Evaluation of pulmonary infections in solid organ transplant patients: 12 years of experience.

BACKGROUND: Recipients of solid organ transplants (SOTs) are at higher risk to develop pulmonary infections (PIs) owing to their immunocompromised state. Flexible bronchoscopy (FB) is frequently performed to diagnose nature of these infections. The aim of 12-year review was to evaluate the demographic characteristics of SOT recipients with PIs and to study diagnostic utility of FB in this group of patients. METHODS: Medical records of patients who underwent SOT as well as FB between 2000 and 2012 were retrospectively reviewed. Patients' demographics, type of transplantation, primary diagnoses, thoracic computed tomography (CT) findings, total blood count and chemistry, indication for FB, FB results, specimen culture results, and suspected and final diagnoses were all recorded. If the bronchoscopy findings altered medical management and produced improvement in PI, the procedure was considered diagnostic. RESULTS: Ninety of 998 liver, heart, or kidney transplant recipients underwent FB (73 renal, 16 liver, and 1 heart; mean age, 42.3 ± 12.1 years) during the study period. CT findings were as follows: Consolidation (49.4%), lymphadenopathy (3.4%), nodular infiltrates (5.6%), and cavitary lesion (1.1%). FB was unremarkable in 29, but showed increased secretions in 33 patients (36.7%), chronic mucosal changes in 9 (10%), edema in 7 (7.8%), mucosal plaque in 7 (7.8%), friable mucosa in 3 (3.3%), and endobronchial lesion in 2 (2.2%). A total of 29 bronchial washings (BW; 32.6%) and 10 bronchoalveolar lavages (BAL; 11.2%) were performed. PI was diagnosed in 82% of the patients (n = 73). In 32 patients (36%), micro-organism growth was observed on either BW or BAL. Mycobacterium tuberculosis was detected in 6 (6.7%), Staphylococcus aureus in 4 (4.4%), Moraxella catharralis in 4 (4.4%), Candida albicans in 6 (6.7%), Klebsiella pneumonia in 2 (2.2%), Escherichia coli in 2 (2.2%), Streptococcus pneumoni in 2 (2.2%), Stenotrofomonas maltofilia in 1 (1.1%), Aspergillus fumigatus in 4 (4.5%), and Pseudomonas aeruginosa in 1 (1.1%). Final diagnosis was established by FB (n = 33) with a diagnostic yield of 36%. No significant finding was observed between the type of the transplant and the culture results (P > .05). CONCLUSION: Suspected PI is the most common indication for FB in SOT recipients. It may identify the causative organism in >30% of patients. Tuberculosis was found to be the most frequent agent, which is not surprising from such an endemic area. Bacteria were more common than fungal or viral micro-organisms. FB should be considered in SOT recipients presenting with lung infiltrates and suspected to have PI.

The prevalence and course of pulmonary hypertension and right ventricular dysfunction in patients undergoing orthotopic heart transplantation.

BACKGROUND: Pulmonary hypertension (PHT) and right ventricular (RV) dysfunction are among the commonly observed and potentially serious complications following heart transplantation. RV dysfunction is reported to occur in as much as half of these patients. In this study, the authors sought to examine the prevalence and the course of these prognostically important complications. METHODS: The records of 30 patients who had undergone orthotopic heart transplantation at our center were examined. Demographic and clinical variables were noted; RV dysfunction, pulmonary artery pressure on Doppler echocardiographic examination, and catheter findings were recorded. RESULTS: The mean age of the study population was 31.3 years. On preoperative assessment, PHT was present in 21 (70%) patients. The average value of systolic pulmonary artery pressure was 44.5 ± 5.9 mm Hg. The mean value of pulmonary vascular resistance was 3.3 ± 1.8 hybrid reference unit (HRU). RV dysfunction was detected on postoperative assessment in 17 (56.7%) patients. The mean ischemia time was 216 ± 77 minutes; in 3 cases it exceeded 5 hours but in none of the cases did it reach 6 hours. Rejection was detected in 14 (46.7%) patients. Most of the patients received inotropic agents in the early postoperative period. When compared with preoperative values, on follow up at the end of the first year, a significant decrease in pulmonary artery pressure was observed (47.4 ± 4.8 vs 38.5 ± 7.5 mm Hg; P = .03), and the ratio of patients experiencing RV dysfunction decreased to 16.6% (n = 5). CONCLUSION: The findings of this study indicate that RV dysfunction and PHT are common complications following heart transplantation and improve with appropriate management over time with monitoring.

Pulmonary hypertension in patients with end-stage renal disease undergoing renal transplantation.

INTRODUCTION: Pulmonary hypertension (PHT) has been reported to occur in a considerable proportion of patients with end-stage renal disease (ESRD). It is a progressive condition of the pulmonary circulation that poses prognostic importance. In this study, we sought to investigate the prevalence and the predictors of PHT among ESRD patients undergoing renal transplantation. PATIENTS AND METHODS: We retrospectively evaluated the records, clinical and demographic data as well as laboratory results of 500 adult patients who underwent renal transplantation at our institution. A comprehensive Doppler echocardiographic examination was performed in all patients as part of the preoperative assessment. Systolic pulmonary artery pressure (SPAP) was calculated using Bernoulli equation; a value of >30 mm Hg was accepted as PHT. RESULTS: The mean age of the study population was 31.6 +/- 10.2 years. The mean duration of dialysis was 40 months; 432 patients (86.4%) were on hemodialysis (HD) and 68 (13.6%) on peritoneal dialysis (PD). PHT was detected in 85 (17%) patients with a mean SPAP of 46.7 +/- 8.7 mm Hg (range = 35-75 mm Hg). The mean age, sex, and laboratory variables were similar between patients with versus without PHT (P > .05 for all). The mean duration of dialysis therapy was longer in the PHT group than those subjects with normal SPAP (50.8 vs 38.5 months; P = .008). Concerning the type of dialysis, the ratio of patients having PHT was higher in the HD compared with the PD group (18.8% vs 5.9%; P = .008). The prevalence of chronic obstructive pulmonary artery disease, asthma, smoking, hypertension, and diabetes mellitus did not differ between patients with versus without PHT (P > .05 for all). CONCLUSION: The findings of this study revealed that PHT was a common clinical condition among patients with ESRD evaluated for renal transplantation. The time on renal replacement therapy particularly HD as the treatment was associated with greater prevalences. Since it may be of prognostic importance in patients undergoing renal transplantation, a careful preoperative assessment including a comprehensive Doppler echocardiographic examination is needed to identify PHT.

The prevalence and the impact of portopulmonary hypertension on postoperative course in patients undergoing liver transplantation.

INTRODUCTION: Portopulmonary hypertension (PPH) is an uncommon but serious complication of chronic liver disease. It is accepted to be a poor prognostic factor in the follow-up of patients who have undergone orthotopic liver transplantation (OLT). The presence of severe PPH is accepted as a contraindication to OLT. In this study we sought to identify the prevalence and impact of PPH on the outcome of OLT patients. PATIENTS AND METHODS: We retrospectively analyzed the records of 114 adult OLT patients operated on at our institution. A complete transthoracic Doppler echocardiographic examination was performed preoperatively and postoperatively. To identify PPH, patients with Doppler echocardiographically measured systolic pulmonary artery pressure (SPAP) values of >or=30 mm Hg were defined as PPH. We noted the etiology of the liver disease, the postoperative mortality rates, and the pulmonary complications among OLT patients with PPH. RESULTS: In 24 patients we detected PPH, a prevalence of 21.1% among patients referred for OLT. Their mean age was 44.0 +/- 13.5 years; 18 patients (75.0%) were males. With regard to the Child classification, 16 (66.7%) were in class C. The mean SPAP was 46.6 +/- 7.6 mm Hg. Compared with preoperative values, a significant decrease in mean SPAP was noted postoperatively; 46.6 +/- 7.6 mm Hg vs 37.8 +/- 15.5 mm Hg (P < .05). Concerning postoperative pulmonary complications, pneumonia developed in 7 (29.2%), pleural effusion in 6 (25%), and respiratory failure and right ventricular failure in 1 (4.2%) subject. Compared with patients with a normal SPAP, the postoperative pulmonary complication rate was higher and the length of hospitalization longer among patients with PPH (P < .05). However, no difference was observed in terms of mortality rates (P > .05). CONCLUSION: This study indicated that SPAP decreased among patients with PPH following OLT. Although there was an increase in pulmonary complications, we observed no alteration in mortality rates. Therefore, we suggest that PPH may not be regarded as a contraindication for OLT.