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M Greer, M Dierich,
C De Wall,
H Suhling,
J Rademacher,
T Welte,
A Haverich,
G Warnecke,
P Ivanyi,
S Buchholz,
J Gottlieb,
T Fuehner
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ABSTRACT: Chronic lung allograft dysfunction (CLAD) remains the leading cause of mortality in lung transplant recipients after the first year. Treatment remains limited and unpredictable. Existing data suggests extracorporeal photopheresis (ECP) may be beneficial. This study aimed to identify factors predicting treatment response and the prognostic implications. A single center retrospective analysis of all patients commencing ECP for CLAD between November 1, 2007 and September 1, 2011 was performed. In total 65 patients were included, 64 of whom had deteriorated under azithromycin. Median follow-up after commencing ECP was 503 days. Upon commencing ECP, all patients were classified using proposed criteria for emerging clinical phenotypes, including "restrictive allograft syndrome (RAS)", "neutrophilic CLAD (nCLAD)" and "rapid decliners". At follow-up, 8 patients demonstrated ≥10% improvement in FEV(1) , 27 patients had stabilized and 30 patients exhibited ≥10% decline in FEV(1) . Patients fulfilling criteria for "rapid decliners" (n = 21, p = 0.005), RAS (n = 22, p = 0.002) and those not exhibiting neutrophilia in bronchoalveolar lavage (n = 44, p = 0.01) exhibited poorer outcomes. ECP appears an effective second line treatment in CLAD patients progressing under azithromycin. ECP responders demonstrated improved progression-free survival (median 401 vs. 133 days). Proposed CLAD phenotypes require refinement, but appear to predict the likelihood of ECP response.
American Journal of Transplantation 02/2013; · 6.39 Impact Factor
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ABSTRACT: Die Lungentransplantation ist bei weit fortgeschrittenen Lungenerkrankungen nach Ausschöpfung aller Therapiemöglichkeiten
eine Therapieoption, welche die Lebensqualität und – bei bestimmten Indikationen (zystische Fibrose, Lungenfibrose, pulmonal
arterielle Hypertonie) – Lebenserwartung verbessert. Die Anzahl verfügbarer Spenderorgane ist so gering, dass jeder 6.Patient
auf der Warteliste verstirbt. Bei der Auswahl geeigneter Kandidaten sind neben der ursächlichen Lungen- oder Herz-Lungenerkrankung,
das Alter, vorhandene Mobilität, Ernährungs- und Muskelstatus und extrapulmonale Begleiterkrankungen entscheidende Kriterien.
Postoperative Komplikationen können durch die Operation bedingt, durch eine Transplantatabstoßung (akut oder chronisch), Atemwegskomplikationen,
Infektionen und extrapulmonale Folgeerkrankungen auftreten. Die Nachsorge erfolgt immer in Kooperation mit dem Transplantationszentrum
und hat in großen Zentren zu einer spürbaren Verbesserung der Langzeitergebnisse geführt.
Lung transplantation has been established as an appropriate ultimate treatment strategy in end-stage lung disease, when all
conventional therapeutic options have been exhausted. A successful transplantation should result in an improved quality of
life as well as an increase in life-expectancy for certain diseases (cystic fibrosis, pulmonary fibrosis and pulmonary hypertension).
There is still a critical need regarding the number of available donor organs. Presently, one out of six patients dies on
the waiting list. In order to identify suitable candidates for transplantation a number of criteria require consideration.
These include the exact etiology of the pulmonary or cardiac disease, but also patient age, physical mobility, nutritional
and muscular status as well as a comprehensive assessment to exclude significant extra-pulmonary co-morbidities. Complications
arising after transplantation occur because of general perioperative risks, but also as a result of specific issues such as
acute or chronic graft rejection, airway stenoses, infections of the newly immunosuppressed patient as well as a complete
spectrum of secondary extra-pulmonary conditions. Comprehensive follow-up care in lung transplantation patients remains a
vital issue. Analyses have shown a relevant improvement in long-term outcome, when follow-up care is delivered in cooperation
with an established large volume transplant centre.
Der Internist 05/2012; 50(5):561-571. · 0.30 Impact Factor
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ABSTRACT: Bronchial stent insertion is a suitable method to treat airway complications. We present our experience with laryngeal mask airway (LMA) for stent insertion in lung transplant (LT) recipients.
From April 2007 to March 2009, 27 LT recipients underwent insertion of self-expanding nitinol stents to manage airway complications after LT, using LMA for general anesthesia. All procedures were performed with flexible fiberoptic bronchoscopy without fluoroscopy; stent release was visualized with ultrathin bronchoscopes. We followed technical success, safety, improvement of lung function, and clinical symptoms.
Forty-one stents were inserted in 27 patients in 32 sessions. The indications for stent insertion were necrotic lesions (7%) and obstructive lesions (90%). Technical success and safety were 94%. Twice, the stent dislocated, requiring replacements. In 91% of patients, postinterventional improvement in graft function (1 minute forced expiratory volume) was >10% after the intervention. Improvement of clinical symptoms was achieved in 94%. The median procedure time was 38 minutes (range, 30-85 minutes).
LMA offered an excellent condition for stent insertion in LT recipients with airway complications. It provided adequate ventilation and safe airway control during the procedure. This technique may serve as alternative to established techniques using fluoroscopy and rigid bronchoscopy.
Transplantation Proceedings 12/2010; 42(10):4595-9. · 1.00 Impact Factor
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ABSTRACT: Airway complications affect 20% of all lung transplant recipients. Self-expandable metallic stents (SEMS) are one treatment option but their use in benign airway disorders is controversial. We studies the long-term safety of SEMS in lung transplant recipients. Between January 1998 and February 2008, all lung transplant recipients with SEMS were analysed retrospectively at a single centre. Complications were recorded until September 2008. In 65 (9.2%) out of 706 recipients, 111 (91% noncovered) bronchial SEMS were implanted a median (range) 133 (55-903) days after lung transplantation; follow-up was 777 (7-3.655) days. Clinical improvement was noted in 80% of recipients. The forced expiratory volume in 1 s increased by (mean+/-SD) 21+/-33%. Most frequent early complications were migration (3%) and mucus plugging (11%). No procedure-related deaths were noted. Re-stenosis occurred in 34 (52%) out of 65 recipients 85 (7-629) days after insertion. In multivariate analysis, stent insertion before post-operative day 90 was independently associated with an increased risk of re-stenosis (HR 3.29, 95% CI 1.50-7.18; p = 0.003). In 40% of recipients, new bacterial airway colonisation occurred after SEMS insertion. In SEMS patients, 5-yr survival was significantly lower than in the total cohort (60% versus 76%; p = 0.02). Late complications in lung transplant recipients treated with SEMS are frequent. The major problems are re-stenosis and airway colonisation.
European Respiratory Journal 06/2009; 34(6):1417-22. · 5.89 Impact Factor
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[show abstract]
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ABSTRACT: Lung transplantation has been established as an appropriate ultimate treatment strategy in end-stage lung disease, when all conventional therapeutic options have been exhausted. A successful transplantation should result in an improved quality of life as well as an increase in life-expectancy for certain diseases (cystic fibrosis, pulmonary fibrosis and pulmonary hypertension). There is still a critical need regarding the number of available donor organs. Presently, one out of six patients dies on the waiting list. In order to identify suitable candidates for transplantation a number of criteria require consideration. These include the exact etiology of the pulmonary or cardiac disease, but also patient age, physical mobility, nutritional and muscular status as well as a comprehensive assessment to exclude significant extra-pulmonary co-morbidities. Complications arising after transplantation occur because of general perioperative risks, but also as a result of specific issues such as acute or chronic graft rejection, airway stenoses, infections of the newly immunosuppressed patient as well as a complete spectrum of secondary extra-pulmonary conditions. Comprehensive follow-up care in lung transplantation patients remains a vital issue. Analyses have shown a relevant improvement in long-term outcome, when follow-up care is delivered in cooperation with an established large volume transplant centre.
Der Internist 06/2009; 50(5):561-71. · 0.30 Impact Factor
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ABSTRACT: Acute rejection (AR) after lung transplantation (LTx) requires prompt intervention. Most episodes respond to steroid pulse therapy. The aim of this study was to evaluate clinical indicators for non-response to steroid treatment in biopsy proven AR after the early postoperative period.
We prospectively analysed 85 patients more than 6 months after LTx with symptomatic biopsy proven AR (>or=grade A1) from Jan. 2005 until Nov. 2007 in a single centre. In 47 patients, AR was steroid-sensitive (group 1), 38 patients did not respond to steroid pulse therapy (group 2). All AR episodes were associated with clinical symptoms. Fifty-seven (67%) were low-grade rejections (ISHLT A1).
Independent clinical predictors for steroid response vs. non-steroid response in biopsy proven AR were "days after transplantation" (p=0.01, adjusted hazard ratio (HR) 1.2), "decline in home spirometry slope" (p=0.03, HR 0.97), "adherence to home spirometry" (p=0.05, HR 0.98) and "serum CRP" (p=0.02, HR 0.87). Eight patients (21%) of group 2 developed BOS during the following 6 months.
Early detection of deterioration in graft function seems to be crucial for effective treatment of AR. Home spirometry seems to be useful in detecting early changes in graft function and surveillance protocols could be potentially helpful in predicting patients likely to demonstrate a steroid response.
Respiratory medicine 04/2009; 103(8):1114-21. · 2.33 Impact Factor
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ABSTRACT: Bronchiolitis obliterans syndrome (BOS) represents the leading cause of late mortality after lung transplantation (LTx). Cystic fibrosis (CF) patients frequently show airway colonization with gram-negative bacteria (GNB) both before and after LTx. Graft colonization with GNB and its relevance towards BOS development were investigated in a CF population after LTx. Adult CF patients receiving LTx and surviving at least 6 months were included in this prospective observational study between 1/1/2002 and 30/6/2006 in a single center and followed until 31/3/2007. Pre- and post-LTx respiratory culture samples were compared for the presence of identical GNB. BOS-free survival was compared in colonized and non-colonized patients. Fifty-nine adult CF patients with a median age at LTx of 25.5 (18-49) years were included and had a median follow-up of 966 (128-1889) days. Seven patients (15%) demonstrated immediate eradication of GNB in lower respiratory tract samples. A further 18 patients (34%) demonstrated transient colonization. Thirty-four recipients had further positive samples after LTx. Eighteen patients (31%) developed BOS >or=stage 1, 508 (114-1167) days after LTx. Freedom of graft colonization with pseudomonads was independently associated with less frequent development of BOS (p=0.006). Persistent graft colonization with pseudomonads increases the prevalence of BOS after LTx in CF patients. A significant proportion of post-LTx CF patients demonstrates subsequent GNB eradication during later follow-up and this may have a protective role against development of BOS. Strategies to eradicate airway colonization or reduce bacterial load may prevent BOS in CF patients after LTx.
Respiratory medicine 01/2009; 103(5):743-9. · 2.33 Impact Factor
