Acquisition of Carbapenemase-Producing Enterobacteriaceae in Solid Organ Transplantation Recipients.

BACKGROUND: Carbapenemase-producing Enterobacteriaceae (CPE) can lead to life-threatening outcomes with rapid spread of the carbapenemase gene in solid organ transplantation (SOT) recipients because of limitations of available antibiotics. We examined the characteristics and importance of CPE acquisition in SOT recipients with large numbers of CPE isolates. METHODS: Between November 2015 and October 2016, 584 CPE isolates were found in 37 recipients and verified by carbapenemase gene multiplex polymerase chain reaction (PCR). One hundred recipients with at least 2 negative results in carbapenemase PCR for stool surveillance and no CPE isolates in clinical samples were retrospectively included. RESULTS: Most CPE isolates were Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae (546, 93.5%). The most frequent transplantation organ was lung (43.3%), and the most common sample with CPE isolates other than stool was respiratory tract (22.6%). The median time between SOT and first CPE acquisition was 7 days. All-cause mortality was significantly higher in recipients with CPE than in those without CPE (24.3% vs 10.0%; P = .03). In multivariate regression analysis, stool colonization of vancomycin-resistant Enterococci and/or Clostridium difficile during 30 days before SOT (odds ratio [OR], 3.28; 95% CI, 1.24-8.68; P = .02), lung transplantation (OR, 4.50; 95% CI, 1.19-17.03; P = .03), and intensive care unit stay ≥2 weeks (OR, 6.21; 95% CI, 1.72-22.45; P = .005) were associated with acquisition of CPE. CONCLUSIONS: Early posttransplantation CPE acquisition may affect the clinical outcome of SOT recipients. Careful screening for CPE during the early posttransplantation period would be meaningful in recipients with risk factors.

First Report of the Korean Lung Transplantation Registry.

BACKGROUND: The Korean Organ Transplantation Registry (KOTRY) began to register lung transplants in 2015. This is an initial report on the status of patients receiving lung transplants over the past 2 years. METHODS: We analyzed a total of 69 patients who received lung transplants in 2015 and 2016 and who registered with the KOTRY. RESULTS: The 69 patients were treated in 5 institutions. The average (SD) donor age was 39.2 (12.6) years; there were 40 male patients. The average (SD) recipient age was 55.7 (10.0) years, and the number of male recipients was 46. A total of 66 patients underwent bilateral lung transplantation, 3 underwent single-lung transplantation, and 1 underwent simultaneous heart-lung transplantation. The most frequent indication for lung transplantation was idiopathic pulmonary fibrosis (35 patients), followed by connective tissue disease-related interstitial lung disease (9) and acute respiratory failure (8). Prior to transplantation, 23 patients required ventilator care, and 12 required extracorporeal membrane oxygenation while on the waiting list. Episodes of acute rejection during follow-up were reported in 4, 2, 1, and 1 patients at 3, 6, 9, and 12 months, respectively. Infections requiring hospitalization were reported in 27, 10, 4, and 3 patients at 3, 6, 9, and 12 months, respectively. CONCLUSION: The establishment of KOTRY renders it possible to collect nationwide data on lung transplantation, improving research on the topic and clarifying clinical feasibility.

New predictive equation for lung volume using chest computed tomography for size matching in lung transplantation.

PURPOSE: Lung size matching is important in lung transplantation (LT). With advances in computed tomography (CT) technology, multidetector row CT can accurately measure the thoracic cage and lung volumes. The objective of this study was to generate a new regression equation using demographic data based on the measured CT lung volume in a healthy population to predict the CT lung volume of the donor in LT size matching. MATERIALS AND METHODS: The medical records of healthy subjects who underwent chest CT scans to screen for lung cancer were retrospectively reviewed. CT lung volume was semi-automatically measured using a threshold-based auto-segmentation technique. New regression equations for CT lung volume were generated by multiple linear regression analysis using demographic data including height (H, cm), weight (W, kg), and age (A, years). The percentage error rate (%) of the equations were calculated as ([Estimated CT lung volume--Measured CT lung volume]/Measured CT lung volume × 100). A percentage error rate within ± 20% was considered acceptable. RESULTS: A total of 141 men aged 27 to 55 years (mean, 46.7 ± 6.2 years) and 128 women aged 20 to 55 years (mean, 45.4 ± 7.2 years) were enrolled. The final regression equations for CT lung volume were (-5.890 + 0.067 H - 0.030 W + 0.020 A) in men and (-6.698 + 0.072 H - 0.024 W) in women. The mean absolute error rate was 10.9 ± 9.0% and 11.0 ± 8.5% in men and women, respectively. Percentage error rates were within ± 20% in 121 of 141 (85.8%) men and 113 of 128 (88.3%) women. CONCLUSION: These equations could predict the CT lung volume of healthy subjects using demographic data. Using these equations, the predicted CT lung volume of donors could be matched to the measured CT lung volume of recipients in lung transplantation.

HRCT features of acute rejection in patients with bilateral lung transplantation: the usefulness of lesion distribution.

PURPOSE: This study sought to evaluate the high-resolution computed tomography (HRCT) features of acute rejection and to assess the diagnostic accuracy of HRCT for acute rejection considering distribution of lesions in patients with bilateral lung transplantation (BLT). MATERIALS AND METHODS: Between March 2010 and June 2012, 48 transbronchial lung biopsies (TBLBs) and HRCT were performed simultaneously in 26 patients who underwent BLT. We evaluated the presence of ground glass opacity (GGO), consolidation, nodule, bronchial wall thickening, interlobular septal thickening, pleural effusion, atelectasis, bronchiectasis, and cardiomegaly on the HRCT images. The distribution of lesions was analyzed according to bilaterality or upper/lower predominance. Acute rejection was determined on the basis of the pathologic results of TBLB. We evaluated potential correlations of HRCT features with acute rejection, then assessed overall diagnostic accuracy of various HRCT features in combination to diagnose acute rejection in the transplanted lung. RESULTS: Among the 48 TBLBs, 8 were diagnosed as acute rejection (A1, 4 cases; A2, 2 cases; and A3, 2 cases) pathologically. Two A1 rejections and one A2 rejection appeared normal on computed tomography images. Without considering the distribution of lesions, interlobular septal thickening was significantly associated with acute rejection (P = .010) only. Regarding the distribution of lesions on HRCT images, not only interlobular septal thickening but also GGO was significantly associated with acute rejection (P < .05). The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of the HRCT scan in the evaluation of acute rejection were 50%, 97.5%, 80%, 90.1%, and 89.6%, when the bilateral GGO and interlobular septal thickening with lower predominance were considered as the positive finding. CONCLUSIONS: HRCT findings considering lesion distribution could be a useful tool in diagnosing acute rejection in patients with BLT.

The fate of patients on the waiting list for lung transplantation in Korea.

Lung transplantation for end-stage lung disease results in prolonged actuarial survival and improved pulmonary function. However, the shortage of donor lungs has been a major limiting factor in transplantation. The purpose of this study was to analyze the waiting time and mortality rate for each disease entity. The medical records of all patients listed in The Korean Network for Organ Sharing (KONOS) from May 1996 to May 2011 were analyzed to identify waiting times and causes of death. During the study period, 146 patients (86 males and 60 females) of mean age of 46.6 years (range; 5 to 73 years) showed idiopathic pulmonary fibrosis (IPF; n = 61), chronic obstructive pulmonary disease (COPD; n = 19) or bronchiectasis (n = 15). Sixty-five patients (44.5%) underwent lung or heart-lung transplantation. Sixty-two patients (42.5%) expired during the waiting period, and 19 patients are still on the waiting list. The mortality rate while waiting was highest among patients with primary pulmonary hypertension (62.5%) followed by IPF (57.4%), and acute respiratory distress syndrome (ARDS) (55.6%). The mean time from diagnosis to registration in KONOS was 15.5 months among the expired and 13.2 months in the transplanted group (P = .455). The mean time on waiting list was 8.2 months in the expired group and 3.7 months in the transplanted group (P = .012). In the expired group, the mean survival time was significantly shorter among patients with ARDS (2.2 months, P = .004) compared to IPF (7.9 months), COPD (10.7 months), and primary pulmonary hypertension (PPH) (30.0 months). The high mortality rate (42.5%) during the waiting period in Korea may result from the lack of donors and the delay in registration.

Donor evaluation for lung transplantation in Korea.

Lung transplantation for end-stage lung disease results in prolonged survival and improved pulmonary function. However, the shortage of donor lungs has been a major limiting factor in Korea. We sought to investigate the number and utilization of donor lungs by the five institutions performing LTx in Korea, retrospectively reviewing outcomes of organs registered in the Korean Network for Organ Sharing from January to December, 2010. Lungs were offered from 270 brain-dead patients (189 males and 81 females) of mean age of 45.2 ± 14.2 years (range, 12 to 77 years). The most common cause of brain death was hemorrhage (n = 219, 81%). Only 18 (6.7%) donor lungs were used, which was low compared with kidney (93.3%), liver (86.3%), heart (26.7%), and pancreas (11.1%) use. The mean age of donors of transplanted lungs was 35.7 years (range, 14 to 51 years) compared with 45.9 years for other organs (P = .003). The characteristics of utilized donor lungs were: mean partial pressure of oxygen (PaO(2)), 300.9 mm Hg; mean smoking history, as 2.7 pack-years; and mean body mass index, 21.2 kg/m(2). The causes of refusal were medical ineligibility (n = 129) including poor PaO(2), abnormal chest x-ray, long smoking history, older age (n = 46), no properly matched recipient (n = 46), unknown (n = 17), and family withdrawal (n = 14). Only 8 (33.3%) were transplanted from standard criteria and 10 from the lungs that did not satisfy these criteria. An efficient utilization system is needed to improve lung transplantations.

An overview of lung transplantation in Korea.

OBJECTIVE: Lung transplantation (LTx) is the only option for end-stage lung disease refractory to medical treatment. The program was slow to start in Korea; the first LTx was performed in July 1996. By October 2007, 25 lung and 7 heart-lung transplantations have been performed at 5 institutes, with the majority being performed at one center. The aim of this study was to improve the survival rate following LTx by analyzing the operative procedure and its complications. METHODS: We performed a retrospective review of the medical records of 18 patients who underwent lung and heart-lung transplantations from July 1996 to October 2007 at a single institute. Operative mortality was excluded from the analysis of early and late complications. RESULTS: There were 12 males and 6 females of mean age 46.2 +/- 11.5 years (range, 25-63 years). The indications for transplantation included pulmonary emphysema (n = 6), idiopathic pulmonary fibrosis (n = 3), lymphangioleiomyomatosis (n = 3), Eisenmenger's syndrome (n = 2), bronchiectasis (n = 2), primary pulmonary hypertension (n = 1), and primary graft dysfunction after a single lung transplantation (SLT; n = 1). Operations consisted of SLTs in 9 patients, bilateral sequential single lung transplantations (BSSLTs) in 8 patients, and a heart-lung transplantation (HLT) in 1 patient. Early complications were bleeding necessitating rethoracotomy, severe reperfusion injury, seizure, prolonged airleak, chylothorax, and pulmonary artery stenosis. Late complications consisted of cytomegalovirus infection, pulmonary tuberculosis, posttransplantation lymphoproliferative disease, gastric ulcer perforation, pneumothorax, chylothorax, empyema, and aspergillosis. There were 5 operative deaths due to intraoperative bleeding (n = 1), acute graft dysfunction (n = 2), and multiorgan failure (n = 2). Excluding the operative mortality, the mean survival period was 18.5 +/- 23.7 months (range, 3-87 months). CONCLUSIONS: Clinical experience in recent years may have reduced complication rates and led to prolonged survival. Increasing the candidate list through better results and raising awareness of the LTx program is necessary to move forward with thoracic transplantation in Korea.

Maintenance of cAMP in non-heart-beating donor lungs reduces ischemia-reperfusion injury.

Studies suggest that pulmonary vascular ischemia-reperfusion injury (IRI) can be attenuated by increasing intracellular cAMP concentrations. The purpose of this study was to determine the effect of IRI on capillary permeability, assessed by capillary filtration coeficient (Kfc), in lungs retrieved from non-heart-beating donors (NHBDs) and reperfused with the addition of the beta(2)-adrenergic receptor agonist isoproterenol (iso), and rolipram (roli), a phosphodiesterase (type IV) inhibitor. Using an in situ isolated perfused lung model, lungs were retrieved from NHBD rats at varying intervals after death and either ventilated with O(2) or not ventilated. The lungs were reperfused with Earle's solution with or without a combination of iso (10 microM) and roli (2 microM). Kfc, lung viability, and pulmonary hemodynamics were measured. Lung tissue levels of adenine nucleotides and cAMP were measured by HPLC. Combined iso and roli (iso/roli) reperfusion decreased Kfc significantly (p < 0.05) compared with non-iso/roli-reperfused groups after 2 h of postmortem ischemia. Total adenine nucleotide (TAN) levels correlated with Kfc in non-iso/roli-reperfused (r = 0.89) and iso/roli-reperfused (r = 0.97) lungs. cAMP levels correlated with Kfc (r = 0.93) in iso/roli-reperfused lungs. Pharmacologic augmentation of tissue TAN and cAMP levels might ameliorate the increased capillary permeability observed in lungs retrieved from NHBDs.

Fibrovascular polyp of the esophagus in infant.

A five month female was referred complaining of intermittent vomiting with protrusion of a sausage-like mass through the oral cavity. Esophageal endoscopy and esophagogram revealed a mass in the upper esophagus, which was diagnosed as a fibrovascular polyp. Under general anesthesia, the mass was grasped through the oral cavity with a forcep and ligated and excised at the base, where a stump arose from the posterior wall of the cervical esophagus. The pathology was confirmed as a fibrovascular polyp, which is a rare benign esophageal lesion occurring mostly in adult males, and has not been reported in infancy.

A case of parenchymal pulmonary endometriosis.

Pulmonary Endometriosis is a rare disease entity and we report a 23-year-old single woman with a history of hemoptysis in association with menstruation. She was previously treated effectively with hormone therapy for 3 months, but decided to undergo surgical resection because of the high cost of hormone therapy. Radiographic finding of the chest showed haziness in the right lower lung field, and chest CT showed a ground-glass appearance in the posterobasal and laterobasal segment. The patient underwent basal segmentectomy of the right lower lobe. There was no incidence of hemoptysis during her menstruation following the operation.

The changes in main pulmonary artery pressure after bilateral lung autotransplantation in dogs.

In the Respiratory Center, Yongdong Severance Hospital, Yonsei University, we performed 10 cases of bilateral lung autotransplantation in mongrel dogs from July 1994 to June 1996, and we have analyzed the hemodynamic changes. Autotransplantation was performed in order to avoid postoperative rejection. The lung was flushed with an Euro-Collins(E-C) solution containing PGE1 which passed through a 10 French catheter inserted into an incision on the anterior half of the pulmonary artery to pulmonary parenchyme, and the vertical incision was made on the anterior half of the left atrium near the proximal part of the pulmonary vein. However, the bronchus was totally divided after clamping both sides. The lung was kept cold (4 degrees C) in the thoracic cavity for an hour by using slushed ice made from an E-C solution. After an hour of cold ischemia, the pulmonary artery was sutured with Prolene 5-0. The pulmonary vein was sutured with Prolene 6-0 by using the continuous everting mattress method. The main bronchus was anastomosed using the telescope method. The arterial oxygen concentration and the pressures in the femoral and pulmonary arteries were measured both preoperatively and postoperatively. There were no significant hemodynamic differences between the preoperative and postoperative mean pulmonary artery pressure (MPAP) (paired t-test, P = 0.05). Lung preservation using a cold (4 degrees C) E-C solution containing PGE1 may be an acceptable method for short-term storage of a lung (for about an hour) in bilateral lung autotransplantation in dogs.

The role of omentopexy in tracheal transplantation in dogs.

The major step toward successful tracheal transplantation is revascularization of the grafted trachea. There are many reports that although omentopexy is an effective method to facilitate neo-vascularization in tracheal transplantations, the procedure has not been accepted universally in the transplantation field. It remains unclear whether an omentopexy can successfully revascularize tracheal graft regardless of the length of graft. This study was undertaken to assess the usefulness of omentopexy for long-segment(more than 4 cm) tracheal allotransplantation. We have performed six tracheal transplantations with omentopexy (group A) and four tracheal transplantations without omentopexy (group B) in mongrel dogs from July 1993 to February 1995. Five mid-portion tracheal rings were removed from ten donor dogs and ten corresponding tracheal rings were removed from the ten recipient dogs. The excised tracheal rings from the donors were transplanted to the recipient tracheal-excised sites. All the recipients were given cyclosporine, azathioprine, and prednisolone for immunosuppression in the post-operative period. The histologic results of all the surviving members of group B were better than those of the group A. These findings indicate that omentopexy has a limitation, it is not a major method for graft revascularization. Therefore the length of the tracheal graft was greater than 4.0 cm, for its viability, a longer tracheal graft requires some other blood supply aside from the omentopexy.

Pleomorphic adenoma of the trachea--a case report.

An unusual tracheal tumor was found in a 50 year old male who was admitted due to mild dyspnea on exertion. Simple chest X-ray showed an abnormal mass shadow in the trachea and computerized chest tomogram revealed a tumor in the mid 1/3 of the trachea obstructing 80% of the lumen. Through a right thoracotomy incision, resection of a 2.5 cm segment of the trachea with end-to-end anastomosis was done and microscopic findings showed many cystic spaces with myxomatous hyalinous stroma. It was diagnosed as a pleomorphic adenoma of the trachea.

Chest wall implantation of carcinoma after fine needle aspiration biopsy.

Implantation of malignant cells along the needle aspiration tract in patients with lung cancer is a rare but potential complication following percutaneous fine needle aspiration biopsy. Dissemination of cancer cells by aspiration biopsy can change resectable, potentially curable lung cancer to unresectable cancer. We report a 55 year male patient who underwent completion pneumonectomy due to squamous cell carcinoma and one cycle of chemotherapy. He developed outgrowing chest wall tumor at the site of needle aspiration biopsy performed prior to completion pneumonectomy and was pathologically diagnosed as metastatic squamous cell carcinoma. The lesion was successfully treated by radical full-thickness resection of the chest wall and reconstruction with latissimus dorsi musculocutaneous island flap.

Surgical treatment of stage III lung cancer after chemotherapy and radiotherapy.

We have experienced eight patients with advanced bronchogenic carcinomas who underwent resectional surgery after receiving preoperative adjuvant chemotherapy and radiotherapy during the period March, 1990, to February, 1992. Four patients were in stage IIIA and four in stage IIIB, of which six had epidermoid carcinomas and two small cell carcinomas. All patients were male with ages ranging from 48 to 73 (mean 56.7) years. The induction chemotherapy for six patients consisted of cisplatin and VP-16 (Etoposide) only, and two patients were given fluorouracil/cyclophosphamide and cyclophosphamide/adriamycin/cisplatin in addition to cisplatin/VP-16, respectively. All patients also received four to six weeks of radiotherapy following chemotherapy and were re-evaluated for the possibility of surgery after four weeks of observation. All patients underwent pneumonectomies. Postoperative histological staging revealed complete responses in two patients, partial responses in three and no response in three. Patients were followed-up for seven to 33 (mean 21.5) months after the diagnosis of lung cancer. Six patients died 1, 2, 3, 10, 14 and 26 months postoperatively and two patients are alive, revealing no evidence of tumor recurrence 24 months postoperatively. Induction therapy may induce a better resectability by the conversion of the lung cancer to a lower clinical stage by the time of surgery.

Pulmonary leiomyoma--a case report.

A 56 year old female patient was found to have a lung mass in the right upper lobe lobe during evaluation for cough and sputum. The mass had grown slightly over the past 6 months when she was admitted for an operation. Preoperative studies revealed the benign nature of the tumor, and a thoracoscopic right upper lobectomy was performed. Postoperatively, the diagnosis was histologically proven to be pulmonary leiomyoma which is a rare type of benign lung tumor.