Summary
Definitions for chronic lung allograft dysfunction (CLAD) phenotypes were recently revised (2019 ISHLT consensus). Post‐CLAD onset phenotype transition may occur as a result of change in ...obstruction, restriction, or RAS‐like opacities (RLO). We aimed to assess the prevalence and prognostic implications of these transitions. This was a single‐center, retrospective cohort study of bilateral lung transplants performed in 2009–2015. CLAD phenotypes were determined per ISHLT guidelines. CLAD phenotype transition was defined as a sustained change in obstruction, restriction or RLO. We specifically focused on phenotype changes based on RLO emergence. Association of RLO development with time to death or retransplant were assessed using Kaplan–Meier and Cox proportional hazards models. Among 211 patients with CLAD, 47 (22.2%) experienced a phenotype transition. Nineteen patients developed RLO. Development of RLO phenotype after CLAD onset was associated with a shorter time to death/retransplant when considering the entire CLAD patient cohort (HR = 4.00, CI 2.74–5.83, P < 0.001) and also when restricting the analysis to only patients with a Non‐RLO phenotype at CLAD onset (HR 9.64, CI 5.52–16.84, P < 0.0001). CLAD phenotype change based on emergence of RAS‐like opacities implies a worse outcome. This highlights the clinical importance of imaging follow‐up to monitor for phenotype transitions after CLAD onset.
We assessed the prevalence and prognostic implications of post CLAD onset phenotype transitions in a large cohort of lung transplant recipients. We have shown that CLAD patients who later changed their phenotype due to the appearance of RAS‐like opacities had a significantly worse outcome. Potential event leading to these changes also described.
Community‐acquired viral respiratory tract infections (RTI) in lung transplant recipients may have a high rate of progression to pneumonia and can be a trigger for immunologically mediated ...detrimental effects on lung function. A cohort of 100 patients was enrolled from 2001 to 2003 in which 50 patients had clinically diagnosed viral RTI and 50 were asymptomatic. All patients had nasopharyngeal and throat swabs taken for respiratory virus antigen detection, culture and RT‐PCR. All patients had pulmonary function tests at regular intervals for 12 months. Rates of rejection, decline in forced expiratory volume (L) in 1 s (FEV‐1) and bacterial and fungal superinfection were compared at the 3‐month primary endpoint. In the 50 patients with RTI, a microbial etiology was identified in 33 of 50 (66%) and included rhinovirus (9), coronavirus (8), RSV (6), influenza A (5), parainfluenza (4) and human metapneumovirus (1). During the 3‐month primary endpoint, 8 of 50 (16%) RTI patients had acute rejection versus 0 of 50 non‐RTI patients (p = 0.006). The number of patients experiencing a 20% or more decline in FEV‐1 by 3 months was 9 of 50 (18%) RTI versus 0 of 50 non‐RTI (0%) (p = 0.003). In six of these nine patients, the decline in FEV‐1 was sustained over a 1‐year period consistent with bronchiolitis obliterans syndrome (BOS). Community‐acquired respiratory viruses may be associated with the development of acute rejection and BOS.
Ex Vivo Lung Perfusion Mariscal, Andrea; Cypel, Marcelo; Keshavjee, Shaf
Current transplantation reports,
06/2017, Letnik:
4, Številka:
2
Journal Article
Recenzirano
Odprti dostop
Purpose of the Review
Lung transplantation is a lifesaving therapy for patients suffering from end-stage lung diseases. The number of patients waiting for lung transplantation greatly exceeds the ...number of donors available. Currently, only 20% of lungs donors are used for transplantation. Ex vivo lung perfusion (EVLP) has been developed as a tool to assess and also potentially repair lungs before transplantation. This article will review the rationale for EVLP and the different EVLP methods including the Toronto EVLP method, describe technical details of EVLP, report on the clinical results of EVLP, and describe the use of EVLP as a platform to deliver different therapies.
Recent Findings
EVLP has been demonstrated to be a safe method of assessing high-risk donor lungs. The long-term survival and graft function of patients that received high-risk donor lungs assessed and treated with EVLP have been shown to be comparable to those receiving conventional donor lungs. Preclinical studies demonstrate that EVLP can serve as a platform for the delivery of specifically targeted therapies to repair injured lungs.
Summary
EVLP has demonstrated to be a promising tool for the assessment and recovery of injured donor lungs using pharmacologic agents as well as gene and cellular therapies.
CONTEXT Recent clinical trials have demonstrated a decrease in multiple organ
dysfunction syndrome (MODS) and mortality in patients with acute respiratory
distress syndrome (ARDS) treated with a ...protective ventilatory strategy. OBJECTIVE To examine the hypothesis that an injurious ventilatory strategy may
lead to end-organ epithelial cell apoptosis and organ dysfunction. DESIGN AND SETTING In vivo animals: 24 rabbits with acid-aspiration lung injury were ventilated
with injurious or noninjurious ventilatory strategies. In vitro: rabbit epithelial
cells were exposed to plasma from in vivo rabbit studies. In vivo human: plasma
samples from patients included in a previous randomized controlled trial examining
a lung protective strategy were analyzed (lung protection group, n = 9 and
controls, n = 11). MAIN OUTCOME MEASURES In vivo animals: biochemical markers of liver and renal dysfunction;
apoptosis in end organs. In vitro: induction of apoptosis in LLC-RK1 renal
tubular epithelial cells. In vivo human: correlation of plasma creatinine
and soluble Fas ligand. RESULTS The injurious ventilatory strategy led to increased rates of epithelial
cell apoptosis in the kidney (mean SE: injurious, 10.9% 0.88%; noninjurious,
1.86% 0.17%; P<.001) and small intestine villi
(injurious, 6.7% 0.66%; noninjurious, 0.97% 0.14%; P<.001), and led to the elevation of biochemical markers indicating
renal dysfunction in vivo. Induction of apoptosis was increased in LLC-RK1
cells incubated with plasma from rabbits ventilated with injurious ventilatory
strategy at 4 hours (P = .03) and 8 hours (P = .002). The Fas:Ig, a fusion protein that blocks soluble
Fas ligand, attenuated induction of apoptosis in vitro. There was a significant
correlation between changes in soluble Fas ligand and changes in creatinine
in patients with ARDS (R = 0.64, P = .002). CONCLUSIONS Mechanical ventilation can lead to epithelial cell apoptosis in the
kidney and small intestine, accompanied by biochemical evidence of organ dysfunction.
This may partially explain the high rate of MODS observed in patients with
ARDS and the decrease in morbidity and mortality in patients treated with
a lung protective strategy.
OBJECTIVES
Extracorporeal life support (ECLS) for rescue after pulmonary endarterectomy (PEA) has become a viable option. This study aims to present a single-centre experience looking at the ...indications and outcome of ECLS after PEA.
METHODS
Retrospective analysis of all patients undergoing PEA from January 2008 to January 2015 in our institution.
RESULTS
Among 144 consecutive patients undergoing PEA for chronic thromboembolic pulmonary hypertension, 6 (4%) received ECLS postoperatively for right ventricular (RV) failure (n = 3), severe hypoxaemia (n = 2) and haemorrhagic pulmonary oedema (n = 1). ECLS configuration was central veno-arterial (cVA) in 3 patients, peripheral VA (pVA) in 1 and veno-venous (VV) in 2. One patient with cVA was switched to VV after 5 days. Overall ECLS duration ranged between 3 and 39 (median 5) days. ECLS patients had higher preoperative total pulmonary vascular resistance (TPR) compared with non-ECLS patients (1477 ± 671 vs 954 ± 462 Dynes.s.cm−5, P = 0.009) and more frequently required hospital admission for RV failure before surgery (50 vs 9%, P = 0.02). The overall in-hospital mortality rate for all patients was 2% (3/144), including one ECLS patient on pVA. The remaining 5 ECLS patients (83%) were discharged from the hospital and are alive after a median follow-up of 11 (range 6–27) months. Two ECLS patients (40%) are on therapy for residual PH compared with 13 (10%) in the non-ECLS patients (P = 0.09).
CONCLUSIONS
ECLS is a safe and important rescue option after PEA. The use of ECLS may expand eligibility for PEA by allowing sicker patients to undergo surgery.
Solitary fibrous tumors of the pleura de Perrot, Marc; Fischer, Stefan; Bründler, Marie-Anne ...
The Annals of Thoracic Surgery,
07/2002, Letnik:
74, Številka:
1
Book Review, Journal Article
Recenzirano
Solitary fibrous tumor of the pleura is a mesenchymal tumor that has been increasingly recognized over the past few years. The tumor was initially described in the pleura, but it has been reported in ...many other sites lately. Although the majority of these tumors have a benign course, the malignant form still remains enigmatic. Indeed, the behavior of these tumors is often unpredictable and does not always correlate with histologic findings. In addition, benign tumors may remain unproblematic for several years before changing into a malignant form. In order to define more precisely the clinical behavior of solitary fibrous tumors of the pleura, we reviewed the literature with particular attention to the clinical presentation, histopathologic characteristics, and cytogenetic differentiation of these tumors. A staging system and an algorithm for the management and follow-up of these patients are proposed.
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