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

Calcineurim inhibitor time in therapeutic range and outcomes in lung transplant

Introdução: O transplante pulmonar é um tratamento bem estabelecido para pneumopatias graves e terminais, com um número crescente de procedimentos realizados a cada ano. Após a instituição do tratamento com inibidores de calcineurina, houve um aumento da sobrevida dos pacientes transplantados de órgãos sólidos. Apesar disso, cerca de 50% dos transplantados pulmonares evoluem com disfunção crônica de enxerto (DCE) após 5 anos do transplante, sendo esta a principal causa de óbito após o primeiro ano do procedimento. Diversos estudos buscam encontrar os fatores associados ao risco de desenvolver DCE. A monitorização dos níveis terapêuticos dos inibidores de calcineurina pode ser um fator preditor do risco de desenvolvimento de DCE e rejeição celular aguda. Objetivos: O objetivo primário do presente estudo foi avaliar a correlação do tempo em que os pacientes transplantados de pulmão permaneceram no alvo terapêutico de inibidores de calcineurina com o desenvolvimento de disfunção crônica do enxerto e rejeição aguda. Métodos: Em uma coorte retrospectiva, foram analisados todos os pacientes submetidos a transplante pulmonar no serviço de transplante pulmonar do Instituto do Coração do Hospital das Clínicas da FMUSP, de janeiro de 2003 a outubro de 2016, que iniciaram seguimento ambulatorial após a primeira alta hospitalar depois do transplante. Foram excluídos pacientes que perderam seguimento ambulatorial, deixaram de utilizar inibidores de calcineurina, foram submetidos a retransplante (o segundo transplante foi excluído) ou apresentaram dados insuficientes em prontuário. Foram coletados dados de prontuário para cálculo do tempo em alvo terapêutico (TAT) dos inibidores de calcineurina, considerando o nível sérico (TAT exame), e a percepção da equipe considerando o nível sérico como adequado (TAT equipe). Tais valores foram correlacionados com a evolução para DCE. O tempo de seguimento analisado foi do transplante até a última visita hospitalar, óbito ou retransplante, até o momento da coleta dos dados, ou até o desfecho disfunção crônica do enxerto. Este tempo foi subdividido em 0 a 6 meses após o transplante, 6 meses a 1 ano, 1 a 5 anos, > 5 anos, e tempo total de seguimento. Resultados: Foram realizados 283 transplantes de pulmão no período. Destes, 181 pacientes apresentaram critérios para análise e, destes, 81 (44,8%) apresentaram critérios para DCE. O tempo médio de seguimento foi de 6,19 anos. A equipe consistentemente considerou os pacientes com maior tempo dentro do alvo terapêutico em relação ao exame em todos os períodos analisados. Na análise multivariada, houve associação entre TAT equipe no tempo total de seguimento e tempo em imunossupressão total de acordo com a equipe com o desenvolvimento de DCE (p= 0,02 e 0,023, respectivamente). Conclusões: A avaliação multidimensional da equipe quanto a imunossupressão adequada é significativo preditor de DCE e superior à análise unidimensional do nível séricoIntroduction: Lung transplantation is a well-established treatment for severe and terminal lung diseases, with an increasing number of procedures performed each year. After instituting treatment with calcineurin inhibitors, there was an increase in the survival of patients transplanted from solid organs. After the beginning of treatment with calcineurin inhibitors, there was an increase in the survival of solid organ transplanted patients. Despite this, about 50% of patients progress with chronic lung allograft dysfunction (CLAD) after 5 years of transplantation, being the main cause of death after the first year of the procedure. Several studies seek to find factors that may increase the risk of developing CLAD. Monitoring the therapeutic levels of these medications can be a factor that predicts the risk of developing CLAD and acute cellular rejection. Objectives: The primary objective of the present study is to assess the correlation of the Calcineurin Inhibitors time in therapeutic range with the development of chronic lung allograft dysfunction and acute rejection. Methods: In a retrospective cohort, we analyzed all patients undergoing lung transplantation at the lung transplant service of the Heart Institute of the Hospital das Clínicas - FMUSP, from January 2003 to October 2016, who started follow-up after the first hospital discharge after the procedure. The exclusion criteria were patients who lost follow-up, stopped using calcineurin inhibitors, underwent retransplantation (the second transplant was excluded) or had insufficient data in their medical records. Data were collected from medical records to calculate the calcineurin inhibitors time in therapeutic range, considering the serum level (exam TTR), and the team\'s perception considering the serum level as adequate (team TTR). Such values were correlated with the evolution to CLAD. The follow-up time analyzed was from the transplant until the last hospital visit (whether death or retransplantation), until the moment of data collection, or until the start of chronic lung allograft dysfunction. This time was subdivided into 0 to 6 months after transplantation, 6 months to 1 year, 1 to 5 years, > 5 years, and total follow-up time. Results: 283 lung transplants were performed in the period. Of these, 181 patients had criteria for analysis and 81 (44.8%) had criteria for CLAD. The mean follow-up time was 6.19 years (+- 3.66). The team consistently considered the patients with the longest time in therapeutic range in comparison to the exam in all periods analyzed. In the multivariate analysis, there was an association between team TTR in total follow up time and time in total immunosuppression according to the team (p 0.02 and 0.023 respectively). Conclusions: The multidimensional assessment of the team is a better protective predictor against CLAD compared to the onedimensional analysis of the serum leve

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