E.A. Verschuuren

Visual symptoms after lung transplantation: a case of progressive multifocal leukoencephalopathy

After solid organ transplantation, signs and symptoms of the central nervous system may present a diagnostic challenge. A 43‐year‐old patient developed a decrease in vision 15 months after bilateral lung transplantation. The initial diagnosis was a left posterior cataract, but left eye cataract extraction did not improve his vision. Seizures led to investigation of a broader differential diagnosis (cyclosporine intoxication, post‐transplant lymphoproliferative disorder, infectious disease, chronic lymphatic leukemia). The clinical diagnosis of progressive multifocal leukoencephalopathy (PML) was confirmed by demonstration of JC virus in the cerebrospinal fluid and by autopsy findings. Modulation of the immunosuppressive regimen was unsuccessful. This case illustrates that decreased vision in immunocompromised patients may be the first manifestation of PML.

Former Smoking Is a Risk Factor for Chronic Kidney Disease After Lung Transplantation

Chronic kidney disease (CKD) is a common complication after lung transplantation (LTx). Smoking is a risk factor for many diseases, including CKD. Smoking cessation for >6 months is required for LTx enlistment. However, the impact of smoking history on CKD development after LTx remains unclear. We investigated the effect of former smoking on CKD and mortality after LTx. CKD was based on glomerular filtration rate (GFR) (125I‐iothalamate measurements). GFR was measured before and repeatedly after LTx. One hundred thirty‐four patients never smoked and 192 patients previously smoked for a median of 17.5 pack years. At 5 years after LTx, overall cumulative incidences of CKD‐III, CKD‐IV and death were 68.5%, 16.3% and 34.6%, respectively. Compared to never smokers, former smokers had a higher risk for CKD‐III (hazard ratio [HR] 95% confidence interval [95%CI]= 1.69 [1.27–2.24]) and IV (HR = 1.90 [1.11–3.27]), but not for mortality (HR = 0.99 [0.71–1.38]). Adjustment for potential confounders did not change results. Thus, despite cessation, smoking history remained a risk factor for CKD in LTx recipients. Considering the increasing acceptance for LTx of older recipients with lower baseline renal function and an extensive smoking history, our data suggest that the problem of post‐LTx CKD may increase in the future.

A Multicenter Study on Long-Term Outcomes After Lung Transplantation Comparing Donation After Circulatory Death and Donation After Brain Death

The implementation of donation after circulatory death category 3 (DCD3) was one of the attempts to reduce the gap between supply and demand of donor lungs. In the Netherlands, the total number of potential lung donors was greatly increased by the availability of DCD3 lungs in addition to the initial standard use of donation after brain death (DBD) lungs. From the three lung transplant centers in the Netherlands, 130 DCD3 recipients were one‐to‐one nearest neighbor propensity score matched with 130 DBD recipients. The primary end points were primary graft dysfunction (PGD), posttransplant lung function, freedom from chronic lung allograft dysfunction (CLAD), and overall survival. PGD did not differ between the groups. Posttransplant lung function was comparable after bilateral lung transplantation, but seemed worse after DCD3 single lung transplantation. The incidence of CLAD (p = 0.17) nor the freedom from CLAD (p = 0.36) nor the overall survival (p = 0.40) were significantly different between both groups. The presented multicenter results are derived from a national context where one third of the lung transplantations are performed with DCD3 lungs. We conclude that the long‐term outcome after lung transplantation with DCD3 donors is similar to that of DBD donors and that DCD3 donation can substantially enlarge the donor pool.

Acute Abdominal Pain in a Lung Transplant Recipient

Accessible online at: http://BioMedNet.com/karger A 49-year-old man was admitted to the hospital for analysis of an abdominal mass in the right upper quadrant. This patient had received a double-lung transplant for end-stage emphysema 5 years ago. The follow-up since had been unremarkable, although he developed progressive renal failure thought to be related to cyclosporin use. The immunosuppressive regimen also consisted of azathioprine and prednisone. His lung function was excellent. Six months prior to admittance he started to complain of fatigue and later of a dull pain in the right upper abdomen. Ultrasound examination revealed an enlarged liver with several noduli. A biopsy showed a monoclonal proliferation of EBV-positive lymphocytes, consistent with a diagnosis of posttransplantation lymphoproliferative disease (PTLD). Staging including a bone marrow aspirate and CATscan of the chest and abdomen failed to demonstrate abnormalities elsewhere. No consensus exists on the treatment of PTLD but it was decided to start with chemotherapy consisting of biweekly courses of cyclophosphamide, vincristine, Adriamycin and prednisone. Between courses of chemotherapy, prednisone was continued at 30 mg/day. All other immunosuppressive agents were discontinued. The patient responded well, with a swift decrease in pain and a marked decrease in liver size on palpation. However, haemodialysis was necessary because of deteriorating renal function and the fluid load related to the chemotherapy. After the second course of chemotherapy he became neutropenic, and he suddenly complained of severe, gnawing and diffuse abdominal pain. There was no nausea, vomiting, diarrhoea or fever. Physical examination of the abdomen revealed Fig. 1. An abdominal X-ray shows the radioopaque pin in the right lower quadrant.

Voriconazole and squamous cell carcinoma after lung transplantation: A multicenter study

This study evaluated the independent contribution of voriconazole to the development of squamous cell carcinoma (SCC) in lung transplant recipients, by attempting to account for important confounding factors, particularly immunosuppression. This international, multicenter, retrospective, cohort study included adult patients who underwent lung transplantation during 2005‐2008. Cox regression analysis was used to assess the effects of voriconazole and other azoles, analyzed as time‐dependent variables, on the risk of developing biopsy‐confirmed SCC. Nine hundred lung transplant recipients were included. Median follow‐up time from transplantation to end of follow‐up was 3.51 years. In a Cox regression model, exposure to voriconazole alone (adjusted hazard ratio 2.39, 95% confidence interval 1.31‐4.37) and exposure to voriconazole and other azole(s) (adjusted hazard ratio 3.45, 95% confidence interval 1.07‐11.06) were associated with SCC compared with those unexposed after controlling for important confounders including immunosuppressants. Exposure to voriconazole was associated with increased risk of SCC of the skin in lung transplant recipients. Residual confounding could not be ruled out because of the use of proxy variables to control for some confounders. Benefits of voriconazole use when prescribed to lung transplant recipients should be carefully weighed versus the potential risk of SCC.u2028EU PAS registration number: EUPAS5269.

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.

Extradural thoracic spinal cord compression: Unusual initial presentation of post-transplant lymphoproliferative disorder

Post-transplant lymphoproliferative disorder (PTLD) is a serious complication after solid-organ transplantation. We report a lung transplant recipient presenting with lower limb weakness as a result of extradural cord compression from PTLD. Diagnosis was made by laminectomy of T-3 with partial removal of the epidural mass. Further treatment consisted of chemoradiotherapy. The patient recovered completely. To our knowledge, this is the first reported case of PTLD presenting with signs and symptoms of spinal cord compression. The differential diagnosis of spinal cord compression in a patient who has had a transplant should include primary presentation of PTLD.