Shruti Gadre

Overview of Lung Transplantation, Heart-Lung Transplantation, Liver-Lung Transplantation, and Combined Hematopoietic Stem Cell Transplantation and Lung Transplantation

Lung transplantation (LTx) has evolved to represent the therapy of choice for many patients with end-stage lung diseases. Appropriate candidate selection for LTx is an important determinant of a positive outcome from transplantation. Posttransplantation survival has steadily improved, but long-term survival continues to be a challenge with a median survival of 5.8 years. Similarly, combined heart-lung transplantation and simultaneous liver-lung transplantation has been performed successfully in select patients who are not expected to survive either organ transplant alone. Moreover, LTx has been performed in patients who develop end-stage pulmonary complications following hematopoietic stem cell transplantation.

Granulomatosis with polyangiitis and associated pulmonary emphysema: Breathtaking vasculitis

Pulmonary emphysema occasionally occurs in the absence of smoking or noxious exposures. Other than through a known association with alpha-1 antitryspin deficiency, to our knowledge, no reports implicate granulomatosis with polyangiitis (GPA) in causing airflow obstruction with small airway involvement and severe air trapping. To extend available experience, we report a 51-year-old male with biopsy-proven cytoplasmic-antineutrophilic cytoplasmic antibody proteinase 3 (ANCA PR3)-positive GPA who developed centrilobular emphysema and airflow obstruction during a phase of active vasculitis. He was a lifelong non-smoker and had a normal alpha-1 antitrypsin level and a PIFNx01MM phenotype. Treatment with corticosteroids and cyclophosphamide caused clinical remission of his vasculitis which was associated with improvement in his respiratory symptoms. However, to date, structural changes of emphysema have persisted for over 9 years of follow-up. Clinicians should remain vigilant to the possibility of emphysema in patients with pulmonary vasculitis.

Effect of Anemia on Mortality in Mechanically Ventilated Patients With Chronic Obstructive Pulmonary Disease

Rationale: The effect of anemia on patients with chronic obstructive pulmonary disease (COPD) requiring invasive mechanical ventilation for acute respiratory failure is unknown. Objectives: To examine the association between anemia (hemoglobin <12 g/dL) and 90-day and overall mortality in patients with COPD having acute respiratory failure requiring invasive mechanical ventilation. Methods: Retrospective study of patients admitted to a quaternary referral medical intensive care unit (ICU) between October 2007 and December 2012 with a diagnosis of COPD and requiring invasive mechanical ventilation for acute respiratory failure of any cause. Results: We identified 1107 patients with COPD who required invasive mechanical ventilation for acute respiratory failure. Mean age was 64.2 ± 12.7 years; 563 (50.9%) were females. The mean Acute Physiology and Chronic Health Evaluation III score at ICU admission was 80.5 ± 29.3. The median duration of mechanical ventilation was 35.7 hours (interquartile range: 20.0-54.0). In all, 885 (79.9%) patients were anemic (Hb < 12g/dL) on ICU admission, and 312 patients (28.2%) received blood transfusion during their ICU stay. A total of 351 inhospital deaths were recorded, the majority (n = 320) occurring in the ICU. The 90-day mortality, though lower in the nonanemic patients compared to the patients with anemia, was not statistically significant (35.6% vs 44.9%; hazard ratio [HR] [95% confidence interval; CI] = 1.16 [0.91 -1.48], P = .22). The overall mortality was lower in the nonanemic patients compared to patients with anemia (HR [95% CI] = 0.68 [0.55-0.83], P < .001). There was a 5% decrease in risk of death for every unit increase in hemoglobin (P = .01). There was no difference in terms of both 90-day and overall mortality in patients who received blood transfusions compared to patients who did not receive any transfusion. Conclusions: Critically ill patients with COPD requiring invasive mechanical ventilation for acute respiratory failure without anemia on admission had a better overall survival when compared to those with anemia. No difference was noted in the 90-day mortality. Further studies are needed to determine the impact of the trajectory of hemoglobin on mortality.

Lung or Heart-Lung Transplant in Pulmonary Arterial Hypertension: What Is the Impact of Systemic Sclerosis?

OBJECTIVES Little is known about recipient characteristics and outcomes of patients with pulmonary arterial hypertension undergoing lung transplant, particularly those with systemic sclerosis-associated disease. Here, we describe the characteristics and outcomes of patients with pulmonary arterial hypertension undergoing lung transplant, focusing on systemic sclerosis-associated disease. MATERIALS AND METHODS This retrospective study included pulmonary arterial hypertension patients undergoing lung or heart-lung transplant between July 1992 and August 2013 at a single center. RESULTS We evaluated 51 patients with pulmonary arterial hypertension (37.3% males; mean age of 45.3 ± 11.9 y). Of 51 patients, 9 (17.6%) had systemic sclerosis-associated pulmonary arterial hypertension. Pulmonary arterial hypertension patients without systemic sclerosis-associated disease had higher mean pulmonary arterial pressure (P = .002), higher pulmonary vascular resistance (P = .008), and were more likely to have severe right ventricular systolic dysfunction (P = .006) than individuals with the disease. Mean hospital stay posttransplant was similar in the 2 groups (42.2 ± 43.3 vs 43.1 ± 19.4 d; P = .20). Higher pretransplant creatinine clearance (P = .0005), forced vital capacity (P = .01), and absence of vasopressor/inotrope use (P = .03) were associated with shorter hospital stay. Mortality for pulmonary arterial hypertension patients with versus without systemic sclerosis-associated disease was 0% versus 13% at 1 year, 29% versus 24% at 2 years, and 86% versus 53% at 5 years. Female sex (hazard ratio, 0.23; 95% confidence interval, 0.08-0.68) and less severe tricuspid regurgitation (hazard ratio, 0.31; 95% confidence interval, 0.11-0.89) were independently associated with long-term survival. CONCLUSIONS Pulmonary arterial hypertension patients with versus without systemic sclerosis-associated disease have comparable short-term and 2-year outcomes after lung or heart-lung transplant. Female sex and less severe tricuspid regurgitation were independently associated with better long-term survival. These outcomes did not vary when adjusted for the year of transplant.

Noninfectious Pulmonary Complications of Liver, Heart, and Kidney Transplantation: An Update

Despite significant advances in surgical techniques, perioperative care, and immunosuppressive therapy, solid organ transplantation still carries considerable risk of complications. Pulmonary complications, in particular, are a major cause of morbidity and mortality. Although infectious complications prevail, the lungs are also vulnerable to a variety of noninfectious complications related to the transplant surgery and adverse effects of the immunosuppressive regimen. This article focuses on noninfectious pulmonary complications associated with the 3 most commonly performed solid organ transplant procedures: liver, kidney, and heart.