M. Benzimra

Oral ribavirin for respiratory syncytial virus infection after lung transplantation: Efficacy and cost-efficiency

BACKGROUND Respiratory syncytial virus (RSV) causes serious respiratory tract infections in lung transplant (LTx) recipients, is associated with development of bronchiolitis obliterans syndrome, and has no proven effective therapy. We evaluated the efficacy, safety, and cost-effectiveness of oral ribavirin for the treatment of RSV infection after LTx. METHODS Between December 2011 and May 2014, 52 LTx recipients developed 56 episodes of symptomatic RSV infection, which was diagnosed by positive RSV polymerase chain reaction on nasopharyngeal swabs. An intravenous (IV) loading dose of ribavirin (33 mg/kg) was given in 52 of 56 episodes; an equivalent oral loading dose was given in 2 episodes. Oral ribavirin (20 mg/kg/day) was given by day 2 in 53 of 56 episodes. Median duration of therapy was 8 days (range 6-31 days). RESULTS Mean forced expiratory volume in 1 sec decreased from 2.38 ± 0.78 liters to 2.07 ± 0.85 liters (p < 0.001) at presentation, recovered to 2.26 ± 0.82 liters at cessation of ribavirin, and was maintained at 2.31 ± 0.81 liters within 3 months. New-onset bronchiolitis obliterans syndrome developed in 1 of 38 patients (2.6%) at 3 months. Anemia worsened in 23 episodes, and de novo anemia developed in 5 episodes. Mean hemoglobin decreased from 118 ± 16 g/liter to 113 ± 21 g/liter (p = 0.015). There were 4 late deaths. Compared with IV therapy, mean drug cost saving was US

Blood and Anticoagulation Management in Extracorporeal Membrane Oxygenation for Surgical and Nonsurgical Patients: A Single-Center Retrospective Review

6,035 per episode, and mean inpatient bed days was reduced by 6.7 days (p < 0.001). CONCLUSIONS To our knowledge, we report the largest series of LTx recipients treated with oral ribavirin for RSV. Oral ribavirin appears to be an effective, well-tolerated alternative to IV or inhaled ribavirin; provides considerable cost savings and reduces length of hospital stay. Potential long-term benefits in preventing development of chronic lung allograft dysfunction are yet to be determined.

Bronchoscopy Post Lung Transplantation

OBJECTIVE To describe blood management and anticoagulation practice for cardiac and respiratory extracorporeal membrane oxygenation (ECMO) with consideration of major surgery at the time of its initiation. DESIGN A single-center retrospective review over 18 months of blood product usage and anticoagulation in patients treated with veno-venous (VV) ECMO versus veno-arterial (VA) ECMO and after major surgery (Sx) versus no surgery (Nsx). SETTING Tertiary metropolitan hospital and state ECMO referral and heart and lung transplantation center. PARTICIPANTS The study comprised 42 patients representing 48 consecutive ECMO runs (16 VV, 32 VA, 26 Sx, 22 Nsx). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Thirty-three percent of the total run time of 362 days was with no continuous infusion of heparin. The mean (standard deviation) daily dose of heparin was lower for Sx versus Nsx patients (11,397 [9,297] v 17,324 [10,387] U, p = 0.047). Sx patients also received more fresh frozen plasma (1.1 [1.93] v 0.2 [0.59] U per day, p = 0.049) and platelets (0.5 [0.51] v 0.1 [0.25] U per day, p = 0.003). VV patients received fewer packed red cells (0.7 [0.45] v 2.0 [2.04] U per day, p = 0.016) and platelets (0.1 [0.18] v 0.4 [0.49] U per day, p = 0.008) compared with VA patients. Survival to hospital discharge was 69%. CONCLUSIONS Heparin doses were low, with frequent interruption of anticoagulation. This was more pronounced in patients with a high bleeding risk recovering from major surgery. The overall usage of blood products was low in VV and Nsx patients, with an overall excellent survival rate.

Surveillance Bronchoscopy: Is It Still Relevant?

The post-operative care of lung transplant patients is complex with the main goal of management being the preservation of allograft function. Being able to perform bronchoscopy with bronchoalveolar lavage as well as trans-bronchial biopsy (TBBX) as part of the routine investigation of a drop in lung function greater than 20% is a vital skill for clinicians caring for lung transplant recipients. Bronchoscopy provides clinicians with a rich source of microbiological, cytological, and histological sampling thereby enhancing the ability to make an accurate diagnosis, particularly the differentiation of rejection from infection or the presence of both. The following chapter aims to provide an insight into the use of bronchoscopy post lung transplantation.

Lung Transplant Rejection and Surveillance in 2016: Newer Options

&NA; The performance of bronchoscopy with bronchoalveolar lavage and transbronchial biopsy is an essential tool and skill required by any clinician caring for patients postlung transplantation. Making a confident diagnosis is crucial in initiating different treatment strategies which may be in turn hazardous to the patient in light of an inaccurate diagnosis. Having more information available for evaluation optimizes the chances of tailoring appropriate therapeutic options in this complex patient population. Performing a bronchoscopy with bronchoalveolar lavage and transbronchial biopsy indeed provides a wealth of information via microbiological, cytological, and histological samples that assist us to differentiate infection from rejection, or to confirm the presence of both. This review aims to discuss the utility of bronchoscopy postlung transplantation in the diagnosis of rejection, infection, and airway complications, as well as looking into the ongoing controversy regarding monitoring practices worldwide and safety concerns.

(377) – Transplanting the Human Respiratory Virome

Lung allograft rejection is a major risk factor for the development of chronic lung allograft dysfunction. It is a significant cause of morbidity and mortality, and limits survival post lung transplantation, which is lower than any other solid organ transplant. The invasive nature of current methods of diagnosis which consists of histological diagnosis via transbronchial biopsy and the lack of sensitivity of clinical surveillance warrants the search for novel less invasive and more accurate methods of diagnosis. This review aims to highlight recent changes to current methods of surveillance and diagnosis as well as present some of the novel methods that are becoming available.