Seminars in respiratory and critical care medicine
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This article reviews recent developments in the selection, assessment, and management of the potential lung donor, which aim to increase donor organ use. The scarcity of suitable donor organs continues to limit lung transplantation, but the situation is changing. An expanded donor pool, including the now widespread use of donation after cardiac death (DCD) lungs; the use of extended donor lungs; and the ability of ex vivo lung perfusion (EVLP) to evaluate and improve donor lungs are key initiatives. ⋯ It is now quite clear that many of the historical factors used to define a lung as "extended" do not actually produce significantly inferior outcomes. There has been a dramatic increase in research and clinical interest in donor lung assessment, management, and novel therapeutic strategies. The lessons learned are now being applied widely beyond the lung as researchers aim to increase availability and optimize other solid organs for transplantation.
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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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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.
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Semin Respir Crit Care Med · Jun 2013
ReviewBronchiolitis obliterans syndrome: the Achilles' heel of lung transplantation.
Lung transplantation is a therapeutic option for patients with end-stage pulmonary disorders. Unfortunately, chronic lung allograft dysfunction (CLAD), most commonly manifest as bronchiolitis obliterans syndrome (BOS), continues to be highly prevalent and is the major limitation to long-term survival. The pathogenesis of BOS is complex and involves alloimmune and nonalloimmune pathways. ⋯ There are few controlled studies assessing treatment efficacy, but only a minority of patients respond to current treatment modalities. Ultimately, preventive strategies may prove more effective at prolonging survival after lung transplantation, but their remains considerable debate and little data regarding the best strategies to prevent BOS. A better understanding of the risk factors and their relationship to the pathological mechanisms of chronic lung allograft rejection should lead to better pharmacological targets to prevent or treat this syndrome.