终末期肺病患者等待肺移植期间的临床分析

目的 总结单中心终末期肺病患者等待肺移植期间的临床结局及其影响因素,探讨等待期患者排序的参考因素.方法 回顾性分析自2003年1月至2013年1月83例等待肺移植的终末期肺病患者的临床资料.结果 22例(26.5％)患者死于等待期,41例(49.4％)接受同种异体肺移植,20例(24.1％)仍在等待供肺.相对于慢性阻塞性肺疾病(COPD)患者,特发性肺纤维化(IPF)患者等待期间死亡率较高,死亡率分别为39.1％和15.6％(P=0.09).存活患者的等待期存活时间为(377.5±527.6)d,死亡患者的等待期存活时间为(181.7±196.9)d(P=0.016).存活的患者的平均肺动脉压力为(38.8±14.1)mm Hg(1 mm Hg=0.133 kPa),死亡患者的平均肺动脉压力为(54.3±25.9)mm Hg(P=0.08).死亡病例中,IPF患者的存活时间为(137.8±199.6)d,其他疾病患者为(212.1±196.9)d(P=0.397).等待期需要常规氧疗和无创正压通气的患者的死亡率为23.9％,接受机械通气患者的死亡率为41.7％(P=0.287).结论 原发疾病的类型、肺动脉高压和机械通气可能是影响终末期肺病患者等待期预后的主要因素,拟定肺移植等待排序时应综合考虑上述因素.     

Long-term outcome of lung transplantation for cystic fibrosis — Danish results

Objective: Over the last decades improvements in medical therapies have delayed the progression of lung disease in cystic fibrosis (CF). However, lung disease is still the most common cause of premature death, and lung transplantation today is the only treatment for end-stage lung disease in patients with CF. We present a retrospective review of the outcome of CF patients transplanted in Denmark since start of the national lung transplantation programme in 1992. Methods: In a 10-year period, 47 patients with CF were listed for lung transplantation; 29 patients underwent transplantation and 18 patients died while waiting for donor organs. Eleven patients received en block double lung transplantation with direct bronchial artery revascularization and 18 patients received bilateral sequential lung transplantation. Median age at transplantation was 29 years (range 11–50). Results: The perioperative mortality (≤30 days) was 3.5% (1/29 patients). Actuarial survival of transplanted patients at 1, 3, 5 and 8 years was 89, 80, 80 and 70%, respectively. Actuarial survival of non-transplanted patients on the waiting list at 1 and 2 years was 28 and 11% (P<0.0001). Causes of death of transplanted patients were: respiratory failure on day 7 (n=1), bronchiolitis obliterans syndrome (n=2), infection (Cytomegalovirus, Aspergillus fumigatus) (n=2), bronchial anastomosis dehiscence (n=1). Pulmonary function (FEV₁% predicted) improved from median 20% (range 13–31) pre-transplant to 71% (range 19–118) after 5 years (P<0.0001). Renal function (⁵¹Cr-EDTA clearance) decreased from median 97 ml/min (range 45–190) pre-transplant to 32 ml/min (range 8–84) 6 months after transplantation (P<0.001). Three patients (11%) received dialysis post-transplant of whom two underwent kidney transplantation. Immunosuppressive induction therapy with rabbit-antithymocyte-globulin compared to daclizumab resulted in fewer treatments for acute rejection within the first 3 months post-transplant (P=0.05 at 5–8 weeks). Burkholderia multivorans was present in three patients pre-transplant with satisfying long-term outcome in one patient. Conclusions: Lung transplantation is a well-established life-extending treatment for patients with CF and end-stage lung disease. The operative mortality is low and CF patients have a significant early survival benefit after lung transplantation. Satisfying long-term results can be achieved in this young and severely ill group of patients.     

单肺移植治疗终末期肺气肿一例报告

目的 探讨肺移植治疗终末期肺病肺气肿的手术适应证、手术方式、围术期的处理及术后生存率。方法 2002年9月28日为1例肺气肿、肺功能重度减损的患者进行左肺移植。结果 术后93h顺利脱机，术后第9d发生1次急性排斥，经大剂量甲泼尼龙冲击治疗后症状消退，术后40d胸部CT示左肺扩张良好，左肺血液灌注良好，术后肺功能明显改善，术后47d出院，现已恢复工作。结论 终末期肺气肿是肺移植最常见的手术适应证。单肺移植术后肺功能改善明显。     

Antireflux surgery for patients with end-stage lung disease before and after lung transplantation

Background Gastroesophageal reflux disease (GERD) is prevalent among patients with end-stage lung disease (ESLD). This disease can lead to microaspiration and may be a risk factor for lung damage before and after transplantation. A fundoplication is the best way to stop reflux, but little is known about the safety of elective antireflux surgery for patients with ESLD. This study aimed to report the safety of laparoscopic fundoplication for patients with ESLD and GERD before or after lung transplantation. Methods Between January 1997 and January 2007, 305 patients were listed for lung transplantation, and 189 patients underwent the procedure. In 2003, routine esophageal studies were added to the pretransplantation evaluation. After the authors’ initial experience, gastric emptying studies were added as well. Results A total of 35 patients with GERD or delayed gastric emptying were referred for surgical intervention. A laparoscopic fundoplication was performed for 32 patients (27 total and 5 partial). For three patients, a pyloroplasty also was performed. Two patients had a pyloroplasty without fundoplication. Of the 35 operations, 15 were performed before and 20 after transplantation. Gastric emptying of solids or liquids was delayed in 12 (92%) of 13 posttransplantation studies and 3 (60%) of 5 pretransplantation studies. All operations were completed laparoscopically, and 33 patients recovered uneventfully (94%). The median hospital length of stay was 2 days (range, 1–34 days) for the patients admitted to undergo elective operations. Hospitalization was not prolonged for the three patients who had fundoplications immediately after transplantation. Conclusions The results of this study show that laparoscopic antireflux surgery can be performed safely by an experienced multidisciplinary team for selected patients with ESLD before or after lung transplantation, and that gastric emptying is frequently abnormal and should be objectively measured in ESLD patients. Presented as a Poster of Distinction at the Spring 2007 Meeting of the Society of Gastrointestinal and Endoscopic Surgeons (SAGES) at Las Vegas, Nevada, 18–22 April 2007     

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.     

Pulmonary hemodynamics as predictors of mortality in patients awaiting lung transplantation.

Lung transplantation (LTx) is a therapeutic option for patients with end-stage lung disease. However, the mortality rate of patients on the waiting list is high. The purpose of this study was to examine the prognostic value of cardio-pulmonary hemodynamics for death in patients awaiting LTx. Retrospectively, 177 patients with advanced lung disease accepted for LTx at Sahlgrenska University Hospital from January 1990 through December 2003 were studied. Patient demographics, pulmonary function tests, gas exchange and hemodynamic variables were included in the analysis. Death while awaiting LTx was the primary endpoint for all analyses. Mean age was 49 +/- 9 years. Main diagnoses were alpha 1 antitrypsin deficiency (n = 56), chronic obstructive pulmonary disease (n = 61), cystic fibrosis (n = 14) and interstitial lung disease (n = 46). Thirty patients died (17%). LTx was performed in 143 cases. By univariate analyses, forced vital capacity (FVC) % of predicted, pulmonary vascular resistance (PVR) and diagnosis were associated with risk for death. In multivariate analysis PVR (HR, 1.22; 95% CI, 1.06-1.41; P = 0.006) and FVC% of predicted (HR, 0.97; 95% CI, 0.94-0.99; P = 0.01) were independently associated with death. Patients with increased PVR and a lower FVC % of predicted awaiting LTx should be considered for a higher organ allocation priority. Assessment of pulmonary hemodynamics needs to be considered during evaluation for LTx.     

等待肺移植患者生存质量及其影响因素研究

目的了解等待肺移植患者的生存质量及其影响因素。方法采用简明健康问卷(SF-36)、焦虑自评量表(SAS)、抑郁自评量表(SDS)和领悟社会支持量表(PSSS)对55例等待肺移植患者进行调查。结果等待肺移植患者SF-36各维度得分23.18~74.57,显著低于常模(均P<0.01);SAS、SDS得分分别为48.09±9.06、52.18±9.98,显著高于常模(均P<0.01);PSSS社会总支持因子得分为5.56±1.04,其中家庭内支持因子得分显著高于家庭外支持因子(P<0.05)。多因素分析结果显示生存质量的影响因素为呼吸困难和抑郁(P<0.05,P<0.01)。结论等待肺移植患者的生存质量较低,其生存质量受呼吸困难和抑郁的影响。医务人员应从患者生理及心理方面进行有效干预,以提高其生存质量。     

Impact of lung transplantation on site of death in cystic fibrosis

BACKGROUND: Cystic fibrosis (CF) remains a lethal condition where a palliative approach is often taken at the end of life. We wanted to evaluate how lung transplantation impacts end of life care in adult CF patients. METHODS: Data were abstracted using a standardized data collection instrument from all outpatient and inpatient records of adult CF patients with an FEV1< or =30% or prior lung transplantation followed at our Center. Comparisons were made between those who were listed/received lung transplant and those who were not listed. RESULTS: A total of 41 patients met the entry criteria. Of these, 63% (n=26) were referred for lung transplant evaluation and 39% (n=16) had undergone lung transplantation. Of these 41, 59% (n=24) are deceased. The majority of deceased patients expired in an acute care hospital (63%, n=15). There was no difference in site of death between the two groups (hospital versus home). However, listed/transplanted patients were more likely to die in an intensive care unit setting compared to patients not listed/transplanted (p=.013). CONCLUSIONS: Most of our CF patients' deaths occurred in an acute care hospital. Lung transplant significantly alters site of death and shifts it from medical floors to the intensive care unit.     

Risk analysis for thoracoscopic lung volume reduction: a multi-institutional experience

Objective: Most reports of thoracoscopic lung volume reduction (TLVR) are relatively small and early experiences from a single institution, factors which limit both the statistical validity and the applicability to the population at large. In order to address these shortcomings we undertook an analysis of the TLVR experience at five separate institutions to assess operative morbidity and identify predictors of mortality. Methods: Questionnaires were sent to four groups of surgical investigators at five institutions actively performing TLVR. Data was requested regarding preoperative, operative and postoperative parameters. Twenty-five potential predictors of mortality were analyzed and seven proved to be at least marginally significant (P<0.10). These parameters were entered into a stepwise logistic regression analysis to identify independent predictors. Results: The 682 patients (415 males, 267 females, mean age 64.0 years) underwent unilateral (410) or bilateral (272) TLVRs. Overall, operative mortality was 6% with half of the deaths resulting from respiratory causes. The remaining patients were discharged to home (88%), a rehabilitation facility (4%) or a ventilator facility (2%). There were 25 perioperative factors chosen representing clinically important indices such as spirometry, oxygenation, functional status, clinical and demographic variables. Univariate analysis identified seven variables as predictors of mortality (P<0.10) and these were entered into a stepwise logistic regression analysis. Only age, 6-min walk, gender (male 8%, female 3% mortality) and the procedure performed (unilateral 4.6%, bilateral 8%) were independent predictors while preoperative steroid therapy, preoperative oxygen administration, and time since smoking cessation dropped out of the model. The specific institution, learning curve (early vs. late experience), type of lung disease, spirometric indices and predicted maximum VO₂ were not significant predictors. Conclusion: This experience suggests that unilateral and bilateral lung volume reduction procedure can be performed with acceptable morbidity and mortality. Although age, gender, exercise capacity and the procedure performed are all independent predictors of mortality, the risk of operative death did not appear excessive in this fragile patient subset.     

特发性肺间质纤维化伴肺动脉高压患者肺移植前应用多层螺旋CT的价值

目的 探讨多层螺旋CT(MSCT)用于特发性肺间质纤维化(IPF)患者肺移植术前肺动脉高压评估的临床价值.方法 回顾分析2002年9月至2010年8月间的单中心肺移植资料.以30例IPF伴肺动脉高压患者为观察组,以1 5例肺动脉压正常的患者为对照组.两组术前常规均行MSCT,测量肺动脉主干直径(PPA)、肺动脉主干与升主动脉横径比(rPA),并用右心Swan-Ganz漂浮导管测定平均肺动脉压(mPAP).结果 对照组PPA为(25.3±3.3)mm,观察组为(34.4±4.4)mm(P＜0.01);对照组rPA为0.77±0.12,观察组为1.03±0.09 (P＜0.01).观察组患者PPA与右心漂浮导管测得mPAP具有直线相关关系,相关系数(r)=0.861(P＜0.01);观察组患者rPA与右心漂浮导管测得mPAP也具有直线相关关系,r=0.887(P＜0.01).当IPF伴肺动脉高压患者PPA为28.5mm时,诊断肺动脉高压的灵敏度为86.7％,特异性为80％;当rPA为0.935时,诊断灵敏度为96.7％,特异性为93.3％.结论 MSCT用于肺移植术前评估IPF伴肺动脉高压具有较好的临床价值,rPA对IPF患者伴肺动脉高压的评估相关性好,准确性高.     

术前肺动脉高压对肺纤维化患者肺移植术后早期存活率的影响

目的 探讨术前肺动脉高压对特发性肺纤维化(IPE)患者肺移植术后早期(<90 d)存活率的影响.方法 2002年9月至2009年4月为30例特发性肺纤维化患者进行了肺移植.根据术前肺动脉压的检测结果,将30例患者分为两组.肺动脉高压组:13例,术前平均肺动脉压≥30 mmHg;对照组:17例,术前平均肺动脉压<30 mm Hg.对两组患者的年龄、术式(单、双肺移植)、肺动脉乐力、是否应用体外膜氧合(ECMO)等进行多因素逻辑同归分析比较.结果 肺动脉高压组和对照组患者肺移植术后早期存活率分别为61.5%和94.1%,两组比较,差异有统计学意义(P相似文献   

Introducing the need for lung transplantation in children with cystic fibrosis: Parental experiences

Lung transplantation (LTx) is the only treatment available for adult and pediatric end-stage lung disease secondary to cystic fibrosis (CF). The timing of introducing LTx has significant medical and psychological implications for the child and the family. This study explored the views and recommendations of parents of children with CF, who had been asked to consider LTx and referred to a national transplant centre. Parents participated in a telephone-based, semi-structured interview. Responses were analysed using Content Analysis. Parental recommendations and the emergent protocol are discussed, together with implications for clinical practice.     

Cumulative radiation dose after lung transplantation in patients with cystic fibrosis

Purpose

The purpose of this study was first to evaluate the imaging-related cumulative post-transplantation radiation dose in cystic fibrosis (CF) lung transplantation (LT) recipients and second, to identify the occurrence and type of malignancies observed after LT.

Risk factors and outcomes of vocal cord paralysis after lung transplantation – a retrospective cohort study

Vocal cord paralysis (VCP) may complicate thoracic surgery and is associated with increased morbidity and mortality. Among lung transplant (LTx) recipients, chronic pulmonary aspiration can contribute to chronic allograft dysfunction (CLAD). We herein assessed the unknown incidence and clinical impact of VCP in a large LTx cohort. All first‐time bilateral LTx recipients, transplanted between January 2010 and June 2015 were included in a single‐centre retrospective analysis. Bronchoscopy reports were assessed for VCP. Patients exhibiting VCP were compared to propensity score‐matched negative controls regarding CLAD onset and graft survival and secondary end‐points, including inpatient duration and complications; lower respiratory tract infections (LRTI) within 24 months. In total, 583/713 (82%) patients were included in the analysis. A total of 52 (8.9%) exhibited VCP, which was transient in 34/52 patients (65%), recovering after median 6 months (IQR 2–12). Compared to 268 controls, 3‐year graft survival and CLAD‐free survival were non‐inferior in VCP [HR 0.74 (95% CI 0.35–1.57), and HR 0.74 (95% CI 0.39–1.41)] respectively. Duration of hospitalization was similar and no differences in LRTI rates or airway complications were observed. Lower pre‐Tx BMI increased risk for VCP [HR 0.88 (95% CI 0.79–0.99)]. Overall, VCP did not adversely affect graft and CLAD‐free survival and secondary outcomes including LRTIs and hospitalizations.     

Heart–lung and lung transplantation in grown-up congenital heart disease: long-term single centre experience

Objective: Because of considerable progress in paediatric cardiac surgery life expectancy of patients with congenital heart disease (CHD) has improved significantly over the years. There are a growing number of adults with CHD presenting with progressive decline of cardiopulmonary function and Eisenmenger's syndrome. We analysed our experience with heart–lung and lung transplantation in this patient group. Methods: Since 1988, a total of 46 heart–lung transplantations and 5 double lung transplantations have been performed in adults with CHD at our institution. Underlying diagnoses were: ventricular septal defect, atrial septal defect, persistent ductus arteriosus and others. Pulmonary hypertension was present in all patients. Twelve patients had undergone previous cardiac procedures. All patients were included in this retrospective analysis. Mean follow up was 5.1 ± 4.7 years. Patient survival was estimated with the Kaplan–Meier method and analysed using the log-rank test. Results: Thirty-day mortality was 11.8% (n = 6). Survival was 80% at 1 year, 69% at 5 years and 53% at 10 years. Major causes of death were infection and sepsis, chronic rejection, initial graft failure and acute rejection. Compared to the overall mortality after lung and heart–lung transplantation for other indications at our institution there was no significant difference (1 year, 5 years, 10 years: 76%; 60%; 45%), but a tendency towards a better long-time survival of the CHD patients. Conclusions: Lung and heart–lung transplantation can be performed with an acceptable risk and a favourable long-term outcome in patients with grown-up CHD. Careful patient selection and planning of the surgical strategy is essential in this high-risk patient population.     

Procurement of lungs for transplantation following donation after circulatory death: the Alfred technique

Introduction

Donation after circulatory death (DCD) is an evolving method for lung transplantation (LTx) with results comparable to donation after brain death (DBD).

Materials and Methods

DCD lung transplant program requires a systematic approach for an efficient utilization of hospital resources. The surgical techniques have been developed to minimize the ischemic time during lung procurement. We have presented our management protocol and the surgical techniques as used at the Alfred Hospital in Melbourne, Australia.

Results

We have transplanted 92 recipients with lungs procured from 91 donors over an 8 year period from May 2006 to July 2014. This accounted for an extra 19% lung transplant operations performed during this time period. Operative mortality was 1% and 8 year survival was 71% in DCD lung recipients.

Conclusions

DCD lung transplantation provides an additional significant pool of lung donors with satisfactory short and long term outcomes.     

肺移植治疗终末期肺疾病的单中心十年经验总结

目的 探讨肺移植治疗终末期肺疾病的效果,并对单中心肺移植的经验进行总结.方法 回顾2003年1月至2012年12月间52例肺移植病例的临床资料,受者年龄为24～76岁,≥65岁者13例;受者原发病主要为肺气肿33例(63.5％)及特发性肺间质纤维化8例(15.4％).术后对所有受者的并发症发生率、死亡情况及存活率进行分析.结果 供肺缺血时间＞6 h者28例(53.8％),其中缺血超过10 h者20例(38.5％).术后出现吻合口狭窄3例(5.8％),住院期间发生细菌感染14例(26.9％),真菌感染13例(25.0％),巨细胞病毒性肺炎1例(1.9％).发生急性排斥反应20例(38.5％),经甲泼尼龙冲击治疗3d后均逆转;发生慢性排斥反应7例(13.5％),其中2例接受再次肺移植后效果良好,3例调整免疫抑制方案后缓解,2例死亡.术后1年内死亡9例(17.3％),术后1、3和5年的总体累积存活率分别为81.4％,54.5％和30.9％.结论 肺移植是治疗终末期肺疾病的有效方法,恰当的病例选择、良好的肺保护、正确的围手术期处理及系统的术后管理是肺移植成功的关键.     

Pre-transplant factors associated with mortality after lung transplantation in cystic fibrosis: A systematic review and meta-analysis

BackgroundMortality risk stratification is essential in lung transplantation (LTx) to allow listing, prioritization and mitigating strategies. In cystic fibrosis (CF) patients, predictors of post-LTx mortality are not established.MethodsFor this systematic review and meta-analysis, seven databases were searched until January 3, 2018 to identify predictors of post-LTx mortality in CF. We excluded studies of multi-organ transplantation, re-transplantation and graft survival. For multiple studies assessing the same population during overlapping time-periods, the largest one was analyzed. Risk of bias was assessed with the Newcastle-Ottawa scale (NOS). Pooled hazard ratios were calculated using random-effects models.ResultsFifty-four studies were included in the systematic review and 11 studies in the meta-analyses (low-to-moderate bias risk, NOS score ≥ 5). Among 10 factors assessed in the meta-analysis, B. cepacia complex (BCC) (N = 1451, unadjusted HR = 2.35, 95%CI:1.80–3.06; I² = 20.4% and adjusted HR = 2.49, 95%CI:1.74–3.57; I² = 46.2%) and ascending chronological year of LTx (N = 4207, unadjusted HR = 0.98, 95%CI:0.97–0.98, I² = 4.8%) were predictors of post-LTx mortality. Male gender (N = 2903, adjusted HR = 1.12, 95%CI:1.0–1.26, I² = 0%) and age in adults (N = 3677, unadjusted HR = 0.99, 95%CI:0.97–1.00; I² = 64.1% and N = 2605, adjusted HR = 0.98, 95%CI:0.97–0.99; I² = 34.3%) had borderline significant associations with post-LTx mortality. P. aeruginosa colonization, forced expiratory volume in one second (FEV₁), pulmonary hypertension, body mass index (BMI), pancreatic insufficiency and CF-related diabetes (CFRD) were not predictors of mortality.ConclusionsBCC was associated with a higher post-LTx mortality whereas FEV₁, pulmonary hypertension, BMI, CFRD and female gender were not associated with post-LTx mortality. These findings indicate that CF-specific risk estimates of post-LTx mortality should be considered.     

Osteoporosis is a prevalent finding in patients with solid organ failure awaiting transplantation – a population based study

Dolgos S, Hartmann A, Isaksen GA, Simonsen S, Bjørtuft Ø, Boberg KM, Bollerslev J. Osteoporosis is a prevalent finding in patients with solid organ failure awaiting transplantation – a population based study
Clin Transplant 2010 DOI: 10.1111/j.1399‐0012.2010.01231.x.
© 2010 John Wiley & Sons A/S. Abstract: Post‐transplant bone disease is common in solid organ recipients; however, there is limited information on their pre‐transplant bone status. We aimed to compare bone mineral density (BMD) in different categories of patients with end‐stage organ failure awaiting transplantation (Tx) in Norway. Overall 291 adult patients were enrolled, including 60, 84, 81 and 66 patients with end‐stage lung, liver, kidney and heart failure, respectively. Mean age was 51 ± 12 yr with no significant differences between the groups. We measured BMD in lumbar spine, femur, proximal one third and ultra‐distal radius by dual energy X‐ray absorptiometry. Differences in T‐ and Z‐scores between the groups were compared by ANOVA. Low bone mass was found in all four groups of patients. Both T‐ and Z‐scores differed (p < 0.05) at all measured sites between the groups. Patients with lung failure had the highest prevalence of osteoporosis (67%) and lowest Z‐scores, followed by patients with liver (31%), kidney (24%), and heart (23%) failure. Osteoporosis is prevalent in all groups of organ transplant candidates, and poor bone health is remarkably pronounced in patients with chronic lung disease. General practitioners and specialists who care for these patients before they are referred for transplantation should consider measures to prevent osteoporosis at an earlier stage.