Non-pulmonary complications after lung transplantation: Part I.

Lung transplantation (LT) is a viable therapeutic option in the treatment of advanced lung disease. With improvements in post-transplant survival, complications involving different organ systems after LT are increasingly seen. While non-infectious, extrapulmonary complications after LT are not frequently responsible for early post-transplant mortality, they significantly impact the quality of life and long-term survival. These complications are, therefore, becoming increasingly relevant as patients with LT are living longer. These complications encompass almost all organ systems and are driven by a combination of the preexisting comorbidities, events, and complications around the operative procedure and recovery, and perhaps most importantly, medication side effects of the post-LT regimen. We will discuss the wide array of non-infectious extrapulmonary complications after LT in a two-part series of review articles. While we intend to discuss the relevant literature around these complications, there is little in terms of consensus documents to guide the management approach of these complications. We will, therefore, share our experience and learnings that have shaped the management protocols we have in place in an effort to prevent and treat such complications. The goal of the first part of this two-part review is to provide an overview of the most pertinent non-infectious extrapulmonary complications pertaining to cardiovascular, renal, neuropsychiatric and ophthalmologic organ systems.

Non-pulmonary complications after lung transplantation: part II.

Lung transplantation (LT) is a viable therapeutic option in the treatment of advanced lung disease. With improvements in post-transplant survival, complications involving different organ systems after LT are increasingly seen. While non-infectious, extrapulmonary complications after LT are not frequently responsible for early post-transplant mortality, they significantly impact the quality of life and long-term survival. These complications are, therefore, becoming increasingly relevant as patients with LT are living longer. These complications encompass almost all organ systems and are driven by a combination of the pre-existing comorbidities, events, and complications around the operative procedure and recovery, and perhaps most importantly, medication side effects of the post-LT regimen. In the first of the two-part review, we covered the general approach to management of extrapulmonary complications and covered specific complications pertaining to cardiovascular, renal, neuropsychiatric, and ophthalmologic organ systems. In the current article, we discuss most relevant complications pertaining to the hematologic, endocrine, and gastrointestinal organ systems. In addition, we discuss two of the most common and consequential complications under the miscellaneous category, namely malignancy and venous thrombo-embolism after LT. These two complications have gained increasing significance in the lung allocation score era where progressively sicker and older patients are being transplanted.

Spectrum of findings on ventilation‒perfusion lung scintigraphy after lung transplantation and association with outcomes.

BACKGROUND: Air trapping (AT) is one of the hallmarks of allograft dysfunction after lung transplantation (LT). Inert gas‒based ventilation‒perfusion (VQ) lung scintigraphy has excellent sensitivity in the detection of AT. METHODS: We reviewed the charts of patients who underwent single or double LT between January 2012 and December 2014 (N = 193). Patients without a VQ scintigraphy at the first annual visit (n = 16) and those who did not survive till 1 year (n = 26) were excluded (final n = 151, mean age = 55.8 [SD =14] years, male = 85, female = 66). VQ scintigraphy was independently reviewed and reconciled for the presence and severity of AT by 2 investigators blinded to the clinical data (D.F.P. and D.M.). A 3-year post-transplant survival was the primary end-point. RESULTS: AT was common (n = 73, 48.3%). Patients with obstructive lung diseases as the underlying diagnosis (adjusted odds ratio [OR], 4.36, 95% CI: 1.64‒11.6; p = 0.003) and those with lower body mass index (BMI) (BMI < 25 kg/m2 and 25‒30 kg/m2; p < 0.001) had an increased risk of developing AT in the allograft. The presence of AT (adjusted OR, 2.33, 95% CI: 1.01‒5.36; p = 0.04) and peak forced expiratory volume in 1 sec (FEV1) <60% predicted during the first year after LT were independently associated with 3-year mortality. The association of AT with post-transplant mortality was the strongest among patients with BMI <30 kg/m2 and peak FEV1 <60% predicted. CONCLUSIONS: The finding of AT on VQ scintigraphy at the first annual visit after LT is independently associated with worse post-transplant mortality. The sub-group of patients who fail to achieve a peak FEV1 of 60% predicted during the first year after LT appears to be the key driver of this association.

Characteristics and outcomes among patients with community-acquired respiratory virus infections during the first year after lung transplantation.

BACKGROUND: The current study describes the spectrum of community-acquired respiratory infections (CARV) during the first year after lung transplantation (LT). Additionally, we elucidate variables associated with CARV, management strategies utilized, and impact on early and late outcomes. METHODS: This was a retrospective study among patients transplanted between 2012 and 2015 (n = 255, mean age 55.6 ± 13.5 years, M: F 152:103). The diagnosis of CARV was based on the multiplex PCR on nasopharyngeal swab samples. Baseline characteristics, post-transplant variables, and outcomes were compared among patients with and without CARV. RESULTS: Eighty CARV infections developed among a quarter of the study group (n = 62, 24.3%). Rhinovirus/enterovirus was the most commonly isolated CARV (n = 24) followed by coronavirus (n = 17) and RSV (n = 9). A significant proportion of episodes (43.8%) required hospitalization. The use of nasal corticosteroids and left single LT was independently associated with an increased risk of CARV. CARV infections did not impact the lung functions during the first year or the CLAD-free survival at 3 years. CONCLUSIONS: There is a significant burden of CARV infections during the first year after LT. The use of nasal corticosteroids may increase the risk of CARV infection. CARV infections did not impact outcomes.

Significance of Best Spirometry in the First Year After Bilateral Lung Transplantation: Association With 3-Year Outcomes.

BACKGROUND: Spirometry is the cornerstone of monitoring allograft function after lung transplantation (LT). We sought to determine the association of variables on best spirometry during the first year after bilateral LT with 3-year posttransplant survival. METHODS: We reviewed charts of patients who survived at least 3 months after bilateral LT (n = 157; age ± SD: 54 ± 13 y, male:female = 91:66). Best spirometry was calculated as the average of 2 highest measurements at least 3 weeks apart during the first year. Airway obstruction was defined as forced expiratory volume in 1-second (FEV1)/forced vital capacity (FVC) ratio <0.7. Survival was compared based on the ventilatory defect and among groups based on the best FEV1 and FVC measurements (>80%, 60%-80%, and <60% predicted). Primary outcome was 3-year survival. RESULTS: Overall, 3-year survival was 67% (n = 106). Obstructive defect was uncommon (7%) and did not have an association with 3-year survival (72% versus 67%, P = 0.7). Although one-half patients achieved an FVC>80% predicted (49%), 1 in 5 (19%) remained below 60% predicted. Irrespective of the type of ventilatory defect, survival worsened as the best FVC (% predicted) got lower (>80: 80.8%; 60-80: 63.3%; <60: 40%; P < 0.001). On multivariate logistic regression analysis, after adjusting for age, gender, transplant indication, and annual bronchoscopy findings, best FVC (% predicted) during the first year after LT was independently associated with 3-year survival. CONCLUSIONS: A significant proportion of bilateral LT patients do not achieve FVC>80% predicted. Although the type of ventilatory defect on best spirometry does not predict survival, failure to achieve FVC>80% predicted during the first year was independently associated with 3-year mortality.