RESUMO
Pediatric lung transplantation for pulmonary vascular diseases has seen notable advancements and trends. Medical therapies, surgical options, and bridging techniques like extracorporeal membrane oxygenation and different forms of transplants have expanded treatment possibilities. Current challenges include ensuring patient adherence to post-transplant therapies, addressing complications like primary graft dysfunction and rejection, and conducting further research in less common conditions like pulmonary veno-occlusive disease and pulmonary vein stenosis. In this review article, the authors will explore the advancements, emerging trends, and persistent challenges in pediatric lung transplantation for pulmonary vascular diseases.
Assuntos
Transplante de Pulmão , Pneumopatia Veno-Oclusiva , Humanos , Transplante de Pulmão/tendências , Transplante de Pulmão/métodos , Criança , Pneumopatia Veno-Oclusiva/cirurgia , Pneumopatia Veno-Oclusiva/terapia , Estenose de Veia Pulmonar/cirurgia , Estenose de Veia Pulmonar/terapia , Oxigenação por Membrana Extracorpórea , Rejeição de EnxertoRESUMO
Lung transplantation is a well-established treatment for advanced lung disease, improving survival and quality of life. Over the last 60 years all aspects of lung transplantation have evolved significantly and exponential growth in transplant volume. This has been particularly evident over the last decade with a substantial increase in lung transplant numbers as a result of innovations in donor utilization procurement, including the use donation after circulatory death and ex-vivo lung perfusion organs. Donor lungs have proved to be surprisingly robust, and therefore the donor pool is actually larger than previously thought. Parallel to this, lung transplant outcomes have continued to improve with improved acute management as well as microbiological and immunological insights and innovations. The management of lung transplant recipients continues to be complex and heavily dependent on a tertiary care multidisciplinary paradigm. Whilst long term outcomes continue to be limited by chronic lung allograft dysfunction improvements in diagnostics, mechanistic understanding and evolutions in treatment paradigms have all contributed to a median survival that in some centres approaches 10 years. As ongoing studies build on developing novel approaches to diagnosis and treatment of transplant complications and improvements in donor utilization more individuals will have the opportunity to benefit from lung transplantation. As has always been the case, early referral for transplant consideration is important to achieve best results.
Assuntos
Transplante de Pulmão , Transplante de Pulmão/tendências , Transplante de Pulmão/métodos , Humanos , Doadores de Tecidos/provisão & distribuição , Obtenção de Tecidos e Órgãos , Pneumopatias/cirurgia , Qualidade de Vida , Resultado do TratamentoRESUMO
PURPOSE OF REVIEW: To provide an update regarding the state of thoracoabdominal normothermic regional perfusion (taNRP) when used for thoracic organ recovery. RECENT FINDINGS: taNRP is growing in its utilization for thoracic organ recovery from donation after circulatory death donors, partly because of its cost effectiveness. taNRP has been shown to yield cardiac allograft recipient outcomes similar to those of brain-dead donors. Regarding the use of taNRP to recover donor lungs, United Network for Organ Sharing (UNOS) analysis shows that taNRP recovered lungs are noninferior, and taNRP has been used to consistently recover excellent lungs at high volume centers. Despite its growth, ethical debate regarding taNRP continues, though clinical data now supports the notion that there is no meaningful brain perfusion after clamping the aortic arch vessels. SUMMARY: taNRP is an excellent method for recovering both heart and lungs from donation after circulatory death donors and yields satisfactory recipient outcomes in a cost-effective manner. taNRP is now endorsed by the American Society of Transplant Surgeons, though ethical debate continues.
Assuntos
Transplante de Pulmão , Preservação de Órgãos , Perfusão , Humanos , Perfusão/métodos , Perfusão/tendências , Perfusão/efeitos adversos , Estados Unidos , Transplante de Pulmão/tendências , Preservação de Órgãos/métodos , Preservação de Órgãos/tendências , Resultado do Tratamento , Transplante de Coração , Análise Custo-Benefício , Doadores de Tecidos/provisão & distribuiçãoRESUMO
Lung transplantation is currently the gold standard treatment for end-stage lung diseases. Advances in the preservation of donor lungs, the surgical technique and immunosuppressive therapy have led to lung transplantation now being a routine procedure. Nevertheless, the shortage of donor organs, the acute and particularly chronic lung allograft dysfunction (CLAD) still represent major challenges even in experienced centers. Research in this area is still necessary to improve the long-term survival of lung recipients.
Assuntos
Transplante de Pulmão , Humanos , Terapia de Imunossupressão , Pulmão/patologia , Pulmão/cirurgia , Transplante de Pulmão/métodos , Transplante de Pulmão/tendências , Tórax , Doadores de TecidosRESUMO
BACKGROUND: Lung transplantation is a lifesaving intervention for people with advanced lung disease, but it is costly and resource-intensive. To investigate the cost-effectiveness of lung transplantation as a treatment option in pulmonary disease, we must understand costs attributable to end-of-life hospitalizations for end-stage lung disease. RESEARCH QUESTION: What are the costs associated with end-of-life hospitalizations for people with pulmonary disease, and how have these trends changed over time? STUDY DESIGN AND METHODS: Adults aged 18 to 74 years with hospitalization data in the Cost and Utilization Project National Inpatient Sample data from 2009 to 2019 with a pulmonary disease admission were included in this analysis. Those with a history of lung transplantation were excluded. International Classification of Diseases codes were used to identify pulmonary disease admissions, complications, and procedures and interventions. Total charges were calculated for hospitalizations and stratified by patient status at time of discharge. Trends in charges over time were assessed by demographic and hospital factors. RESULTS: One hundred nine thousand nine hundred twenty-four (4.1%) hospital admissions for pulmonary disease resulted in in-hospital mortality. Those with obstructive lung disease accounted for 94.1% of hospitalizations and 88.1% cases of in-hospital mortality. Estimated costs for end-of-life hospitalizations were $29,981 on average with wide variation in cost by diagnosis and procedure utilization. Inpatient costs were highest for younger people who received more procedures. Among the most expensive admissions, mechanical ventilation accounted for the greatest proportion of interventions. Significant increases in the use of mechanical ventilation, extracorporeal membrane oxygenation, and dialysis occurred over the time period. The rate of hospital transfers increased with a proportionately greater increase across admissions resulting in in-hospital mortality. INTERPRETATION: Costs accrued during end-of-life hospitalizations vary across people but represent a significant health care cost that can be averted for selected people who undergo lung transplantation. These costs should be considered in studies of cost-effectiveness in lung transplantation.
Assuntos
Hospitalização , Humanos , Pessoa de Meia-Idade , Estados Unidos/epidemiologia , Masculino , Feminino , Adulto , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Idoso , Adolescente , Assistência Terminal/economia , Assistência Terminal/tendências , Pneumopatias/economia , Pneumopatias/terapia , Pneumopatias/epidemiologia , Mortalidade Hospitalar/tendências , Adulto Jovem , Transplante de Pulmão/economia , Transplante de Pulmão/tendências , Transplante de Pulmão/estatística & dados numéricos , Custos Hospitalares/tendências , Custos Hospitalares/estatística & dados numéricosRESUMO
BACKGROUND: This study compared utilization and outcomes of the 2 widely utilized ex vivo lung perfusion (EVLP) platforms in the United States: a static platform and a portable platform. METHODS: Adult (age 18 years or older) bilateral lung-only transplants utilizing EVLP between February 28, 2018, and December 31, 2022, in the United Network for Organ Sharing database were included. Predischarge acute rejection, intubation at 72 hours posttransplant, extracorporeal membrane oxygenation at 72 hours posttransplant, primary graft dysfunction grade 3 at 72 hours posttransplant, 30-day mortality, and 1-year mortality were evaluated using multivariable regressions. RESULTS: Overall, 607 (6.3%) lung transplants during the study period used EVLP (51.2% static, 48.8% portable). Static EVLP was primarily utilized in the eastern United States, whereas portable EVLP was primarily utilized in the western United States. Static EVLP donors were more likely to be donation after circulatory death (33.4% vs 26.0%; P = .005), have a >20 pack-year smoking history (13.5% vs 6.5%; P = .005), and be extended criteria donors (92.3% vs 85.0%; P = .013), whereas portable EVLP donors were more likely to be older than age 55 years (14.2% vs 8.0%; P = .02). Transplants utilizing the static and portable platforms had similar risk of acute rejection, intubation at 72 hours, extracorporeal membrane oxygenation at 72 hours, primary graft dysfunction grade 3 at 72 hours, and posttransplant mortality at 30 days and 1 year (all P values > .05). CONCLUSIONS: The static and portable platforms had significant differences in donor characteristics and geographic distributions of utilization. Despite this, posttransplant survival was similar between the 2 EVLP platforms.
Assuntos
Transplante de Pulmão , Perfusão , Humanos , Transplante de Pulmão/mortalidade , Transplante de Pulmão/estatística & dados numéricos , Transplante de Pulmão/tendências , Masculino , Feminino , Pessoa de Meia-Idade , Estados Unidos , Adulto , Perfusão/métodos , Perfusão/mortalidade , Perfusão/efeitos adversos , Perfusão/instrumentação , Resultado do Tratamento , Estudos Retrospectivos , Fatores de Tempo , Bases de Dados Factuais , Fatores de Risco , Rejeição de Enxerto , Sobrevivência de Enxerto , IdosoRESUMO
BACKGROUND This single-center study analyzed distinctions between lung transplants performed in the Department of Cardiac and Vascular surgery of the University Clinical Center in Gdansk, Poland before and during the COVID-19 pandemic. MATERIAL AND METHODS There were 189 patients who underwent the qualification procedure to lung transplantation in the Department of Cardiac and Vascular Surgery of the University Clinical Center in Gdansk, Poland in the years 2019 and 2020. The control group consisted of 12 patients transplanted in 2019, and the study group consisted of 16 patients transplanted in 2020. RESULTS During 2019, the qualification process was performed in 102 patients with pulmonary end-stage diseases. In 2020, despite the 3-month lockdown related to organizational changes in the hospital, 87 qualification processes were performed. The mortality rate of patients on the waiting list in 2020 was 14.3% (6 patients died), and during 2019 the rate was also 14.3% (4 patients died). Donor qualifications were according to ISHLT criteria. The distribution of donors in both years was similar. There was no relationship between the geographic area of residence and source of donors. In 2019, all 12 patients had double-lung transplant. In 2020, 11 patients had double-lung transplant and 5 patients had single-lung transplant. There was no difference in ventilation time and PGD aside from a shorter ICU stay in 2020. CONCLUSIONS Lung transplants were relatively well-conducted despite the continued obstacles of the COVID-19 pandemic.
Assuntos
COVID-19 , Acessibilidade aos Serviços de Saúde/tendências , Transplante de Pulmão/tendências , Obtenção de Tecidos e Órgãos/tendências , Listas de Espera/mortalidade , Adulto , Idoso , COVID-19/epidemiologia , COVID-19/prevenção & controle , Feminino , Seguimentos , Acessibilidade aos Serviços de Saúde/organização & administração , Humanos , Transplante de Pulmão/mortalidade , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Pandemias , Polônia/epidemiologia , Obtenção de Tecidos e Órgãos/organização & administraçãoRESUMO
BACKGROUND: Regional variation in lung transplantation practices due to local coronavirus disease 2019 (COVID-19) prevalence may cause geographic disparities in access to lung transplantation. METHODS: Using the United Network for Organ Sharing registry, we conducted a descriptive analysis of lung transplant volume, donor lung volume, new waitlist activations, and waiting list deaths at high-volume lung transplant centers during the first 3 months of the pandemic (March 1. 2020, to May 30, 2020) and we compared it to the same period in the preceding 5 years. RESULTS: Lung transplant volume decreased by 10% nationally and by a median of 50% in high COVID-19 prevalence centers (range -87% to 80%) compared with a median increase of 10% (range -87% to 80%) in low prevalence centers (P-for-trend 0.006). Donation services areas with high COVID-19 prevalence experienced a greater decrease in organ availability (-28% range, -72% to -11%) compared with low prevalence areas (+7%, range -20% to + 55%, P-for-trend 0.001). Waiting list activations decreased at 18 of 22 centers. Waiting list deaths were similar to the preceding 5 years and independent of local COVID-19 prevalence (P-for-trend 0.36). CONCLUSIONS: Regional variation in transplantation and donor availability in the early months of the pandemic varied by local COVID-19 activity.
Assuntos
COVID-19/epidemiologia , Transplante de Pulmão , Pandemias , SARS-CoV-2 , Obtenção de Tecidos e Órgãos , Adulto , Idoso , Estudos de Coortes , Feminino , Humanos , Transplante de Pulmão/estatística & dados numéricos , Transplante de Pulmão/tendências , Masculino , Pessoa de Meia-Idade , Prevalência , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Doadores de Tecidos/estatística & dados numéricos , Doadores de Tecidos/provisão & distribuição , Obtenção de Tecidos e Órgãos/estatística & dados numéricos , Obtenção de Tecidos e Órgãos/tendências , Estados Unidos/epidemiologia , Listas de Espera/mortalidade , Adulto JovemRESUMO
There is a severe shortage in the availability of donor organs for lung transplantation. Novel strategies are needed to optimize usage of available organs to address the growing global needs. Ex vivo lung perfusion has emerged as a powerful tool for the assessment, rehabilitation, and optimization of donor lungs before transplantation. In this review, we discuss the history of ex vivo lung perfusion, current evidence on its use for standard and extended criteria donors, and consider the exciting future opportunities that this technology provides for lung transplantation.
Assuntos
Seleção do Doador/tendências , Transplante de Pulmão/tendências , Preservação de Órgãos/tendências , Perfusão/tendências , Doadores de Tecidos/provisão & distribuição , Animais , Difusão de Inovações , Previsões , Sobrevivência de Enxerto , Humanos , Transplante de Pulmão/efeitos adversos , Preservação de Órgãos/efeitos adversos , Perfusão/efeitos adversos , Pneumonectomia/tendências , Sobrevivência de Tecidos , Coleta de Tecidos e Órgãos/tendências , Resultado do TratamentoRESUMO
BACKGROUND: The purpose of this study is to examine the effects of the coronavirus disease 2019 (COVID-19) pandemic on adult lung transplants and report practice changes in the United States. METHODS: A retrospective analysis of a public dataset from the United Network for Organ Sharing was performed regarding adult lung transplantation (January 19, 2020-June 30, 2020). Data were stratified into 3 periods: pre-COVID-19 (January 19, 2020-March 14, 2020), first COVID-19 era (March 15, 2020-May 8, 2020), and second COVID-19 era (May 9, 2020-June 30, 2020). Weekly changes in waitlist inactivations (COVID-19 precautions or not), waitlist additions, transplant volume, and donor recovery were examined across eras and changes across era were correlated. RESULTS: During the first COVID-19 era, 301 patients were added to the waitlist, representing a 40% decrease when compared to the prior 8-week period. This was followed by a significant increase in listing during the second COVID-19 era (t = 2.16, P = 0.032). Waitlist inactivations decreased in the second COVID-19 era from the first COVID-19 era (t = 3.60, P < 0.001). There was no difference in waitlist inactivations between the pre-COVID era and the second COVID-19 era (P = 0.10). Weekly volume was not associated with trends in COVID-19 cases across any era, but was negatively associated with waitlist inactivations due to COVID-19 precautions entering the first COVID-19 era (r = -0.73, P = 0.04) and second COVID-19 era (r = -0.89, P = 0.003). CONCLUSIONS: Due to the COVID-19 pandemic, the United States experienced a decrease in lung transplant volume. While overall volume has returned to normal, additional studies are needed to identify areas of improvement to better prepare for future pandemics.
Assuntos
COVID-19/epidemiologia , Transplante de Pulmão/tendências , SARS-CoV-2 , Estudos Transversais , Humanos , Transplante de Pulmão/estatística & dados numéricos , Estudos Retrospectivos , Doadores de Tecidos , Estados Unidos/epidemiologia , Listas de EsperaRESUMO
The current COVID-19 pandemia affects health care systems worldwide, however, to a variable extent depending on the caseload in each country. We aimed to provide a cross-sectional overview of current limitations or adaptions in lung transplant programs in Germany in from January to May 2020 due to the COVID-19 pandemia caused by severe acute respiratory syndrome coronavirus 2. A cross-sectional survey assessing various aspects of lung transplant activity was sent to all active lung transplant programs (n = 12) in Germany. Eight centers (66%) responded to the survey within the requested time frame. Four centers (50%) reported their activity is not restricted at all and four centers (50%) reported on moderate general limitations. The overall lung transplant activity in Germany from January to May 2020 contains 128 bilateral and 11 single lung transplantations, which is similar to the same period in the year 2019 (126 bilateral transplantations and 12 single lung transplantations). The results suggest that the influence of the COVID-19 pandemia on lung transplantation activity in Germany has been moderate so far. Nevertheless, adaptions such as extensive testing of donors and recipients were introduced to reduce the likelihood of infections and increase patient safety. Alertness to changes in COVID-19 reproduction rates might be required until effective antiviral therapy or vaccination is available.
Assuntos
COVID-19 , Transplante de Pulmão/tendências , Estudos Transversais , Seleção do Doador/tendências , Alemanha , Pesquisas sobre Atenção à Saúde , Humanos , Transplante de Pulmão/efeitos adversos , Segurança do Paciente , Medição de Risco , Fatores de Risco , Fatores de Tempo , Doadores de Tecidos/provisão & distribuição , Listas de Espera/mortalidadeRESUMO
BACKGROUND: Monitoring efforts to improve access to transplantation requires a definition of the population attributable to a transplant center. Previously, assessment of variation in transplant care has focused on differences between administrative units-such as states-rather than units derived from observed care patterns. We defined catchment areas (transplant referral regions [TRRs]) from transplant center care patterns for population-based assessment of transplant access. METHODS: We used US adult transplant listings (2006-2016) and Dartmouth Atlas catchment areas to assess the optimal method of defining TRRs. We used US Renal Data System and Scientific Registry of Transplant Recipient data to compare waitlist- and population-based kidney transplant rates. RESULTS: We identified 110 kidney, 67 liver, 85 pancreas, 68 heart, and 43 lung TRRs. Most patients were listed in their assigned TRR (kidney: 76%; liver: 75%; pancreas: 75%; heart: 74%; lung: 72%), although the proportion varied by organ (interquartile range for kidney, 65.7%-82.5%; liver, 58.2%-78.8%; pancreas, 58.4%-81.1%; heart, 63.1%-80.9%; lung, 61.6%-76.3%). Patterns of population- and waitlist-based kidney transplant rates differed, most notably in the Northeast and Midwest. CONCLUSIONS: Patterns of TRR-based kidney transplant rates differ from waitlist-based rates, indicating that current metrics may not reflect transplant access in the broader population. TRRs define populations served by transplant centers and could enable future studies of how transplant centers can improve access for patients in their communities.
Assuntos
Área Programática de Saúde , Acessibilidade aos Serviços de Saúde/tendências , Disparidades em Assistência à Saúde/tendências , Falência Renal Crônica/cirurgia , Transplante de Rim/tendências , Indicadores de Qualidade em Assistência à Saúde/tendências , Transplante de Coração/tendências , Humanos , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/epidemiologia , Transplante de Fígado/tendências , Transplante de Pulmão/tendências , Transplante de Pâncreas/tendências , Encaminhamento e Consulta/tendências , Estados Unidos/epidemiologia , Listas de EsperaRESUMO
BACKGROUND: Despite improvement in lung function, most lung transplant (LTx) recipients show an unexpectedly reduced exercise capacity that could be explained by persisting peripheral muscle dysfunction of multifactorial origin. We analyzed the course of symptoms, including dyspnea, muscle effort and muscle pain and its relation with cardiac and pulmonary function parameters during an incremental exercise testing. METHODS: Twenty-four bilateral LTx recipients were evaluated in an observational cross-sectional study. Recruited patients underwent incremental cardio-pulmonary exercise testing (CPET). Arterial blood gases at rest and peak exercise were measured. Dyspnea, muscle effort and muscle pain were scored according to the Borg modified scale. Potential associations between the severity of symptoms and exercise testing parameters were analyzed using a Forest-Tree Machine Learning approach, which accomplishes for a ratio between number of observations and number of screened variables less than unit. RESULTS: Dyspnea score was significantly associated with maximum power output (WR, watts), and minute ventilation (VE, L/min) at peak exercise. In a controlled subgroup analysis, dyspnea score was a limiting symptom only in LTx recipients who reached the higher levels of WR (≥ 101 watts) and VE (≥ 53 L/min). Muscle effort score was significantly associated with breathing reserve as percent of maximal voluntary ventilation (BR%MVV). The lower the BR%MVV at peak exercise (< 32) the higher the muscle effort perception. Muscle pain score was significantly associated with VO2 peak, arterial [HCO3-] at rest, and VE/VCO2 slope. In a subgroup analysis, muscle pain was the limiting symptom in LTx recipients with a lower VO2 peak (< 15 mL/Kg/min) and a higher VE/VCO2 slope (≥ 32). CONCLUSIONS: The majority of our LTx recipients reported peripheral limitation as the prevalent reason for exercise termination. Muscle pain at peak exercise was strictly associated with basal and exercise-induced metabolic altered pathways. The onset of dyspnea (breathing effort) was associated with the intensity of ventilatory response to meet metabolic demands for increasing WR. Our study suggests that only an accurate assessment of symptoms combined with cardio-pulmonary parameters allows a correct interpretation of exercise limitation and a tailored exercise prescription. The role and mechanisms of muscle pain during exercise in LTx recipients requires further investigations.
Assuntos
Dispneia/fisiopatologia , Teste de Esforço/métodos , Exercício Físico/fisiologia , Transplante de Pulmão/tendências , Aprendizado de Máquina , Mialgia/fisiopatologia , Transplantados , Adulto , Estudos Transversais , Dispneia/diagnóstico , Tolerância ao Exercício/fisiologia , Feminino , Humanos , Transplante de Pulmão/efeitos adversos , Masculino , Pessoa de Meia-Idade , Mialgia/diagnóstico , Estudos ProspectivosRESUMO
BACKGROUND: Idiopathic pulmonary fibrosis (IPF) is a progressive disease with high mortality. Patient characteristics associated with diagnostic delays are not well described. METHODS: Subjects who had not been diagnosed with IPF prior to referral and received a new diagnosis of IPF at an enrolling centre for the IPF-PRO (Idiopathic Pulmonary Fibrosis Prospective Outcomes) Registry were characterised as having a longer (>1 year) or shorter (≤1 year) time from symptom onset to diagnosis and from first imaging evidence of fibrosis to diagnosis. Patient characteristics, evaluations and time to death or lung transplant were compared between these cohorts. RESULTS: Among 347 patients with a symptom onset date, 49% were diagnosed with IPF >1 year after symptom onset. These patients were slightly younger and had more cardiac comorbidities than patients diagnosed ≤1 year after symptom onset. Among 454 patients with a date for imaging evidence of fibrosis, 78% were diagnosed with IPF ≤1 year later. A greater proportion of patients with >1 year versus ≤1 year from imaging evidence of fibrosis to diagnosis had cardiac comorbidities and gastro-oesophageal reflux. There was no significant difference in time to death or lung transplant between groups by time to diagnosis. CONCLUSIONS: The time from symptom onset to diagnosis remains over 1 year in approximately half of the patients with IPF, but once imaging evidence is obtained, most of the patients are diagnosed within a year. Cardiac conditions and gastro-oesophageal disorders were more commonly reported in patients with a longer time to diagnosis.
Assuntos
Fibrose Pulmonar Idiopática/diagnóstico , Fibrose Pulmonar Idiopática/mortalidade , Transplante de Pulmão/mortalidade , Sistema de Registros , Idoso , Comorbidade , Feminino , Humanos , Fibrose Pulmonar Idiopática/cirurgia , Transplante de Pulmão/tendências , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Tempo , Estados Unidos/epidemiologiaRESUMO
The unprecedented public health emergency caused by the acute viral respiratory coronavirus disease (COVID-19) has drastically changed current practices in solid organ transplantation, markedly so for transplantation of the lungs, the major target of the virus. Although national and state authorities do not recommend postponing transplant procedures, most specialists are reluctant to proceed due to substantial uncertainty and increased risks in the midst of the pandemic. There is an urgent need for evidence-based directions to move forward. Here, we offer our insights as specialists at a high-volume center located in a geographical area with high infection rates.
Assuntos
COVID-19/prevenção & controle , Controle de Infecções/métodos , Transplante de Pulmão/métodos , Assistência Perioperatória/métodos , Coleta de Tecidos e Órgãos/métodos , Obtenção de Tecidos e Órgãos/métodos , COVID-19/diagnóstico , COVID-19/epidemiologia , Teste para COVID-19 , Acessibilidade aos Serviços de Saúde , Hospitais com Alto Volume de Atendimentos , Humanos , Controle de Infecções/tendências , Transplante de Pulmão/tendências , Pandemias , Assistência Perioperatória/tendências , Philadelphia/epidemiologia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/terapia , Coleta de Tecidos e Órgãos/tendências , Obtenção de Tecidos e Órgãos/tendênciasRESUMO
Systemic sclerosis (SSc) is a multi-organ autoimmune disease with complex interactions between immune-mediated inflammatory processes and vascular pathology leading to small vessel obliteration, promoting uncontrolled fibrosis of skin and internal organs. Interstitial lung disease (ILD) is a common but highly variable manifestation of SSc and is associated with high morbidity and mortality. Treatment approaches have focused on immunosuppressive therapies, which have shown some efficacy on lung function. Recently, a large phase 3 trial showed that treatment with nintedanib was associated with a reduction in lung function decline. None of the conducted randomized clinical trials have so far shown convincing efficacy on other outcome measures including quality of life determined by patient reported outcomes. Little evidence is available for non-pharmacological treatment and supportive care specifically for SSc-ILD patients, including pulmonary rehabilitation, supplemental oxygen, symptom relief and adequate information. Improved management of SSc-ILD patients based on a holistic approach is necessary to support patients in maintaining as much quality of life as possible throughout the disease course and to improve long-term outcomes.
Assuntos
Necessidades e Demandas de Serviços de Saúde/tendências , Saúde Holística/tendências , Doenças Pulmonares Intersticiais/terapia , Qualidade de Vida , Escleroderma Sistêmico/terapia , Humanos , Doenças Pulmonares Intersticiais/diagnóstico , Doenças Pulmonares Intersticiais/epidemiologia , Transplante de Pulmão/tendências , Cuidados Paliativos/métodos , Cuidados Paliativos/tendências , Escleroderma Sistêmico/diagnóstico , Escleroderma Sistêmico/epidemiologiaRESUMO
Lung transplantation is currently the only curative treatment for patients with end-stage lung disease; however, donor organ shortage and the need for intense immunosuppression limit its broad clinical application. Bioartificial lungs created by combining native matrix scaffolds with patient-derived cells might overcome these problems. Decellularization involves stripping away cells while leaving behind the extracellular matrix scaffold. Cadaveric lungs are decellularized by detergent perfusion, and histologic examination confirms the absence of cellular components but the preservation of matrix proteins. The resulting lung scaffolds are recellularized in a bioreactor that provides biomimetic conditions, including vascular perfusion and liquid ventilation. Cell seeding, engraftment, and tissue maturation are achieved in whole-organ culture. Bioartificial lungs are transplantable, similarly to donor lungs, because the scaffolds preserve the vascular and airway architecture. In rat and porcine transplantation models, successful anastomoses of the vasculature and the airway were achieved, and gas exchange was evident after reperfusion. However, long-term function has not been achieved because of the immaturity of the vascular bed and distal lung epithelia. The goal of this strategy is to create patient-specific transplantable lungs using induced pluripotent stem cell (iPSC)-derived cells. The repopulation of decellularized scaffolds to create transplantable organs is one of possible future clinical applications of iPSCs.