Marvin C Borja

Johns Hopkins Medicine, Baltimore, MD, United States

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Publications (18)60.61 Total impact

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    ABSTRACT: The Lung Allocation Score (LAS) dramatically changed organ allocation in lung transplantation. The impact of this change on patient outcomes is unknown. The purpose of the study was to examine early mortality after lung transplantation under the LAS system. All patients undergoing first-time lung transplantation during the period from May 1, 2005 through April 30, 2008 were included in the study. The cohort was divided into quintiles by LAS. A high-risk group (LAS >46) was comprised of the highest quintile, Quintile 5, and a low-risk group (LAS < or =46) included the lower quintiles, Quintiles 1 through 4. A time-to-event analysis was performed for risk of death after transplantation using Kaplan-Meier survival and Cox proportional hazards models. There were 4,346 patients who underwent lung transplantation during the study period. Patients in the high-risk group (LAS >46) were more likely to have idiopathic pulmonary fibrosis (IPF; 52.9% vs 23.8%, p < 0.001) and diabetes (25.8% vs 16.8%, p < 0.001) and to require mechanical ventilatory support (15.4% vs 2.2%, p < 0.001) at the time of transplant as compared with patients in the low-risk group. One-year survival using the Kaplan-Meier product limit estimator was significantly worse in the high-risk group (75% vs 83%, p < 0.001 by log-rank test). Patients in the high-risk group were also found to have increased risk of death (hazard ratio 1.46, 95% confidence interval 1.24 to 1.73) compared with the low-risk group. Overall 1-year survival under the new LAS system appears to be similar to that in historic reports. However, risk of death was significantly increased among patients with LAS >46.
    The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 08/2009; 28(8):769-75. · 3.54 Impact Factor
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    ABSTRACT: Lung transplantation has been increasingly applied to patients over the age of 60 years. Importantly, the procedure of choice, single versus bilateral lung transplantation, remains unclear. Therefore, the purpose of this study was to examine short- and midterm outcomes in this age group with particular attention to procedure type. All first lung transplant recipients, 60 years of age or older, reported to the United Network for Organ Sharing from 1998 to 2004 were divided into two groups: bilateral and single lung transplantation. A retrospective review of pertinent baseline characteristics, clinical parameters, and outcomes was performed. Kaplan-Meier methodology was used to estimate and Cox proportional hazards regression modeling was used to compare posttransplant survival between these groups. Additionally, propensity scores analysis was performed. During the study period, 1656 lung transplant recipients were 60 years of age or older (mean 62.7 +/- 2.4 years, median 62 years). Of these, 364 (28%) had bilateral and 1292 (78%) had single lung transplantation. Survival was not statistically different between the two groups. In the multivariate analysis, bilateral versus single lung transplantation was not a predictor of mortality. Idiopathic pulmonary fibrosis and a donor tobacco history of more than 20 pack-years were significantly associated with mortality (P = .003, CI 1.12-1.76; and P = .006, CI 1.09-1.63; respectively). The survival of lung transplant recipients 60 years of age or older who underwent bilateral versus single lung transplantation is comparable. These data suggest that type of procedure is not a predictor of mortality in this age group. Idiopathic pulmonary fibrosis and donor cigarette use of more than 20 pack-years were independently associated with mortality.
    The Journal of thoracic and cardiovascular surgery 03/2007; 133(2):541-7. · 3.41 Impact Factor
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    ABSTRACT: Lung transplantation is a viable, life-saving intervention for several primary pulmonary disorders complicated by severe lung dysfunction. This study was undertaken to evaluate whether patients with systemic sclerosis (scleroderma), a systemic autoimmune rheumatic disorder, would receive similar benefit from this intervention. Survival following lung transplantation was examined at 2 university medical centers among 29 patients with scleroderma as compared with 70 patients with idiopathic pulmonary fibrosis (IPF) and 38 with idiopathic pulmonary arterial hypertension (IPAH), the latter groups representing pathologically related primary pulmonary disorders. The end point was death from any cause. Risk of mortality in patients with scleroderma was compared with that in patients with IPF or IPAH, with adjustment for demographic and clinical parameters. During 2 years of followup, 11 patients with scleroderma (38%), 23 with IPF (33%), and 14 with IPAH (37%) died. Cumulative survival at 6 months posttransplantation was 69% in the scleroderma group compared with 80% in the IPF group (log-rank P = 0.21) and 79% in the IPAH group (P = 0.38). The estimated risk of mortality at 6 months was increased in patients with scleroderma compared with those with IPF (relative risk [RR] 1.70, 95% confidence interval [95% CI] 0.74-3.93) and those with IPAH (RR 1.52, 95% CI 0.59-3.96), but the differences were not statistically significant. Over the following 18 months, there was convergence in the survival rates such that cumulative survival at 2 years was comparable, at approximately 64%, among all 3 groups. Patients with scleroderma who are recipients of lung transplantation experience similar rates of survival 2 years after the procedure compared with those with IPF or IPAH. Lung transplantation may represent a viable therapeutic option to consider for patients with end-stage lung disease due to scleroderma.
    Arthritis & Rheumatology 01/2007; 54(12):3954-61. · 7.48 Impact Factor
  • Journal of Heart and Lung Transplantation - J HEART LUNG TRANSPLANT. 01/2007; 26(2).
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    ABSTRACT: Primary CMV infection in lung transplant recipients (LTRs) is associated with increased mortality. We studied 22 donor CMV-positive, recipient-negative (D(+)R(-)) LTRs for the development of posttransplant CMV-specific immunity. We found that 13 of 22 D(+)R(-) LTRs (59.1%) seroconverted (CMV IgG Ab(+)). Using pooled peptides of the immunodominant CMV Ags pp65 and IE1, we detected CMV-specific CD8(+)IFN-gamma(+) T cells in the PBMC of 90% of seroconverted individuals following primary infection by intracellular cytokine staining. In contrast, few seroconverters had detectable CMV-specific CD4(+)IFN-gamma(+) T cells during viral latency. However, the majority of IgG(+) LTRs demonstrated CMV-specific CD4(+) and CD8(+) T cell proliferative responses from PBMC, with CD4(+)IFN-gamma(+) T cells detectable upon re-expansion. Examination of lung allograft mononuclear cells obtained by bronchoalveolar lavage revealed both CMV-specific CD4(+) and CD8(+)IFN-gamma(+) T cells, including patients from whom CD4(+)IFN-gamma(+) T cells were simultaneously undetectable in the PBMC, suggesting differential effector memory populations between these compartments. Moreover, both responses in the PBMC and lung allograft were found to persist, despite substantial immunosuppression, long after primary infection. Clinical correlation in this cohort demonstrated that the acquisition of CMV immunity was associated with freedom from CMV disease (p < or = 0.009) and preservation of allograft function (p < or = 0.02) compared with those who failed to develop CMV immunity. Together, our data reveal immunologic heterogeneity in D(+)R(-) LTRs, with the development and persistence of primary CMV responses that may provide clinical benefit.
    The Journal of Immunology 02/2006; 176(4):2625-34. · 5.52 Impact Factor
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    ABSTRACT: Fear of transmission of donor organisms that may result in recipient pneumonia has a negative impact on donor lung utilization. We reviewed our experience with routine donor bronchial aspiration and culture at the time of transplantation to study the impact of donor bronchial organisms on the development of recipient post-lung transplant pneumonia (PTP) and other outcomes. We reviewed 80 consecutive single and bilateral lung transplants (SLTs and BLTs) from August 1998 to August 2001. Pediatric recipients and those not surviving >3 days were excluded. All donors met standard criteria for donor acceptance. All recipients received broad-spectrum antibiotics pending the results of final operating room cultures. PTP required clinical evidence (fever, leukocytosis and hypoxia), radiologic evidence (infiltrate), and culture confirmation during initial hospitalization or within 30 days. Sixty-four donors for 71 recipients (39 SLTs, 32 BLTs) comprised the study population. Organisms were grown from 57 (89%) donors and 46 were polymicrobial. A total of 149 organisms were cultured consisting of 21 different species, with Staphylococcus (n = 35) and Streptococcus (n = 33) being the most common. PTP was seen in 31 (41%) recipients, with Pseudomonas species (n = 13) the most prevalent. Of the 71 donor-recipient pairs, 2 had both donor and recipient with no growth and PTP. The donor organisms had a sensitivity of 0.75 with a low specificity of 0.04 and were negatively correlated with development of PTP. PTP was an independent predictor of overall mortality. The presence of donor organisms does not predict PTP. Therefore, donor acceptance criteria need to be re-examined.
    The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 01/2006; 25(1):99-105. · 3.54 Impact Factor
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    ABSTRACT: Secondary pulmonary hypertension (SPH), defined as a mean pulmonary artery pressure (PAM) greater than 25 mm Hg, complicates end-stage lung diseases of varying etiology. Although previous studies have suggested that SPH does not adversely affect outcome, no study has assessed the impact of the degree of SPH. A retrospective review of the lung transplant database was used to identify patients who underwent either single-lung (SLT) or bilateral lung transplantation (BLT) complicated by SPH. SPH patients were stratified into low SPH (PAM = 30-40 mm Hg) and high SPH (PAM > or = 40 mm Hg). Each group was further sub-categorized into SLT or BLT. Patients with a heart-lung transplant or primary pulmonary hypertension were excluded. Recipients without pulmonary hypertension transplanted over the same time were used as controls. Data are reported as controls vs low SPH vs high SPH. One hundred-four patients received lung transplants between August 1998 and March 2003. There were 45 patients (18 men and 27 women) with SPH. Of these, 28 patients had low SPH, and 17 patients had high SPH. Forty-two patients (18 men and 24 women) without PH were the controls. There were no significant differences between groups except pre-operative oxygen dependence (81% vs 100% vs 94%, respectively) and use of CPB (28.6% vs 57.1% vs 64.7%, respectively). PAO2-PaO2 gradients and PaO2/FIO2 ratios were significantly worse in the high SPH group (116.2 vs 132.9 vs 186.3; p < 0.006) and (277.8 vs 234.3 vs 214.4; p < 0.026) respectively. There was no statistical difference in length of mechanical ventilation or duration of intensive care unit stay between groups. PAMs were significantly different pre-operatively (22.2 +/- 0.8 vs 34.0 +/- 0.6 vs 47.8 +/- 2.0; p < 0.001) and post-operatively (20.9 +/- 1.1 vs 23.7 +/- 1.3 vs 24.8 +/- 2.1; p < 0.001). There were no operative deaths. There were 3 early deaths in the control group, 1 in the low SPH group, and 3 in the high SPH group, none were related to pulmonary hypertension. Actuarial survival at 12, 24, and 48 months was not significantly different among the groups nor between SLT or BLT with SPH. Although SPH increases the risk of reperfusion injury; survival is equivalent with mild or moderate pulmonary hypertension. Either SLT or BLT may be used in patients with SPH without compromising outcome. This has the added benefit of expanding the donor pool.
    The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 10/2005; 24(9):1254-9. · 3.54 Impact Factor
  • Journal of Heart and Lung Transplantation - J HEART LUNG TRANSPLANT. 01/2005; 24(2).
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    ABSTRACT: The morbidity of lung transplantation is higher than other solid organ transplants. Little is known about the outcomes of patients who require pulmonary resection following lung transplantation. We reviewed our experience to evaluate and discern any variables affecting outcome of pulmonary resections performed following lung transplantation. A retrospective review of the lung transplant database was performed. Data are presented as mean +/- standard error (median). A total of 136 lung transplants (80 single lung transplants [SLT], 55 bilateral lung transplants [BLT], and 3 heart-lung transplants [HLT]) were performed from August 1995 to February 2002. Twelve pulmonary resections, 7 lobectomies, and 5 wedge resections were performed on 11 patients. The indication for lobectomy was infection in 5 of 7 lobectomies (3 fungal, 2 bacterial), mass in 1 of 7, and infarction in 1 of 7. The indication for wedge resection was native lung hyperinflation in 4 of 5 wedge resections and mass in 1 of 5. The native lung was resected in 3 of 7 lobectomies and 4 of 5 wedge resections. An allograft lobectomy was performed following 1 SLT and 3 BLT and a wedge resection was performed after 1 SLT. The mean time to pulmonary resection was 12.4 +/- 3.9 (9.1) months. Survival postresection was 17.2 +/- 5.8 (8.3) months and 5 of 11 patients are still alive. There were no bronchial stump leaks following lobectomy. Major pulmonary resections can safely be performed following lung transplant. We recommend early intervention to optimize outcomes.
    The Annals of Thoracic Surgery 12/2003; 76(5):1680-5; discussion 1685-6. · 3.45 Impact Factor
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    ABSTRACT: The effect of tracheostomy on patients receiving lung transplantation is unknown. We reviewed our experience by performing a retrospective analysis on all lung transplant recipients at our institution. Patients were assigned to each study group based on whether or not they received a tracheostomy in the acute postoperative period. One hundred and fourteen lung transplants were performed, and 16 of those patients received a tracheostomy. In the tracheostomy group, more patients had undergone bilateral-lung transplantation (81% vs. 34%, p = 0.001), more required cardiopulmonary bypass (75% vs. 38%, p = 0.005), more acquired postoperative pneumonia (88% vs. 30%, p < 0.001), had greater reperfusion injury at 48 h (PaO2/FiO2 of 233 vs. 345, p = 0.047), had longer initial periods on the ventilator (21 +/- 7 vs. 2 +/- 0.5 days, p < 0.001), more required re-intubation (56% vs. 18%, p = 0.001), spent longer times in the intensive care unit (30 +/- 7 vs. 5.5 +/- 0.9 days, p < 0.001), and had longer lengths of stay (67 +/- 10 vs. 22 +/- 2 days, p < 0.001). Despite these differences between the two groups, a significant difference in survival at 180 days (75 vs. 81%) did not exist (p = 0.89). Although tracheostomy is more likely in sicker patients, it is not associated with poor long-term outcomes.
    American Journal of Transplantation 07/2003; 3(7):891-5. · 6.19 Impact Factor
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    ABSTRACT: Currently the relationship between the evaluation of the donor chest radiograph and the final disposition of potential donor lungs is unknown, yet potential lung donors receive frequent x-rays. We sought to clarify the role donor chest radiographs and donor lung acceptability. We conducted a retrospective review of 84 potential organ donors. Radiographs were reviewed separately by three thoracic surgeons and three pulmonologists and either accepted or rejected with no other information. Data was analyzed by Kappa statistic to judge inter-observer variance and it was compared to actual outcome to determine predictive value. The Kappa statistics for observer agreement was 0.149 among the surgeons, 0.510 among the pulmonologists, and 0.336 overall, representing slight, moderate and fair agreement respectively. The reviewers' decisions to accept or reject a lung concurred with the actual clinical outcome 64.2% of the time. The positive predictive value of an accept decision was found to be 78.3% and the negative predictive value of a reject decision was 36.3%. This study suggests that evaluation of the donor chest x-ray is a highly subjective process and demonstrated the limited role the radiograph presently holds in the determination of organ suitability.
    European Journal of Cardio-Thoracic Surgery 05/2003; 23(4):484-7. · 2.67 Impact Factor
  • Journal of Heart and Lung Transplantation - J HEART LUNG TRANSPLANT. 01/2003; 22(1).
  • Journal of Heart and Lung Transplantation - J HEART LUNG TRANSPLANT. 01/2003; 22(1).
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    ABSTRACT: Combined heart-lung transplantation has been a proven therapeutic option for patients with end-stage cardiopulmonary disease since 1981. Occasional patients are not candidates to receive both lungs en bloc. We describe such a case and propose indications and a surgical technique and present the limited published experience of combined heart-single-lung transplantation.
    The Journal of Heart and Lung Transplantation 12/2002; 21(11):1250-3. · 5.11 Impact Factor
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    ABSTRACT: Because acute rejection is associated with inferior outcomes in lung transplantation, we have routinely employed OKT3, anti-thymocyte globulin (ATG), or daclizumab as adjuncts to reduce rejection. We performed a 4-year prospective, controlled clinical trial of these 3 therapies to determine differences in post-operative infection, rejection, survival, and bronchiolitis obliterans syndrome (BOS). Eighty-seven consecutive lung transplant patients received OKT3 (n = 30), ATG (n = 34), and daclizumab (n = 23) as induction agents. The groups had similar demographics and immunosuppression protocols differing only in induction agents used. No differences were observed in immediate post-operative outcomes such as length of hospitalization, ICU stay, or time on ventilators. Twelve months post-transplant, OKT3 had more infections per patient than the other agents, a difference that only became significant 2 months post-operatively (p = 0.009). The most common infection was bacterial and OKT3 had more bacterial infections than any other agent. Daclizumab had more patients remain infection free in the first year (p = 0.02), having no fungal infections and a low rate of viral infections. No patient receiving daclizumab developed drug specific side-effects. Only those patients with episodes of acute rejection developed BOS. There were no significant differences in the freedom from acute rejection or BOS between the groups. The 2-year survival for the entire cohort was 68%, with no differences observed in patient survival. This study again reveals the importance of acute rejection in the subsequent development of BOS. Although daclizumab offers a low risk of post-transplant infection and drug specific side-effects, no drug is superior in delaying rejection or BOS or in prolonging long-term survival.
    The Journal of Heart and Lung Transplantation 01/2002; 20(12):1282-90. · 5.11 Impact Factor
  • The Journal of Heart and Lung Transplantation 01/2002; 21(1):61-61. · 5.11 Impact Factor
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    ABSTRACT: Lung transplantation from a donor with chronic renal failure has never been reported. This paper reports our successful experience with 2 transplants from donors with end-stage renal disease who were on chronic hemodialysis, and reviews the relevant literature on the effects of renal failure on pulmonary function and on the use of marginal donors.
    The Journal of Heart and Lung Transplantation 10/2000; 19(9):894-6. · 5.11 Impact Factor
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    ABSTRACT: We performed lung transplantation in nine patients with Scleroderma related lung disease. Patient characteristics included: 7 (78%) females, 6 (67%) with limited and 3 (33%) with diffuse Scleroderma. Pulmonary fibrosis was present in 7 (78%) and pulmonary hypertension in 4 (44%). All patients were carefully screened by the Johns Hopkins and University of Maryland Scleroderma Center and only referred for transplantation when concomitant renal insufficiency (creatinine clearance < or = 50 ml/min), aspiration, and skin brakdown were excluded. When compared to a similar group of transplant patients with nonscleroderma lung disease (primary pulmonary fibrosis), there was no significant difference in post-transplant survival at four years (76.2 +/- 0.15% vs. 69.2% +/- 0.12%), mean annual incidence rate for acute rejection (0.14 +/- 0.14 vs. 0.47 +/- 0.13) and infection (viral 0.17 +/- 0.17 vs. 0.29 +/- 0.11) (bacterial 0.17 +/- 0.17 vs. 1.4 +/- 0.4) (fungal 0.99 +/- 0.69 vs. 0.36 +/- 0.16) or serum creatinine (1.55 +/- 0.34 mg/dl vs. 1.15 +/- 0.09 mg/dl). We conclude that lung transplantation is viable option for carefully selected patients with scleroderma related lung disease.
    Annals of transplantation: quarterly of the Polish Transplantation Society 01/2000; 5(3):38-43. · 0.82 Impact Factor