Complications - 2 Post Transplant Lymphoproliferative Disorder (PTLD) - Posttransplant lymphoproliferative disease (PTLD) is an unusual entity that has many of the features of immune system malignancy. It is characterized by uncontrolled proliferation of B cells in a setting of posttransplant immunosuppression. In some situations, reducing the immunosuppression can reverse this proliferation. PTLD has emerged as a significant complication of solid organ transplantation.FOR MORE INFORMATION - SEE THE FEATURE "PTLD".
Pulmonary Air Leaks - Air leaks after pulmonary resections may contribute to increased patient morbidity, delayed removal of chest drainage tubes, and prolonged hospitalization. A study was performed with a new synthetic, absorbable sealant on the healing of healthy bronchial and lung tissue, and its safety and efficacy to stop air leaks after lung resection. There were no acute or late undesirable side efffects related to the sealant application. The surgical adhesive investigated demonstrated a compelling safety profile and significant clinical efficacy to stop air leaks after lung resections.
Pulmonary Nodules Not Uncommon in Lung Transplant Recipients (ADDED 9/22/04) About 10% of patients who receive a lung transplant will develop pulmonary nodules, new research suggests. The most common causes are invasive pulmonary aspergillosis and posttransplant lymphoproliferative disorder."Not much is known about pulmonary nodules in lung transplant recipients--only a few small case series have looked at it," study co-author Dr. Omar A. Minai, from the Cleveland Clinic Foundation in Ohio. Analyzed data from 234 patients who underwent lung transplantation. 23 patients (10%) had one or more pulmonary nodules, the researchers note. Sixteen of these patients died from their nodular disease and invasive pulmonary aspergillosis was noted to be universally fatal.The most common presenting symptoms were cough and dyspnea. Although most nodules were detected with chest X-ray, they were best characterized with CT scan, the authors note.The nodules were due to posttransplant lymphoproliferative disorder in nine patients, invasive pulmonary aspergillosis in eight patients, and other causes in six patients. In most cases, the diagnosis was made with bronchoscopy with lavage and transbronchial lung biopsy.Seven patients had solitary nodules and the remainder had multiple nodules. Posttransplant lymphoproliferative disorder and invasive pulmonary aspergillosis were the most common diagnoses in both patient groups.
Reimplantation Reponse (Reperfusion Edema): This condition occurs in more than 97% of transplanted lungs. Reimplantation response is a diagnosis of exclusion-left ventricular failure, transplant rejection, fluid overload, and infection must all be excluded. The response almost always begins by the first post transplantation day, and is always present by day 3. It frequently progresses over the first few days, but peaks by day 4-5. Radiographically it appears as perhilar and/or basal air space disease. In double lung transplant patients, the disorder is asymmetric in 50% of cases. The response is noted to gradually change from air-space to reticular interstitial disease over the first few weeks and then gradually clear. The time to complete clearance can vary from 2 weeks to 6 months.
Reversible Cortical Blindness with Lung Transplantation - Cortical blindness is a rare manifestation of cyclosporine (CYA) toxicity.(Source: Southern Medical Journal 2003)
Sepsis - Sepsis is a serious infection caused by bacteria or other microorganisms that have entered a wound or body tissue. Tissue damage and a dramatic drop in blood pressure result from the presence of these organismx, their toxins or other products in the blood. People with diseases such as diabetes and cancer that compromise the immune system are at a higher risk of developing sepsis. -
Xigris - the first biologic treatment for sepsis, a life threatening reaction to infection that can lead to organ failure. The treatment is a genetically engineered version of the naturally occurring protein, Activated Protein C. It was engineered to mimic the protein's seeming ability to "balance" the underlying forces in the body that cause inflammation, clotting and bleeding. Eli Lilly & Co maker of Xigris
Shingles (Varicella Zoster) - Shingles appear as a rash or small water blisters, ofent on the chest, back or hips. The rash may or may not be painful. You will need treatment for shingles with acyclovir.
Tracheostomy - Tracheostomy Following Lung Transplantation Predictors and Outcomes - The effect of tracheostomy on patients receiving lung transplantation is unknown. We reviewed our experience by performing a retrospective analysis on all lung transplant recipients at our institution. Patients were assigned to each study group based on whether or not they received a tracheostomy in the acute postoperative period. One hundred and fourteen lung transplants were performed, and 16 of those patients received a tracheostomy. In the tracheostomy group, more patients had undergone bilateral-lung transplantation (81% vs. 34%, p = 0.001), more required cardiopulmonary bypass (75% vs. 38%, p = 0.005), more acquired postoperative pneumonia (88% vs. 30%, p < 0.001), had greater reperfusion injury at 48 h (PaO2/FiO2 of 233 vs. 345, p = 0.047), had longer initial periods on the ventilator (21 ± 7 vs. 2 ± 0.5 days, p < 0.001), more required re-intubation (56% vs. 18%, p = 0.001), spent longer times in the intensive care unit (30 ± 7 vs. 5.5 ± 0.9 days, p < 0.001), and had longer lengths of stay (67 ± 10 vs. 22 ± 2 days, p < 0.001). Despite these differences between the two groups, a significant difference in survival at 180 days (75 vs. 81%) did not exist (p = 0.89). Although tracheostomy is more likely in sicker patients, it is not associated with poor long-term outcomes. (Source: American Journal of Transplantation Volume 3 Issue 7 Page 891 - July 2003)
Vascular Complications - Stenoses at vascular anastomoses are uncommon (fewer than 4% of cases) and are more common at the arterial anastomosis, than the venous anastomosis. Pulmonary embolism occurs in up to 12% of patients following lung or heart/lung transplant.
Transcutaneous electrical nerve stimulation for severe gastroparesis after lung transplantation - (ADDED 9/1/05) Gastroparesis is a serious complication of lung transplantation that can lead to weight loss, gastroesophageal reflux disease, and recurrent aspiration pneumonia. We present 2 lung allograft recipients in whom gastroparesis resolved with the use of transcutaneous electrical nerve stimulation (TENS). In both patients, severe symptoms of gastroparesis refractory to medical therapy were completely ablated after 20 and 30 days of therapy. Both patients are currently asymptomatic with a normal diet, without the use of promotility agents. Lung transplant recipients with severe gastroparesis can derive significant benefit from TENS.(SOURCE: The Journal of Heart and Lung Transplantation )
Comparative safety of amphotericin B lipid complex and amphotericin B deoxycholate as aerosolized antifungal prophylaxis in lung-transplant recipients (Added 10/4/04) -Background. Aerosolized administrations of amphotericin B deoxycholate (AmBd) and amphotericin B lipid complex (ABLC) in lung transplant recipients were compared for safety and tolerability. The incidence of invasive fungal infections in patients receiving aerosolized amphotericin B formulations as sole prophylaxis was determined.Methods. A prospective, randomized (1:1), double-blinded trial was conducted with 100 subjects. AmBd and ABLC were administered postoperatively by nebulizer at doses of 25 mg and 50 mg, respectively, which were doubled in mechanically ventilated patients. The planned treatment was once every day for 4 days, then once per week for 7 weeks. Subjects receiving AmBd were more likely to have experienced an adverse event Conclusions. Both aerosol AmBd and ABLC appear to be associated with a low rate of invasive pulmonary fungal infection in the early posttransplant period. Patients receiving ABLC were less likely to experience a treatment-related adverse event.Invasive fungal infections (IFIs) in patients undergoing lung transplantation are relatively common and have been associated with significant attributable mortality. Therefore, several antifungal prophylactic strategies have been used in an attempt to reduce the impact of IFIs on patient survival. However, the use of systemic antifungal therapies may be limited by lack of in vitro activity against Aspergillus sp (fluconazole), drug interactions (itraconazole, voriconazole), significant treatment-limiting toxicities, and requirements for intravenous administration (amphotericin B, caspofungin). Intolerance leading to treatment discontinuation has been reported to be as high as 48% in one report with AmBd. Therefore, it is important to compare the safety of various formulations of amphotericin B when used prophylactically in patients at increased risk of IFIs to determine the best preparation for use. (Source: Transplantation: 27 January 2004 )
Phrenic nerve dysfunction after heart-lung and lung transplantation (Added 10/4/04) -Phrenic nerve dysfunction (PND) 27 heart–lung (HLTx) and 111 lung (LTx) transplantations performed from July 1991 to June 2001 at the LeuvenUniversity Hospital, Leuven, Belgium. On clinical suspicion of diaphragmatic dysfunction, nerve conduction studies were performed, which were completed with a needle electromyogram (EMG) of the diaphragm when the conduction study was non-conclusive.The incidence of PND in 21 evaluable HLTx recipients was 42.8% (9 of 21 patients), resulting in significantly more ventilator days for PND patients and a prolonged ICU LOS. In the 97 evaluable LTx patients, 9.3% (9 of 97 patients) developed PND. This resulted in more ventilator days for the PND group Conclusions:PND represents an important clinical problem after HLTx and LTx and has a considerable influence onboth number of ventilator days and ICU resource utilization. When PND was clinically suspected, a nerve conduction study was performed according to the method described by MacLean and co-workers. If the nerve conduction study was inconclusive, then a needle electromyogram (EMG) of the diaphragm was carried out, as described by Bolton et al. Phrenic nerve dysfunction was defined as an abnormal unilateral or bilateral nerve conduction study of the phrenic nerve, or signs of denervation on needle EMG of the diaphragm.Consequences of phrenic nerve dysfunction A recovery to a predicted forced vital capacity (FVC) of at least 90% was considered as full recovery of diaphragmatic function. Twenty-one HLTx patients were evaluable for PND (4 early deaths, 2 missing data files), representing 42 phrenic nerves at risk. Nine of 21 HLTx patients developed PND (42.8%), including 5 with unilateral lesions (3 right-sided and 2 left-sided) and 4 with bilateral lesions. Both number of ventilator days and ICU LOS were significantly increased in the group of 9 HLTx patients with PND. 97 LTx patients were evaluable (11 missing data files and 3 early deaths). Nine of 97 patients developed PND (9.3%). Six patients had unilateral PND (2 left-sided, 4 right-sided) and 3 patients had bilateral lesions. Of the 142 phrenic nerves at risk, 12 developed PND (8.45%). Phrenic nerve dysfunction occurred predominantly in patients with sequential single-lung transplantation and the right side was most affected. The method used to confirm diaphragmatic dysfunction in the other studies was fluoroscopy of the diaphragmatic movement plus nerve conduction study of the phrenic nerve,[1] ultrasonography confirmed with fluoroscopy,and fluoroscopy or ultrasound. The only precaution required is to ensure at least 24 hours between the left and right needle EMGs of the diaphragm to minimize the risk of pneumothorax, which is inherent to the technique. ICU stay and hospitalization were longer for LTx patients with PND in the study by Maziak et al, but did not result in significantly adverse outcomes. The mean intubation time in their post-HTx or post-LTx patients was not different between the affected and the control groups. We clearly demonstrated a significant increase in number of ventilator days. Also, we demonstrated that LTx patients with PND are likely to receive a tracheostomy. Only a minority of the HLTx and LTx patients with PND had full recovery to predicted FVC, and that the time interval to achieve this was extremely long. Phrenic nerve dysfunction after HLTx and LTx is believed to be due to hypothermia from cold ice slush, retraction or manipulation of the pericardium, and use of electrocautery for dissection. Despite knowledge of the anatomy, extensive adhesions secondary to previous surgical procedures, pleurodesis or even the underlying disease process may complicate dissection during the transplant procedure. In this study group, uses of cold ice slush and surgical retractors during anastomosis were related to the development of PND. Avoiding the use of ice slush and the switch to suspending stitches, rather than using mechanical retractors, clearly reduced the incidence of this disorder in subsequent HLTx and LTx. (Source: The Journal of Heart and Lung Transplantation January 2004)
|
