Double Lung Transplant Recipient Research Articles

Successful prevention of BK-polyomavirus nephropathy using extracorporeal photopheresis for immunosuppression minimisation following severe BK polyomavirus replication after kidney transplantation in a double lung transplant recipient, a case report

BackgroundBK-polyomavirus (BKpyV) nephropathy (BKVN) is associated with end-stage kidney disease in kidney and non-kidney solid organ transplantation, with no curative treatment.Case presentationA 45-year-old woman with a past medical history of double lung transplantation subsequently developed end-stage kidney disease, of undetermined origin. One month after receiving a kidney transplant, a diagnosis of early BKVN was suspected, and in retrospect was a reasonable cause for the loss of her native kidneys. Minimisation of immunosuppression, achieved through extracorporeal photopheresis, allowed clearance of BKpyV and so prevented nephropathy. Both lung and kidney grafts had a satisfactory and stable function after one year of follow-up, with no rejection.ConclusionsExtracorporeal photopheresis may have facilitated minimisation of immunosuppression and BKpyV clearance without lung allograft rejection.

Atypical HUS Unmasked by Infection and Calcineurin Inhibitors Post Lung Transplant

<h3>Introduction</h3> Lung transplant recipients are maintained on multiple lifelong immunosuppressive medications including steroids, calcineurin inhibitors (CNI), and antimetabolite (AM) medications. We report a unique case of a double lung transplant (DLT) recipient developing thrombotic microangiopathy (TMA) from atypical hemolytic uremic syndrome (aHUS) unmasked by infection and CNI therapy. <h3>Case Report</h3> 63-year-old male developed delirium and thrombocytopenia after initiation of CNI therapy with tacrolimus post DLT. Evaluation was otherwise negative and patient improved with cessation of therapy. CNI was switched to cyclosporine without further issues. Four-week biopsy was negative for acute cellular rejection. Five days later, he presented with hypoxia, dyspnea, dizziness, confusion, and impaired gait. His immunosuppressive regimen included prednisone & cyclosporine. His AM therapy was held for leukopenia. All testing and imaging were negative apart from bronchial lavage cultures positive for pseudomonas, klebsiella, and parainfluenza. Appropriate antibiotics and antiviral therapies were started. He developed delirium, acute kidney injury, hemolysis, and thrombocytopenia. Impression was CNI-induced TMA, and CNI was held. All additional work up was negative including shiga-like toxin producing E.Coli. He failed to improve with removal of offending agent and concern was for aHUS given complement panel was suggestive of alternative pathway dysregulation (absent AH50, normal C4 and decreased factors B and H). Patient did not respond to plasmapheresis, and eculizumab was started. He remained thrombocytopenic with positive hemolytic parameters despite 2 doses of therapy. Complement genetic panel testing is pending. Treatment is now held due to respiratory failure and septic shock. <h3>Summary</h3> aHUS is a rare form of TMA, associated with excess activation of the alternate complement pathway which is part of innate immunity. It usually responds to treatment with eculizumab, an anti-C5 monoclonal antibody that inhibits terminal complement complex generation. Our case is inconsistent with secondary HUS from drugs or solid organ transplant and has failed standard aHUS therapy. This is a complex and uniquely challenging case, limited second line options are available including a recently approved long-acting C5 complement inhibitor, which is under review at our institution.

Chronic Type A Aortic Dissection Repair in a Double Lung Transplant Recipient.

A 69-year-old man presented with a chronic Stanford Type A aortic dissection (CTAAD). The patient had undergone bilateral sequential lung transplantation 15 years prior for α-1-antitrypsin deficiency. We describe the management of CTAAD in the context of lung transplantation from the surgical and anesthetic perspectives.

Pregabalin-Induced Myopathy in a Double Lung Transplant Recipient

Pregabalin is a gamma-aminobutyric acid (GABA) derivative that was commercially approved by the Food and Drug Administration (FDA) in 2004. It is commonly used in the treatment of diabetic neuropathy, peripheral neuropathy, and spinal cord injury. We present the case of a 36-year-old Caucasian male double lung transplant recipient who presented with an 18-month history of fatigue and muscle weakness. He had elevated creatinine kinase level and his muscle biopsy showed evidence of drug-induced myopathy that improved after the cessation of pregabalin. We present a case of drug-induced myopathy as a rare complication of pregabalin therapy in a double lung transplant recipient.

Removal of Remdesivir’s Metabolite GS-441524 by Hemodialysis in a Double Lung Transplant Recipient with COVID-19

Remdesivir has reported efficacy against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in vitro and in vivo Drug-drug interactions limit therapeutic options in transplant patients. Remdesivir and its metabolite GS-441524 are excreted principally in urine. In intensive care unit (ICU) settings, in which multiple-organ dysfunctions can occur rapidly, hemodialysis may be a viable option for maintaining remdesivir treatment, while improving tolerance, by removing both remdesivir's metabolite (GS-441524) and sulfobutylether β-cyclodextrin sodium (SEBCD). Additional studies may prove informative, particularly in the evaluations of therapeutic options for coronavirus disease 2019 (COVID-19).

S2003 Cytomegalovirus (CMV)-Induced Acute Esophageal Necrosis (Black Esophagus) in the Lung Transplant Recipient: A Rarest Combination

INTRODUCTION: Acute esophageal necrosis (AEN) also known as black esophagus is a rare clinical entity with characteristic endoscopic appearance of diffuse circumferential necrosis of distal esophagus with relative sparing of proximal esophagus. We report a 60-year-old man with a double lung transplant a year ago, who developed cytomegalovirus induced AEN. To the best of our knowledge and literature review, this is the first and only case of CMV related AEN with resistant stricture in double lung transplant recipient. CASE DESCRIPTION/METHODS: A 60-year-old male with advanced COPD status post double lung transplant a year ago presented with acute onset of odynophagia with solids/liquids for two days. CT scan of the chest showed diffuse thickening of distal esophageal wall without evidence of perforation. An upper endoscopy revealed severe diffuse necrotic mucosa extending from 26 cm to 39 cm from the incisors (Figure A). Biopsies showed CMV related acute and chronic inflammation with granulation tissue (Figure B). Patient was kept NPO and managed with intravenous hydration, total parenteral nutrition, ganciclovir along with proton pump inhibitors for aggressive acid suppression. Repeat endoscopic evaluation two weeks later showed complete resolution of necrosis but moderately severe stenosis in the lower third of the esophagus (Figure C) that required serial dilations over the course of 1 year without significant improvement. DISCUSSION: Acute esophageal necrosis is a rare condition with an incidence of 0.01-0.28%. Infection is a major contributor in post-transplant patients with immunosuppressed state. Proposed pathophysiology contributing to AEN includes impaired esophageal mucosal reparative mechanisms seen in chronically debilitated patients along with esophageal ischemia seen in low flow states. Most common presentation is upper gastrointestinal bleeding in up to 90% of cases. EGD is diagnostic with distal esophageal involvement in 97% of cases. Esophageal biopsy aids in exclude/confirm infectious etiology and typically not associated with increased risk of perforation. Treatment is mainly supportive with management of underling etiology. Potential complication includes stricture formation and perforation. AEN should be considered in the differential diagnosis of UGI bleed and dysphagia especially in post-transplant patients. In conclusion, isolated CMV related AEN is extremely rare in lung transplant recipients and this is the first ever case reported in the literature.Figure A.: Initial EGD showing black necrotic esophagus and follow up EGD two weeks later with healing of necrosis along with distal esophageal stricture.Figure B.: Giant cell with inclusion body characteristic of CMV esophagitis.Figure C.: Barium Esophagram showing long tapering distal esophageal stricture.

Covid-19 Pneumonia in Bilateral Lung Transplant Recipient: Case Report

The clinical course of Coronavirus disease 2019 (covid-19) in lung transplant recipients remains unknown. We present the fatal clinical course of a 63-year-old double lung transplant recipient with severe Covid-19 pneumonia. She had stable graft function before Covid-19 infection. Despite all the supportive care and treatment graft injury progressed, causing patient death. Therefore, the prognosis in lung transplant recipients with Covid-19 infection is not optimistic.

Complex Inpatient Pain Management in a Critically Ill Lung Transplant Recipient: A Case Report

Thoracic surgery is known to cause severe pain that may not subside during the course of hospitalization. Early pain control is important in these patients because it improves ventilation and promotes mobility. Lung transplant recipients can experience post-operative complications that lead to extended hospital stays. This increases the time a patient is sedentary, which further deconditions patients; therefore, rehabilitation should be initiated early post-operatively. We present a unique case of a critically ill double lung transplant recipient whose rehabilitation post-operatively was hindered by severe vasopressor-induced ischemic pain. Due to debilitating pain, he was unable to regain mobility. His pain management course was challenging due to sensitivity to opioids, renal failure, and anticoagulation.

Cystic Fibrosis and Lower-Extremity Edema: A Case of Intraoperative Diagnosis of Acute Deep Venous Thrombosis and Pulmonary Embolism in a Double-Lung Transplant Recipient Using Point-of-Care Ultrasound

Cystic Fibrosis and Lower-Extremity Edema: A Case of Intraoperative Diagnosis of Acute Deep Venous Thrombosis and Pulmonary Embolism in a Double-Lung Transplant Recipient Using Point-of-Care Ultrasound

Persistent Human Cosavirus Infection in Lung Transplant Recipient, Italy

Human cosavirus is a novel picornavirus recently identified in feces from children in southern Asia. We report infection with human cosavirus in a patient in the Mediterranean area. The patient was an adult double lung transplant recipient who had chronic diarrhea associated with persistent infection with human cosavirus.

Wireless Connection between Guide Wires and Bone Cement: Extravasated Methyl Methacrylate Mimicking a Retained Guide Wire

We present the case of a 56-year-old double lung transplant recipient with chest pain who underwent an attempted endovascular retrieval of what was described as a retained guide wire in the azygos vein. After successfully grasping the tip, the object further migrated to the right pulmonary artery complicating the retrieval. It was realized that the “wire” was extravasated methyl methacrylate from a recent percutaneous kyphoplasty. This is believed to be the first report of attempted endovascular retrieval of extravasated methyl methacrylate in the azygos system. We include the details of this case and briefly review the current literature on the management of extravasated methyl methacrylate from vertebral augmentation procedures. Extravasated methyl methacrylate in the venous system is a common finding after vertebral augmentation procedures and any radiopaque stripe arising from a cemented vertebral body should be first described as probable cement leakage.

182-P

Aim This case study investigates a living simultaneous double lung transplant recipient with post-transplant DQA DSA towards one donor. Methods All post-transplant testing was performed by One Lambda (OLI) FlowPRA ® Screening (FPRA) Class I and II, LABScreen ® Mixed (LSMIX) and LABScreen ® Single Antigen Class I/II (LSA1/2) beads. DQA1 ∗ typings were performed by OLI LABType ® SSO. Results A 33 year old female presented with cystic fibrosis and end stage lung disease and was evaluated for lung transplant in 2000. She was negative by Class I ELISA. The patient was transplanted in Feb 2001 with 2 of 3 potential living donors; the patient’s father and a friend ( Table 1 ). The patient did well post-operatively and was not screened by our lab until 2007. FPRA and LSA were negative. In 2011 the patient was evaluated for declining lung function. The FPRA was Class I 0% Class II 60% with significant architecture. LSA2 revealed strong DQA1 ∗ 04, 05 and 06. DQA typings on the recipient and donors were performed. DSA to DQA1 ∗ 05 was confirmed with donor 1 typing as homozygous DQA1 ∗ 01, donor 2 as DQA1 ∗ 01 DQA1 ∗ 05 and the recipient DQA1 ∗ 01:03 DQA1 ∗ 03. No Class I DSA were detected by LSA. FEV1 correlates with the DSA detected in July 2011. The patient was treated for AMR with thymoglobulin, rituximab and high dose IVIG. Follow up LSA testing in November 2011 and March 2012 reveals persistent antibody to DQA1 ∗ 04, 05 and 06 however they do not appear to be increasing in strength. The recipient currently has some compromised lung function and is being closely monitored. Conclusions This is an interesting case of late AMR due to DQA DSA towards one of two simultaneous living donor lungs. The specificity of the DSA highlights the importance of class II mismatches in late AMR and particularly DQA1 in cases where either DQA1 ∗ 04, 05, or 06 are mismatched and all are absent in the recipient.

Percutaneous Mechanical Thrombectomy for Extensive Acute Lower-Extremity Deep Venous Thrombosis in a Patient After Double-Lung Transplantation

Venous thromboembolism, which includes deep venous thrombosis (DVT) and pulmonary embolism (PE), has been estimated to affect 25% of patients after major surgery; however, the literature on venous thromboembolism after thoracic transplantation and optimal approach remains limited. We report the status of a 67-year-old female who developed massive right lower-extremity DVT after double-lung transplantation. Because her surgery had taken place a week before this event, it was decided that pharmaco-thrombolysis was contraindicated due to the high risk of bleeding complications in a fresh double-lung transplant recipient. The patient was taken emergently to the operating room for percutaneous mechanical thrombectomy, which provided grade III (complete lysis) and restored venous patency in the affected extremity. This report highlights the successful use of purely percutaneous mechanical thrombectomy for acute DVT in a double-lung recipient, and also advocates inferior vena cava filter placement to prevent embolic events during the mechanical thrombectomy.

Chronic norovirus gastroenteritis in a double hematopoietic stem cell and lung transplant recipient

N. Boillat Blanco, R. Kuonen, C. Bellini, O. Manuel, C. Estrade, J. Mazza‐Stalder, J.D. Aubert, R. Sahli, P. Meylan. Chronic norovirus gastroenteritis in a double hematopoietic stem cell and lung transplant recipient. Transpl Infect Dis 2011: 13: 213–215. All rights reserved

Bradycardia leading to asystole during dexmedetomidine infusion in an 18 year-old double-lung transplant recipient

The case of an 18 year-old double-lung transplant recipient recovering from acute respiratory distress syndrome who developed repeated episodes of bradycardia and asystole (maximum duration: 10 sec) during dexmedetomidine administration is presented. Increased baseline vagal tone, paroxysmal coughing spells, and opioid administration were likely contributors to the episodes. Discontinuation of the drug restored regular sinus rhythm. Double-lung transplant recipients may be at especially increased risk for this phenomenon as a result of changes in the autonomic innervation of the heart.

Salvage chemotherapy for refractory or relapsed post-transplant lymphoproliferative disorder in patients after solid organ transplantation with a combination of carboplatin and etoposide.

This pilot study assessed the feasibility and efficacy of salvage chemotherapy (carboplatin and etoposide; CE) supported by granulocyte colony-stimulating factor (GCSF) in patients with refractory or relapsed post-transplant lymphoproliferative disorder (PTLD) following solid organ transplantation. Intensified salvage regimens were not feasible for these patients, due to their immunosuppressive conditions and potential organ (especially kidney and bone marrow) malfunctions. Salvage chemotherapy consisted of carboplatin [area under the curve (AUC) 4], on day 1, etoposide (120 mg/m2), on days 1-3 and GCSF (5 microg/kg) starting on day 5. This therapeutic regimen was planned to be repeated every 21 d. Nine patients (seven with refractory, two with relapsed disease) were enrolled. Five patients were heart transplant recipients, three liver transplant recipients and one patient had been a double lung transplant recipient. Five patients achieved a complete remission (CR), with follow-up at 92, 39, 55+, 17 and 9+ months. One patient showed stable disease after two cycles of CE and one patient had progressive disease. Two patients experienced early deaths, after the first and third cycles of chemotherapy respectively. One died of septic complications and one because of a perforated intestine, which had been infiltrated by lymphoma. In respect of the difficulties experienced in treating patients with refractory or relapsed PTLD after solid organ transplantation, the combination of carboplatin and etopoide with GCSF support (filgrastim) proved to be an effective regimen.

Multidrug-resistant tuberculosis in a lung transplant recipient

Tuberculosis infection has been a relatively rare complication after lung transplantation. However, as more countries in which Mycobacterium tuberculosis infection remains endemic embark on lung transplant programs, the occurrence of multidrug-resistant tuberculosis after transplantation is a genuine threat. We report the first case of multidrug-resistant tuberculosis in a double-lung transplant recipient who probably acquired the disease from the donor. We discuss the problems in clinical management of post-transplant tuberculosis infection and of drug-resistance.

Use of the aortic homograft in the reconstruction of complex tracheobronchial tree injuries

Background/Purpose: The repair of complex tracheobronchial tree injuries often is associated with complications including stenosis and excessive granulation tissue formation. Patch reconstruction using pericardium or synthetic material decreases the incidence of stenosis. The authors report on the use of the ascending aorta cryopreserved homograft in reconstructing the tracheobronchial tree of three children.Results: A 10 year old had a through-and-through gun shot wound to the left main stem bronchus with cartilaginous loss. A 12 year old double lung transplant recipient had a breakdown of one bronchial anastomosis after stent placement. A 1 year old had an acquired tracheoesophageal fistula secondary to a long standing foreign body. In all three patients, the aortic patches were secured with interrupted sutures. All three had uneventful recoveries, and postoperative bronchoscopy showed the patches to be completely covered with epithelium without stenosis or granulation tissue.Conclusions: This is the first report of the use of the cryopreserved ascending aorta homograft in the reconstruction of the tracheobronchial tree. The homograft is strong yet malleable. It gets completely covered with epithelium and results in no stenosis because of the lack of tension. These characteristics make it an attractive alternative for the patch reconstruction of complex tracheobronchial tree injuries.

Atypical mycobacteriosis in a lung transplant recipient

Although mycobacterial infections are more frequent in lung transplant recipients than in other solid organ recipients only occasional reports of infection from atypical Mycobacteria have been reported in patients receiving lung transplantation. We present a case of pleural and cutaneous infection due to Mycobacterium fortuitum in a double-lung transplant recipient. The infection was rapidly responsive to therapy with a two drug regimen and no reduction of immunosuppression was necessary.

Donor Selection for Single and Double Lung Transplantation: Chest Size Matching and Other Factors Influencing Posttransplantation Vital Capacity

In six single lung transplant (SLT) and six double lung transplant (DLT) recipients, the relationships of the recipient's posttransplantation vital capacity (posttx VCR) to the recipient's predicted normal vital capacity (pred VCR) and the donor's predicted normal vital capacity (pred VCD) were investigated. After left SLT the left posttx VCR was correlated with the left predicted VCD (r = 0.83; p less than 0.05); however, no correlation was found between these after DLT. In contrast, there was a tendency toward correlation between the posttx VCR and the predicted VCR after DLT (r = 0.75; p less than 0.1), but no such trend was apparent after SLT. These results suggest that posttx VCR depends primarily on predicted VCD after SLT and on pred VCR after DLT. Therefore, in donor-recipient size matching for lung transplantation a donor with a pred VCD greater than the pred VCR should be chosen for a left SLT recipient, whereas a donor with a pred VCD near the pred VCR would be suitable for a DLT recipient.