BALF cytokines in different phenotypes of chronic lung allograft dysfunction in lung transplant patients

The long‐term success of lung transplantation (LT) is limited by chronic lung allograft dysfunction (CLAD). Different phenotypes of CLAD have been described, such as bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS). The purpose of this study was to investigate the levels of cytokines and chemokines in bronchoalveolar lavage fluid (BALF) as markers of these CLAD phenotypes. BALF was collected from 51 recipients who underwent (bilateral and unilateral) LT. The study population was divided into three groups: stable (ST), BOS, and RAS. Levels of interleukin (IL)‐4, IL‐5, IL‐6, IL‐10, IL‐13, tumor necrosis factor alpha (TNF‐α), interferon‐gamma (IFN‐γ), and granulocyte‐macrophage colony‐stimulating factor (GM‐CSF) were measured using the multiplex technology. BALF neutrophilia medians were higher in BOS (38%) and RAS (30%) than in ST (8%) (P=.008; P=.012). Regarding BALF cytokines, BOS and RAS patients showed higher levels of INF ‐ γ than ST (P=.02; P=.008). Only IL‐5 presented significant differences between BOS and RAS (P=.001). BALF neutrophilia is as a marker for both CLAD phenotypes, BOS and RAS, and IL‐5 seems to be a potential biomarker for the RAS phenotype.     

Comparison of Two Types of Neonatal Extracorporeal Life Support Systems With Pulsatile and Nonpulsatile Flow

We compared the effects of two neonatal extracorporeal life support (ECLS) systems on circuit pressures and surplus hemodynamic energy levels in a simulated ECLS model. The clinical set‐up included the Jostra HL‐20 heart–lung machine, either the Medtronic ECMO (0800) or the MEDOS 800LT systems with company‐provided circuit components, a 10 Fr arterial cannula, and a pseudo‐patient. We tested the system in nonpulsatile and pulsatile flow modes at two flow rates using a 40/60 glycerin/water blood analog, for a total of 48 trials, with n = 6 for each set‐up. The pressure drops over the Medtronic ECLS were significantly higher than those over the MEDOS system regardless of the flow rate or perfusion mode (144.8 ± 0.2 mm Hg vs. 35.7 ± 0.2 mm Hg, respectively, at 500 mL/min in nonpulsatile mode, P < 0.001). The preoxygenator mean arterial pressures were significantly increased and the precannula hemodynamic energy values were decreased with the Medtronic ECLS circuit. These results suggest that the MEDOS ECLS circuit better transmits hemodynamic energy to the patient, keeps mean circuit pressures lower, and has lower pressure drops than the Medtronic Circuit.     

Early lymphocyte recovery predicts superior outcomes after unmanipulated haploidentical blood and marrow transplant for acute myeloid leukemia

We investigated whether early lymphocyte recovery, after unmanipulated haploidentical blood and marrow transplant (HBMT), affected clinical outcomes in 134 patients with acute myeloid leukemia (AML). Lymphocyte recovery was based on the absolute lymphocyte count on day 30 (ALC‐30). Patients with high ALC‐30 (≥294 cells/μL) had higher overall survival (OS) (77.6% vs 59.7%, P=.020) and higher leukemia‐free survival (LFS) (74.6% vs 53.7%, P=.016) than those with low ALC‐30 values. Multivariate analysis demonstrated that a high ALC‐30 was associated with improved overall survival (HR: 0.443, 95% CI: 0.233–0.841; P=.013) and LFS (HR: 0.499, 95% CI: 0.275–0.906; P=.022). Our results suggest that the ALC‐30 can predict a superior outcome after unmanipulated HBMT.     

Isolation of Stenotrophomonas maltophilia in asymptomatic lung transplant recipients: effects of treatment on eradication and outcome

In this retrospective, single‐center data analysis, we audited our clinical practice to treat Stenotrophomonas maltophilia in asymptomatic lung transplant recipients (LTRs). Eighteen LTRs with confirmed isolation of S. maltophilia were identified. Twelve of these LTRs have been treated with antibiotics, while 6 were managed without treatment. Treatment was based on antibiograms (trimethoprim/sulfamethoxazole [TMP/SMX] (8/12), levofloxacin (1/12), or both (3/12). Clearance (12/12 vs 6/6), eradication (10/12 vs 3/6, P=.27), and freedom from S. maltophilia recurrence (83%±11% vs 40%±22% after one year, log‐rank P=.09) were not found to differ significantly between treated and untreated patients. None of the patient groups showed significant changes in lung function or biochemical variables. Creatinine levels at the end of the study period were found to be higher in treated patients compared to the untreated group (P=.049). De novo acquired TMP/SMX resistance in S. maltophilia strains was not observed. These results indicate no evidence that antibiotic treatment for S. maltophilia in asymptomatic LTRs alters lung function or the clinical outcome.     

Double‐lung versus heart‐lung transplantation for precapillary pulmonary arterial hypertension: a 24‐year single‐center retrospective study

Transplant type for end‐stage pulmonary vascular disease remains debatable. We compared recipient outcome after heart‐lung (HLT) versus double‐lung (DLT) transplantation. Single‐center analysis (38 HLT–30 DLT; 1991–2014) for different causes of precapillary pulmonary hypertension (PH): idiopathic (22); heritable (two); drug‐induced (nine); hepato‐portal (one); connective tissue disease (four); congenital heart disease (CHD) (24); chronic thromboembolic PH (six). HLT decreased from 91.7% [1991–1995] to 21.4% [2010–2014]. Re‐intervention for bleeding was higher after HLT; (P = 0.06) while primary graft dysfunction grades 2 and 3 occurred more after DLT; (P < 0.0001). Graft survival at 90 days, 1, 5, 10, and 15 years was 93%, 83%, 70%, 47%, and 35% for DLT vs. 82%, 74%, 61%, 48%, and 30% for HLT, respectively (log‐rank P = 0.89). Graft survival improved over time: 100%, 93%, 87%, 72%, and 72% in [2010–2014] vs. 75%, 58%, 42%, 33%, and 33% in [1991–1995], respectively; P = 0.03. No difference in chronic lung allograft dysfunction (CLAD)‐free survival was observed: 80% & 28% for DLT vs. 75% & 28% for HLT after 5 and 10 years, respectively; P = 0.49. Primary graft dysfunction in PH patients was lower after HLT compared to DLT. Nonetheless, overall graft and CLAD‐free survival were comparable and improved over time with growing experience. DLT remains our preferred procedure for all forms of precapillary PH, except in patients with complex CHD.     

Extracorporeal Life Support After Cardiac Surgery in Children: Outcomes From a Single Institution

Extracorporeal life support (ECLS) is used after congenital heart surgery for several indications, including failure to separate from cardiopulmonary bypass, postoperative low cardiac output syndrome, and extracorporeal cardiopulmonary resuscitation. Here, we assessed the outcomes of ECLS in children after cardiac surgery at our institution. Medical records of all children who required postoperative ECLS at our institution were reviewed. Between 2003 and 2011, 36 (1.4%) of 2541 pediatric cardiac surgical cases required postoperative ECLS. Median age of patients was 64 days (range: 0 days–4.1 years). ECLS was in the form of either extracorporeal membrane oxygenation (ECMO; n = 24) or ventricular assist system (VAS; n = 12). Mean duration of ECLS was 4.9 ± 4.2 days. Overall, 21 patients (58%) were weaned off ECLS, and 17 patients (47%) were successfully discharged from the hospital. Patients with biventricular heart (BVH) had higher survival‐to‐hospital discharge rates compared with those with univentricular heart (UVH) (P = 0.019). Regarding ECLS type, UVH patients who received VAS showed higher rates of device discontinuation than UVH patients who received ECMO (P = 0.012). However, rates of hospital discharge were not significantly different between UVH patients who received VAS or ECMO. Surgical interventions, such as banding of Blalock–Taussig shunt to reduce pulmonary blood flow or placing bidirectional cavopulmonary shunt to minimize ventricular volume overload, were effective for weaning off ECLS in patients with UVH. ECLS is beneficial to children with low cardiac output after cardiac surgery. Rates of survival‐to‐hospital discharge were higher in BVH patients than UVH patients. Additional interventions to reduce ventricular volume load may be effective for discontinuing ECLS in patients with UVH.     

Central Extracorporeal Life Support With Left Ventricular Decompression to Berlin Heart Excor: A Reliable “Bridge to Bridge” Strategy in Crash and Burn Patients

The aim of this study was to compare patients with severe biventricular heart failure who underwent Berlin Heart Excor implantation with (cardiogenic shock [CS] status) or without the need for preoperative extracorporeal life support (ECLS) as a bridge to long‐term device. A total of 40 consecutive patients with severe biventricular heart failure underwent Berlin Heart Excor implantation with (CS status, n = 20, 50%) or without (control, n = 20, 50%) the need for preoperative ECLS as a bridge to long‐term device from March 2007 to May 2015 at our institution. Demographics and preoperative baseline characteristics as well as early and long‐term outcomes including mortality and complication rates were retrospectively compared between the two groups. There were no statistically significant differences in terms of demographics and most preoperative clinical characteristics. The mean age in the ECLS (CS group) and control group was 43.5 ± 19.4 and 41.3 ± 16.4 (P = 0.705), whereas 20 and 25% of patients were females (P = 1.000). However, patients from the ECLS group had preoperatively higher lactate (P = 0.037), aspartate aminotransferase (P < 0.001), and alanine aminotransferase (P < 0.001) levels, all of them significantly decreased after surgery (P  = 0.004, P = 0.017, and P = 0.001, respectively) and did not show any statistical differences to the corresponding values from the control group (P = 0.597, P = 0.491, and P = 0.339, respectively). Postoperatively, patients from the control and ECLS groups had statistically similar incidences of liver failure (30 vs. 35%, P = 0.736), renal failure (45 vs. 70%, P = 0.110), need for reopening (35 vs. 60%, P = 0.113), major cerebrovascular events (35 vs. 30%, P = 0.736), sepsis (10 vs. 25%, P = 0.407), wound infection (20 vs. 30%, P = 0.716), abdominal ischemia requiring surgery (28.6 vs. 36.8%, P = 0.719), and acute respiratory distress syndrome (25 vs. 35.3%, P = 1.000). The proportion of patients who were bridged to transplantation was statistically similar between the ECLS and the control groups (40 vs. 52.6%, P = 0.429). Furthermore, there were no statistically significant differences in terms of early (Breslow [generalized Wilcoxon] P = 0.907) and long‐term (log‐rank [Mantel–Cox] P = 0.787) overall cumulative survival accounting for 30‐day survival of 75 versus 75%, 6‐month survival of 60 versus 55%, 1‐year survival of 54 versus 40%, and 7‐year survial of 47 versus 40% in the control and ECLS groups, respectively. ECLS in critical CS as a bridge to implantation of the Berlin Heart Excor ventricular assist device is safe and is associated with improvement in end‐organ function leading to similar excellent early and long‐term survival and incidences of major complications as in patients without the need for preoperative ECLS support.     

Predictors and outcomes of unplanned early rehospitalization in the first year following lung transplantation

Unplanned early rehospitalization (UER), defined as an unscheduled admission within 30 days of a hospital discharge, is associated with graft loss and recipient mortality in some solid organ transplants but has not been investigated in lung transplant. In this retrospective study, we collected socio‐demographic and clinical factors to determine predictors and outcomes of UER in the first year following lung transplantation. There were 193 patients who underwent lung transplantation and survived to discharge during the 7.9‐year study period. There were 116 (60.1%) patients with at least one UER. Infections (32.8%) and post‐surgical complications (11.8%) were the most common reasons for UER. On multivariate analysis, the strongest predictor of having an UER was discharge to a long‐term acute care facility (odds ratio: 3.01, 95% confidence interval [CI] 1.46–6.20; P=.003). Patients with any UER in the first year following transplantation had worse adjusted survival (hazard ratio: 1.89, 95% CI 1.02–3.50; P=.04). It is unclear, however, to what extent UERs reflect preventable outcomes. Further large‐scale, prospective research is needed to identify the extent to which certain types of UER are modifiable and to define patients at high‐risk for preventable UER.     

Complement C3F allotype synthesized by liver recipient modifies transplantation outcome independently from donor hepatic C3

Complement component 3 (C3) presents both slow (C3S) and fast (C3F) variants, which can be locally produced and activated by immune system cells. We studied C3 recipient variants in 483 liver transplant patients by RT‐PCR‐HRM to determine their effect on graft outcome during the first year post‐transplantation. Allograft survival was significantly decreased in C3FF recipients (C3SS 95% vs C3FS 91% vs C3FF 83%; P=.01) or C3F allele carriers (C3F absence 95% vs C3F presence 90%, P=.02). C3FF genotype or presence of C3F allele independently increased risk for allograft loss (OR: 2.38, P=.005 and OR: 2.66, P=.02, respectively). C3FF genotype was more frequent among patients whose first infection was of viral etiology (C3SS 13% vs C3FS 18% vs C3FF 32%; P=.04) and independently increased risk for post‐transplant viral infections (OR: 3.60, P=.008). On the other hand, C3FF and C3F protected from rejection events (OR: 0.54, P=.03 and OR: 0.63, P=.047, respectively). Differences were not observed in hepatitis C virus recurrence or patient survival. In conclusion, we show that, independently from C3 variants produced by donor liver, C3F variant from recipient diminishes allograft survival, increases susceptibility to viral infections, and protects from rejection after transplantation. C3 genotyping of liver recipients may be useful to stratify risk.     

Does an Open Recirculation Line Affect the Flow Rate and Pressure in a Neonatal Extracorporeal Life Support Circuit With a Centrifugal or Roller Pump?

The objective of this study is to evaluate the impact of an open or closed recirculation line on flow rate, circuit pressure, and hemodynamic energy transmission in simulated neonatal extracorporeal life support (ECLS) systems. The two neonatal ECLS circuits consisted of a Maquet HL20 roller pump (RP group) or a RotaFlow centrifugal pump (CP group), Quadrox‐iD Pediatric oxygenator, and Biomedicus arterial and venous cannulae (8 Fr and 10 Fr) primed with lactated Ringer's solution and packed red blood cells (hematocrit 35%). Trials were conducted at flow rates ranging from 200 to 600 mL/min (200 mL/min increments) with a closed or open recirculation line at 36°C. Real‐time pressure and flow data were recorded using a custom‐based data acquisition system. In the RP group, the preoxygenator flow did not change when the recirculation line was open while the prearterial cannula flow decreased by 15.7–20.0% (P < 0.01). Circuit pressure, total circuit pressure drop, and hemodynamic energy delivered to patients also decreased (P < 0.01). In the CP group, the prearterial cannula flow did not change while preoxygenator flow increased by 13.6–18.8% (P < 0.01). Circuit pressure drop and hemodynamic energy transmission remained the same. The results showed that the shunt of an open recirculation line could decrease perfusion flow in patients in the ECLS circuit using a roller pump, but did not change perfusion flow in the circuit using a centrifugal pump. An additional flow sensor is needed to monitor perfusion flow in patients if any shunts exist in the ECLS circuit.     

Risk factors for early bleeding complications after lung transplantation – a retrospective cohort study

Risk factors for early bleeding complications after lung transplantation are not well described. Our aim was to evaluate coagulation test results and the use of extracorporeal membrane oxygenation as risk factors for bleeding after lung transplantation. We analyzed a single‐center cohort of bilateral lung transplants between January 2009 and August 2015. Predictors of severe postoperative bleeding (bleeding requiring reoperation within 48 h of transplantation) were assessed using multivariable logistic regression. The effect of bleeding on survival was assessed using a Cox proportional‐hazards model. Twenty‐nine (4.5%) of 641 patients experienced severe postoperative bleeding. Postoperative fibrinogen levels (OR = 0.99, 95% CI 0.98–0.995, P = 0.001; per mg/dl increase) and pre‐ and postoperative use of extracorporeal membrane oxygenation (OR = 14.41% 95% CI 5.4–40.19, P < 0.001 and OR = 4.25, 95% CI 1.0–11.09, P = 0.002, respectively) were associated with an increased risk of severe postoperative bleeding. Severe postoperative bleeding was associated with decreased survival within 60 days after transplantation (adjusted HR = 5.73, 95% CI 2.52–13.02, P < 0.001). Low postoperative fibrinogen levels, and pre‐ and postoperative use of extracorporeal membrane oxygenation were risk factors for bleeding after lung transplantation.     

In Vitro Hemodynamic Evaluation of a Novel Pulsatile Extracorporeal Life Support System: Impact of Perfusion Modes and Circuit Components on Energy Loss

The objective of this study is to investigate the impact of every component of extracorporeal life support (ECLS) circuit on hemodynamic energy transmission in terms of energy equivalent pressure (EEP), total hemodynamic energy (THE), and surplus hemodynamic energy (SHE) under nonpulsatile and pulsatile modes in a novel ECLS system. The ECLS circuit consisted of i‐cor diagonal pump and console (Xenios AG, Heilbronn, Germany), an iLA membrane ventilator (Xenios AG), an 18 Fr femoral arterial cannula, a 23/25 Fr femoral venous cannula, and 3/8‐in ID arterial and venous tubing. The circuit was primed with lactated Ringer's solution and human whole blood (hematocrit 33%). All trials were conducted under room temperature at the flow rates of 1–4 L/min (1 L/min increments). The pulsatile flow settings were set at pulsatile frequency of 75 beats per minute and differential speed values of 1000–4000 rpm (1000 rpm increments). Flow and pressure data were collected using a custom‐based data acquisition system. EEP was significantly higher than mean arterial pressure in all experimental conditions under pulsatile flow (P < 0.01). THE was also increased under pulsatile flow compared with the nonpulsatile flow (P < 0.01). Under pulsatile flow conditions, SHE was significantly higher and increased differential rpm resulted in significantly higher SHE (P < 0.01). There was no SHE generated under nonpulsatile flow. Energy loss depending on the circuit components was almost similar in both perfusion modes at all different flow rates. The pressure drops across the oxygenator were 3.8–24.9 mm Hg, and the pressure drops across the arterial cannula were 19.3–172.6 mm Hg at the flow rates of 1–4 L/min. Depending on the pulsatility setting, i‐cor ECLS system generates physiological quality pulsatile flow without increasing the mean circuit pressure. The iLA membrane ventilator is a low‐resistance oxygenator, and allows more hemodynamic energy to be delivered to the patient under pulsatile mode. The 18 Fr femoral arterial cannula has acceptable pressure drops under nonpulsatile and pulsatile modes. Further in vivo studies are warranted to confirm these results.     

Gender differences in long‐term survival post‐transplant: A single‐institution analysis in the lung allocation score era

The purpose of this study was to clarify the significance of recipient gender status on lung transplant outcomes in a large single‐institution experience spanning three decades, we analyzed data from all lung transplants performed in our institution since 1986. Kaplan‐Meier curves and Cox proportional hazard models were used to evaluate the effect of recipient characteristics on survival and BOS score ≥1‐free survival. Logistic regression analysis was used to explore the association of gender with short‐term graft function. About 876 lung transplants were performed between 1986 and 2016. Kaplan‐Meier survival estimates at 5 years post‐transplant for females vs males in the LAS era were 71% vs 58%. In the LAS era, females showed greater unadjusted BOS≥1‐free survival than males (35% vs 25%, P=.02) over 5 years. Female gender was the only factor in the LAS era significantly associated with improved adjusted 5‐year survival [HR 0.56 (95% CI 0.33, 0.95) P=.03]. Conversely, in the pre‐LAS era female gender was not associated with improved survival. Female recipients showed significantly improved survival over 5 years compared to males in the LAS era. A prospective analysis of biologic and immunologic differences is warranted.     

Patterns and correlates of adherence to self‐monitoring in lung transplant recipients during the first 12 months after discharge from transplant

Self‐monitoring of lung function, vital signs, and symptoms is crucial for lung transplant recipients (LTRs) to ensure early detection of complications and prompt intervention. This study sought to identify patterns and correlates of adherence to self‐monitoring among LTRs over the first 12 months post‐discharge from transplant. This study analyzed existing data from the usual care arm participants of a randomized clinical trial who tracked self‐monitoring activities using paper‐and‐pencil logs. Adherence was calculated as the percent of days LTRs recorded any self‐monitoring data per interval: hospital discharge‐2 months, 3‐6 months, and 7‐12 months. The sample (N=91) was mostly white (87.9%), male (61.5%), with a mean age of 57.2±13.8 years. Group‐based trajectory analyses revealed two groups: (i) moderately adherent with slow decline (n=29, 31.9%) and (ii) persistently nonadherent (n=62, 68.1%). Multivariate binary logistic regression revealed the following baseline factors increased the risk in the persistently nonadherent group: female (P=.035), higher anxiety (P=.008), and weaker sense of personal control over health (P=.005). Poorer physical health over 12 months were associated with increased risk in the persistently nonadherent group (P=.004). This study highlighted several modifiable factors for future interventions to target, including reducing post‐transplant anxiety, and strengthening sense of personal control over health in LTRs.     

Post‐transplant lymphoproliferative disease in lung transplantation: A nested case‐control study

Post‐transplant lymphoproliferative disorder (PTLD) may compromise long‐term outcome of lung transplant (LTx) recipients. A case‐control study was performed, comparing LTx recipients with PTLD (n=31) to matched recipients without PTLD (Controls, n=62). Risk factors for PTLD and post‐transplant outcomes were assessed. PTLD prevalence was 3.9%, time to PTLD 323 (166‐1132) days; and 54.8% had early‐onset PTLD versus 45.2% late‐onset PTLD. At LTx, more Epstein‐Barr virus (EBV)‐seronegative patients were present in PTLD (42%) compared to Controls (5%) (P<.0001); most of whom had undergone EBV seroconversion upon PTLD diagnosis. EBV viral load was higher in PTLD versus Controls (P<.0001). Overall, lower hemoglobin and higher C‐reactive protein levels were present in PTLD versus Controls (P<.0001). EBV status at LTx (P=.0073) and EBV viral load at PTLD (P=.0002) were the most important risk determinates for later PTLD. Patients with PTLD demonstrated shorter time to onset of chronic lung allograft dysfunction (CLAD) (P=.0006) and poorer 5‐year survival post‐LTx (66.6% versus 91.5%), resulting in worse CLAD‐free survival (HR 2.127, 95%CI 1.006‐4.500; P=.0483) and overall survival (HR 3.297 95%CI 1.473‐7.382; P=.0037) compared to Controls. Late‐onset PTLD had worse survival compared to early‐onset PTLD (P=.021). Primary EBV infection is a risk for PTLD; which is associated with worse long‐term outcome post‐LTx.     

The impact of obesity on outcomes in patients receiving extracorporeal life support

Extracorporeal life support (ECLS) has been increasingly utilized to manage cardiac and pulmonary dysfunction. The impact of obesity on outcomes of ECLS is poorly defined. The purpose of the study was to compare in-hospital mortality, resource use, complications, and readmissions in obese versus non-obese patients receiving ECLS. We performed a retrospective cohort study of all adult ECLS patients with and without an obesity diagnosis using the 2010–2016 Nationwide Readmissions Database (NRD). Mortality, length of stay (LOS), hospital charges, complications, and readmissions were evaluated using multivariable logistic and linear regression. Of 23 876, patients who received ECLS, 1924 (8.1%) were obese. Obese patients received ECLS more frequently for respiratory failure (29.5% vs. 23.7%, P = .001). After adjustment for patient and hospital factors, obesity was not associated with increased odds of mortality (AOR = 1.06, P = .44) and was associated with decreased LOS (13.7 vs. 21.2 days, P < .001), hospital charges ($171 866 vs. $211 445, P < .001), and 30-day readmission (AOR = 0.71, P = .03). Obesity was also associated with reduced odds of hemorrhage (AOR = 0.43, P < .001), neurologic complications (AOR = 0.55, P = .004), and acute kidney injury (AOR=0.83, P = .04). After stratification by ECLS indication, obesity remained predictive of shorter LOS (AOR range: 0.53-0.78, all P < .05 ) and did not impact mortality (all P > .05). Respiratory support remains the most common indication for ECLS among obese patients. Among all patients, as well as by individual ECLS indication, obesity was not associated with increased odds of mortality. These findings suggest that obesity should not be considered a high-risk contraindication to ECLS.     

Recreational marijuana use is not associated with worse outcomes after renal transplantation

As marijuana (MJ) legalization is increasing, kidney transplant programs must develop listing criteria for marijuana users. However, no data exist on the effect of MJ on kidney allograft outcomes, and there is no consensus on whether MJ use should be a contraindication to transplantation. We retrospectively reviewed 1225 kidney recipients from 2008 to 2013. Marijuana use was defined by positive urine toxicology screen and/or self‐reported recent use. The primary outcome was death at 1 year or graft failure (defined as GFR<20 mL/min/1.73 m²). The secondary outcome was graft function at 1 year. Using logistic regression analyses, we compared these outcomes between MJ users and non‐users. Marijuana use was not associated with worse primary outcomes by unadjusted (odds ratio 1.07, 95% CI 0.45–2.57, P=.87) or adjusted (odds ratio 0.79, 95% CI 0.28–2.28, P=.67) analysis. Ninety‐two percent of grafts functioned at 1 year. Among these, the mean creatinine (1.52, 95% CI 1.39–1.69 vs 1.46, 95% CI 1.42–1.49; P=.38) and MDRD GFR (50.7, 95% CI 45.6–56.5 vs 49.5, 95% CI 48.3–50.7; P=.65) were similar between groups. Isolated recreational MJ use is not associated with poorer patient or kidney allograft outcomes at 1 year. Therefore, recreational MJ use should not necessarily be considered a contraindication to kidney transplantation.     

The characteristics of malignant breast tumors in hormone replacement therapy users versus nonusers

Background The purpose of this study was to investigate the characteristics of breast cancer in hormone replacement therapy (HRT) users vs. nonusers. Methods We investigated the characteristics of all patients between the ages of 50 and 75 years with breast tumors. Then, an age-adjusted group of 55 nonusers was chosen to match and compare with HRT users. Results Of the 243 patients available for evaluation, 55 (22.6%) used HRT. Disease stages in HRT users vs. nonusers were as follows: ductal carcinoma in situ (DCIS), 20% and 17.1%; stage I, 45.5% and 41.7%; stage II, 30.9% and 26.2%; stage III, 3.6% and 13.4%; and stage IV, 0% and 1.6% (P=.27). In the age-adjusted cohort, stages in nonusers were as follows: DCIS, 7.3%; stage I, 47.3%; stage II, 25.5%; stage III, 20%; and stage IV, 0% (P=.03). Tumor grades in HRT users vs. nonusers were as follows: grade I, 30.4% and 15.7%; grade II, 52.2% and 52.2%; and grade III, 17.4% and 32.1% (P=.035). Grades in cohort nonusers were as follows: I, 13.2%; II, 52.8%; and III, 34% (P=.05). In the invasive tumors, the positive estrogen receptor (ER) rates were 81.6% and 85.7% (P=.89); positive progesterone receptor (PR) rates were 53.1% and 54% (P=.95); and Her 85.7% (P=.89); positive progesterone receptor (PR) rates were 53.1% and 54% (P=.95); and Her 2-neu positive rates were 18.4% and 17.6% (P=.95), respectively. No significant difference was found in intratumor DCIS, vascular invasion, and Ki-67 (P=.14, .9, and .79, respectively). The rate to lobular and favorable histological types was higher in the HRT user group: 26.6% vs. 15%. Conclusions Breast tumors in HRT users vs. nonusers were of a significantly lower stage and grade and accounted for a higher number of favorable histological types, but all other parameters were similar in the two groups.     

Elevated HbA1c in donor organs from patients without a diagnosis of diabetes portends worse liver allograft survival

Recipients of liver allografts from diabetic donors have decreased graft survival. However, limited data exist on the effects of donor HbA1c. We hypothesized that allografts from nondiabetic donors with elevated HbA1c would be associated with decreased survival. Liver transplant recipients from the UNOS database from nondiabetic donors were stratified into two groups: euglycemic (HbA1c<6.5) and hyperglycemic (HbA1c≥6.5). Propensity score matching (10:1) was used to adjust for donor and recipient characteristics. Kaplan‐Meier analysis was used to assess survival. Donors of hyperglycemic allografts were older (49 vs 36, P<.001), were more likely to be non‐white, had a higher BMI (29.8 vs 26.2, P<.001), were more likely to engage in heavy cigarette use (1.5% vs 1.3%, P=.004), had higher serum creatinine levels (1.3 vs 1.0, P=.002), and were more likely to be an expanded‐criteria donor (35.8% vs 14.4%, P<.001). After propensity matching to account for these differences, allograft survival was significantly decreased in the recipients of hyperglycemic allografts (P=.049), and patient survival showed a trend toward reduction (P=.082). These findings suggest that HbA1c may be a simple and inexpensive test with potential utility for better organ risk stratification.     

Gravity is an important determinant of oxygenation during one‐lung ventilation

Background: The role of gravity in the redistribution of pulmonary blood flow during one‐lung ventilation (OLV) has been questioned recently. To address this controversial but clinically important issue, we used an experimental approach that allowed us to differentiate the effects of gravity from the effects of hypoxic pulmonary vasoconstriction (HPV) on arterial oxygenation during OLV in patients scheduled for thoracic surgery. Methods: Forty patients with chronic obstructive pulmonary disease scheduled for right lung tumour resection were randomized to undergo dependent (left) one‐lung ventilation (D‐OLV; n=20) or non‐dependent (right) one‐lung ventilation (ND‐OLV; n=20) in the supine and left lateral positions. Partial pressure of arterial oxygen (PaO₂) was measured as a surrogate for ventilation/perfusion matching. Patients were studied before surgery under closed chest conditions. Results: When compared with bilateral lung ventilation, both D‐OLV and ND‐OLV caused a significant and equal decrease in PaO₂ in the supine position. However, D‐OLV in the lateral position was associated with a higher PaO₂ as compared with the supine position [274.2 (77.6) vs. 181.9 (68.3) mmHg, P<0.01, analysis of variance (ANOVA)]. In contrast, in patients undergoing ND‐OLV, PaO₂ was always lower in the lateral as compared with the supine position [105.3 (63.2) vs. 187 (63.1) mmHg, P<0.01, ANOVA]. Conclusion: The relative position of the ventilated vs. the non‐ventilated lung markedly affects arterial oxygenation during OLV. These data suggest that gravity affects ventilation–perfusion matching independent of HPV.