Burkholderia cepacia, cystic fibrosis and outcomes following lung transplantation: experiences from a single center in Brazil

OBJECTIVES: To evaluate the impact of Burkholderia cepacia complex colonization in cystic fibrosis patients undergoing lung transplantation. METHODS: We prospectively analyzed clinical data and respiratory tract samples (sputum and bronchoalveolar lavage) collected from suppurative lung disease patients between January 2008 and November 2013. We also subtyped different Burkholderia cepacia complex genotypes via DNA sequencing using primers against the recA gene in samples collected between January 2012 and November 2013. RESULTS: From 2008 to 2013, 34 lung transplants were performed on cystic fibrosis patients at our center. Burkholderia cepacia complex was detected in 13 of the 34 (38.2%) patients. Seven of the 13 (53%) strains were subjected to genotype analysis, from which three strains of B. metallica and four strains of B. cenocepacia were identified. The mortality rate was 1/13 (7.6%), and this death was not related to B. cepacia infection. CONCLUSION: The results of our study suggest that colonization by B. cepacia complex and even B. cenocepacia in patients with cystic fibrosis should not be considered an absolute contraindication to lung transplantation in Brazilian centers

Extracorporeal Membrane Oxygenation and Lung Transplantation: Initial Experience at a Single Brazilian Center

OBJECTIVE: To report initial experience from the use of extracorporeal membrane oxygenation (ECMO) in patients who received lung transplantation. METHODS: Retrospective study of a single tertiary center in the Brazilian state of Sa˜o Paulo, a national reference in lung transplantation, based on the prospective collection of data from electronic medical records. The period analyzed extended from January 2009 (beginning of the program) until December 2018. RESULTS: A total of 75 lung transplants were performed, with ECMO used in 8 (10.7%) cases. Of the patients, 4 (50%) were female. The mean age was 46.4±14.3 years. The causes of the end-stage lung disease that led to transplantation were pulmonary arterial hypertension in 3 (37.5%) patients, bronchiectasis in 2 (25%) patients, pulmonary fibrosis in 2 (25%) patients, and pulmonary emphysema in 1 (12.5%) patient. In our series, 7 (87.5%) cases were sequential bilateral transplantations. Prioritization was necessary in 4 (50%) patients, and in 1 patient, ECMO was used as a bridge to transplantation. The ECMO route was central in 4 (50%), peripheral venovenous in 2 (25%) and peripheral venoarterial in 2 (25%) patients. The mean length of the intensive care unit (ICU) stay was 14±7.5 days and of the hospital stay was 34.1±34.2 days. The mean ECMO duration was 9.3±6.6 days with a 50% decannulation rate. Three patients were discharged (37.5%). CONCLUSION: Lung transplantation requires complex treatment, and ECMO has allowed extending the indications for transplantation and provided adjuvant support in the clinical management of these patients

Histopathological findings in transbronchial biopsies of lung transplanted patients according to the diagnosis of gastroesophageal reflux disease by 24-hour esophageal pH monitoring

Introdução: A doença do refluxo gastroesofágico (DRGE) já foi demonstrada com um fator de risco para desenvolvimento de complicações no transplantado pulmonar, sobretudo da disfunção crônica do enxerto pulmonar (DCE), que representa a principal causa de mortalidade no período pós-operatório tardio. No entanto ainda faltam informações na literatura sobre os possíveis mecanismos mediadores da lesão do enxerto e padrões histomorfológicos correlacionados. O estudo desses padrões histológicos pode nos fornecer dados que identifiquem pacientes com diagnóstico de DRGE com risco elevado para o desenvolvimento de DCE. Objetivos: O objetivo principal desse estudo é descrever e comparar os achados histopatológicos encontrados nas biópsias de pacientes transplantados de pulmão, diferentes de rejeição celular aguda, de acordo com o diagnóstico da DRGE pelo exame de pHmetria esofágica de 24 horas. Métodos: Em uma coorte retrospectiva foram incluídos os pacientes submetidos a transplante pulmonar no Instituto do Coração do Hospital das Clínicas da FMUSP no período de setembro de 2003 a agosto de 2018, que realizaram estudo funcional esofágico com pHmetria de 24 horas. Critérios de exclusão definidos como menos de 1 ano de sobrevida após a cirurgia ou dados insuficientes em prontuário. Variáveis demográficas, exames de função pulmonar, diagnóstico de rejeição celular aguda (RCA) e culturas de lavado broncoalveolar (LBA) foram coletados em prontuário. Todas as biópsias disponíveis no arquivo do serviço de Patologia da FMUSP foram revisadas para achados inflamatórios considerados inespecíficos diferentes de RCA. A frequência dos achados histológicos presentes nos grupos separados de acordo com a presença ou ausência de DRGE foram correlacionados com parâmetros clínicos, incluindo RCA, culturas de LBA, função pulmonar e diagnóstico de DCE. Para todas as análises estatísticas foi considerado significante valor de p < 0,05. Resultados: Foram realizados 281 transplantes no período, destes 42 apresentavam critérios de inclusão, e 2 foram excluídos por tempo de seguimento inferior a 1 ano pós-operatório. Do total de 40 pacientes, vinte e sete foram do grupo DRGE presente (casos) e 13 do grupo DRGE ausente (controles). Um total de 209 biópsias, sendo 143 em 23 casos e 66 em 11 controles, estavam disponíveis para análise. Achados inflamatórios sem etiologia específica foram observados em mais de 60% das lâminas revisadas em ambos os grupos. Edema de submucosa brônquica foi mais frequente nos pacientes com DRGE presente (p=0,044), enquanto erosão de mucosa brônquica nos controles (P=0,047). Culturas q G ( 0,017), e não houve diferença quanto a RCA ou DCE entre os grupos. Conclusão: Os resultados sugerem uma nova percepção diagnóstica da DRGE para acompanhamento dos pacientes transplantados, e trazem pela primeira vez uma avaliação histológica ampla com enfoque em possíveis alterações associadas à lesão do enxerto pela doençaIntroduction: Gastroesophageal reflux disease (GERD) has already been shown to be a risk factor for the development of complications in lung transplant recipients, especially chronic lung allograft dysfunction (CLAD), which represents the main cause of mortality in the late postoperative period. However, there is still a lack of information in the literature about the possible mediating mechanisms of graft injury and correlated histomorphological patterns. The study of these histological patterns can provide us with data that identify patients diagnosed with GERD at high risk for the development of DCE. Objectives: The main objective of this study is to describe and compare the histopathological findings in the biopsies of lung transplant recipients, different from acute cellular rejection (ACR), according to the diagnosis of GERD by 24-hour esophageal pH monitoring. Methods: In a retrospective cohort, patients who underwent lung transplantation at the Instituto do Coração of Hospital das Clínicas da FMUSP from September 2003 to August 2018, who had an esophageal functional study with 24-hour pH monitoring, were included. Exclusion criteria defined as less than 1 year of survival after surgery or insufficient data in medical records. Demographic variables, pulmonary function tests, diagnosis of acute cellular rejection (ACR) and bronchoalveolar lavage (BAL) cultures were collected from medical records. All biopsies available in the FMUSP Pathology service file were reviewed for nonspecific inflammatory findings. The frequency of histological findings presented in the groups separated according to the presence or absence of GERD was correlated with clinical parameters, including ACR, BAL cultures, lung function, and CLAD diagnosis. For all statistical analyses, p < 0.05 was considered significant. Results: A total of 281 transplants were performed in the period, of which 42 met the inclusion criteria, and 2 were excluded for a follow-up period of less than 1 year after the procedure. Of the total of 40 patients, twenty-seven were from the GERD group present (cases) and 13 from the GERD group absent (controls). A total of 209 biopsies, 143 in 23 cases and 66 in 11 controls, were available for analysis. Inflammatory findings with no specific etiology were observed in more than 60% of slides reviewed in both groups. Bronchial submucosal edema was more frequent in patients with present GERD group (p=0.044), while bronchial mucosal erosion was more frequent in controls (P=0.047). Positive cultures in BAL were more frequent in the abse G (0.017), and there was no difference in ACR or CLAD between the groups. Conclusion: The results suggest a new diagnostic perception of GERD for the follow-up of transplanted patients, and for the first time bring a broad histological evaluation with a focus on possible changes associated with graft damage caused by the diseas

Burkholderia cepacia, cystic fibrosis and outcomes following lung transplantation: experiences from a single center in Brazil

OBJECTIVES: To evaluate the impact of Burkholderia cepacia complex colonization in cystic fibrosis patients undergoing lung transplantation. METHODS: We prospectively analyzed clinical data and respiratory tract samples (sputum and bronchoalveolar lavage) collected from suppurative lung disease patients between January 2008 and November 2013. We also subtyped different Burkholderia cepacia complex genotypes via DNA sequencing using primers against the recA gene in samples collected between January 2012 and November 2013. RESULTS: From 2008 to 2013, 34 lung transplants were performed on cystic fibrosis patients at our center. Burkholderia cepacia complex was detected in 13 of the 34 (38.2%) patients. Seven of the 13 (53%) strains were subjected to genotype analysis, from which three strains of B. metallica and four strains of B. cenocepacia were identified. The mortality rate was 1/13 (7.6%), and this death was not related to B. cepacia infection. CONCLUSION: The results of our study suggest that colonization by B. cepacia complex and even B. cenocepacia in patients with cystic fibrosis should not be considered an absolute contraindication to lung transplantation in Brazilian centers

Psychological criteria for contraindication in lung transplant candidates: a five-year study

Lung transplantation presents a wide range of challenges for multidisciplinary teams that manage the care of the recipients. Transplant teams should perform a thorough evaluation of transplant candidates, in order to ensure the best possible post-transplant outcomes. That is especially true for the psychologist, because psychological issues can arise at any point during the perioperative period. The objective of our study was to evaluate the psychological causes of contraindication to waiting list inclusion in a referral program for lung transplantation. We retrospectively analyzed data on psychological issues presented by lung transplant candidates, in order to understand these matters in our population and to reflect upon ways to improve the selection process