Aspergillus infections in lung transplant recipients: risk factors and outcome.

This retrospective study of 251 lung transplant patients aimed to determine the prevalence, clinical presentation and mortality of Aspergillus infection in order to define specific risk factors and to compare survival in patients with and without infection. Aspergillus was isolated from 86 (33%) cases, which involved colonisation (n = 50), tracheobronchial lesions (n = 17) or invasive aspergillosis (n = 19). Overall, aspergillosis had an impact on survival (p < 0.05); in fact the 5-year mortality rate was substantially higher in single lung transplant recipients with bronchial anastomotic infection, and in those with late-onset infections and chronic rejection. A significant association (p < 0.05) was found between acute rejection and the time at which fungal infection was diagnosed. Aspergillus infection was not related to cytomegalovirus infection or treatment with corticosteroids. The mortality rate for invasive infections was 78% and was related to survival (p < 0.0001); invasive aspergillosis was also associated with chronic rejection (p < 0.05), but not with high corticosteroid doses (p 0.49) or use of tacrolimus (p 0.73). In conclusion, Aspergillus infection was associated with a reduction in the 5-year survival rate of lung transplant recipients, and this was particularly true for patients infected with the invasive forms and for patients with single lung transplants, bronchial anastomotic infection and chronic rejection. Isolation of Aspergillus spp. from respiratory samples preceded acute rejection, and may be a marker of graft dysfunction and/or airway inflammation. Close monitoring, or even pre-emptive antifungal therapy, is recommended for patients with chronic rejection or bronchial airway mechanical abnormalities and persistent Aspergillus colonisation.

Cardiopulmonary transplantation: experience of a lung transplant group.

Cardiopulmonary transplantation (CPT) is indicated for patients eligible for heart transplantation (HT) or lung transplantation (LT) who have severe concomitant lung or heart disease. Only 2 groups perform CPT in Spain. We report our experience with 18 CPTs representing 8.2% and 5% compared with LT (220) and HT (362), respectively, from February 13, 1990 to October 15, 2002. The mean time on a waiting list was 138 days. The current number of surviving patients is 7 (39%), with a mean follow-up of 602 days (range, 3 to 4627 days). They all remain asymptomatic with normal respiratory function in 4 patients. No cardiac graft rejection has been detected. Two patients experienced sustained gastroparesis during the first year with spontaneous resolution. Death occurred within the first 3 months in 9 patients. These outcomes contrast with the early mortality associated with LT and HT in our series, namely 10.6% and 11%, respectively. The different causes of death were as follows: sepsis and multiorgan failure in 5 patients, hemorrhagic shock in 3 patients, and suture dehiscence and fungal aortic perforation in 1 patient. Late mortalities were recorded in 2 cases. Overall patient survival in our series is lower than that reported by the International Registry (IR), with an early mortality rate of 50% (30% IR). Nevertheless, our survival rate at 10 years after transplantation is 30% (26% IR). We conclude that CPT should be considered despite the greater early morbidity and mortality.

[Chronic obstructive pulmonary disease and lung transplants: results in Spain]. / EPOC y trasplante pulmonar: resultados en España.

OBJECTIVE: To determine the outcome of lung transplantation in patients with chronic obstructive pulmonary disease (COPD) in Spain. METHODS: In all COPD patients transplanted at four Spanish hospitals over a period of seven years, we studied actuarial survival rates retrospectively using the Kaplan Meier test in relation to demographic characteristics, type of transplant, underlying disease, lung function evolution in terms of forced vital capacity (FVC), maximum expiratory flow in 1 second (FEV1) and gasometric evolution (PaO2 and PaCO2). RESULTS: Seventy-four transplants were performed in COPD patients over a five-year period. Mean age was 47 +/- 7 years (26-61) and 77% of the patients were men. A diagnosis of emphysema was made in 58%, alpha-1 antitrypsin deficiency emphysema in 14% and chronic bronchitis in 28%. The likelihood of survival was 75% for the first year, 63% for two years and 41% for the third year. Lung function and blood gases improved significantly by the third month after transplantation: FVC was 1677 +/- 637 ml before transplantation and 2631 +/- 670 ml afterwards; FEV1 was 585 +/- 189 ml before transplantation and 2118 +/- 673 ml afterwards (p < 0.001). Double lung transplants achieved significantly greater improvement in function variables than did single-lung transplants (FVC 2843 +/- 681 ml and FEV1 2543 +/- 620 ml by the third month in DLT patients versus FVC 2402 +/- 587 ml and FEV1 1659 +/- 350 ml for SLT), with no significant differences in blood gases after the two types of transplant. Half the sing-lung transplant patients developed hyperinflation of the native lung and reached maximum lung function values, which tended to be lower than those for patients who did not experience this complication (FEV1 1638 +/- 349 ml versus 1930 +/- 307 ml, p = 0.051). CONCLUSIONS: First-year mortality in patients with COPD undergoing lung transplantation in Spain is similar to that described in the International Transplant Registry. We found no differences between double- and single-lung transplant patients. Functional change is good for both types of transplantation, although this aspect of outcome is significantly better when two lungs are transplanted.

[Application of selection criteria in sequential double lung transplantation]. / Ampliación de los criterios de selección en el trasplante bipulmonar secuencial. Grupo de Trasplante Pulmonar de Valencia.

Since the first sequential double lung transplant was performed in 1986, such procedures have been increasing in number and the criteria used as indications for this type of surgery have broadened. Our aim was to reflect on the application of selection criteria and to describe the anesthetic and surgical techniques and postoperative follow-up of 72 patients who underwent this type of transplant surgery between March 1993 and December 1998. Actuarial survival five years after surgery was 74.4%. Among patients requiring transplantation after septic disease, actuarial survival was 90.8% for cystic fibrosis and 88.2% for bronchiectasis. Of the preoperative risk factors analyzed (prior surgery, pachypleuritis, multiresistant germs, poor nutrition, mechanical ventilation and corticoid therapy), only prior treatment with high doses of corticoids proved significant. Eleven patients have been diagnosed of bronchiolitis obliterans, four have died and only two continue to experience difficulties in daily living. The high survival rate and the restriction-free life after recovery lead us to consider sequential double lung transplantation to be the treatment of choice for all pulmonary diseases.