Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Apr 2010
Lung transplantation for chronic obstructive pulmonary disease: special considerations.
Since the introduction of lung transplantation nearly half a century ago, more procedures have been performed for chronic obstructive pulmonary disease (COPD) than for any other single indication. Because COPD tends to progress slowly and long-term survival is possible even in the advanced stages, the time at which transplantation should be offered remains unclear. Current recommendations rely on use of the BODE index to provide guidance on listing. ⋯ Whether lung transplantation truly extends survival for patients with COPD is uncertain. Preliminary answers have come from use of survivorship models that suggest a subset of COPD patients do derive a survival benefit, and that the size of this subgroup can be enhanced by selecting patients with extremely severe airflow obstruction and preferentially utilizing BLT. Those undergoing SLT are uniquely at risk for complications related to the remaining native lung-bronchogenic carcinoma and progressive hyperinflation-which are fortunately rare.
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Semin Respir Crit Care Med · Apr 2010
ReviewPrimary graft dysfunction: definition, risk factors, short- and long-term outcomes.
Primary graft dysfunction (PGD) is a form of early lung graft dysfunction that is a major cause of early morbidity and mortality following lung transplantation. Survivors of PGD have decreased long-term lung function and an increased risk of developing bronchiolitis obliterans syndrome (BOS), a manifestation of chronic graft dysfunction. ⋯ Studies examining the short- and long-term effects of PGD on lung transplant outcomes are reviewed. Lastly, we highlight the emerging concepts in lung transplantation that will potentially impact PGD incidence and outcomes.
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Idiopathic pulmonary fibrosis (IPF) is the most common of the idiopathic interstitial pneumonias and carries the worst prognosis. Currently the best treatment option is lung transplantation. ⋯ Although prioritizing all patients with IPF on the waiting list has led to a dramatic decline in waiting-list mortality, further improvements may be made by prioritizing which patients with IPF should be transplanted, with an emphasis on 6-minute walk testing, biomarkers, and the presence of pulmonary hypertension rather than traditional pulmonary function tests. The choice of surgical procedure and the prediction and management of posttransplant complications may also influence long-term outcomes.
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The landscape of fungal infections in lung transplant recipients has significantly changed over the course of time. The initial predominance of CANDIDA species has given way to the prominence of ASPERGILLUS species in the current era followed by other mold infections, namely, SCEDOSPORIUM and Zygomycetes, which are emerging as newer pathogens. CRYPTOCOCCUS NEOFORMANS is another important pathogen responsible for the morbidity in lung transplant recipients. ⋯ The risk factors for other mold infections such as SCEDOSPORIUM or Zygomycetes are being elucidated. Infections with these organisms, however, carry mortality up to 80%. The current article reviews the changes in the epidemiology of invasive molds and CRYPTOCOCCUS infections and other emerging fungal pathogens and highlights the controversies surrounding antifungal prophylaxis in lung transplant recipients.