Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Apr 2010
ReviewCurrent trends in immunosuppression for lung transplantation.
Lung transplant has become an established therapy in the treatment of end-stage lung disease. Many of the advances in the modern immunosuppression regimen have provided more quality and quantity of life to transplant patients. Immunosuppression agents target various aspects of the immune system to maximize graft tolerance while minimizing medication toxicities and side effects. ⋯ For these reasons, long-term lung transplantation success remains a challenge. Further improvement in immunosuppression will be geared toward minimizing rejection and infection as well as being tailored to the individual patient. This review details the current armamentarium of immunosuppression medications and the current body of evidence supporting the current trends of usage.
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Heart-lung transplantation (HLT) and lung transplantation (LT) remain important therapies for idiopathic pulmonary arterial hypertension (IPAH), but recent advances in medical therapy can substantially delay or even obviate the need for transplantation, especially in certain PAH populations. By the early 1990s, the advent of epoprostenol, initially introduced as a bridge therapy to transplantation, in fact resulted in a survival advantage for IPAH. ⋯ In the new millennium, the balance between the role of available medical therapies for PAH, the existing issues of the current LAS regarding the PAH patient, and the inherent morbidity associated with transplantation of PAH, will be critical to optimizing patient outcomes. The following discussion mainly focuses on adult IPAH, with some reference to congenital heart disease (CHD) and secondary PAH.
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Lung transplant (LT) can be successfully performed on patients with advanced bronchiectatic lung disease with subsequent good posttransplant quality of life and long-term outcome. Most of the data are derived from patients with cystic fibrosis (CF), but LT can be effective in patients with non-CF bronchiectasis as well. ⋯ Although benefit of LT for young children with CF is somewhat controversial, LT can clearly benefit older children and adults with advanced lung disease due to bronchiectasis. This article reviews indications (and contraindications) for LT, discusses particular problems that may arise posttransplant, and provides a rationale for referring patients with bronchiectasis for LT.
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The lung allocation score (LAS) was developed in an effort to facilitate lung transplantation to more urgent and ill patients, to decrease wait time, and to change the allocation process to a more merit-based system. Four years after the implementation of the LAS, we now evaluate the impact and outcomes of this system. We have found that registrations on the wait list as well as wait time have decreased. ⋯ There has been significant change in the distribution of diagnoses receiving transplantation with no significant difference in survival in most areas. Patients with higher LAS scores have increased short-term mortality. The LAS has affected the allocation process as well as significant outcomes in the transplant patient population.
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Sepsis is a common illness of intensive care unit patients that carries a high morbidity, mortality, and increases hospital cost. Although mortality from sepsis remains high when compared with other critical illnesses, it has declined over the last few decades due to several adjunctive therapies and focused care programs or guidelines. ⋯ However, other therapies still have an unclear benefit and remain controversial. This article discusses the controversial roles of intensive insulin therapy, corticosteroids, and activated protein C in the treatment of sepsis.