Sarosh Irani

Extracorporeal Photopheresis After Lung Transplantation : A 10-Year Single-Center Experience

We report the largest single-center experience with extracorporeal photopheresis (ECP) for bronchiolitis obliterans syndrome (BOS) and recurrent acute rejection (AR) after lung transplantation. Lung transplant recipients undergoing ECP for BOS and recurrent AR were included (1997-2007). The rate of forced expiratory volume in 1 second (FEV1) decline was used as the primary measure and graft survival post-ECP as the secondary measure of efficacy. Twenty-four transplant recipients were included (BOS, n=12; recurrent AR, n=12). In recipients with BOS, decline in FEV1 was 112 mL/month before the start of ECP and 12 mL/month after 12 ECP cycles (P=0.011), mean (95% CI) change in rate of decline was 100 (28-171). Median patient survival was 7.0 (range, 3.0-13.6) years, median patient survival post-ECP 4.9 (range, 0.5-8.4) years. No ECP-related complications occurred. Extracorporeal photopheresis reduces the rate of lung function decline in recipients with BOS and is well tolerated. Furthermore, recipients with recurrent AR experience clinical stabilization. However, the underlying mechanism of ECP remains subject to further research.

Airway complications after lung transplantation: risk factors, prevention and outcome

PURPOSE Anastomotic complications following lung transplantation (LuTx) have been described in up to 15% of patients. Challenging to treat, they are associated with high morbidity and a mortality rate of 2-5%. The aim of this study was to analyze the incidence of complications in a consecutive series of bronchial anastomosis after LuTx at our center and to delineate the potential risk factors. METHODS Between 1992 and 2007, 441 bronchial anastomoses were performed in 235 patients. Indications for transplantation were cystic fibrosis (35.7%) emphysema (28.1%) pulmonary fibrosis (12.8%) and pulmonary hypertension (7.7%). There were 206 sequential bilateral and 28 single transplants including lobar engraftments in 20 cases. The donor bronchus was shortened to the plane of the lobar carina including the medial wall of the intermediate bronchus. Peribronchial tissue was left untouched. Anastomosis was carried out using a continuous absorbable running suture (PDS 4/0) at the membranous and interrupted sutures at the cartilaginous part. Six elective surveillance bronchoscopies were done monthly during the first half-year post-LuTx, with detailed assessment of the pre- and post-anastomotic airways. RESULTS One-year survival since 2000 was 90.5%. In all 441 anastomoses performed, no significant dehiscence was observed. In one patient, a small fistula was detected and closed surgically on postoperative day five. Fungal membranes were found in 50% of the anastomoses at 1 month and in 14% at 6 months. Discrete narrowing of the anastomotic lumen without need for intervention was found in 4.9% of patients at 1 month and in 2.4% at 6 months. Age, cytomegalovirus status, induction therapy, immunosuppressive regimen, ischemic time, and ventilation time had no influence on bronchial healing. CONCLUSIONS Clinically relevant bronchial anastomotic complications after LuTx can be avoided by use of a simple standardized surgical technique. Aggressive antibiotic and antifungal therapy might play an important supportive role.

True survival benefit of lung transplantation for cystic fibrosis patients: the Zurich experience.

BACKGROUND Lung transplantation is the ultimate therapy for end-stage cystic fibrosis (CF) lung disease; however, the debate continues as to whether lung transplantation improves survival. We report post-transplant outcome in CF at our institution by comparing 5-year post-transplant survival with a calculated 5-year survival without lung transplantation, using a predictive 5-year survivorship model, and describe pre-transplant parameters influencing transplant outcome. METHODS CF patients undergoing lung transplantation at our center were included (1992 to 2007). Survival rates were calculated and compared, and univariate and multivariate Cox regression analyses were used for statistical assessment. RESULTS Eighty transplants were performed in CF patients, 11 (13.8%) of whom were children. Mean age at transplant was 26.2 years (95% confidence interval: 24.4 to 28.0). The Liou raw score at transplant was -20 (95% confidence interval: -16 to -24), resulting in an estimated 5-year survival without transplantation of 33 +/- 14%, compared with a 5-year post-transplant survival of 68.2 +/- 5.6%. Further improvement was noted in the recent transplant era (since 2000), with a 5-year survival of 72.7 +/- 7.3%. Univariate analysis revealed that later year of transplant and diagnosis of diabetes influenced survival positively. Pediatric age had no negative impact. In the multivariate analysis, only diabetes influenced survival, in a positive manner. CONCLUSION Lung transplantation performed at centers having experience with the procedure can offer a true survival benefit to patients with end-stage CF lung disease.

Lung Transplant Recipients Holding Companion Animals: Impact on Physical Health and Quality of Life

Since lung transplant recipients are susceptible to infections and inhaled pollution, many centers warn against pets. However, data supporting this recommendation are lacking. Our program is less restrictive regarding pets. This study, for the first time, investigates the association of pets with physiological and psychological parameters in these patients. A questionnaire concerning pets was sent to 104 lung transplant recipients. Lung function tests, levels of exhaled nitric oxide (FENO), need for antibiotic treatments and hospitalizations, creatinine clearance, body mass index (BMI) and demographic data were assessed. Additionally, the questionnaire of life satisfaction (FLZ), a question on summarized life satisfaction (LS), the life orientation test (LOT), the hospital anxiety depression scale (HADS) and the social support questionnaire (F‐SozU) were assessed.

Mycophenolate mofetil reduces alveolar inflammation, acute rejection and graft loss due to bronchiolitis obliterans syndrome after lung transplantation

BACKGROUND Bronchiolitis obliterans syndrome (BOS) is still the main complication after lung transplantation. Besides other improvements in post-operative management, newer immunosuppressive regimens might decrease the devastating sequelae of this complication. METHODS We compared the prospectively collected data of lung transplant recipients treated either with azathioprine (AZA; n = 48) or mycophenolate mofetil (MMF; n = 108), who underwent regular monthly surveillance bronchoscopies for at least 6 post-operative months. RESULTS Patients on MMF had significantly fewer acute (P < 0.001) and recurrent (P < 0.001), as well as less severe rejection episodes (P = 0.01). In addition, MMF significantly reduced the number of alveolar lymphocytes, eosinophils and neutrophils (P < 0.001), and decreased the hemosiderin score reflecting non-specific alveolar-capillary damage (P < 0.001). Although there was no change in the three stages of BOS, there was a trend towards improved survival (P = 0.062) and a significant decrease in graft loss due to BOS (P = 0.049) in patients receiving MMF. CONCLUSIONS Immunosuppression with MMF significantly decreased the incidence, severity and recurrence of acute rejection episodes in lung transplant recipients. Parameters of alveolar inflammation and alveolar-capillary damage were also decreased. As a potential consequence, MMF significantly reduced graft loss due to BOS and tended to improve overall survival in these patients.

Disseminated Infection With Bartonella henselae in a Lung Transplant Recipient

We present the case of a lung transplant recipient with disseminated infection with Bartonella henselae. In non-immunosuppressed humans, the organism typically causes a local infection that manifests itself as regional lymphadenopathy. The role of the host immune response to B henselae is critical in preventing progression to systemic disease. Only rare cases of bartonellosis in transplant recipients have been reported. We discuss aspects and difficulties of diagnosis and treatment of bartonellosis in a lung transplant recipient who suffered from a severe multisystem involvement of this disease. In our case, the initial response to therapy was unsatisfying and necessitated an extended anti-infective combination therapy, which eventually was successful.

Medication Errors: An Important Component of Nonadherence to Medication in an Outpatient Population of Lung Transplant Recipients

Data about medication errors in outpatients are limited.

Donor predicted post-operative forced expiratory volume in one second predicts recipients' best forced expiratory volume in one second following size-reduced lung transplantation.

OBJECTIVE The limited number of available grafts is one of the major obstacles of lung transplantation. Size-reduced lung transplantation allows the use of oversized grafts for small recipients. Optimal lung size matching is vital to achieve best functional outcome and avoid potential problems when using oversized grafts. We hypothesise that donor-predicted postoperative forced expiratory volume in 1s (ppoFEV1) correlates with the recipient best FEV1 after size-reduced lung transplant, being useful for the estimation of function outcome. METHODS All patients undergoing size-reduced or standard bilateral lung transplantation were included (1992-2007). Donor ppoFEV1 was calculated and corrected with respect to size reduction and correlated with recipient measured best FEV1 post-transplant. In addition, pre- and postoperative clinical data including surgical complications and outcome of all size-reduced lung transplant recipients were compared with standard lung transplant recipients. RESULTS A total of 61 size-reduced lung transplant recipients (lobar transplants, n=20; anatomic or non-anatomic resection, n=41) were included and compared to 145 standard transplants. The mean donor-recipient height difference was statistically significant between the two groups (p=0.0001). The mean donor ppoFEV1 was comparable with recipient best FEV1 (2.7±0.6 vs 2.6±0.7 l). There was a statistically significant correlation between donor ppoFEV1 and recipient best FEV1 (p=0.01, r=0.688). The 30-day mortality rate and 3-month, 1- and 5-year survival rates were comparable between the two groups. CONCLUSIONS In size-reduced lung transplantation, postoperative recipient best FEV1 could be predicted from donor-calculated and corrected FEV1 with respect to its size reduction. Compared to standard lung transplantation, equivalent morbidity, mortality and functional results could be obtained after size-reduced lung transplantation.

Lung function, sociodemographic characteristics, and psychological reaction to transplant associated with chronic stress among lung recipients

Abstract Chronic stress is a well-known consequence of somatic diseases. In this study, we investigated whether physical, sociodemographic, or transplant-related psychological factors were associated with the patients chronic stress level. A cross-sectional study enrolling 76 patients measured chronic stress (Screening Scale, Screening Subscale of Chronic Stress of the Trier Inventory for the Assessment of Chronic Stress) and the emotional effects of the transplant (Transplant Effects Questionnaire), as well as physical and sociodemographic conditions (lung function, bronchiolitis obliterans syndrome, working status, and parenting). Chronic stress after a lung transplant was significantly lower than in a normal community sample. In the multiple regression analysis, worries concerning the transplant were significantly associated with the patients chronic stress, but not with physical or sociodemographic parameters, nor with interactions between physical and psychological parameters. These results underscore the importance of transplant-related worries, regardless of the patients current state of health.

Endoscopic narrow-band imaging—quantitative assessment of airway vascularity after lung transplantation

In lung transplant recipients, the submucosal vascular plexus of the airway wall potentially represents one of the key structures of graft injury. Narrow band imaging is a novel endoscope technique that allows visual enhancement of the mucosa vasculature. It was our aim to investigate the ability of narrow-band imaging in combination with computerized image analysis to quantitatively assess airway vascularity in lung transplant recipients. In consecutive lung transplant recipients, in addition to the routine procedures, optical analysis of the main carina (autologous tissue) and the upper lobe carina (allogeneic tissue) were performed. From every site, three representative pictures were chosen. A total of 63 bronchoscopies were analyzed. The intraclass correlation coefficient (measure for test-retest reliability) of the three measurements were 0.69 and 0.74 for the main carina and the upper lobe carina, respectively. A mixed linear regression revealed increased vascularity in autologous tissue of patients with cystic fibrosis (p=0.06) and decreased vascularity in allogeneic tissue with time after transplantation (p=0.09). Endoscopic narrow-band imaging (NBI) in combination with computerized image analysis allows consistent assessment of airway vascularity in vivo. In lung transplant recipients, there might be differences in airway vascularity in both autologous and allogeneic large airways.