Feasibility of Lung Transplantation From Donation After Circulatory Death Donors Following Portable Ex Vivo Lung Perfusion: A Pilot Study.

BACKGROUND: Donation after circulatory death (DCD) has the potential to significantly alleviate the shortage of transplantable lungs. We report our initial experience with the use of portable ex vivo lung perfusion (EVLP) with the Organ Care System Lung device for evaluation of DCD lungs. METHODS: We performed a retrospective review of the DCD lung transplantation (LTx) experience at a single institution through the use of a prospective database. RESULTS: From 2011 to 2015, 208 LTx were performed at the University of Alberta, of which 11 were DCD LTx with 7 (64%) that underwent portable EVLP. DCD lungs preserved with portable EVLP had a significantly shorter cold ischemic time (161 ± 44 vs 234 ± 60 minutes, P = .045), lower grade of primary graft dysfunction at 72 hours after LTx (0.4 ± 0.5 vs 2.1 ± 0.7, P = .003), similar mechanical ventilation time (55 ± 44 vs 103 ± 97 hours, P = .281), and hospital length of stay (29 ± 11 vs 33 ± 10 days, P = .610). All patients were alive at 1-year follow-up after LTx with improved functional outcomes and acceptable quality of life compared with before LTx, although there were no intergroup differences. CONCLUSIONS: In our pilot cohort, portable EVLP was a feasible modality to increase confidence in the use of DCD lungs with validated objective evidence of lung function during EVLP that translates to acceptable clinical outcomes and quality of life after LTx. Further studies are needed to validate these initial findings in a larger cohort.

Outcomes of Lung Transplantation in Recipients With Hepatitis C Virus Infection.

Hepatitis C virus (HCV) infection negatively impacts patient and graft survival following nonhepatic solid organ transplantation. Most data, however, are in kidney transplant, where despite modest impact on outcomes, transplantation is recommended for those with mild to moderate hepatic fibrosis given overall benefit compared to remaining on dialysis. In lung transplantation (LuTx), there is little data on outcomes and international guidelines are vague on the criteria under which transplant should be considered. The University of Alberta Lung Transplant Program routinely considers patients with HCV for lung transplant based on criteria extrapolated from the kidney transplant literature. Here we describe the outcomes of 27 HCV-positive, compared to 443 HCV-negative LuTx recipients. Prior to transplant, five patients were treated for HCV and cured. At the time of transplant, 14 patients remained HCV RNA positive. The 1-, 3-, and 5-year survival were similar in HCV RNA-positive versus -negative recipients at 93%, 77%, and 77% versus 86%, 75%, and 66% (p = 0.93), respectively. Long-term follow-up in eight patients demonstrated no significant progression of fibrosis. In our cohort, HCV did not impact LuTx outcomes and in the era of interferon-free HCV therapies this should not be a barrier to LuTx.

Strategies for safe living among lung transplant recipients: a single-center survey.

BACKGROUND: Lung transplant (LT) recipients are at high risk for infection owing to lifelong immunosuppression and direct communication of the graft with the environment. Guidelines have been established for safe-living strategies after transplantation. We conducted a survey of LT patients to determine compliance with these strategies. METHODS: Adult LT outpatients completed a survey consisting of questions on a 5-point Likert scale with the following categories: hand washing, gardening, respiratory infections, food and water safety, animal contact, travel, and occupation. RESULTS: A total of 194 LT recipients completed the survey (age 54.4 ± 13.3 years; time post transplant 4.76 ± 3.5 years). Regular hand washing was practiced usually or always by 87.6%. Of those who worked with soil/gardened, 70/99 (70.7%) never wore a mask and 15.7% never wore gloves. Pet ownership was common (52%), but most patients used specific precautions during handling. Over one-third of patients continued employment after transplant but, of these, 56% had modified their occupation often because of perceived infectious risks. Most patients were fully compliant with influenza vaccination (92.3%). Patients <40 years of age were less likely to wear long-sleeved clothing in mosquito season (P = 0.002), more likely to handle pet feces (P = 0.005), and less likely to wear a mask with sick contacts (P = 0.021). CONCLUSIONS: We provide important insight into safe-living practices following lung transplantation and identify specific areas and subgroups of patients that could be targeted for enhanced education, with potential significant clinical benefit.

A case report of living-donor lobar lung transplantation for scleroderma-associated usual interstitial pneumonia: eight years and counting.

INTRODUCTION: Scleroderma-associated interstitial lung disease is a life-limiting complication of scleroderma, often requiring lung transplantation. Living-donor lobar lung transplantation (LDLLT) is a viable alternative to deceased-donor lung transplantation in specialized centers under select circumstances. CLINICAL CASE: A 47-year-old female underwent LDLLT after nine years of symptomatic scleroderma-associated usual interstitial pneumonia and three years awaiting deceased-donor lung transplantation. Her manifestations of scleroderma included mild sclerodactyly, periungual erythema, Raynaud's phenomenon, and gastroesophageal reflux, with positive antinuclear autoantibodies. Several years post-transplantation, manometry revealed feeble lower esophageal sphincteric pressure with ineffective esophageal motility. Bronchiolitis obliterans syndrome developed 64 months post-transplantation without evidence of aspiration or reflux on transbronchial biopsy. Currently, she has normal renal function and good allograft function [FEV1 1.52 L (73% predicted) and FVC 2.50 L (99% predicted)]. RELEVANCE: This is the second reported case of LDLLT in scleroderma, and the first reporting long-term pulmonary, renal, and esophageal function post-transplantation.

Case report of vertebral osteomyelitis and mycotic abdominal aortic aneurysm caused by Scedosporium apiospermum in a lung transplant patient with cystic fibrosis.

Cystic fibrosis patients are frequently plagued by infections, often with unusual or hardy organisms. Their infections are only complicated by transplantation. In this report, we review the case of a young woman who had a double lung transplant secondary to cystic fibrosis who developed a lumbar osteomyelitis/discitis several years after transplantation. After treatment, she went on to develop a mycotic abdominal aortic aneurysm. The patient underwent thoracic and abdominal aortic replacement, and histopathology revealed Scedosporium apiospermum infection. The patient recovered well from surgery and was discharged home on long-term antifungal therapy. This represents the first reported case of S apiospermum mycotic aneurysm in a lung transplant patient, and possibly the largest number and longest duration of S apiospermum infections reported in a single patient.

Long-term outcome of lung transplantation in previous intravenous drug users with talc lung granulomatosis.

Talc lung granulomatosis results from the intravenous use of medication intended for oral use. Talc (magnesium silicate) acts as filler in some oral medications; when injected intravenously, it deposits in the lungs leading to airflow obstruction and impaired gas exchange. Allocation of donor lungs to previous intravenous drug users is controversial. After a careful selection process, 19 patients with talc lung granulomatosis have received lung allografts in our program. Long-term survival for these patients is excellent and our results suggest the previous use of intravenous drugs should not necessarily preclude lung transplantation.

Lung transplantation for severe antineutrophilic cytoplasmic antibody-associated vasculitis.

Antineutrophil cytoplasmic antibody-associated vasculitis is a life-threatening disorder for which medical therapy has greatly improved survival. However, there is still significant mortality associated with antineutrophil cytoplasmic antibody-associated vasculitis. Little data exists on the utility of lung transplantation for patients, especially with an acute and severe form of this disease. Herein, we report successful lung transplantation for a patient with life-threatening pulmonary hemorrhage and respiratory failure as a consequence of this pulmonary renal syndrome.

Pneumocystis jirovecii pneumonia after rituximab therapy for antibody-mediated rejection in a renal transplant recipient.

We report the case of a 54-year-old woman who underwent living-related renal transplantation for end-stage renal disease from IgA nephropathy. She was subsequently diagnosed with antibody-mediated rejection (AMR) and received rituximab, a potent B-cell suppressive agent. After therapy with rituximab, she developed Pneumocystis jirovecii pneumonia (PJP) requiring hospitalization. We discuss the increasing literature for the use of rituximab for AMR and the need for PJP prophylaxis in this setting.