Effect of cytomegalovirus immunoglobulin on the incidence of lymphoproliferative disease after lung transplantation: single-center experience with 1157 patients.

BACKGROUND: Posttransplantation lymphoproliferative disorder (PTLD), a complication of lung transplantation with an incidence ranging from as much as 20%, is mainly associated with Epstein-Barr virus (EBV) infection. In renal transplantation, the use of immunoglobulin (Ig) cytomegalovirus (CMV) prophylaxis, which contains anti-EBV antibodies, resulted in a significant lower incidence of PTLD. In this study, we report our experience with PTLD in lung transplantation with CMV Ig prophylaxis. METHODS: One-thousand one-hundred fifty-seven consecutive patients who underwent lung transplantation at the Medical University of Vienna between November 1989 and December 2011 were included in this retrospective analysis on PTLD. CMV prophylaxis consisted in all patients of antiviral drugs (ganciclovir/valganciclovir) combined with anti-CMV Ig for 4 weeks. RESULTS: A total of 18 patients (1.5%) developed PTLD of B cell origin. Fifteen patients were diagnosed in the first posttransplantation year, and three patients, beyond 1 year. One- and three-year survival after diagnosis of PTLD was 50% and 38%, respectively. CONCLUSION: The incidence of PTLD in our center is extremely low when compared with the scientific literature. We hypothesize that CMV Ig prophylaxis also protects from EBV-associated PTLD.

Antithymocyte globulin induction therapy improves survival in lung transplantation for cystic fibrosis.

Cystic fibrosis (CF) is an inherited condition that leads to respiratory failure and is the third most common indication for adult bilateral lung transplantation (LuTX). In contrast to other lung diseases, the immune system of CF patients is up-regulated and we therefore hypothesized that these patients would benefit from induction therapy. In the current study, we investigated the impact of antithymocyte globulin (ATG) induction therapy in CF patients after LuTX. One hundred and forty six patients who underwent LuTX for CF at our centre between January 1999 and December 2010 were included in the study and retrospectively analysed. They were divided into two groups according to the immunosuppressive protocol: group-A (n = 103) with and group-B (n = 43) without induction therapy on top of the basic calcineurin inhibitor based triple immunosuppression with mycophenolate mofetil and steroids. Perioperative survival was significantly better in the ATG group, a benefit sustained for the entire follow-up. ATG induction resulted in a significantly lower incidence of acute rejections without an increase in infectious complications. Taken together, our results indicate that ATG induction therapy confers a significant survival benefit in CF patients undergoing LuTX and reduces rejection. We advocate the use of induction therapy in this patient cohort.

Primary lung transplantation after bridge with extracorporeal membrane oxygenation: a plea for a shift in our paradigms for indications.

BACKGROUND: The introduction of the lung allocation score has brought lung transplantation (LTX) of patients on extracorporeal membrane oxygenation (ECMO) bridge into the focus of interest. We reviewed our institutional experience with ECMO as a bridge to LTX. METHODS: Between 1998 and 2011, 38 patients (median age 30.1 years, range 13-66 years) underwent ECMO support with intention to bridge to primary LTX. The underlying diagnosis was cystic fibrosis (n=17), pulmonary hypertension (n=4), idiopathic pulmonary fibrosis (n=9), adult respiratory distress syndrome (n=4), hemosiderosis (n=1), bronchiolitis obliterans (n=1), sarcoidosis (n=1), and bronchiectasis (n=1). The type of extracorporeal bridge was venovenous (n=18), venoarterial (n=15), interventional lung assist (n=1), or a stepwise combination of them (n=4). The median bridging time was 5.5 days (range 1-63) days. The type of transplantation was double LTX (n=7), size-reduced double LTX (n=8), lobar LTX (n=16), split LTX (n=2), and lobar LTX after ex vivo lung perfusion (n=1). RESULTS: Four patients died before transplantation. Thirty-four patients underwent LTX, of them eight patients died in the hospital after a median stay of 24.5 days (range 1-180 days). Twenty-six patients left the hospital and returned to normal life (median hospital stay=47.5 days; range 21-90 days). The 1-, 3-, and 5-year survival for all transplanted patients was 60%, 60%, and 48%, respectively. The 1-, 3-, and 5-year survival conditional on 3-month survival for patients bridged with ECMO to LTX (78%, 78%, and 63%) was not worse than for other LTX patients within the same period of time (90%, 80%, and 72%, respectively, P=0.09, 0.505, and 0.344). CONCLUSION: Transplantation of patients bridged on ECMO to LTX is feasible and results in acceptable outcome.