Outcome of lung transplantation for adults with interstitial lung disease associated with genetic disorders of the surfactant system

Background

Interstitial lung disease associated with genetic disorders of the surfactant system is a rare entity in adults that can lead to lung transplantation. Our objective was to describe the outcome of these patients after lung transplantation.

Methods

We conducted a retrospective, multicentre study, on adults who underwent lung transplantation for such disease in the French lung transplant centres network, from 1997 to 2018.

Results

20 patients carrying mutations in SFTPA1 (n=5), SFTPA2 (n=7) or SFTPC (n=8) were included. Median interquartile range (IQR) age at diagnosis was 45 (40-48) years, and median (IQR) age at lung transplantation was 51 (45-54) years. Median overall survival after transplantation was 8.6 years. Two patients had a pre-transplant history of lung cancer, and two developed post-transplant lung cancer. Female gender and a body mass index <25 kg·m-2 were significantly associated with a better prognosis, whereas transplantation in high emergency was associated with a worst prognosis.

Conclusions

Lung transplantation in adults with interstitial lung disease associated with genetic disorders of surfactant system may be a valid therapeutic option. Our data suggest that these patients may have a good prognosis. Immunosuppressive protocol was not changed for these patients, and close lung cancer screening is needed before and after transplantation.

Coordination régionale et suivi prospectif du traitement prophylactique et curatif de 301 patients traités par anticorps monoclonaux anti-SARS-CoV-2

Introduction

La pandémie a particulièrement mis en danger nos patients immunodéprimés et questionne notre place dans l’organisation de l’administration des anticorps monoclonaux à titre préventif et curatif. L’objectif de l’étude a été d’évaluer l’activité d’une cellule régionale mise en place pour évaluer l’indication, organiser le traitement prophylactique ou curatif par anticorps monoclonaux ou par antiviraux, quelle que soit la pathologie chronique des patients concernés.

Matériels et méthodes

La cellule « anticorps monoclonaux et traitements du COVID », composée d’un médecin coordonnateur, de médecins retraités, et d’une secrétaire médicale, a été mise en place début janvier 2022 grâce à un financement par l’ARS. Tous les médecins ont été informés par l’ARS et les URPS, des critères d’éligibilité aux anticorps monoclonaux et du rôle de la cellule dans l’évaluation de l’indication, l’aide apportée pour la demande d’accès précoce et la logistique (injections en hospitalisation de jour ou en hospitalisation à domicile (HAD)). Les structures d’HAD ont été spécifiquement formées aux formalités de prescription, à l’administration et au suivi de ces patients. Les patients ayant reçu un traitement prophylactique ont été recontactés par la cellule la semaine suivant l’injection, 3 mois et 6 mois suivant l’injection. Des questionnaires ont été adressés aux médecins généralistes pour évaluer leur perception concernant les anticorps monoclonaux et les antiviraux.

Résultats

Au total, 216 patients (dont 121 patients ayant des facteurs de risque cardiovasculaire) ont reçu un traitement prophylactique par anticorps monoclonaux (Evusheld), pour les indications suivantes : 110 patients transplantés d’organe, 95 patients traités par anti-CD20, 2 patients traités par chimiothérapie, 8 patients ayant d’autres facteurs d’immunodépression et 1 contre-indication au vaccin. Les sollicitations de la cellule dans cette indication émanaient quasi exclusivement de médecins spécialistes. Avec un suivi médian de 6 mois, aucun événement indésirable (EI) grave, y compris cardiovasculaire, n’est survenu. Des EI non graves ont été observés chez 50 patients (23 %). Trente patients (14 %) ont été infectés par le SARS-CoV-2, dont 2 ont été traités par anticorps monoclonaux à titre curatif et 2 par Paxlovid. Aucun patient n’a été hospitalisé pour COVID, aucun n’a développé de COVID sévère. Sur les 214 patients recontactés pour une ré-administration d’anticorps à visée prophylactique, 12 (5 %) l’ont refusée. Au total, 85 patients ont été traités par anticorps monoclonaux à visée curative dont 3 par Ronapreve, 68 par Xevudy, 14 par Evusheld, dont 53 (62,3 %) en HAD et 30 patients ont été traités par Paxlovid. Les sollicitations de la cellule dans cette indication émanaient le plus souvent de médecins généralistes. Aucun effet indésirable grave n’a été observé.

Conclusion

La coordination régionale pour l’aide au traitement par anticorps monoclonaux et antiviraux est utile pour faciliter la prescription de ces traitements. Le suivi prospectif confirme leur tolérance très satisfaisante. Cette coordination a également permis d’évaluer les difficultés rencontrées par les médecins généralistes, en partie liées au caractère innovant, aux difficultés logistiques ou aux contraintes administratives de ces traitements.

The social and clinical impact of the COVID-19 epidemic on the Strasbourg lung transplant cohort: A single-center retrospective cohort study

The clinical and social impacts of the COVID-19 epidemic on lung transplant (LTx) recipients remain poorly known. We aimed to evaluate its social, clinical, and behavioral consequences on the LTx patients followed in Strasbourg university hospital. A questionnaire was used to collect details concerning patients' lifestyles, their protection methods used to avoid COVID-19 contamination, and clinical infection-related information for March 2020. A specific score was created to quantify patients' contacts and the associated risk of infectious contagion. Data were collected from 322 patients (91.2%). A majority reported a higher application than usual of social distancing and barrier measures. 43.8% described infectious-related symptoms and 15.8% needed an anti-infective treatment. There was no difference in symptom onset according to age, native lung disease, diabetes, or obesity. Nineteen patients were tested for COVID-19, and four were diagnosed positive, all with a favorable outcome. The infection risk contact score was higher for symptomatic patients (p: 0.007), those needing extra-medical appointments (p < .001), and those receiving anti-infective treatments (p = .02). LTx patients reported a careful lifestyle and did not seem at higher risk for COVID-19. Our score showed encouraging preliminary results and could become a useful tool for the usual infection-related follow-up of the LTx patients.

Blood CD9+ B cell, a biomarker of bronchiolitis obliterans syndrome after lung transplantation

Bronchiolitis obliterans syndrome is the main limitation for long-term survival after lung transplantation. Some specific B cell populations are associated with long-term graft acceptance. We aimed to monitor the B cell profile during early development of bronchiolitis obliterans syndrome after lung transplantation. The B cell longitudinal profile was analyzed in peripheral blood mononuclear cells from patients with bronchiolitis obliterans syndrome and patients who remained stable over 3 years of follow-up. CD24^hi CD38^hi transitional B cells were increased in stable patients only, and reached a peak 24 months after transplantation, whereas they remained unchanged in patients who developed a bronchiolitis obliterans syndrome. These CD24^hi CD38^hi transitional B cells specifically secrete IL-10 and express CD9. Thus, patients with a total CD9⁺ B cell frequency below 6.6% displayed significantly higher incidence of bronchiolitis obliterans syndrome (AUC = 0.836, PPV = 0.75, NPV = 1). These data are the first to associate IL-10-secreting CD24^hi CD38^hi transitional B cells expressing CD9 with better allograft outcome in lung transplant recipients. CD9-expressing B cells appear as a contributor to a favorable environment essential for the maintenance of long-term stable graft function and as a new predictive biomarker of bronchiolitis obliterans syndrome-free survival.

Acute Cardiac Failure Due to Takotsubo Cardiomyopathy Secondary to a Phone Call for Lung Transplantation: A Case Report

Lung transplantation is a therapeutic option for certain end-stage lung diseases. The phone call for lung transplantation is a major event in the life of these patients; as a result, it can generate significant stress. We herein present the case of a 58-year-old female patient with end-stage chronic obstructive pulmonary disease (COPD) who, while on the lung transplantation waiting list, received such a call. Complete transplant work-up, including cardiac tests undertaken shortly before, had revealed no contraindication to lung transplantation. She was admitted with severe acute respiratory failure, and her extensive work-up was compatible with pulmonary edema due to takotsubo cardiomyopathy. The lung transplantation was thus cancelled, owing to the patient's health condition and the poor quality of the graft as well. The patient stayed in the intensive care unit for several days, requiring noninvasive ventilation. The left ventricular function recovered completely within 10 days postdiagnosis, and the patient was discharged 13 days after her admission. The patient was transplanted 1 month thereafter, without any particular problems; she is currently, 8 months post-transplantation, in good condition. In the given case, the call for lung transplantation could have generated emotional stress severe enough to lead to takotsubo cardiomyopathy.

Regulator of telomere length 1 (RTEL1) mutations are associated with heterogeneous pulmonary and extra-pulmonary phenotypes

Regulator of telomere length 1 (RTEL1) mutations have been evidenced in 5-9% of familial pulmonary fibrosis; however, the phenotype of patients with interstitial lung disease (ILD) and RTEL1 mutations is poorly understood.Whole exome sequencing was performed in 252 probands with ILD and we included all patients with ILD and RTEL1 mutation. RTEL1 expression was evaluated by immunochemistry in the lungs of controls, as well as in RTEL1 and telomerase reverse transcriptase (TERT) mutation carriers.We identified 35 subjects from 17 families. Median age at diagnosis of ILD was 53.1 years (range 28.0-80.6). The most frequent pulmonary diagnoses were idiopathic pulmonary fibrosis (n=20, 57%), secondary ILD (n=7, 20%) and unclassifiable fibrosis or interstitial pneumonia with autoimmune features (n=7, 20%). The median transplant-free and overall survival periods were 39.2 months and 45.3 months, respectively. Forced vital capacity at diagnosis was the only factor associated with decreased transplant-free survival. Extra-pulmonary manifestations were less frequent as compared to other telomere-related gene mutation carriers. A systematic analysis of the literature identified 110 patients with ILD and RTEL1 mutations (including this series) and confirmed the heterogeneity of the pulmonary phenotype, the prevalence of non-idiopathic diseases and the low prevalence of extra-pulmonary manifestations.Immunohistochemistry showed that RTEL1 was expressed by bronchial and alveolar epithelial cells, as well as by alveolar macrophages and lymphocytes, but not by fibroblasts.

First case of Arthrographis kalrae fungemia in a patient with cystic fibrosis

Arthrographis kalrae is a hyalin fungus. It is a saprophyte of the environment, mainly found in soil and compost. In recent years, cases of opportunistic infections attributed to this pathogen have been described. Our patient was a 19-year-old woman with cystic fibrosis. She presented a bacterial and fungal pulmonary colonization with Aspergillus fumigatus and Arthrographis. kalrae. After her lung transplantation, she developed an A. kalrae fungemia, treated with caspofungin 50 mg/day associated to liposomal amphotericin B i.v. 3 mg/kg/day. The patient died 8 months after her transplantation as the result of a bacterial septic shock.