Results of a randomized, prospective, multicenter trial of mycophenolate mofetil versus azathioprine in the prevention of acute lung allograft rejection.

BACKGROUND: Although the use of mycophenolate mofetil (MMF) has reduced the incidence of acute rejection in heart and kidney allograft recipients, its role in lung transplantation remains controversial. Therefore, we conducted a randomized, prospective, open-label, multicenter study in lung transplant recipients to determine whether MMF decreases episodes of acute allograft rejection when compared with azathioprine (AZA). METHODS: Between March of 1997 and January of 1999, 81 consecutive lung transplant recipients from two centers were prospectively randomized to receive cyclosporine, corticosteroids, and either 2 mg/kg per day of AZA or 1 g twice daily of MMF. The primary study endpoint was biopsy-proven acute allograft rejection over the first 6 months posttransplant. Secondary endpoints included clinical rejection, cytomegalovirus (CMV) infection, adverse events, and survival. Surveillance bronchoscopies were performed at 1, 3, and 6 months, or if clinically indicated. Pathologists interpreting the biopsy results were blinded to the randomization. Results were analyzed according to intention-to-treat. Between group comparisons of means and proportions were made by using two sample t tests and Fisher's exact tests, respectively. Six-month survival was calculated by the Kaplan-Meier method and compared by the log rank test. RESULTS: Thirty-eight patients were prospectively randomized to receive AZA, and 43 MMF. The incidence of biopsy proven grade II or greater acute allograft rejection at 6 months was 58% in the AZA group and 63% in the MMF group (P=0.82). The 6-month survival rates in the MMF and AZA groups were 86% and 82%, respectively (P=0.57). Rates of CMV infection and adverse events were not significantly different between the two groups. CONCLUSIONS: Acute rejection rates and overall survival at 6 months are similar in lung transplant recipients treated with either MMF- or AZA-based immunosuppression.

Anastomotic infections in lung transplant recipients.

OBJECTIVES: Anastomotic infections are an uncommon but potentially devastating complication after lung transplantation. The incidence, microbiology, predisposing factors, and clinical outcomes of anastomotic infections have not been well described. METHODS: We performed a retrospective chart review of the first 283 lung or heart-lung transplant recipients performed at Duke University Medical Center and identified all cases of anastomotic infection. RESULTS: Fifteen patients (5.3%) developed anastomotic infections. Aspergillus caused infection in six patients, Candida in eight patients and Staphylococcus aureus in one patient. Bilateral or right lung transplantation and the use of induction immunosuppression with monoclonoal or polyclonal antibodies are associated with a higher incidence of anastomotic infections. All patients with fungal anastomotic infections were treated with a combination of systemic and inhaled antifungal agents. All patients had improvement of their anastomotic sites after treatment and no patients developed anastomotic dehiscence. CONCLUSIONS: Anastomotic infection is an infrequent complication after lung transplantation, and is caused predominately by fungal pathogens. In contrast to previous reports, anastomotic dehiscence did not occur in any patient in our series. Treatment with the combination of inhaled and systemic antimicrobial agents may have favorably affected clinical outcomes.

Lung transplantation for cystic fibrosis: effective and durable therapy in a high-risk group.

BACKGROUND: The purpose of this study was to review our experience with lung transplantation in patients with end-stage cystic fibrosis. METHODS: Eight-two patients with cystic fibrosis have undergone bilateral lung transplantation (n=76) or bilateral lower lobe transplantation (n=6) since October 1990. RESULTS: Actuarial survival for the entire cohort is 79% at 1 year and 57% at 5 years. The development of bronchiolitis obliterans syndrome is the leading cause of death after the first year. Freedom from bronchiolitis obliterans syndrome is 84% at 1 year and 51% at 3 years. Pulmonary function tests improve dramatically in recipients. There was no association between death within 1 year and recipient age, weight, graft ischemic time, cytomegalovirus seronegativity, or the presence of pan-resistant organisms. Similarly, there was no association between the development of bronchiolitis obliterans syndrome within 2 years and ischemic time, number of rejection episodes, cytomegalovirus seronegativity, or the presence of panresistant organisms. CONCLUSIONS: Despite their poor nutritional status and the presence of multiply resistant organisms, patients with cystic fibrosis can undergo bilateral lung transplantation with acceptable morbidity and mortality.

Neurogenic electrocardiographic abnormalities in subarachnoid hemorrhage.

ECG abnormalities are a frequent, potentially life-threatening complication of subarachnoid hemorrhage. Yet, the mechanism behind these ECG abnormalities is poorly understood. Nursing literature has given this phenomenon little attention. However, neurogenic ECG abnormalities have implications for critical care nursing practice and research. In this article the most frequently documented neurogenic ECG abnormalities occurring in patients with subarachnoid hemorrhage have been discussed. The proposed pathophysiologic mechanisms and nursing implications were also discussed. Patients with neurogenic ECG abnormalities require complex, multifaceted nursing assessment and intervention. Only with a better understanding of the phenomenon will the critical care nurse be able to meet the needs of these patients.