Female Lung Transplant Recipients Research Articles

Increased Donor Organ Size and Age is Associated with Reduced Survival in Female Lung Transplant Recipients

BackgroundOrgan selection in lung transplantation (LTx) is still controversial. We here analyze the impact of mismatches in size, age, and gender on early and long-term outcome after LTx. MethodsRetrospective analysis of donor and recipient characteristics of patients who underwent double lung transplantation (DLTx) between 03/2003 and 12/2021. Statistical analysis was performed using SPSS and GraphPad software. Results203 patients were included (94 female and 109 male). In the whole cohort, oversizing donor organs 10%-20% compared to the recipients’ predicted total lung capacity (pTLC) led to a decreased incidence of severe primary graft dysfunction (PGD2/3) (15% vs. 41%, p=0.03), and further oversizing >20% was associated with reduced long-term survival (HR 2.33, p=0.011). Analysing donor and recipient age, we found that increased donor age correlated with reduced long-term survival (p=0.013). In this cohort, female recipients received older organs (median 57 vs. 46 years, p=0.0003) and had a higher incidence of >20% oversizing (13% vs. 4%, p=0.019) of donor lungs which resulted in a significantly reduced long-term survival (p=0.02) compared to male recipients. Median LAS scores were similar in both groups. ConclusionMismatch of donor age and size can be important for organ function and survival in lung transplant recipients. Particularly female recipients seem to have a higher risk for unfavourable long-term outcome when transplanting organs of increased size and age. Multicentre studies are warranted to further address this question.

A single center Israeli experience in pregnancy post lung transplantation: Feasibility of successful two or more full-term pregnancies in individual lung transplant recipients.

Female lung transplant recipients (LTRs) of reproductive age are increasingly considering pregnancy due to advances in post-transplant management and improved survival. We report our experience with pregnancy in LTRs, with an emphasis on two or more successful full-term pregnancies in individual transplant recipients. We conducted a retrospective analysis of pregnancies in LTRs at our transplant center and collected maternal and fetal outcomes. In our patient cohort, eight female LTRs conceived a total of 17 pregnancies, resulting in 13 newborns, 12 at full term, and 11 with a birth weight>2.5kg. Three of the LTRs had two or more successful full-term pregnancies. LTRs required a significant tacrolimus dose increase to maintain target trough levels during pregnancy. Six recipients are currently clinically stable and active, three with lung function comparable to pre-pregnancy values, and three with evidence of chronic lung allograft dysfunction (CLAD), but stable lung function. Two of the eight LTRs died subsequent to childbirth secondary to chronic respiratory failure due to CLAD, at a mean of 11years post-transplantation and a mean of 4.5years after childbirth. Pregnancy following lung transplantation is feasible and can be achieved with acceptable maternal and newborn outcomes. Importantly, LTRs can successfully have two or more full-term pregnancies.

(75) Pregnancy Outcomes in 42 Female Lung Transplant Recipients

(75) Pregnancy Outcomes in 42 Female Lung Transplant Recipients

Drug-Induced Thrombotic Microangiopathy Caused by Ciprofloxacin Use in a Lung Transplant Recipient

Introduction Drug-induced thrombotic microangiopathy (DITMA) is a potentially life-threatening condition causing hemolytic anemia with microvascular damage. DITMA is generally associated with calcineurin inhibitor use when observed in solid organ transplant recipients. Herein, we describe a rare case of ciprofloxacin-induced TMA in a lung transplant recipient who recovered immediately after discontinuation of the drug. Case Report A 67-year-old female bilateral lung transplant recipient presented 21 months post-transplant with a one-week history of weakness and increasing fatigue. Maintenance immunosuppression consisted of tacrolimus, prednisone, and mycophenolate mofetil. The patient was receiving antibiotic therapy with ciprofloxacin prior to admission for recent Nocardia infection. Physical exam revealed multiple ecchymoses on the bilateral upper extremities, attributed to frail skin in the setting of chronic prednisone use. Complete blood count on admission revealed anemia (hemoglobin, 7.6 g/dL), leukopenia (3 × 109/L), and thrombocytopenia (26 × 109/L). Urea and creatinine were elevated (36 mmol/L and 136 μmol/L, respectively). Coagulation panel was normal with no evidence of disseminated intravascular coagulation. Peripheral blood smear showed marked red cell fragmentation consistent with TMA. Further investigation revealed elevated serum lactate dehydrogenase (560 U/L) and total bilirubin (39 μmol/L), with low haptoglobin levels ( Summary On review of literature, we identified a rare association of ciprofloxacin with DITMA, and thus this medication was discontinued immediately. Within 48 hours, platelet count and haptoglobin levels improved. Rarely, clinicians may need to consider other possible offending agents when TMA persists after discontinuing calcineurin inhibitor use in transplant recipients.

Elevated Liver Function in a Bilateral Lung Transplant Recipient with Scleroderma: Is the Medication to Blame?

<h3>Introduction</h3> Scleroderma (SSc) is an autoimmune disease that can result in end-stage interstitial lung disease (ILD). Rarely, SSc has been associated with primary sclerosing cholangitis (PSC). Lung transplant may be considered for the advanced treatment of SSc-related ILD. Herein, we describe the case of a lung transplant recipient with SSc who also presented a challenging diagnosis of PSC. <h3>Case Report</h3> The patient is a 47-year-old female bilateral lung transplant recipient with history of SSc-related ILD and pulmonary hypertension. Maintenance immunosuppression consisted of tacrolimus, prednisone, and mycophenolate mofetil, and itraconazole was administered for anti-fungal prophylaxis. Early post-transplant, the patient experienced a tonic-clonic seizure related to tacrolimus toxicity. Decision was made to substitute cyclosporine, and levetiracetam was initiated for seizure prophylaxis. We then observed subtle elevations in her liver function tests. All medications were discontinued, without change in liver function, prompting MRI of the abdomen (Figure 1) which revealed multifocal areas of beaded appearance of the central intrahepatic ducts, suggesting PSC. Liver biopsy revealed focal portal tract fibrosis with bile duct lymphocytic exocytosis and vacuolar change, bile ductular proliferation, focal central venous minimal endothelialitis, and focal lobular necrosis with scattered lobular microgranulomata, with a differential of graft versus host disease. Ursodiol was started, and the patient underwent endoscopic retrograde cholangiopancreatography, which confirmed PSC. With no other interventions, liver function normalized. <h3>Summary</h3> Extrapulmonary sclerosis is a concern in lung transplant recipients with SSc. Esophageal involvement tends to garner the most attention from clinicians, yet this case raises awareness for PSC as a rare condition coincident with SSc. Medication use may be misleading when diagnosing the cause of elevated liver function.

A Case of Unremitting Cellulitis in a Lung Transplant Recipient: What is the Infectious Etiology?

<h3>Introduction</h3> <i>Mycobacterium chelonae</i> is a rare, non-tuberculous mycobacterium that is highly pathogenic in immunosuppressed patients. Herein, we describe a chronic presentation of cellulitis which was later biopsy-proven as <i>M. chelonae</i> in a lung transplant recipient. <h3>Case Report</h3> A 61-year-old female bilateral lung transplant recipient presented 15-months post-transplant with multiple erythematous cutaneous lesions of the right arm. She had a 3-month history of waxing and waning cutaneous lesions that had not fully cleared despite antibiotic therapy. The first transplant year was eventful with two episodes of acute cellular rejection necessitating high-dose corticotherapy. Dermatological biopsy performed in a prior visit demonstrated features consistent with dermatitis. Autoimmune etiologies were ruled out, and the patient reported no history of trauma or other nidus of entry for infection. At the time of the current presentation, we observed nodular changes to the cutaneous lesions, which necessitated repeat biopsy, revealing granulomatous infiltrate (Figure 1). Acid-fast staining was positive, and <i>M. chelonae</i> was properly identified. Given her immunosuppressed state, the patient was started on multidrug antibiotic therapy, guided by antibiogram. Skin showed some improvement on observation, however, one large, nodular cutaneous lesion persisted. Decision was made to perform excision in effort to reduce bacterial growth burden. Subsequent biopsy findings were negative, likely a result of immunological phenomenon. She ultimately finished multidrug treatment with complete resolution of skin nodules. <h3>Summary</h3> This case underlines the role of corticotherapy and immunosuppression as a major risk factor for atypical infections, such as <i>M. chelonae</i>, in lung transplant recipients. Eradication can be difficult as demonstrated, and thus early recognition and multidrug antibiotic therapy are the cornerstone for management in this population.

SARS-CoV-2 and Norovirus Co-Infection after Lung Transplantation

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is spreading as a pandemic in 2020. Few reports on infections in thoracic transplantation have been published so far. We present a case of COVID-19 in a 55-year old female lung transplant recipient infected 5 months posttransplant, who additionally was co-infected with a Norovirus. Respiratory and gastrointestinal symptoms were observed without need of therapeutic escalation except for antibiotic therapy. We observed a moderate disease evolution likely due to triple immunosuppression.

Chronic Pulmonary Silicone Embolism from Breast Augmentation Is Not a Common Finding in Explanted Lungs

Objective Acute pulmonary silicone embolism (APSE) related to subcutaneous silicone injections is a well-known entity. Recently, a few cases of pathologically confirmed chronic pulmonary silicone embolism (CPSE) from breast implants have been reported. The prevalence of CPSE in women with breast augmentation is unknown. This study was done to determine the prevalence of CPSE in female lung transplant recipients with a history of breast augmentation and to determine whether breast augmentation plays a role in chronic lung diseases requiring lung transplantation. Methods A retrospective chart review was performed to identify female lung transplant recipients with a history of breast augmentation prior to or at the time of lung transplantation. Ten patients meeting these criteria were identified. The pathologic features of the explanted lungs of these patients were reexamined for CPSE by a board-certified pathologist with expertise in lung transplantation and pulmonary embolism. Results Of 1518 lung transplant recipients at Cleveland Clinic, 578 were females. Of 578 females, 10 (1.73%) had history of breast augmentation. A total of 84 H&E-stained slides from the explanted lungs from 10 cases were examined. No pathologic evidence of chronic silicone embolism was seen in any of the 10 cases. Conclusions CPSE is not associated with pulmonary disease leading to lung transplantation. Breast augmentation is not a significant contributor to pulmonary disease requiring lung transplantation. Further studies are required to ascertain the prevalence of CPSE in the general breast augmentation populace and to define the relationship between breast augmentation and pulmonary disease.

Identification of the Gender-Specific Health Needs of Women Following Lung Transplantation.

Little is known of the prevalence and severity of menstrual dysfunction, climacteric symptoms, pelvic floor disorders, sexual problems, and psychological wellbeing after lung transplantation in women. Adult female lung transplant recipients, attending the Alfred Hospital Lung Transplant Service in Melbourne, Australia participated in a women's health, cross-sectional questionnaire-based study. The 123 of 149 potential participants were recruited between September 2014 and July 2015. Their median age was 53.5 years, and 44 were premenopausal, 3 perimenopausal, and 76 postmenopausal. Moderate-severe menstrual and premenstrual symptoms were common, and 43% of partnered premenopausal women were not using contraception. Vasomotor symptoms (VMS) were common in postmenopausal women <55 years (80.0%), and the use of menopausal hormone therapy was low (8.9%). The estimated prevalence of low sexual desire associated with distress was 24.4%. Low wellbeing was significantly and independently associated with being aged 50 ≤ 60 years, moderate-severe VMS, impaired forced expiratory volume in 1 second, and psychotropic medication use. Our findings demonstrate that premenopausal lung transplant recipients need to be asked about bothersome menstrual symptoms, and contraceptive compliance needs regular review. Transplant recipients at midlife have substantially lower wellbeing than women of other ages and this needs attention, including assessment and management of menopausal symptoms.

(864) - Cervical Neoplasia in Female Lung Transplant Recipients: Inadequate Screening and a High Burden of Disease

(864) - Cervical Neoplasia in Female Lung Transplant Recipients: Inadequate Screening and a High Burden of Disease

National Transplantation Pregnancy Registry: Pregnancy Outcomes in Lung Transplant Recipients.

The purpose of this study was to analyze pregnancy outcomes in female lung transplant recipients. Data were collected by the National Transplantation Pregnancy Registry (NTPR) via questionnaires, interviews, and medical records. There were 24 females transplanted between 1991-2010 who reported 33 pregnancies with 35 outcomes (one triplet pregnancy). The mean age at transplant was 28±5.0 yrs (range 19.7-38.5 yrs) and mean transplant-to-conception interval was 3.7±3.2 yrs (range 0.1-11.3 yrs). Conceptions occurred between June 1992 and September 2013. Outcomes included: 19 live births, 11 spontaneous abortions, and 5 therapeutic abortions. Immunosuppression included: cyclosporine (CsA) in 10 and tacrolimus in 23 pregnancies. Comorbid conditions during pregnancy included: hypertension 55%, diabetes 24%, infections 20%, and preeclampsia 5%. Five rejections were reported during pregnancy followed by 3 maternal deaths (9.9 mos, 1.6 yrs, and 4.3 yrs after pregnancy); all of these recipients were on CsA and were transplanted prior to 1996. With a maternal follow-up of 8.1±5.9 yrs, 15 recipients had adequate function (2 re-transplants), 3 had reduced function, 1 had a non-functioning transplant (with reduced native lung function), and 5 had died. Among the 19 newborn, mean gestational age was 33.9±5.0 wks; 63% were preterm (<37 wks). Mean birthweight was 2202±910 g; 63% were low birthweight (<2500 g). Neonatal deaths were reported in association with a triplet pregnancy: one fetus spontaneously aborted at 14 weeks, followed by the death of the two remaining infants delivered at 22 wks. Two children had birth defects: one had atrial and ventricular defects (pacemaker placed to treat arrhythmias) and the other had both hypospadias (repaired at 8 mos) and arteriovenous malformation (corrected when discovered at age 18). At last child follow-up, age 9.3±6.1 yrs, all 17 children were reported otherwise healthy and developing well. Conclusions: Successful pregnancy is possible after lung transplantation. These are high-risk pregnancies with an increased incidence of prematurity and low birthweight infants. Close surveillance of these recipients is warranted due to the potential impact of rejection during pregnancy on graft and recipient survival. All transplant centers are encouraged to participate in the NTPR. DISCLOSURES:Armenti, V.: Grant/Research Support, Novartis, Astellas, Pfizer, BMS.

Hormonal contraception in female lung transplant recipients: a case series

We present a case series of eight female lung transplant recipients who used combined hormonal contraception (CHC). Pregnancies after lung transplantation are rare1 but can put the woman and the...

Pregnancy after Lung Transplant

The purpose of this study was to analyze pregnancy outcomes in female lung transplant recipients. Data were collected from the National Transplantation Pregnancy Registry via questionnaires, interviews, and hospital records. Twenty-one female lung recipients reported 30 pregnancies with 32 outcomes (1 triplet pregnancy). Outcomes included 18 live births, 5 therapeutic abortions, and 9 spontaneous abortions. No stillbirths or ectopic pregnancies were reported. Mean (SD) interval from transplant to conception was 3.6 (3.3) years (range, 0.1-11.3 years). Comorbid conditions during pregnancy included hypertension in 16, infections in 7, diabetes in 7, preeclampsia in 1, and rejection in 5 women. Ten of the 21 recipients received a transplant because of cystic fibrosis and accounted for 12 pregnancy outcomes (7 live births, 3 spontaneous abortions, and 2 therapeutic abortions). At last recipient contact, 13 had adequate function, 2 had reduced function, 5 recipients had died (2 with cystic fibrosis), and 1 recipient had a nonfunctioning transplant. Mean gestational age of the newborn was 33.9 (SD, 5.2) weeks, and 11 were born preterm (<37 weeks). Mean birthweight was 2206 (SD, 936) g and 11 were low birthweight (<2500 g). Two neonatal deaths were associated with a triplet pregnancy; one fetus spontaneously aborted at 14 weeks and 2 died after preterm birth at 22 weeks. At last follow-up, all 16 surviving children were reported healthy and developing well. Successful pregnancy is possible after lung transplant, even among recipients with a diagnosis of cystic fibrosis.

Tuberculous meningitis in a lung transplanted patient

A 57-year-old female lung transplant recipient developed tuberculosis after quadruple maintenance immunosuppression for acute cellular rejection with respiratory compromise. Deteriorating neurological status led to cerebral imaging and lumbar puncture, which showed Mycobacterium tuberculosis. Tuberculous meningitis with elevated intracranial pressure was treated for 2 weeks on a neurosurgical ward, and intensive care therapy was necessary for another 2 weeks. Complete neurological recovery was achieved after 3 months.

Haemolysis after treatment with intravenous immunoglobulin due to anti-A

Intravenous immunoglobulin (IVIG) is used to treat an increasing number of conditions. IVIG contains immunoglobulin G (IgG) directed against many targets, including red blood cell (RBC) antigens. We report on three patients identified within a 7-month period in a single institution who developed haemolysis because of passively transferred anti-A. The patients were a 34-year-old A (non-A1) D-positive male with aplastic anaemia, a 61-year-old A1 D-negative female with myasthenia gravis and a 57-year-old AB D-positive female lung transplant recipient. The haemoglobin decreased from 11.1 to 5.3 g dL(-1) over 2 days, 12.8 to 7.8 g dL(-1) over 6 days and 7.8 to 6.0 g dL(-1) over several hours, respectively. All three patients had a negative antibody screen, positive direct antiglobulin test for IgG only and an elution containing anti-A1 reactivity. The patients were transfused with O RBC with an appropriate rise in haemoglobin. These cases illustrate the potential severity of haemolysis after IVIG because of passively transferred antibodies to blood group antigens. Lack of recognition of IVIG as a cause for haemolysis by clinicians may be further confounded if routine testing fails to detect the passively transferred ABO blood group antibodies.

Progressive Multifocal Leukoencephalopathy Following Heightened Immunosuppression After Lung Transplant

Progressive multifocal leukoencephalopathy (PML) is a rare demyelinating disease of the central nervous system caused by the JC virus that occurs in the setting of immunosuppression. A 38-year-old female lung transplant recipient at our institution received treatment for episodes of acute rejection with steroids, anti-thymocyte globulin and alemtuzumab, in addition to maintenance immunosuppression. She was diagnosed with PML 13 months after the last episode of rejection, for which she had received alemtuzumab. Despite attempted treatment with cidofovir followed by mirtazapine, PML progressed, and she ultimately died of an acute pulmonary infection and respiratory failure. We provide a detailed clinical and radiographic description of PML in a lung transplant patient and highlight its potential relationship to intensive immunosuppression, as the disease developed in the setting of markedly reduced CD4 counts.

Exacerbation of underlying pulmonary disease in pregnancy

The presence of underlying pulmonary disease in women of childbearing potential can present a significant challenge during pregnancy and the postpartum period. Management of the underlying disease, recognizing and preventing disease progression, and, most important, managing and minimizing toxic side effects of various therapies require the expertise of an interdisciplinary team. This team must involve close collaboration between intensive care physicians, pulmonary physicians, and high-risk obstetricians familiar with these disease states in an effort to minimize fetal and maternal morbidity and mortality. We will review the impact of the pregnant state in lung transplant recipients, patients with pulmonary arterial hypertension, and patients with underlying cystic fibrosis. Review of the literature in regards to pregnancy outcomes and issues for patients with cystic fibrosis, pulmonary hypertension, and lung transplants. A review of the epidemiology, pathophysiology, risk factors, classification, clinical features, and outcomes for pregnant patients with underlying pulmonary diseases. Safety of pregnancy in the female lung transplant recipient concerns three outcomes: maternal outcome, fetal outcome, and transplanted graft outcome.

Pregnancy outcomes in female lung transplant recipients

Pregnancy outcomes in female lung transplant recipients

Pregnancy in lung transplant recipients

Eight female lung transplant recipients, all of whom became pregnant after transplant, were reported to the National Transplantation Pregnancy Registry from US transplant centers. Outcomes of the 8 pregnancies were 4 live births, 3 therapeutic abortions, and 1 spontaneous abortion. Three of the 4 newborns were premature, with low birth weight (< 2500 grams). Rejection during pregnancy occurred in 3 pregnancies (38%). All 8 transplant recipients reported at least 1 complication during pregnancy, including shortness of breath, rejection, and infection. Two of the 4 deliveries were by cesarean section. At follow-up, all children were developing well with no residual problems. Female lung transplant recipients may face higher risks during pregnancy than other solid organ transplant recipients.

Pregnancy in lung transplant recipients.

Eight female lung transplant recipients, all of whom became pregnant after transplant, were reported to the National Transplantation Pregnancy Registry from US transplant centers. Outcomes of the 8 pregnancies were 4 live births, 3 therapeutic abortions, and 1 spontaneous abortion. Three of the 4 newborns were premature, with low birth weight (< 2500 grams). Rejection during pregnancy occurred in 3 pregnancies (38%). All 8 transplant recipients reported at least 1 complication during pregnancy, including shortness of breath, rejection, and infection. Two of the 4 deliveries were by cesarean section. At follow-up, all children were developing well with no residual problems. Female lung transplant recipients may face higher risks during pregnancy than other solid organ transplant recipients.