Nontuberculous Mycobacterial Pulmonary Infection Among Lung Transplant Recipients.

OBJECTIVES: Data are limited regarding the clinical significance of nontuberculous mycobacteria pulmonary infections among lung transplant recipients. We investigated the incidence and characteristics of pulmonary nontuberculous mycobacteria infection in ourlung transplant patient population. MATERIALS AND METHODS: We obtaineddata of the patients who underwent lung transplant in our center from January 1997 to March 2019. RESULTS: Of 690 patients, nontuberculous mycobacteria were identified in 58 patients (8.4%) over a median follow-up of 3 years. Types of species were as follows: Mycobacterium simiae (n = 24), avium complex (n = 12), abscessus (n = 9), fortuitum (n = 6), chelonae (n = 2), szulgai (n = 1), kansasii (n = 1), lentiflavum (n = 1), and undefined mycobacteria (n = 2). When we compared infections in the early versus late period posttransplant (before and after 6 months), infections with Mycobacterium simiae (16 vs 8 incidents) and Mycobacterium fortuitum (5 vs 1 incident) were more often observed within the early period, whereas most Mycobacterium abscessus (7 vs 1 incident) and Mycobacterium avium complex (9 vs 3 incidents) were observed in the later period. The median forced expiratory volume in 1 second overtime did not differ significantly between patients with and without nontuberculous mycobacteria infection (P = .29). Nontuberculous mycobacteria acquisition was significantly associated with decreased survival (relative risk of 2.41, 95% CI, 1.70-3.43; P ⟨ .001). CONCLUSIONS: The nontuberculous mycobacteria species isolated varied according to the time elapsed since transplant. Among lung transplant recipients, nontuberculous mycobacteria infection was associated with increased mortality but not with lung dysfunction.

Tacrolimus Levels Are Not Associated with Risk of Malignancy in Lung Transplant Recipients.

BACKGROUND Lung transplant (LTx) recipients suffer from high rates of malignancy. Exposure to immunosuppressive medication such as tacrolimus has been proposed as a risk factor for tumorigenesis. We hypothesized that chronically high levels of tacrolimus would be associated with risk of malignancy. MATERIAL AND METHODS The study was performed in a transplant center in Israel, with a nested case-control design. Cases were LTx recipients who were diagnosed with any solid or hematological malignancy except non-melanoma skin cancer. Controls were tumor-free during their entire follow-up after LTx and had at least the same follow-up time as their matched case. Controls were matched to cases by age and type of transplant received (single/double). Tacrolimus levels were extracted and analyzed for median drug level and also integrated over time (area under the curve - AUC-tacrolimus). RESULTS We reviewed 412 LTx recipients in our registry. Thirty-nine cases of malignancy were diagnosed and 160 controls were matched, giving a crude tumor incidence rate of 26/100 000/year. Lung cancers were the commonest diagnosis. Cases and controls were well matched by age, smoking status, and LTx type. Median tacrolimus levels were 11.0 ng/ml and 11.3 ng/ml in cases and controls, respectively (p=0.88). The median log (AUC-tacrolimus) was 9.4 in the cases and 9.5 in the controls (p=0.59). CONCLUSIONS In this nested case-control study, exposure to tacrolimus was similar in tumor cases and non-tumor controls. These data, based on a cohort with modest size, suggest either that tumorigenesis in LTx recipients is unrelated to tacrolimus exposure or that levels in these patients are above an unknown threshold at which the dose-response effect is saturated.

Prospective Randomized Trial Evaluating Ketamine for Adult Bronchoscopy.

BACKGROUND AND OBJECTIVES: Ketamine has been used in pediatric flexible fiberoptic bronchoscopy (FFB). Its efficacy and safety for sedation of adults undergoing FFB has not been thoroughly investigated, and, consequently, it is not used by most interventional bronchoscopists. We aimed to evaluate the safety and efficacy of sedation for FFB under ketamine-propofol-midazolam (KPM) compared with the fentanyl-propofol-midazolam (FPM) regimen. MATERIALS AND METHODS: This was a prospective randomized trial of adult patients (n=80) undergoing FFB, randomized to receive sedation with either KPM (n=39) or FPM (n=41). Vital signs including transcutaneous carbon dioxide tension (TcPCO2) were continuously monitored. Sedation-related complications and interventions to maintain respiratory and hemodynamic stability were compared. Both operator and patient were blinded to the sedation regimen used. The operator's and patient's satisfaction from sedation were assessed following recovery. RESULTS: Maximal intraprocedural TcPCO2 values and minimal oxygen saturation did not differ significantly between the KPM and FPM groups (63.2±11.4 mm Hg vs. 61.1±7.2 mm Hg) and (77.1%±12.5% vs. 81.8%±12.0%), respectively. No significant differences were noted between the KPM and FPM groups with respect to sedation-related respiratory or hemodynamic complications. The operator's and patient's satisfaction from sedation was similar between the groups. CONCLUSIONS: Ketamine is as safe and effective as fentanyl for adult analgesia and sedation during FFB. In light of this observation and the fact that ketamine does not cause hemodynamic suppression, like most sedative agents, and is a potent bronchodilator, should encourage its more widespread use for adult sedation during FFB.

Pandemic influenza (H1N1): impact on lung transplant recipients and candidates.

BACKGROUND: The year 2009 was notable for the outbreak of a novel strain of influenza A (H1N1). We report the outcomes of H1N1 infection in a large cohort of lung transplant (LTx) recipients and candidates. METHODS: This was a retrospective review of 22 suspected cases of H1N1 influenza screened using real-time polymerase chain reaction from nasal secretions. There were 15 confirmed cases (10 LTx recipients, 5 LTx candidates). RESULTS: All patients were treated with oseltamivir at the time of the first clinical assessment. In the LTx recipients group, 7 of the 10 confirmed cases were treated at home with oseltamivir alone. Three patients were admitted with complications (2 pneumonia, 1 acute rejection). Two patients required mechanical ventilation. Two patients had prolonged viral shedding. No deaths occurred among the LTx recipients. In the 5 LTx candidates with confirmed H1N1, 2 deaths occurred from pneumonia and acute respiratory distress syndrome. CONCLUSIONS: Influenza H1N1 had a significant complication rate amongst LTx recipients and a high mortality rate amongst LTx candidates.