Recipients Of LTx Research Articles

Ambulatory Blood Pressure Monitoring in the Diagnosis and Management of Hypertension after Renal Transplantation

Objective: To evaluate the behavior of blood pressure (BP) to ambulatory blood pressure monitoring (ABPM) in stable renal transplant recipients (LTx), comparing their findings with manual measurements. Method:Cross-sectional study including 44 recipients of LTx from quaternary public hospital, with stable renal function, between the 3th and 6th months after LTx. Agreement analyses between conventional measurement and ABPM were performed considering two limits of normality: limits I: ambulatory BP < 130/80 mmHg and mean total ABPM < 125/75 mmHg; limits II: ambulatory BP < 140/90 mmHg and mean total ABPM < 130/80 mmHg. Results: There was a predominance of men (54.5%) with a mean age of 44 years, taking antihypertensives (75%). The prevalence of maskedsystemic arterial hypertension (SAH) considering the limits I was 15.9% when compared to the closest measurement to the ABPM, and 31.8% when compared to the average of the three measurements prior to the ABPM. Considering the limits II, masked SAH occurred in 22.7% when compared with the closest measurement to the ABPM and in 38.6% when the average of the measurements was used. Nocturnal descent impairment occurred in 40 (90.9%) patients. Considering ABPM as the gold standard, the accuracy of manual gauging closest to monitoring was 72.7% for limits I. When considering the average of the measurements, the accuracy was 56.8% for the same limits. The accuracy according to the limits II was 68.2% and 54.6% for the closest measurement to the ABPM and for the average of the measurements, respectively. There was poor diagnostic agreement between ABPM and ambulatory measures (Kappa = 0.095 to 0.374). The linear coefficient (R) values for systolic pressures were 0.609 and 0.671 for the first measurement closest to the MAP and for the average of the measurements, respectively. These coefficients for diastolic pressures were 0.521 and 0.454, respectively. Conclusion: There was low agreement between manual measurements and ABPM, especially for diastolic BP. Most patients had an altered nocturnal descent. These data indicate the usefulness of ABPM in addressing hypertension in this population, as well as providing additional information regarding the circadian behavior of BP.

Severe Diaphragm Fiber Weakness And Normal Response To Intraoperative Phrenic Stimulation In An ECMO‐Dependent Adult Receiving Lung Transplant

IntroductionProlonged mechanical ventilation (MV) places patients at an increased risk for ventilator‐induced diaphragm dysfunction (VIDD), which can delay weaning from MV. We previously reported that intraoperative phrenic stimulation may preserve diaphragm fiber contractile function in those undergoing cardiac surgeries, but benefits are unclear in those with significant pulmonary disease who require extracorporeal membrane oxygenation (ECMO) support.Case DescriptionA 55‐year‐old male with end‐stage pulmonary fibrosis underwent bilateral lung transplantation (LTX) after a two‐week pre‐operative hospitalization that included ECMO support. Phrenic stimulation commenced upon initial surgical exposure of the diaphragm, and supramaximal twitch stimulations were administered every 30 minutes to one hemidiaphragm over 136 minutes. The contralateral side served as an inactive control. Diaphragm biopsies of the LTX patient were acquired after 5 stimulations. Maximal single‐fiber diaphragm twitch force was then compared to nine male participants (56 (12) years) admitted for cardiac bypass or valvuloplasty surgery, who underwent 6 (1) bouts of unilateral intraoperative stimulation followed by diaphragm biopsy. In each subject, we tested maximal single‐fiber force on an average of 22 (4) slow‐ and 22 (3) fast‐twitch fibers.Compared to cardiac surgical patients, the LTX subject had increased slow fiber cross‐sectional area (CSA) (Control side, cardiac: slow 5166 (1645) mm2; fast 6792 (732) mm2; LTX: slow 6827 (1504) mm2; fast 6159 (1173) mm2). Diaphragm fiber CSA of the stimulated side trended higher in the LTX patient (slow: 8588 (1908) mm2, p=0.080 vs control side; fast: 7232 (1976) mm2, p=0.094 vs control). Specific force (absolute force normalized to fiber CSA) in LTX was reduced by ~32% in slow fibers and ~30% in fast fibers (Table), as compared to cardiac patients. Specific force of stimulated fibers trended higher for slow‐ but not fast‐twitch fibers in LTX; response to stimulation resembled that of cardiac surgical patients. The patient was extubated 26 hours post‐LTX, as compared to 12 (7) hours in the cardiac patients.Impact (Novelty and Importance)This novel model of functional electrical stimulation suggests that phrenic stimulation preserved fiber CSA in an ECMO‐dependent adult with pulmonary fibrosis. Phrenic stimulation increased maximal specific force in slow‐twitch fibers, but responding forces remained well below expected values. These findings suggest that critically ill adult recipients of LTX may require additional duration and volume of diaphragm training, whether through voluntary or evoked contractions, to recover functional inspiratory muscle strength post‐operatively.

P0569ACUTE KIDNEY INJURY AFTER LUNG TRANSPLANTATION: INCIDENCE, RISK FACTORS AND OUTCOMES IN A MONOCENTRIC RETROSPECTIVE COHORT STUDY

Abstract Background and Aims Acute kidney Injury (AKI) occurs in more than 50% of patients after lung transplantation (LTx). Our aim was to describe the incidence, risk factors and outcomes associated with AKI after LTx in a retrospective monocentric cohort study. Method We studied all recipients of LTx (> 16 years of age) occurring at Ospedale Maggiore Policlinico Milano between Jan 1st 2015 and Dec 31st 2017. AKI was defined according to KDIGO classification, eGFR was calculated according to CKD (Chronic Kidney Disease) Epidemiology Collaboration formula and CKD was defined by an eGFR< 60 ml/min per 1.73 m2. Chi square, Fisher exact test, t.-test and logistic regression were used to define risk factors for AKI in the early post-surgical period and for CKD at 1 and 2 years after LTx. AKI-related survival was estimated using Kaplan Meyer model. Results Of 78 LTx patients enrolled in our Center, 50% of patients was affected by cystic fibrosis. Median age at transplant was 43 years (27-55); median follow- up was 31 months (20-40). Survival rate was 80.77% at 1 year, 69.23% at 2 years and 66.67% on Dec 31st 2019 (last follow-up). AKI occurred in 42 (53.85%) patients within the first week after LTx, respectively grade I and II in 12 each (15.38%) and grade III in 18 (23.08%) patients. Pre-transplant low albumin levels and hypertension were independently associated with AKI at univariate and multivariate (p= 0.0018 and 0.0004 respectively) analysis. Pre-transplant low albumin levels, pre-transplant ECMO-use, hypertension, ECMO-use during transplant surgery were associated with severe AKI in univariate analysis but only pre-transplant hypertension and ECMO-use during transplant surgery were independently associated in the multivariate one (p=0.0266 and 0.0463 respectively). Survival was significantly reduced in patients affected by AKI (p=0.035); this observation became strongly significant when only mild and moderate (grade I and II) AKI was considered (p=0.0071). CKD was diagnosed in 38.09% of patients at 1 year and 35.18% at 2 years. While numerous risk factors were related to the occurrence of CKD at 1 and 2 years after LTx at univariate analysis, only grade III AKI remained independently associated with CKD at multivariate analysis (p= 0.0081 for 1 year-CKD, p=0.0154 for 2 year-CKD). Conclusions In our population, AKI after LTx occurred in about half of the patients and was predicted by history of hypertension, low albumin levels and hemodynamic instability during the surgery. Mild-moderate AKI, often clinically underestimated, was strongly associated with reduced survival. Severe forms of AKI were predictive of occurrence of CKD.

Safety of Antithymocyte Globulin in Patients Undergoing Liver Transplantation With Livers From Donation After Circulatory Death Donors.

Background: Studies suggest that rabbit-antithymocyte globulin (rATG) decreases biliary complications (BCs) after donation-after-circulatory-death-donor liver transplantation (DCD LTx), but safety data are lacking. Objective: Our aim was to assess the safety of rATG for this indication. The secondary end point was efficacy of rATG for this indication. Methods: Adult recipients of DCD LTx were divided into 2 cohorts: protocolized use of rATG in the modern era (July 1, 2013, to December 31, 2016) and a historical control without rATG (January 1, 2005, to June 30, 2013). Incidence of infection, leukopenia, and thrombocytopenia were compared for the safety assessment, incidence of BCs, ischemic cholangiopathy (IC), and transplant outcomes for the efficacy assessment. Results: A total of 83 patients met inclusion criteria: 42 in the historical cohort and 41 in the modern cohort. The modern cohort had significantly fewer bacterial infections at 3 months (historical 54.8% vs modern 23%; P = 0.004) and 1 year (historical 62.1% vs modern 34.2%, P = 0.004). The modern cohort also had fewer fungal infections at these time points (historical 33.3% and 47.9% vs modern 15% and 15%; P = 0.001). There were no significant differences in platelet or white blood cell reduction between groups. There was a nonsignificant, but numerical, trend toward reduced IC/BC in the modern cohort at 1 year (IC: historical 30.1% vs modern 13.2%, P = 0.08; BC: historical 51% vs modern 37.5%, P = 0.13). There was no difference in graft/patient survival. Conclusion and Relevance: Our data suggest no major safety issues with rATG in DCD LTx. Our study should ease clinical apprehension surrounding rATG use for this indication. Future prospective studies are needed to further evaluate the role of rATG and its impact on efficacy end points.

Feasibility of lung transplantation from donors mechanically ventilated for prolonged periods.

When patients are mechanically ventilated for more than 5 days, they are usually declined as donors for lung transplantation (LTx); thus, the long-term outcomes of LTx from such donors remain unclear. We investigated the feasibility of LTx from donors that had been mechanically ventilated for prolonged periods. The subjects of this retrospective comparative investigation were 31 recipients of LTx from donors who had been mechanically ventilated for < 5 days (short-term group) and 50 recipients of LTx from donors who had been mechanically ventilated for ≥ 5 days (long-term group). The median duration of donor mechanical ventilation was 3days in the short-term group and 8.5days in the long-term group. However, other than the difference in the duration of donor ventilation, there were no significant differences in the clinical characteristics of the donors or recipients between the groups. The overall survival rate after LTx was comparable between the long-term group and short-term group (5-year survival rate, 66.6% vs. 75.2%). The potential inclusion of donors who have been on mechanical ventilation for more than 5 days could be a feasible strategy to alleviate donor organ shortage.

Predictive Utility of Lung Allocation Score for Retransplantation Outcomes

Treatment of primary graft failure after lung transplantation (LTx) may include retransplantation (rLTx). The number of rLTx cases has doubled since implementation of the Lung Allocation Score in 2005. The Lung Allocation Score was intended to predict LTx outcomes, but its predictive utility has not been assessed in rLTx. We investigated whether 1-year outcomes of LTx and rLTX were equally well predicted by the Lung Allocation Score. Recipients of LTx and rLTx aged 18 years or more were identified in 2005 to 2015 United Network for Organ Sharing data. The Lung Allocation Score was entered in multivariable logistic regression models of 1-year retransplant-free survival. Areas under the receiver-operating characteristics curve summarized model predictive value. We examined whether the Lung Allocation Score and its components were differentially associated with outcomes of LTx and rLTx. There were 16,837 LTx and 765 rLTx cases meeting inclusion criteria. Crude 1-year retransplant-free survival rates were 86% after LTx compared with 74% after rLTx. On univariate analysis, both LTx and rLTx cohorts showed poor predictive utility of the Lung Allocation Score (area under the curve 0.55 and 0.57, respectively; difference by transplant type, p= 0.307). Neither the Lung Allocation Score nor its components was differentially associated with LTx compared with rLTx outcomes. The Lung Allocation Score achieved comparable, but poor, predictive utility for 1-year outcomes of primary LTx and rLTx. We found no evidence that Lung Allocation Score components should be weighted differently for rLTx candidates.

Adverse outcomes associated with pulmonary hypertension in chronic obstructive pulmonary disease after bilateral lung transplantation

BackgroundThe impact of pulmonary hypertension (PH) in chronic obstructive pulmonary disease (COPD) on survival after lung transplantation (LTx) is not known. Material and methodsFirst-time adult LTx recipients with COPD transplanted between May 2005 and September 2013 were identified in the United Network for Organ Sharing Registry database, and tracked from transplant date until death or censoring. Right heart catheterization (RHC) measurements at time of wait listing were used to predict all-cause mortality after LTx, with multivariable analyses stratified by transplant type. ResultsOf 3362 COPD LTx recipients, 3105 were included in the analytic sample, with multiple imputation used to complete missing data on covariates. Multivariable analysis found the hazard of death to increase with a 10 mmHg increase in mean pulmonary artery pressure (mPAP) among recipients of bilateral LTx (HR = 1.12; 95% CI = 1.01, 1.24; p = 0.032), but not among recipients of single LTx (HR = 0.92; 95% CI = 0.80, 1.06; p = 0.234). ConclusionPH prior to bilateral LTx in patients with COPD is associated with higher mortality risk.

Comparison Between 2 Strategies of Fluid Management on Blood Loss and Transfusion Requirements During Liver Transplantation

To compare the effects of low central venous pressure (LCVP) and transesophageal Doppler (TED)-guided fluid management on blood loss and blood transfusion during liver transplantation (LTx). Retrospective study. Single institution, university hospital. Adult recipients of LTx. Two groups: control (LCVP G), n=45 with CVP maintained 40% lower than the preoperative value during the preanhepatic phase. The mean arterial pressure was kept >60 mmHg. This group was matched with the second group (TED G); n = 45, in which a TED protocol was followed maintaining the systemic vascular resistance (SVR) more than 750 dynes•s•cm-5. Coagulation defects were corrected following thromboelastometry. Intraoperative blood loss, blood products, perioperative creatinine, lactate, and postoperative patients' stratification according to the Acute Kidney Injury Network classification were compared. Prior to the anhepatic phase, CVP was significantly lower in LCVP G (p < 0.001). TED G tended to have less but nonsignificant, blood loss, packed red blood cells, fresh frozen plasma, and platelets and received significantly less colloid and higher norepinephrine. Lactate was significantly higher in LCVP G at the end of the anhepatic phase and end of surgery while urine output in the preanhepatic phase was significantly lower. Creatinine was significantly lower on postoperative days 1 and 3, and Acute Kidney Injury Network stages were better on postoperative day 1 in TED G. During LTx, TED-guided fluid management, with norepinephrine used to maintain SVR, was similar to LCVP regarding blood loss and transfusion requirements and had better impacts on kidney function and lactate.

Association between transient acute kidney injury and morbidity and mortality after lung transplantation: A retrospective cohort study

PurposeAcute kidney injury (AKI) is a common occurrence after lung transplantation (LTx). Whether transient AKI or early recovery is associated with improved outcome is uncertain. Our aim was to describe the incidence, factors, and outcomes associated with transient AKI after LTx. Materials and MethodsWe performed a retrospective cohort study of all adult recipients of LTx at the University of Alberta between 1990 and 2011. Our primary outcome transient AKI was defined as return of serum creatinine below Kidney Disease–Improving Global Outcome AKI stage I within 7days after LTx. Secondary outcomes included occurrence of postoperative complications, mortality, and long-term kidney function. ResultsOf 445 LTx patients enrolled, AKI occurred in 306 (68.8%) within the first week after LTx. Of these, transient AKI (or early recovery) occurred in 157 (51.3%). Transient AKI was associated with fewer complications including tracheostomy (17.2% vs 38.3%; P<.001), reintubation (16.4% vs 41.9%; P<.001), decreased duration of mechanical ventilation (median [interquartile range], 69 [41-142] vs 189 [63-403] hours; P<.001), and lower rates of chronic kidney disease at 3 months (28.5% vs 51.1%, P<.001) and 1 year (49.6% vs 66.7%, P=.01) compared with persistent AKI. Factors independently associated with persistent AKI were higher body mass index (per unit; odds ratio [OR], 0.91; 95% confidence interval, 0.85-0.98; P=.01), cyclosporine use (OR, 0.29; 0.12-0.67; P=.01), longer duration of mechanical ventilation (per hour [log transformed]; OR, 0.42; 0.21-0.81; P=.01), and AKI stages II to III (OR, 0.16; 0.08-0.29; P<.001). Persistent AKI was associated with higher adjusted hazard of death (hazard ratio, 1.77 [1.08-2.93]; P=.02) when compared with transient AKI (1.44 [0.93-2.19], P=.09) and no AKI (reference category), respectively. ConclusionsTransient AKI after LTx is associated with fewer complications and improved survival. Among survivors, persistent AKI portends an increased risk for long-term chronic kidney disease.

Incidence and outcomes of acute kidney injury following orthotopic lung transplantation: a population-based cohort study.

Acute kidney injury (AKI) is a serious complication following lung transplantation (LTx). We aimed to describe the incidence and outcomes associated with AKI following LTx. A retrospective population-based cohort study of all adult recipients of LTx at the University of Alberta between 1990 and 2011. The primary outcome was AKI, defined and classified according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria, in the first 7 post-operative days. Secondary outcomes included risk factors, utilization of renal replacement therapy (RRT), occurrence of post-operative complications, mortality and kidney recovery. Of 445 LTx recipients included, AKI occurred in 306 (68.8%), with severity classified as Stage I in 38.9% (n = 173), Stage II in 17.5% (n = 78) and Stage III in 12.4% (n = 55). RRT was received by 36 (8.1%). Factors associated with AKI included longer duration of cardiopulmonary bypass [per minute, odds ratio (OR) 1.003; 95% confidence interval (CI), 1.001-1.006; P = 0.02], and mechanical ventilation [per hour (log-transformed), OR 5.30; 95% CI, 3.04-9.24; P < 0.001], and use of cyclosporine (OR 2.03; 95% CI, 1.13-3.64; P = 0.02). In-hospital and 1-year mortality were significantly higher in those with AKI compared with no AKI (7.2 versus 0%; adjusted P = 0.001; 14.4 versus 5.0%; adjusted P = 0.02, respectively). At 3 months, those with AKI had greater sustained loss of kidney function compared with no AKI [estimated glomerular filtration rate, mean (SD): 68.9 (25.7) versus 75.3 (22.1) mL/min/1.73 m(2), P = 0.01]. By the KDIGO definition, AKI occurred in two-thirds of patients following LTx. AKI portended greater risk of death and loss of kidney function.

Therapeutic rather than prophylactic platelet transfusion policy for severe thrombocytopenia during liver transplantation

Platelet transfusion (PTx) has been identified as an important risk factor for morbidity and mortality after liver transplantation (LTx). Our aim was to evaluate the safety of therapeutic rather than prophylactic PTx policy in severe thrombocytopenic patients undergoing LTx. Recipients of LTx were divided into two groups: group I (GI) (n = 76) platelet count (PC) ≥ 50 × 109/l and group II (GII) PC < 50 × 109/l (n = 76). Platelets were transfused following a thromboelastometry protocol and clinical signs of diffuse bleeding. Both groups were compared regarding hemoglobin (Hb), international normalized ratio (INR), fibrinogen level, blood loss (BL), blood products required, percentage of bloodless surgery, duration of mechanical ventilation, ICU stay, and vascular complications. Each group was further subdivided according to PTx into (GI NPTx and GII NPTx) with no platelet transfusion (NPTx) and (GI PTx and GII PTx) received PTx. These subgroups were further compared for some variables. Base line Hb was significantly higher while INR was significantly lower in GI.75% avoided PTx in GII. Comparisons of BL, packed red blood cells (PRBCs), and cryoprecipitate transfusion were insignificant. Fresh frozen plasma (FFP) transfusion was higher and the percentage of bloodless surgery was lower in GII. In GII, PC increased after start of surgery. Two cases of hepatic artery thrombosis in GI and one in GII were recorded. Recovery of platelets was quicker, and duration of mechanical ventilation and ICU stay was shorter in NPTx patients regardless the base line PC. Cut-off values of PC 30 × 109/l (with sensitivity 73.7% and specificity 78.8%, p < 0.01), BL of 3750 ml in GI (sensitivity of 75% and specificity of 69%, p < 0.01) and of 3250 ml in GII (sensitivity of 84.2% and specificity of 87.7% (p < 0.01)) could indicate the need of PTx. With therapeutic approach, 75% of patients in GII could avoid unnecessary PTx with its hazards without excessive bleeding. PC in GII increased intraoperatively, PTx may lead to delayed recovery of platelets, increased duration of mechanical ventilation and ICU stay. The given cut-off values may help to guide PTx.

The efficacy and safety of valganciclovir vs. oral ganciclovir in the prevention of symptomatic CMV infection in children after solid organ transplantation

Routine prophylaxis for CMV with valganciclovir is common in adult recipients but data to support its use in children are scarce. The aim of this study was to compare the efficacy and safety of valganciclovir vs. ganciclovir in a pediatric cohort. We performed a retrospective analysis of 92 children after KTx and/or LTx. All children have received IV ganciclovir for two wk, and then oral ganciclovir (TID; n = 41) before 2004, or valganciclovir (OD; n = 51) thereafter. Treatment was given for three months in R+/D+ or R+/D- recipients and for six months in R-/D+. Patients were followed for one yr post transplant. Both groups were comparable in their demographic and transplant-related history. Symptomatic CMV infection/disease developed in 13.7% vs. 19.5% of valganciclovir and ganciclovir groups, respectively (P-NS). Time-to-onset of CMV infection was comparable in both groups (P-NS); rates of acute allograft rejection were similar in both groups (3.9% vs. 9.8%). Risk factors for CMV infection included young age, serostatus of R-/D+, and allograft from cadaver donor. No significant side effects were noted in both groups. As in adults, valganciclovir appears to be as efficacious and safe as oral ganciclovir. Valganciclovir should be considered as a possible prophylactic treatment for CMV in pediatric recipients of KTx or LTx.

Basiliximab Versus Steroids in Double Therapy Immunosuppression in Liver Transplantation: A Prospective Randomized Clinical Trial

: Basiliximab (B), an anti-CD25 monoclonal antibody, may represent an alternative to steroids (S) in immunosuppression after liver transplantation (LTx). The aim of this prospective randomized clinical trial was to compare B with S in a cyclosporin A (CsA)-based immunosuppression regimen in primary LTx. : Forty-seven adult recipients of LTx were randomly assigned to receive B or S. CsA was administered at the initial dose of 10 mg/kg/day and adjusted to the target C2 level of 800 to 1000 ng/mL by day 7. Clinically suspected acute cellular rejection (ACR) was histologically confirmed. Endpoints include ACR, survival, and disease-free survival. : In group B (26 patients), there were seven biopsy-confirmed ACR with an ACR rate of 15.4%; in group S (21 patients), 8 ACR with an ACR rate of 28.6% (P=n.s.). Cumulative survival at 36 months after transplantation was 84.3% for group B and 61.0% for group S. In hepatitis C virus patients (n=20: 12 in group B, 8 in group S), the ACR rate was 25% in group B and 50% in group S. The incidence of infection and other adverse events was similar in the two treatment groups. : B may represent a valid alternative to S in the induction of immunosuppression in LTx. Further studies of basiliximab in a large cohort are needed.

Immunizations and infectious diseases in pediatric liver transplantation

Liver transplantation (LTx) is an established and effective treatment for children with end-stage and metabolic liver disease. Improved surgical techniques and immunosuppressive regimens have led to enhanced short-term and long-term survival rates, which now approach or exceed 90%. Consequently, more children are being referred for LTx, and an increasing numbers of pediatric centers routinely perform this procedure. Infectious complications are an important cause of morbidity and mortality in children undergoing LTx. However, improvements in immune suppression management along with the availability of new antimicrobial agents and diagnostic tools have resulted in improved treatment and preventative regimens, thus reducing the impact of infectious complications on these children. This review provides an overview of the infectious complications and prevention strategies for children undergoing LTx.

Health-Related Quality of Life Following Single or Bilateral Lung Transplantation: A 7-Year Comparison to Functional Outcome

To compare long-term health-related quality of life (HRQL) in single and bilateral lung transplant recipients independent of the underlying disease, and in a subset of patients with native pulmonary emphysema. Forty-four lung transplant recipients (mean [+/- SD] age, 44.8 +/- 11.6 years) were followed up for > 2 years after single lung transplantation (LTx) [14 recipients] or bilateral LTx (30 recipients). Data were prospectively collected, before undergoing LTx and annually after undergoing LTx, measuring FEV1, 6-min walk test (6MWT) results, and quality of life using the St. George respiratory questionnaire (SGRQ) and a visual analog scale (VAS). The SGRQ addresses three domains, namely, respiratory symptoms, accomplishment of routine activities, and disease impact on daily life. Statistically significant correlation coefficients were found comparing the SGRQ and the VAS (r = 0.812; p < 0.0001), the SGRQ and the 6MWT (r = 0.610; p < 0.0001), and the SGRQ and the FEV1 (r = 0.523; p < 0.0001) in all patients. Significant improvements on the FEV1, 6MWT, and SGRQ were observed after LTx in both single and bilateral LTx recipients. Increased risk for the development of bronchiolitis obliterans syndrome (BOS) [relative risk, 2.86; 95% confidence interval, 1.22 to 6.67; p = 0.03] and significantly lower FEV1 values were observed in patients following a single graft, compared to that in patients following a bilateral graft (p < 0.01). In contrast, the 6MWT and the SGRQ scores were not significantly different between recipients of single and double LTx. The same patterns of results were observed in comparisons between single and bilateral lung recipients with prior pulmonary emphysema. Despite poorer FEV1 recovery and increased risk of BOS after LTx, single lung transplant recipients had comparable long-term exercise tolerance and quality-of-life scores as patients who received bilateral transplants. These results suggest the limited influence of functional performance on objective and subjective markers of HRQL recovery after LTx.

ACCURACY OF CIMETIDINE-CORRECTED SERUM CREATININE, CREATININE CLEARANCE AND CALCULATED CREATININE CLEARANCE TO ASSESS THE GLOMERULAR FILTRATION RATE IN LONG-TERM KIDNEY-PANCREAS AND LIVER TRANSPLANT PATIENTS

P863 Serum creatinine (Scr) and the endogenous creatinine clearance (CrCl) overestimate the glomerular filtration rate (GFR). Cimetidine decreases the tubular secretion of creatinine and improves the accuracy of the CrCl and calculated (Calc) CrCl (based on the Cockroft-Gault formula), in pts with various renal diseases. Aim: To determine the effect of cimetidine on renal function markers (Scr, CrCl and the CalcCrCl) and to correlate these markers with the radionuclide GFR in long-term recipients of kidney/pancreas (KP) Tx and liver (L) Tx. Methods: We enrolled 18 pts (5 women, 13 men, 46±8 yrs), who were >1 yr (28±20 mo.) post-KPTx and 38 pts (14 women, 24 men, 61±11 yrs), who were >1-yr (57±34 mo.) post-LTx. All the pts were on a calcineurin inhibitor. All the pts received cimetidine 800 mg t.i.d for 1 day and collected urine (24-hr) during the same day, the day before the annual radionuclide GFR. Scr, CrCl and the CalcCrCl (cimetidine-corrected) were measured on the day of the annual GFR. Results: LTx pts were older (P<0.0001). Cimetidine was well tolerated and no side-effects were observed. The cost of 2,400 mg of cimetidine was lower than the cost of the radionuclide GFR (CDN $0.48 vs. $66.00). Table 1. Effect of Cimetidine on renal function markersFigureTable 2. Correlation (r2) between the GFR and cimetidine-corrected markers of renal functionFigureaP = 0.006, bP = 0.0003, cP < 0.0001, dP = 0.0007, cP = 0.034 Conclusion: Renal function markers are overestimated in long-term recipients of KPTx and LTx. Our results suggest that cimetidine improves the accuracy of CrCl and CalcCrCl to assess the GFR in KPTx pts. The cimetidine-corrected CalcCrCl, may become a cost-effective alternative to assess the GFR in these pts. In LTx pts, cimetidine-corrected Scr appears to correlate better with the GFR compared to the cimetidine-corrected CrCl and CalcCrCl. A modified CalcCrCl formula needs to be developed to assess the GFR in LTx pts.