RESUMEN
This study evaluated the independent contribution of voriconazole to the development of squamous cell carcinoma (SCC) in lung transplant recipients, by attempting to account for important confounding factors, particularly immunosuppression. This international, multicenter, retrospective, cohort study included adult patients who underwent lung transplantation during 2005-2008. Cox regression analysis was used to assess the effects of voriconazole and other azoles, analyzed as time-dependent variables, on the risk of developing biopsy-confirmed SCC. Nine hundred lung transplant recipients were included. Median follow-up time from transplantation to end of follow-up was 3.51 years. In a Cox regression model, exposure to voriconazole alone (adjusted hazard ratio 2.39, 95% confidence interval 1.31-4.37) and exposure to voriconazole and other azole(s) (adjusted hazard ratio 3.45, 95% confidence interval 1.07-11.06) were associated with SCC compared with those unexposed after controlling for important confounders including immunosuppressants. Exposure to voriconazole was associated with increased risk of SCC of the skin in lung transplant recipients. Residual confounding could not be ruled out because of the use of proxy variables to control for some confounders. Benefits of voriconazole use when prescribed to lung transplant recipients should be carefully weighed versus the potential risk of SCC. EU PAS registration number: EUPAS5269.
Asunto(s)
Antifúngicos/efectos adversos , Carcinoma de Células Escamosas/etiología , Enfermedades Pulmonares/cirugía , Trasplante de Pulmón/efectos adversos , Neoplasias Cutáneas/etiología , Voriconazol/efectos adversos , Adolescente , Adulto , Anciano , Carcinoma de Células Escamosas/patología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Neoplasias Cutáneas/patología , Receptores de Trasplantes , Adulto JovenRESUMEN
This single-center study examines the incidence, etiology, and outcomes associated with prolonged mechanical ventilation (PMV), defined as time to definite spontaneous ventilation >21 days after double lung transplantation (LTx). A total of 690 LTx recipients between January 2005 and December 2012 were analyzed. PMV was necessary in 95 (13.8%) patients with decreasing incidence during the observation period (p < 0.001). Independent predictors of PMV were renal replacement therapy (odds ratio [OR] 11.13 [95% CI, 5.82-21.29], p < 0.001), anastomotic dehiscence (OR 8.74 [95% CI 2.42-31.58], p = 0.001), autoimmune comorbidity (OR 5.52 [95% CI 1.86-16.41], p = 0.002), and postoperative neurologic complications (OR 5.03 [95% CI 1.98-12.81], p = 0.001), among others. Overall 1-year survival was 86.0% (90.4% for LTx between 2010 and 2012); it was 60.7% after PMV and 90.0% in controls (p < 0.001). Conditional long-term outcome among hospital survivors, however, did not differ between the groups (p = 0.78). Multivariate analysis identified renal replacement therapy (hazard ratio [HR] 3.55 [95% CI 2.40-5.25], p < 0.001), post-LTx extracorporeal membrane oxygenation (HR 3.47 [95% CI 2.06-5.83], p < 0.001), and prolonged inotropic support (HR 1.95 [95% CI 1.39-2.75], p < 0.001), among others, as independent predictors of mortality. In conclusion, PMV complicated 14% of LTx procedures and, although associated with increased in-hospital mortality, outcomes among patients surviving to hospital discharge were unaffected.
Asunto(s)
Oxigenación por Membrana Extracorpórea/mortalidad , Enfermedades Pulmonares/mortalidad , Trasplante de Pulmón/efectos adversos , Complicaciones Posoperatorias/mortalidad , Respiración Artificial/mortalidad , Adolescente , Adulto , Niño , Femenino , Estudios de Seguimiento , Alemania/epidemiología , Mortalidad Hospitalaria/tendencias , Humanos , Incidencia , Enfermedades Pulmonares/complicaciones , Enfermedades Pulmonares/cirugía , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia , Factores de TiempoRESUMEN
Herpesvirus infections cause morbidity in lung transplant recipients. The study was conducted to investigate the incidence and impact of herpes simplex virus (HSV) and cytomegalovirus (CMV) detection in the respiratory tract (RT) of lung and heart-lung transplant recipients (LTR) during the postoperative phase. In a prospective cohort study, 91 LTR having at least 1 nasopharyngeal swab (NPS) sent for virus diagnostics were monitored for CMV and HSV detection in NPS during their post-transplant hospital stay on cardiothoracic surgery wards (median 4 weeks) by direct immunofluorescence testing for HSV, virus culture, and CMV and HSV polymerase chain reaction (PCR). Bronchoalveolar lavages (BALs) were analyzed with the same protocol except that HSV PCR was only performed on request. Risk factor analysis for the outcome '90-day mortality' was performed. Fifteen LTR had virus detection in NPS (16.5%): 9 had CMV, 5 had HSV, and 1 had both CMV and HSV. Four of 84 LTR had CMV detection in BAL (4.8%). Absence of CMV detection in NPS had a negative predictive value of 98.8% for absence of CMV detection in BAL. HSV DNA detection in NPS, especially if detected within 8 days after transplantation, was associated with 90-day mortality. In conclusion, detection of herpesviruses in the RT was clinically relevant and frequent, despite antiviral prophylaxis.
Asunto(s)
Citomegalovirus/aislamiento & purificación , Trasplante de Corazón/efectos adversos , Trasplante de Pulmón/efectos adversos , Infecciones del Sistema Respiratorio/epidemiología , Infecciones del Sistema Respiratorio/virología , Simplexvirus/aislamiento & purificación , Adolescente , Adulto , Anciano , Niño , Preescolar , Estudios de Cohortes , Citomegalovirus/genética , Infecciones por Citomegalovirus/epidemiología , Infecciones por Citomegalovirus/virología , Femenino , Herpes Simple/epidemiología , Herpes Simple/mortalidad , Herpes Simple/virología , Humanos , Incidencia , Lactante , Masculino , Persona de Mediana Edad , Reacción en Cadena de la Polimerasa/métodos , Infecciones del Sistema Respiratorio/mortalidad , Infecciones del Sistema Respiratorio/fisiopatología , Simplexvirus/genética , Adulto JovenRESUMEN
We report on a case of intentional blood group incompatible lung transplantation. A blood group O cystic fibrosis patient was mechanically ventilated and put on interventional lung assist for severe respiratory decompensation. Since timely allocation of a blood group O donor lung was impossible, an AB deceased donor lung rescue allocation was accepted and the transplant performed using a pre-, peri- and postoperative antibody depletion protocol including plasmapheresis, ivIg administration, rituximab and immunoadsorption. Nine months after the transplant the patient is at home and well.
Asunto(s)
Sistema del Grupo Sanguíneo ABO/inmunología , Fibrosis Quística/sangre , Fibrosis Quística/terapia , Trasplante de Pulmón/métodos , Adsorción , Adulto , Incompatibilidad de Grupos Sanguíneos/inmunología , Femenino , Supervivencia de Injerto , Humanos , Inmunosupresores/uso terapéutico , Plasmaféresis , Respiración Artificial , Resultado del TratamientoRESUMEN
Obstructive sleep apnoea (OSA) is linked with increased cardiovascular morbidity and mortality, possibly through an enhancement of atherosclerotic vascular changes. Up to now, however, only a few studies have tried to evaluate the occurrence of atherosclerosis in patients with OSA. In the present study, ultrasonography of the large extracranial vessels was performed in a group of consecutively admitted OSA patients (n = 35) and a control group of non-OSA patients (n = 35). Common carotid artery-intima media thickness (CCA-IMT) was measured at the far wall of both proximal carotid arteries. Furthermore, the presence of plaques and stenoses of the extracranial vessels was determined. All measurements were carried out blinded to the status of the patients. In the OSA group, CCA-IMT was significantly increased when compared with the non-OSA patients and was related to the degree of nocturnal hypoxia. Additionally, the formation of plaques was more pronounced and extracranial vessel stenosis was more common in the OSA patients. In conclusion, these findings are in favour of an independent influence of obstructive sleep apnoea on atherosclerotic changes of the arterial wall, and represent further strong arguments for obstructive sleep apnoea being a risk factor on its own for the emergence of cardiovascular disease.