transplant compared with lungs ventilated with AG. Ventilation of cadaver lungs with AG induces pulmonary injury in this model. retrieval of donor lungs from circulation-arrested cadavers has potential for increasing the pulmonary donor pool.

Wegener's granulomatosis mimicking a sternal abscess

Bone destruction as a manifestation of Wegener's granulomatosis has been reported, but these cases were limited to the head and face. We present a case in which a sternal abscess was the initial manifestation of Wegener's granulomatosis. We believe this is the first reported case of bone destruction due to Wegener's occurring in a location other than the head and face.

Donor lungs from ventilated cadavers: impart of a free radical scavenger

BACKGROUND

The shortage of donors for lung transplantation may be alleviated with the use of lungs retrieved from cadavers. The purpose of this study was to determine whether a free radical scavenger, dimethylthiourea, would improve the function of lungs retrieved from ventilated cadavers.

METHODS

Left lung transplantation was performed in 21 dogs. Donors were sacrificed then ventilated with 100% oxygen. After 2 hours, donor lungs were flushed in a blinded fashion with 2 L of modified Euro-Collins solution, with either dimethylthiourea (n = 10) or saline solution (n = 11) added, then harvested. A donor right lung lobe was perfused with trypan blue vital dye to assess cell viability at harvest and after the transplantation. Percentage of nonviability was similar in the dimethylthiourea and control groups (13 versus 20 at retrieval and 38 versus 41 at graft reperfusion). After transplantation, the right pulmonary artery and bronchus were occluded, rendering the recipient on the pulmonary graft. The recipient's lungs were ventilated for 8 hours, with the inspired oxygen fraction maintained at 0.4.

RESULTS

Seven of ten dogs in the dimethylthiourea group survived the 8-hour period, compared with 4 of 11 dogs in the control group. Compared with the control survivors (n = 4) at 8 hours after the operation, the dimethylthiourea survivors (n = 7) had a higher mean arterial oxygen pressure (144 +/- 21 versus 98+/- 12 mm Hg) and cardiac output (2.2 +/- 0.2 versus 1.6 +/- 0.2 L/min) and a lower mean pulmonary vascular resistance (946 +/- 96 versus 1414 +/- 128 dynes.sec-1.cm5, p < 0.05) and extravascular lung water (10.6 +/- 1.2 versus 12.3 +/- 3.2 ml/kg). Differences between groups during the 8-hour period were usually insignificant.

CONCLUSIONS

This model imposes a rigorous challenge to the single transplanted lung, and yet cadaver lungs still supported life in half of the recipients. Dimethylthiourea may confer a benefit to recipients of cadaver lungs.

When does the lung die? Time course of high energy phosphate depletion and relationship to lung viability after "death"

The shortage of lung donors for clinical transplantation could be significantly alleviated if lungs could be retrieved from cadavers hours after death. However, the time course of loss of lung viability after circulatory arrest and organism death remains unclear. To determine postmortem adenine nucleotide tissue levels in the lung and their relationship to lung viability, Sprague-Dawley rats were sacrificed and then ventilated with 100% oxygen (n = 50, O2) or 100% nitrogen (n = 40, N2) or left nonventilated (n = 50). Lungs from control rats (n = 20) were retrieved immediately after sacrifice. Lungs in the three study groups were retrieved at successive intervals postmortem. Adenine nucleotides (ATP, ADP, and AMP) and hypoxanthine and xanthine metabolites of adenosine were extracted from lung tissue and measured using high-performance liquid chromatography. Pulmonary parenchymal cell viability was quantified by pulmonary artery infusion of trypan blue vital dye in the contralateral lung of each animal. By 4 hr postmortem, viability was 85 +/- 1% in the O2-ventilated cadaver rat lungs, significantly higher than in the N2-ventilated (43 +/- 8%) and in the nonventilated (48 +/- 4%) lungs, where the percentage of viable cells was similar. All of the groups showed a time-dependent decrement in ATP levels and total adenine nucleotide (TAN) levels after death, but this was markedly attenuated in O2-ventilated cadaveric rat lung.(ABSTRACT TRUNCATED AT 250 WORDS)

Lung transplantation after previous thoracic surgical procedures

BACKGROUND

This study examined results of lung transplantation after previous thoracic surgical procedures.

METHODS

Twenty percent of the 69 isolated lung transplantations performed at the University of North Carolina between January 1990 and June 1993 were in patients who had undergone a previous thoracic surgical procedure, and an additional 10% had undergone a previous chest tube placement.

RESULTS

No statistically significant increase in morbidity or mortality was observed between those having undergone a previous procedure or chest tube placement and all other patients. Specifically, the length of intubation, length of hospital stay, hospital mortality, or the number of patients who experienced major early complications was not significantly different between these groups. A statistically significant increase in the number of blood products used was observed in the patients with previous thoracic surgical procedures but not with patient having had previous chest tube placements. However, when the data were reanalyzed with respect to the use of cardiopulmonary bypass, those patients requiring bypass had a markedly poorer outcome that reached statistical significance in all of the parameters studied: hospital death, incidence of major complications, length of intubation, hospital stay, incidence of bleeding, and number of blood products used.

CONCLUSIONS

We conclude that although increased bleeding may be encountered, lung transplantation can be performed successfully in patients who have had previous thoracic surgical procedures without increased major morbidity or mortality; however, the use of cardiopulmonary bypass has been associated with significantly increased morbidity and mortality in our patient population.

Analysis of cystic fibrosis referrals for lung transplantation

Patients with cystic fibrosis (CF) are being considered in increasing numbers as candidates for lung transplantation, despite earlier concerns that their nutritional status and the infective nature of their lung disease would contribute to increased morbidity and mortality. We undertook a retrospective analysis of patients with CF referred for consideration of lung transplant to identify factors that helped to select suitable transplant candidates and to identify characteristics that predicted death while on the waiting list. Analysis of 95 referred patients with CF demonstrated a high rate of suitability (78%) by our criteria. The mean weight of listed patients with CF was 77% predicted, and the mean FEV1 was 20% predicted. Sixteen percent of listed patients with CF died awaiting transplant. The FEV1 of these patients was significantly lower than that of patients who survived to transplant. This study implies that patients with CF are being referred for transplant late in the course of their disease. Earlier referral may lead to an increase in the number of patients with CF undergoing successful lung transplantation.

Effect of size (mis)matching in clinical double-lung transplantation

Current United Network for Organ Sharing policy requires listing lung transplant recipients with an acceptable donor weight range, but lung size is a function of height, age, sex, and race. Frequently, lung transplant recipients are underweight, which results in a large discrepancy between donor and recipient weights. We reviewed our experience with size discrepancy between donors (D) and recipients (R) of 49 double-lung transplant (DLTX) procedures since July 1990. Pneumoreduction procedures were performed in 11 recipients of lungs judged to be too large at the time of DLTX (right middle lobectomy, 2; lingulectomy, 2; both, 6; right middle lobectomy and bilateral apical resections, 1). Predicted forced vital capacity (FVC) and total lung capacity (TLC) of donors and recipients were calculated. Donors were larger than recipients in general (D:R height = 1.02; D:R weight = 1.46), and, as a result, recipient-predicted lung volumes were smaller than donor-predicted lung volumes (D:R FVC = 1.1; D:R TLC = 1.1). Recipients undergoing pneumoreduction procedures had a significantly greater size discrepancy between donors and recipients; thus, both the ratio of D:R and the difference between D and R predicted FVC and TLC were significantly greater among recipients who underwent pneumoreduction, compared with nonreduced recipients. For recipients in the pneumoreduction group, predicted FVC and TLC were recalculated, with a proportionate amount subtracted based on the number of pulmonary segments removed. When the "corrected" FVC and TLC of the donors were compared with recipient-predicted FVC and TLC, there was no longer any significant difference between reduced and non-reduced groups, which implies that visual estimate of size mismatch at surgery is an accurate measure of size discrepancy. Post-DLTX spirometry showed identical improvement in FVC in patients who had pneumoreduction and those who did not, and survival at 6 months was identical in both groups. We conclude that pneumoreduction had no adverse effect on survival or post-DLTX spirometry, allowing safe use of larger donors in small recipients. Also, because lung size is more a function of height than weight, this study challenges the United Network for Organ Sharing practice of listing recipients with an acceptable donor weight range.