Unilateral Lung Transplantation Research Articles

V-313.6: The comparison of in-hospital complications and resource utilization between bilateral and unilateral lung transplant in patients with COPD: A 10-year study of National Inpatient Sample.

V-313.6: The comparison of in-hospital complications and resource utilization between bilateral and unilateral lung transplant in patients with COPD: A 10-year study of National Inpatient Sample.

SAT332 Genetic Characterization Of A Case of Pheochromocytoma In A Pulmonary Transplant Patient

Abstract Disclosure: F. Perreault: None. S. Parisien-Lasalle: None. J. Morisset: None. C. Poirier: None. C. Beauregard: None. R. Agnès: None. P. Ferraro: None. I. Bourdeau: None. Background: Pheochromocytomas (PHEOs) and paragangliomas (PGLs) (PPGLs) are rare tumors arising from the chromaffin cells. Approximately 40% of PPGL patients carry germline mutations in susceptibility genes, including pseudohypoxic related SDHx and VHL genes. An association was described between hypoxemia and PPGLs, notably in higher altitude exposition and cyanotic congenital heart disease. In the latter, a chronic hypoxemic state can lead to gain of function somatic mutations in the EPAS1 gene that encodes for hypoxia-inducible factor 2-alpha (HIF-2) (1). Objective: To describe a rare case of PHEO in a pulmonary transplant patient and characterize the genetic background of the tumor. Clinical Case: A 66 year-old man underwent an unilateral lung transplant at the age of 47 for chronic obstructive pulmonary disease associated with alpha-1 antitrypsin deficiency. He required home oxygen therapy for 3 years prior to transplant and was known for new onset diabetes after transplant, chronic kidney disease, hypertension and paroxysmal atrial tachycardia. His family history was non-contributing. Nineteen years after transplant, a thoracic CT-scan showed a 6.1 cm x 3.9 cm right adrenal mass (HU of 7). Retrospectively, the mass had been present for the last seven years, and increased progressively in size. Diagnosis of PHEO was confirmed by the 24-h urinary catecholamines (norepinephrine 713 nmol/d (N< 650), epinephrine 588 nmol/d (N < 145), normetanephrines 900 nmol/d (N < 600) and metanephrines 1191 nmol/d (N < 370)). Chromogranin A was elevated (3297 ng/mL (N < 104)). The adrenal mass showed no uptake at 18F-FDG PET/CT imaging but fixation at MIBG scintigraphy. The patient received alpha blockers and underwent a laparoscopic right adrenalectomy. The pathology report confirmed a PHEO with a PASS score of 8 to 10. Eighteen months following the surgery, the patient showed no signs of biochemical or radiological recurrence. Genetic studies: 1) Germline PPGL multigene panel: After consent, the patient underwent a panel of 14 susceptibility genes for PPGLs (INVITAE, CA, USA) that revealed no pathogenic variants. 2) Somatic genetic analysis for EPAS1 gene: PHEO DNA was extracted and exons 9, 12 and 16 of the EPAS1 gene were studied by Sanger Sequencing. No pathogenic variants were identified.Conclusion: We report a rare case of PHEO in a pulmonary transplant patient. Our genetic analyses demonstrated the absence of a pathogenic germline variant in known susceptibility PPGL genes and no somatic mutations in the EPAS1 gene. Further work is needed to better understand the genetic and molecular events leading to PHEO in this specific case and determine its possible relationship with hypoxemia. (1) Vaidya A, Flores SK, Cheng Z-M, Nicolas M, Deng Y, Opotowsky AR, et al. EPAS1 Mutations and Paragangliomas in Cyanotic Congenital Heart Disease. New England Journal of Medicine. 2018;378(13):1259-61. Presentation: Saturday, June 17, 2023

The Role of Mechanical Thrombectomy for Acute Massive Pulmonary Embolism in a Patient With Unilateral Lung Transplant and Atrial Septal Defect.

The risk of thromboembolic disease is high in patients with lung transplantation and is associated with significant morbidity and mortality with single healthy transplanted lung. We present a case involving successful endovascular management of life-threatening acute massive pulmonary embolism (PE) in a patient with single lung transplant and atrial septal defect (ASD). A 65-year-old man with a history of interstitial lung disease status post single left orthotopic lung transplant in 2012 presented with acute massive PE and clot burden in the pulmonary arteries of the transplanted left lung. Severe right heart dysfunction, hemodynamic instability, and requirement for vasopressors persisted post systemic thrombolytic therapy. As a result, the patient underwent successful endovascular mechanical thrombectomy with immediate improvement in oxygen saturation and hemodynamic status. The procedure was performed without adverse outcomes or paradoxical embolization despite the presence of ASD. The right heart dysfunction resolved, the patient was extubated the next day, and was discharged to home 2 days post procedure. Endovascular mechanical thrombectomy was safely used to treat acute massive PE in a single transplanted lung in the presence of ASD. Endovascular mechanical thrombectomy could be safely utilized to treat patients with lung transplant and acute massive or submassive pulmonary embolism. However, safely of mechanical thrombectomy should be determined in case-based scenarios and based on time interval from transplantation to when the thrombectomy is required.

A National Resource Sharing Program Is Feasible Even in Challenging Lung Recoveries

BackgroundMobile ex vivo lung perfusion (mEVLP) allows transportation of lung allografts while maintaining ventilation and perfusion and has demonstrated safety and efficacy with the potential to expand organ utilization. A nationwide organ recovery service has been implemented to provide surgical expertise for recovery alongside mEVLP transportation services. MethodsWe reviewed patients at our institution who underwent lung transplantation with donor lungs procured with this program. Donor and recipient characteristics, procurement details, and outcomes were collected and descriptively analyzed. Individual patient consent was obtained. ResultsThree patients underwent bilateral lung transplantation and 1 patient received a unilateral lung transplant with allografts procured by the recovery service. Three of the grafts were recovered from donation after circulatory death (DCD) donors and 1 from a brain-dead donor. One DCD donor was particularly challenging, requiring resternotomy. All allografts recovered were of acceptable quality and ultimately used for transplantation. The incidence of adverse events was low, and all patients survived to discharge. ConclusionsA novel national mEVLP procurement service is safe and effective even in challenging procurements. Such a program may be beneficial to increase organ utilization through expanded use of lung donors in general and DCD donors in particular. Further study is warranted for the impact on transplant program resources, organ utilization, and outcomes.

Surviving White-out: How to Manage Severe Noninfectious Acute Lung Allograft Dysfunction of Unknown Etiology.

Surviving White-out: How to Manage Severe Noninfectious Acute Lung Allograft Dysfunction of Unknown Etiology.

Atypical Unilateral SARS-CoV-2 Pneumonia in a Single Lung Re-Transplanted Patient: A Case Report

BackgroundSince December 2019, the SARS-CoV-2 pandemic significantly has impacted the medical community. When infected with SARS-CoV-2, most of the patients developed bilateral pneumonia. We have herein presented the atypical case of a patient who developed unilateral SARS-CoV-2 pneumonia, affecting only the second lung allograft re-transplanted (re-LTX).Case PresentationA SARS-CoV-2 infection occurred in a 2-dose vaccinated patient with LTx with a history of second unilateral lung transplantation performed after an end-stage bronchiolitis obliterans syndrome. The first symptoms started with a flu-like syndrome, and the patient's clinical condition worsened with nonsevere acute respiratory failure requiring conventional oxygen therapy. Treatment consisted in administrating specific anti-SARS-CoV-2 monoclonal antibodies along with probabilistic antibiotherapy, anticoagulation, and steroids. On day 7, the patient was discharged from hospital. We aimed to assess this atypical unilateral pneumonia based on different explorations. A ventilation scintigraphy showed a severe ventilation decrease owing to end-stage bronchiolitis obliterans syndrome within the left first allograft, which may be associated with asymmetrical virus diffusion between the 2 lungs. We did not identify any other relevant differences with respect to the 2 donors’ clinical characteristics. Using specific immunohistochemistry staining against angiotensin converting enzyme-2 receptor, the main known receptor for SARS-CoV-2 binding on airway epithelial cells, no staining difference was observed between the 2 lung biopsies that were collected at re-LTx from each lung.ConclusionsWith the present case report, we aimed to highlight how this kind of unusual presentation may be caused by the difference of ventilation between the 2 lungs.

Idiopathic pulmonary fibrosis: Current and future treatment.

ObjectivesIdiopathic pulmonary fibrosis (IPF) is a chronic fibrotic lung disease characterized by dry cough, fatigue, and progressive exertional dyspnea. Lung parenchyma and architecture is destroyed, compliance is lost, and gas exchange is compromised in this debilitating condition that leads inexorably to respiratory failure and death within 3–5 years of diagnosis. This review discusses treatment approaches to IPF in current use and those that appear promising for future development.Data SourceThe data were obtained from the Randomized Controlled Trials and scientific studies published in English literature. We used search terms related to IPF, antifibrotic treatment, lung transplant, and management.ResultsEtiopathogenesis of IPF is not fully understood, and treatment options are limited. Pathological features of IPF include extracellular matrix remodeling, fibroblast activation and proliferation, immune dysregulation, cell senescence, and presence of aberrant basaloid cells. The mainstay therapies are the oral antifibrotic drugs pirfenidone and nintedanib, which can improve quality of life, attenuate symptoms, and slow disease progression. Unilateral or bilateral lung transplantation is the only treatment for IPF shown to increase life expectancy.ConclusionClearly, there is an unmet need for accelerated research into IPF mechanisms so that progress can be made in therapeutics toward the goals of increasing life expectancy, alleviating symptoms, and improving well‐being.

COVID-19: Unilateral Involvement of Transplanted Lung, Sparing Contralateral Fibrotic Lung

Introduction: Organ transplant recipients might be more likely to develop COVID-19, as they receive long-term immunosuppressives and have comorbidities. Case Presentation: Herein, we reported the case of a 32-year-old man with unilateral lung transplantation due to unclassifiable lung fibrosis on pathologic evaluation who presented with cough, fever, and headache. After evaluation with RT-PCR test and chest CT scan, COVID-19 in the previously transplanted lung was diagnosed. However, the other non-transplanted fibrotic lung was not involved. Conclusions: Lack of COVID-19 involvement in the fibrotic lung tissue in our case without any other risk factors might be related to the fact that the lung with underlying diseases was less susceptible to COVID-19 as unhealthy lungs have lower ACE2 receptors, or it might be related to genetic differences between the donor and recipient.

Incidence and Predictive Factors of Acute Kidney Injury After Off-pump Lung Transplantation

To determine the incidence and predictive factors of acute kidney injury (AKI) after off-pump lung transplantation. A retrospective cohort study. The operating room and intensive care unit. Adult patients who underwent lung transplant without cardiopulmonary bypass or extracorporeal membrane oxygenator between 2006 and 2016 at the Vanderbilt University Medical Center. None. The presence of postoperative AKI was assessed by the Kidney Disease: Improving Global Outcomes criteria in the first seven postoperative days. Multivariate logistic regression analysis was used to determine the independent predictive factors of AKI. One hundred forty-eight patients were included in the final analysis, of whom 63 (42.6%) subsequently developed AKI: 43 (29.0%) stage 1, ten (6.8%) stage 2, and ten (6.8%) stage 3. Patients who had AKI had a longer hospital length of stay (12 days [interquartile range (IQR): 10-17] vs ten days [IQR: 8-12], p < 0.001). For every one-year increase in age, the odds of AKI decreased by 8% (odds ratio [OR] 0.92, 95% confidence interval [CI]: 0.87-0.98, p=0.008). The odds of having AKI in patients with bilateral lung transplant was lower than patients with unilateral transplant (OR 0.09, 95% CI: 0.01-0.63, p=0.015). Additionally, a diagnosis of chronic obstructive pulmonary disease increased the odds of AKI by four-fold compared with a diagnosis of idiopathic pulmonary fibrosis (OR 4.73, 95% CI: 1.44-15.56, p=0.011). AKI is a common complication after off-pump lung transplantation and is associated with increased hospital length of stay. Younger age, unilateral lung transplant, and diagnosis of chronic obstructive pulmonary disease are independently associated with AKI.

Alveolar Epithelial Damage and Dysfunction as Common Features of Ischemia/Reperfusion Injury and Primary Graft Dysfunction in Lung Transplants

Purpose Ischemia reperfusion injury (I/R) is the major cause of primary graft dysfunction (PGD) after lung transplantation. I/R and PGD feature alveolar epithelial and endothelial damage, lung edema and inflammation. Edema resorption then depends on the restoration of alveolar epithelial integrity and the ability of alveolar cells to reabsorb Na+ (through ENaC channels) and fluid. We hypothesized that alveolar epithelial damage, and repair, are critical in PGD pathophysiology and resolution. Therefore, our aim was to identify novel biomarkers and therapeutic targets associated with I/R using cellular and animal models as well as human samples from lung transplants. Methods The impact of a protocol mimicking hypothermic ischemia and warm reperfusion was first tested on primary rat alveolar epithelial cell cultures. Then, the impact of I/R was studied in vivo using models of inflammatory stress induced by LPS infusion or after unilateral lung transplantation in pigs. Finally, lung biopsies from donor grafts were collected during lung transplantations. After defining PGD grades within the recipients, alveolar alterations were finally analyzed within donor graft tissues. Results In primary rat cell cultures, the I/R mimicking protocol impaired tight junction proteins (ZO-1), transepithelial resistance, wound repair capacity as well as expression in ENaC and CFTR channels. Treatment with a KvLQT1 K+ channel activator (R-L3) accelerated the repair rates and enhanced barrier integrity (ZO-1 staining) as well as ENaC and CFTR protein expressions. In the porcine models, an exacerbated inflammatory response was observed along with alveolar damage, lung edema and decreased ZO-1, ENaC and CFTR expressions. Our preliminary analyses also indicated that among lung transplants subsequently developing PGD, an inflammatory response and reduced ENaC, CFTR and ZO-1 expressions were already observed within biopsies from donor grafts, collected before transplantation. Conclusion Altogether our data support the hypothesis of alveolar epithelial dysfunction, after I/R injury. Based on these observations, our goal is to investigate a potential relationship between donor phenotypic factors, markers of epithelial damage/dysfunction within the grafts, inflammatory levels and the subsequent development of PGD in lung recipients.

A novel experimental porcine model to assess the impact of differential pulmonary blood flow on ischemia\u2013reperfusion injury after unilateral lung transplantation

BackgroundPrimary graft dysfunction (PGD) remains a major obstacle after lung transplantation. Ischemia–reperfusion injury is a known contributor to the development of PGD following lung transplantation. We developed a novel approach to assess the impact of increased pulmonary blood flow in a large porcine single-left lung transplantation model.MaterialsTwelve porcine left lung transplants were divided in two groups (n = 6, in low- (LF) and high-flow (HF) group). Donor lungs were stored for 24 h on ice, followed by left lung transplantation. In the HF group, recipient animals were observed for 6 h after reperfusion with partially clamping right pulmonary artery to achieve a higher flow (target flow 40–60% of total cardiac output) to the transplanted lung compared to the LF group, where the right pulmonary artery was not clamped.ResultsSurvival at 6 h was 100% in both groups. Histological, functional and biological assessment did not significantly differ between both groups during the first 6 h of reperfusion. injury was also present in the right native lung and showed signs compatible with the pathophysiological hallmarks of ischemia–reperfusion injury.ConclusionsPartial clamping native pulmonary artery in large animal lung transplantation setting to study the impact of low versus high pulmonary flow on the development of ischemia reperfusion is feasible. In our study, differential blood flow had no effect on IRI. However, our findings might impact future studies with extracorporeal devices and represent a specific intra-operative problem during bilateral sequential single-lung transplantation.

Summary of perioperative analgesia and sedation management of 19 lung transplant recipients

Objective: To summarize and explore the management experience of postoperative analgesia and sedation in lung transplant recipients. Methods: A total of 19 cases of lung transplantation were performed in Renmin Hospital of Wuhan University from December 2016 to December 2020, and all of them were transferred back to intensive care unit after surgery, the clinical data were retrospectively analyzed. Results: Among the 19 patients, the main diagnoses were chronic obstructive pulmonary disease in 5 cases, idiopathic pulmonary fibrosis in 6 cases, bronchiectasis in 2 cases, pneumoconiosis in 4 cases, Kartagener syndrome in 1 case and COVID-19 pneumonia with advanced pulmonary fibrosis in 1 case. There were 12 cases of double lung transplantation, and 7 cases of unilateral lung transplantation in (4 cases of left single lung transplantation and 3 cases of right single lung transplantation). Nine patients used ECMO to complete the operation, and 5 cases took ECMO back to the intensive care unit. All patients were treated with opioid analgesia, mainly sufentanil at a dose of 0.2-0.3 μg/(kg•h), midazolam and propofol are mainly used as sedatives at doses of 0.02-0.1 mg/(kg•h) and 0.3-0.4 mg/(kg•h), respectively, and the Richmond agitation sedation scale was -3.01±1.32 within 24 hours after operation. The main postoperative adverse events were delirium (1 case) and respiratory depression (1 case). There were 6 deaths during the perioperative period. One case died of multi-drug resistant bacteria infection, 1 case died of circulatory failure caused by active thoracic hemorrhage post-operation, the third case died of intraoperative cardiac arrest, and the other 3 cases were given up because of multiple organs failure. Conclusion: Analgesia and sedation is an important treatment for patients after lung transplantation. Choosing the depth of sedation according to the functional state of organs of lung transplant recipients and implementing the sedation strategy aiming at organ function protection is helpful to maintain the stability of cardiopulmonary function after lung transplantation. © 2021, Editorial Board of Medical Journal of Wuhan University. All right reserved.

Summary of perioperative hemodynamic management of 19 lung transplant recipients

Objective: To summarize and discuss the experience of perioperative hemodynamic management of lung transplant recipients. Methods: A total of 19 lung transplant recipients from December 2016 to December 2020 were investigated in Renmin Hospital of Wuhan University, all of which were transferred to the intensive care unit for further monitoring and treatment, and their clinical data were retrospectively analyzed. Results: The 19 lung transplant recipients included 5 cases of chronic obstructive pulmonary disease (COPD), 5 cases of idiopathic pulmonary fibrosis (IPF), 4 cases of pneumoconiosis, 2 cases of bronchiectasis, 1 case of later lung fibrosis associated with COVID-19, 1 case of connective tissue disease-related pulmonary fibrosis, and 1 case of Kartagener syndrome. Twelve cases adopted double lung transplantation, while seven cases reveived unilateral lung transplantation (4 cases of left single lung transplantation and 3 cases of right single lung transplantation). There were 6 deaths during the perioperative period. One case died of multi-drug resistant bacteria infection, one case died of circulatory failure caused by active thoracic hemorrhage post-operation, the third case died of intraoperative cardiac arrest, and the other 3 cases were given up because of multiple organs failure. The remaining 13 cases were cured and discharged. Of the 19 recipients, 14 received vasopressors. The total and daily fluid output of the recipients in 3 postoperation days were greater than the input volume (P<0.05). Conclusion: Lung transplantation is an effective method for the treatment of end-stage lung disease. The hemodynamic management is a keypoint during perioperative period. It is import to maintain the blood volume as low as possible under the premise of systemic perfusion, limit the amount of fluid, choose albumin or plasma to increase the colloidal osmotic pressure, and strengthen the maintenance of right heart function. These abobe measures may improve the prognosis of lung transplant recipients. © 2021, Editorial Board of Medical Journal of Wuhan University. All right reserved.

Postoperative Management of Hyperinflated Native Lung in Single-Lung Transplant Recipients with Chronic Obstructive Pulmonary Disease: A Review Article.

End-stage chronic obstructive pulmonary disease (COPD) is the most common indication for single- or double-lung transplantation. Acute native lung hyperinflation (ANLH) is a unique postoperative complication of single-lung transplantation for COPD patients, with incidence varying in the medical literature from 15 to 30%. The diagnosis is made radiographically by contralateral mediastinal shift and ipsilateral diaphragmatic flattening. ANLH can deteriorate into hemodynamic instability, and respiratory impairment can result from compression of the allograft, which can precipitate atelectasis, hypoxemia, and hypercapnia, necessitating specific ventilatory intervention or volume reduction surgery. Currently, there is consensus for a therapeutic role of noninvasive positive pressure ventilation (NIPPV) in acute respiratory failure after lung transplantation as a well-tolerated measure to avoid re-intubation. This manuscript presents a concise review on the diagnosis and treatment of ANLH following unilateral lung transplant, along with a management algorithm created by the authors.

Kidney failure after lung transplantation in systemic scleroderma: a case report with literature review

BackgroundSystemic scleroderma (SSc) involves multiple organs including the skin, the lung, the kidney, and the esophagus. Nowadays, patient life prognosis has substantially improved due to more appropriate management of lung complications, including lung transplantation. However, the extension of their survival may increase SSc patients with chronic kidney diseases and requiring renal replacement therapy (RRT).Case presentationA 51-year-old female with SSc who underwent unilateral deceased-donor lung transplantation was referred because of progressive renal dysfunction. Despite no episodes of scleroderma renal crisis, her renal function gradually deteriorated for 2 years with her serum creatinine level increasing from 0.5 mg/dL at transplantation to 4.3 mg/dL. Although we reinforced antihypertensive treatment and reduced calcineurin inhibitor dose, she thereafter developed symptomatic uremia. Due to impaired manual dexterity with contracture of the interphalangeal joints, no caregivers at home, and kidney transplantation donor unavailability, maintenance hemodialysis was chosen as RRT modality. Further, due to the narrowing of superficial vessels in the sclerotic forearm skin and post-transplant immunocompromised status, the native left brachiocephalic arteriovenous fistula was created. Post-operative course was uneventful while any sign of cutaneous infection and pulmonary hypertension was closely monitored. Our literature review also indicates several difficulties with initiating and maintaining RRT in patients with SSc although case reports of kidney failure after lung transplanation in SSc were not accumulated.ConclusionsWith respect to initiating RRT for post-lung transplant patients with SSc, the clinical course of our case exemplifies recent complex trends of renal management. The optimal modality with secured initiation of RRT should be carefully determined based on the severity and risk for the cardiopulmonary, peripheral vascular, cutaneous, and systemic or local infectious complications.

Transplantation of Bioengineered Lungs Created From Recipient-Derived Cells Into a Large Animal Model

The use of bioartificial lungs may represent a breakthrough for the treatment of end-stage lung disease. The present study aimed to evaluate the feasibility of transplanting bioengineered lungs created from autologous cells. Porcine decellularized lung scaffolds were seeded with porcine recipient-derived airway and vascular cells. The porcine recipient-derived cells were collected from lung tissue obtained by pulmonary wedge resection. Following culture of autologous cells in the scaffolds, the resulting grafts were unilaterally transplanted into porcine recipients (n = 3). Allograft left unilateral lung transplantation was performed in the control group (n = 3). Left unilateral transplantation of decellularized grafts was also performed in a separate control group (n = 2). In vivo functions were assessed for 2 hours after transplantation. Histologic evaluation and immunostaining showed the presence of airway and vascular cells in the bioengineered lungs. No animals survived in the decellularized transplant group, whereas all animals survived in the bioengineered transplant and allotransplant groups. However, bioengineered lung grafts showed marked bullous changes. The oxygen exchange was comparable between the bioengineered lung graft transplant and allograft transplant groups. However, the carbon dioxide gas exchange of the bioengineered lung graft transplant group was significantly lower than that of the allograft transplant group at 2 hours after transplantation (4.10 ± 0.87 mm Hg vs 24.7 ± 10.1 mm Hg, P = 0.02). Transplantation of bioartificial lung grafts created from autologous cells was feasible in the super-acute phase. However, bullous changes and poor carbon dioxide gas exchange remain limitations of this method.

Early Surgical Management of Bronchial Dehiscence After Single-Lung Transplantation: A Case Report

Anastomotic airway complications after lung transplantation affect up to 20% of patients. Bronchial stenosis is the most frequent complication, while dehiscence of bronchial anastomosis is a rarely seen complication, with report incidences between 1% and 10%. Despite its low incidence, dehiscence of bronchial anastomoses remains a disastrous complication in the posttransplantation period without a well-established management protocol.We present a challenging case of complete bronchial dehiscence after unilateral lung transplantation in a patient with interstitial lung fibrosis (ILF) that occurred on postoperative day 10. The dehiscence was diagnosed early and the patient’s status was stable for repeat thoracotomy, therefore, an early surgical approach was preferable to conservative management or bronchoscopy.Aggressive early surgical management in a stable patient allows for complete debridement with removal of the detritus that impedes correct anastomosis healing and permits the removal of microbial vegetations with successful results.

Optimization of Transbronchial Cryobiopsy in Lung Transplant Recipients

Previous studies suggest that transbronchial lung biopsy using a cryoprobe is superior to transbronchial lung biopsy using forceps for evaluating lung grafts, although the technique can be associated an increase in complications. Because cryoprobe experience is limited, assessment of a greater number of cases is warranted. This prospective study evaluates the diagnostic yield, complications, and risk factors associated with the cryoprobe technique. From April 2013 to April 2016, 321 consecutive cryoprobe transbronchial biopsies were indicated in single or bilateral lung transplant patients with acuteor chronic clinical lung injury or in asymptomatic patients before hospital discharge after lung transplantation. With a mean of 4.32 lung parenchyma specimens per procedure, adequate alveolar lung parenchyma was obtained in 96.6% (84.27 ± 44.14 mm2) of cases. Obtaining at least 4 samples increased the histological diagnostic certainty (P< .001). Moderate to severe bleeding was observed in 7.48% of patients and was significantly more frequent in patients with unilateral transplantation (odds ratio, 0.10; 95% confidence interval, 0.02-0.30; P < .001) and in those with high blood pressure during scanning (odds ratio, 0.31; 95% confidence interval, 0.12-0.86; P= .019). Pneumothorax was observed in 7.7% of the patients, but only 3.7% of these patients required pleural drainage. Obtaining 4 or more cryobiopsy samples is valuable and safe for lung allograft monitoring. Being a recipient of a unilateral lung transplant or having arterial hypertension during bronchoscopy seem to be risk factors associated with increased bleeding.

Unilateral Versus Bilateral Lung Transplantation: Do Different Esophageal Risk Factors Predict Chronic Allograft Failure?

To assess the effect of unilateral versus bilateral lung transplantation (LTx) on esophageal motility and gastroesophageal reflux, and the association with the development of obstructive chronic lung allograft dysfunction (o-CLAD). We have shown that esophagogastric junction outflow obstruction, incomplete bolus transit, and proximal reflux are all independent risk factors for the development of chronic allograft failure. However, it remains unclear whether these factors are influenced by the type of surgery and how this relates to allograft failure. Patients post-LTx (n=48, 24 female; aged 20 to 73 y) completed high-resolution impedance manometry and 24-hour pH/impedance. Patients who had undergone unilateral LTx were more likely to exhibit esophagogastric junction outflow obstruction (47% vs. 18%; P=0.046) and less likely to exhibit hypocontractility (0% vs. 21%; P=0.058) than those who had undergone bilateral LTx. Although the proportion of patients exhibiting gastroesophageal reflux was no different between groups (33% vs. 39%; P=0.505), those undergoing bilateral LTx were more likely to exhibit proximal reflux (8% vs. 37%; P=0.067). Univariate Cox proportion hazards regression analysis did not show a difference between unilateral versus bilateral LTx in the development of o-CLAD (hazard ratio=1.17; 95% confidence interval, 0.48-2.85; P=0.723). The type of LTx performed seems to lead to different risk factors for the development of o-CLAD. Physicians should be aware of these differences, as they may need to be taken into account when managing patient's post-LTx.

Creatine Supplementation Attenuates Apoptosis and Proliferation of Inflammatory Cells in a Lung Transplantation Model

Creatine supplementation (Cr) facilitates the ATP generation, promoting the maintenance of intracellular levels of Ca2+, decreasing the reactive oxygen species formation and inflammatory process. We hypothesized that Cr supplementation could attenuate the ischemia-reperfusion injury (IRI) after unilateral lung transplantation (LTx) in rats.