Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Jun 2013
ReviewNeutrophilic reversible allograft dysfunction (NRAD) and restrictive allograft syndrome (RAS).
Lung transplantation is currently considered as an ultimate live-saving treatment for selected patients suffering from end-stage pulmonary disease. Long-term survival, however, is hampered by chronic rejection, or chronic lung allograft dysfunction (CLAD). Recently, various phenotypes within CLAD have been identified, challenging the established clinical definition of bronchiolitis obliterans syndrome (BOS). ⋯ This phenotype is called restrictive allograft syndrome (RAS), and patients with RAS have a much worse prognosis after diagnosis. This review further discusses both of these CLAD phenotypes that do not fit the classical definition of BOS. Potential pathophysiological mechanisms, etiology, diagnosis, prognosis, and treatments are discussed.
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Improving health-related quality of life is an important goal of lung transplantation. This review describes background concepts, including definitions, measurement and interpretation of health-related quality of life (HRQL), and other patient-reported outcomes. ⋯ Physical rehabilitation may augment the early improvements in HRQL, whereas bronchiolitis obliterans syndrome and psychological conditions have a negative impact. More research is needed, particularly longitudinal, multicenter studies, to better understand the trajectory and determinants of HRQL after lung transplantation, and the impact of targeted interventions to improve HRQL.
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Semin Respir Crit Care Med · Jun 2013
ReviewDNA viral infections complicating lung transplantation.
DNA viruses with potential to cause complications after lung transplantation include the human Herpesviridae family consisting of cytomegalovirus (CMV), herpes simplex virus 1 and 2 (HSV-1, -2), varicella-zoster virus (VZV), human herpesvirus 6, 7, and 8 (HHV-6, -7, -8), and Epstein-Barr virus (EBV); the Polyomaviridae family consisting of BK virus and JC virus; and the Adenoviridae family consisting of more than 50 adenovirus subtypes. This is a diverse group of viruses with equally diverse immediate and long-term impacts on allograft function and clinical outcomes following lung transplantation. This article discusses the individual pathogens, their epidemiology and clinical manifestations, as well as treatment and preventive strategies in this era of antiviral treatment regimens.
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The number of donors falls short of the number of patients on the wait list for lung transplantation making it necessary to ration the available donor organs. The ideal allocation system is guided by ethical principles and scientifically accurate at identifying patients who will gain the greatest degree of benefit from receiving the organ, in terms of both pre- and posttransplantation survival. The lung allocation score (LAS) was developed in 2005 to reduce mortality on the wait list, prioritize candidates based on urgency, minimize the role of geography, and maximize transplant benefit. ⋯ In prioritizing patients with the most urgent status, a new controversy has come into the forefront: whether or not the increased number of critically ill recipients maximizes transplant benefit. Despite the controversy, the LAS system is an improvement compared with the traditional first-come, first-served system, and it has even been adopted by Eurotransplant. In the future, as modifications are made to improve the LAS, the issue of critically ill patients and maximizing posttransplant benefit will be the focus.
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Semin Respir Crit Care Med · Jun 2013
ReviewAcute cellular and antibody-mediated allograft rejection.
Survival post-lung transplantation remains limited to ∼ 50% at 5 years, far below survival after other solid organ transplants. Allograft rejection is a major cause of this limited survival. At least a third of lung transplant recipients experience acute rejection within 1 year posttransplantation. ⋯ Emerging data on the importance of donor-specific and non-donor-specific anti-human leukocyte antigen (anti-HLA) antibodies as well as non-HLA antibodies are presented. Larger cohorts have improved statistical analyses in recent years, leading to a clearer understanding of important topics related to ACR and AMR. Further collaborative studies and multicenter trials will be key in further advancing lung transplantation knowledge and improving outcomes in years to come.