Development of neoplasms during lung transplantation follow-up.

OBJECTIVE: Lung transplant patient survival has significantly improved over the last 2 decades, which has resulted in an increased incidence of malignant disease. We undertook a descriptive, retrospective study of our series of transplant patients. PATIENTS AND METHODS: The study included 129 transplantations from 1999 to 2006. Ten patients (7.75%) developed 11 neoplastic processes during the follow-up period. RESULTS: In these 10 patients with neoformative processes (group 1), 40% were male and 60% female, compared with 62% male and 38% female in the neoplasia-free group (group 2). The overall mean age was 50.5 +/- 15.4 years in group 1 and 48 +/- 14 years in group 2. The neoplasias were: lymphomas (2) and tumors in the urinary tract (2), colon (2), kidney (1), skin (2), breast (1), and native lung (1). The median time from organ transplantation to diagnosis was 21 +/- 16 months. Of the 10 patients in group 1, 60% died, within a median of 9 months after diagnosis. Treatment consisted of surgery in 4 patients, chemotherapy in 5, and chemoradiotherapy in 1. The immunosuppression was changed after cancer diagnosis in 30% of the patients. CONCLUSIONS: Pharmacological immunomodulation caused a higher incidence of malignant disease, in addition to a worse prognosis for these diseases, which demonstrated the importance of adjusting the dose and searching for adequate therapeutic combinations.

[Cerebrovascular chronic occlusive disease (moyamoya): case report]. / Doença cerebrovascular oclusiva crônica (moyamoya): relato de caso.

A six years old boy, Japanese descendant, born in the city of São Paulo, Brazil, arrived to the hospital with sudden loss of muscular strength at the left side of the body. The cranial computerised tomography showed a right fronto-parietal ischemia and the digital angiography by caterism of femural artery, confirmed the diagnosis of brain obstructive chronic vascular disease(moyamoya). We have checked out in the literature that previous superior aerial ways infection, frequently precede the neurological manifestations. Such symptoms are in agreement with the mentioned case. This has suggested the hypothesis of inflammatory-immunologic origin of this disease.

Influence of body mass index in the postoperative evolution after lung transplantation.

OBJECTIVE: To study the influence of body mass index (BMI) on mortality and postoperative evolution in our 10-year experience as a lung transplant group. METHODS: The study included 256 lung transplants performed between June 1999 and June 2009. BMI was stratified into 4 groups (<20 kg/m2 underweight, 20-25 normal weight, 25-30 overweight, and >30 obese) for posttransplant mortality assessment (chi-square) in relation to age, gender, pathology, and transplant type (logistic regression). Time of mechanical ventilation and length of stay in the intensive care unit and in the hospital were also analyzed (Kruskal-Wallis test). RESULTS: BMI showed a normal distribution with a mean value of 24.8±5 kg/m2 (range, 13-38). Although postoperative mortality was greater in the overweight (23%) and obese (23.7%) groups, it did not reach statistical significance, nor was there a significant increase in the risk of death (odds ratios of 1.06 and 1.17, respectively). Risk of death was independent of BMI and was associated with pathology (lower in emphysema) and transplant type (lower in single lung). There were no significant differences in duration of mechanical ventilation (342 hours in obese patients vs 180 in normal weight; P=.7), length of stay in the intensive care unit (18 days in obese patients vs 14 in normal weight; P=.8), or length of hospital stay of patients that were discharged (37 days in obese patients vs 43 in normal weight; P=.8). CONCLUSIONS: In our experience, BMI is not a risk factor that significantly increases postoperative mortality, probably owing to an adequate selection of recipients and an optimal posttransplant management. However, it must be considered to be a relative contraindication, because it is established in the international guidelines, obliging a correct assessment of patients, especially if there are other comorbidities.

Complications during clinical evolution in lung transplantation: pulmonary embolism.

BACKGROUND: Medical complications after lung transplantation (LT) are frequent despite the advances in management. The objectives of this study were to evaluate the incidence and clinical features of pulmonary embolism (PE) among LT recipients in our center. PATIENTS AND METHODS: We performed a retrospective descriptive study of 280 patients who underwent LT between June 1999 and December 2009. RESULTS: Five patients with PE (1.78%) had undergone single LT due to idiopathic pulmonary fibrosis (IPF). PE developed in the transplanted lung and was bilateral in 2 cases. The only associated risk factor was obesity in 3 patients. The clinical presentation was nonspecific; the most frequent symptom being dyspnea. Computed tomography (CT) angiography and ventilation-perfusion scan were used for diagnosis. Patients underwent treatment with low-molecular weight heparin followed by oral anticoagulation. CONCLUSIONS: Our study showed a low incidence of PE (1.78%), although we focused exclusively on this condition, excluding other entities such as deep vein thrombosis. All PE events occurred in the subpopulation of IPF transplant recipients. Possibly some factors predisposed these patients to PE, although they remain unclear. Because PE can cause significant morbidity in LT recipients, it is important to include PE in the differential diagnosis among LT patients presenting with dyspnea, hypoxia, or clinical deterioration.

Lung transplantation as the first choice in emphysema.

INTRODUCTION: The indication for single or double lung transplantation in patients diagnosed with pulmonary emphysema is a topic of current debate. Our aim was to analyze the differences in the incidence of perioperative complications, survival, and quality of life between single and double lung transplantations. MATERIALS AND METHODS: From 1999 to 2008, 223 subjects underwent transplantation in our department, of whom 62 (28%) had a previous diagnosis of pulmonary emphysema. A retrospective study was performed to establish possible differences between group 1 (single lung) and group 2 (double lung) transplants analyzing overall survival using the Kaplan-Meier method and differences between groups using the log-rank test. Pearson chi-square test was used to compare the frequency of postoperative complications, bronchiolitis obliterans BOS acute rejection episodes, and infections. RESULTS: We included 62 patients who underwent transplantation for emphysema. Cumulative 5-year survival rate, excluding preoperative mortality, was 54% overall, 59% for group 1, and 56% for group 2. No significant differences were observed between the groups (P = .47). The frequency of BOS was 34% in group 1 and 42% in group 2 (P = .52). At least 1 acute rejection episode occurred in 52% of group 1 patients and 51% of group 2 patients (P = .98). Bacterial infections were experienced by 50% of group 1 patients and 54% of group 2 patients (P = .72). Fungal infections affected 10% of group 1 patients and 15% of group 2 patients (P = .71). Intraoperative complications were recorded in 27.6% of group 1 patients versus 54% of group 2 patients, a difference that was statistically significant (P = .032). CONCLUSIONS: The study results supported the decision of our group to consider single lung transplantation the treatment of choice in emphysema, which may be complemented with volume reduction surgery in the native lung or subsequent transplantation of the contralateral lung.

Results of "twinning procedure" in lung transplantation: experience in a single center.

INTRODUCTION: The major limiting factor for lung transplantation (LT), both worldwide and in Spain, is the number of suitable lung donors. This, together with the increased demand for LT, led us to propose the performance of 2 single lung transplantations simultaneously using the same donor (the "twinning procedure"). OBJECTIVE: The objective of this study was to analyze the outcome of patients who underwent transplantation with this procedure, assessing differences between the first and the second transplant. PATIENTS AND METHODS: From November 2001 to August 2008, 46 single lung transplantations (SLTs) were performed with 23 donors. RESULTS: The mean ischemia time was 258 minutes (median, 265) for the first transplantation and 312 minutes (median, 320) for the second transplantation. Primary graft dysfunction occurred in 5 patients (24%) in the first group and 9 in the second group (39%; P = .27). The median intubation time was 8 hours for the first and 6.5 hours for the second group. The mean hospital stay was 39 and 31 days, respectively. Postoperative mortality was 2 (8.7%) and 3 (13%) patient, respectively (P = .99). There was no significant difference in the incidence of acute rejection episodes, infections, or chronic rejections. Five-year survival rates were 67.9% for the first and 61.5% for the second (Kaplan-Meier). CONCLUSIONS: The performance of 2 SLTs using the same donor and in the same hospital was feasible with adequate planning, permitting better use of donors and reducing waiting list time and mortality. Our results showed no increased risk for recipients of the second transplant in the early postoperative and long-term periods.

Reoperation in the postoperative period of lung transplantation.

BACKGROUND: Lung transplantation (LTx) has been established as the last treatment option in certain lung diseases. It is not uncommon for complications to occur that require urgent reoperation. The objective of our study was to analyze the characteristics of lung transplant patients who required reoperation in the postoperative period. PATIENTS AND METHODS: We have conducted a retrospective descriptive study of 224 lung transplants from January 1999 to September 2008, excluding retransplants. A subgroup of 16 subjects (7.2%) required reoperations. RESULTS: These 16 individuals had a mean age of 49.38 +/- 14.32 years with 75% men and 25% women. The disease leading to LTx was emphysema in 6 (37.5%), pulmonary fibrosis in 5 (31.3%), pulmonary hypertension in 2 (12.5%) and bronchiectasis, cystic fibrosis, and lymphangioleiomyomatosis in 1 each (6.3%). Preoperatively, 40% were taking corticosteroids. Double lung transplantation was performed in 56.3% and single lung in 43.7%. LTx surgery was prolonged in 68.8% of patients and intraoperative complications were more frequent than in the other patients (P = .041). The causes for reoperation were bleeding in 13 (of these, 5 had severe adhesions and 4 required extracorporeal circulation during LTx); bronchial dehiscence in 1; wall dehiscence in 1; and vascular stenosis in 1. At the end of the study, 62.5% were alive and among the 6 who died, 3 succumbed as a result of the surgery. Most subjects underwent late reoperation after a mean of 16 days from transplantation (range, 1-55). The need for reoperation was not associated with greater perioperative mortality. CONCLUSIONS: The incidence of reoperation in the postoperative period was low in our series. The main cause was bleeding. In more than half of the cases, LTx surgery was prolonged and intraoperative complications were more frequent. The need for reoperation was not associated with greater perioperative mortality.

Surgical risk factors associated with lung transplantation.

BACKGROUND: Despite years of experience with lung transplantation, perioperative morbidity rates remain high. The objective of this study was to analyze our series of lung transplant recipients, seeking to identify possible intra- and postoperative risk factors associated with mortality. PATIENTS AND METHODS: We performed a descriptive, retrospective study of 224 consecutive patients undergoing lung transplantation over a period of 112 months; we excluded retransplant procedures. We gathered details of the surgical procedure and postoperative period in the recovery unit. Univariate analysis using the chi-square test identified variables associated with the incidence of mortality. RESULTS: From 1999 to 2008, we performed 224 lung transplants, including 66% in men and 34% in women. Their overall mean age was 49.9 +/- 13.5 years. The conditions that led to transplantation were pulmonary fibrosis (38.4%); chronic obstructive pulmonary disease emphysema (29%); cystic fibrosis (10.7%); bronchiectasis (8.9%); pulmonary hypertension (3.1%); and other diseases (9.9%). A total of 124 (55.4%) patients underwent single and 100 (44.6%) received sequential bilateral lung transplantations. Surgical risk factors were identified in 51.3% of the cases, the most frequent being hemorrhage (25.3%), followed by severe pulmonary hypertension (14.7%) and cardiopulmonary bypass (12.1%). Greater perioperative mortality was detected among patients with surgical risk factors, namely, significantly related to cardiopulmonary bypass, pulmonary hypertension, and air leak. A higher frequency of surgical risk factors was observed among patients with bilateral lung transplantations and longer procedures, but they were not associated with greater perioperative mortality. Reoperation was necessary in 16 patients (7.2%), mainly owing to bleeding, it was not significantly related to mortality risk. CONCLUSIONS: The incidence of surgical risk factors in lung transplantation was high, especially in bilateral lung transplantations and prolonged procedures. Postoperative bleeding requiring reoperation was not frequent and not associated with increased preoperative mortality in our series.