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318: Sleep disordered breathing before and after lung transplantation
S174
Abstracts
The Journal of Heart and Lung Transplantation February 2007
dominant T cell clones ranged from one (i.e. clonal) to 4(oligoclonal); the identical T cell profile was maintained over time from a few months up to two years between sequential biopsy samples. The Fox P3 immunohistochemistry stain demonstrated staining of 10 to 15% of the infiltrate. Conclusions: A restricted T cell repertoire that is maintained over time is observed in the setting of lung transplantation. The molecular profile mirrors the restricted clonal T cell infiltrates seen in autoimmune disease. Regulatory T cells may play some role in reducing the extent of the emerging clonal T cell infiltrates; he main implicated cell in biopsies of cellular rejection are not of the regulatory T cell subset. The nature of the T cell epitope specifically in regards to self-antigen versus alloantigen remains to be determined. 317 A SINGLE-INSTITUTION STUDY EVALUATING THE UTILITY OF SURVEILLANCE BRONCHOSCOPY FOLLOWING LUNG TRANSPLANTATION V.G. Valentine,1 D. Weill,2 G.A. Lombard,1 S.G. LaPlace,1 L. Seoane,1 D.E. Taylor,1 G.S. Dhillon,2 1Lung Transplantation, Ochsner Medical Center, New Orleans, LA; 2Medicine, Stanford University Hospital, Stanford, CA Purpose: Most lung transplant physicians advocate surveillance bronchoscopy with transbronchial lung biopsy and bronchoalveolar lavage (TBB/BAL) to monitor the allograft, despite no evidence that this strategy improves outcomes. This report compares rates of infection (INF), acute rejection (REJ), BOS, and survival in lung allograft recipients (LARs) managed with surveillance TBB/BAL vs those with clinically indicated TBB/BAL. Methods and Materials: We reviewed 46 consecutive lung LARs transplanted between 3/2002– 8/2005. 23 LARs consented to a multi-center trial requiring surveillance TBB/BAL (SB) and 23 were managed by our usual practice of clinically indicated procedures (CIB). Clinical indications for TBB/BAL include: 10% decline in FEV1 or 20% decrease in FEF25-75 below baseline; or unexplained respiratory symptoms, signs, or fever. Freedom from treated INF, treated REJ, BOS and survival were compared between groups. Results: A total number of 237 TBB/BALs were performed. The CIB and SB groups underwent 93 (4.0 ⫾ 3.4/pt) and 144 (6.3 ⫾ 2.4) TBB/BAL, respectively. In SB group, 51 (2.2 ⫾ 1.3) TBB/BAL were true surveillance procedures, while 93 (4.0 ⫾ 2.5/pt) procedures had a clinical indication. No REJ episodes requiring treatment were detected by true surveillance procedures. Freedom from INF, REJ, BOS and survival in SB and CIB groups are compared below with no significant differences.Five pts in CIB group remain stable to date without any TBB/BAL. In addition, 4 previously asymptomatic LARs in SB group developed pneumonia 3, 5, 10, and 14 days after surveillance TBB/BAL. Table Freedom from INF (SB) (CIB) Freedom from REJ (SB) (CIB) Freedom from BOS (SB) (CIB) Survival (SB) (CIB)
3 mo
6 mo
12 mo
24 mo
58 41 82 86 100 100 96 91
42 27 72 77 96 95 96 91
28 23 72 67 82 95 83 91
12 14 64 67 73 95 75 91
Conclusions: With no obvious advantage identified, surveillance bronchoscopy may pose a risk to stable LARs. A multi-center controlled trial is required to validate the utility and safety of surveillance bronchoscopy in LT.
318 SLEEP DISORDERED BREATHING BEFORE AND AFTER LUNG TRANSPLANTATION M.A. Malouf,1 R.A. Milross,2 R.R. Grunstein,,3 P.N. Chhajed,1 D.M. Jankelson,3 C.L. Aboyoun,1 P.T. Bye,2 A.R. Glanville,1 1The Lung Transplant Unit, St. Vincent’s Hospital, Sydney, NSW, Australia; 2The Woolcock Research Institute of Medical Research, University of Sydney, Sydney, NSW, Australia; 3The Sleep Disorders Unit, St. Vincent’s Hospital, Sydney, NSW, Australia Purpose: Sleep disordered breathing (SDB) is common in patients with severe chronic respiratory failure but there are no data describing the prevalence of SDB in patients listed for lung transplantation(LTx) or the effect of transplantation on SDB. Objective: To investigate the prevalence and impact of SDB before and after lung transplantation. Methods and Materials: We performed polysomnography (PSG) on 117/183 (64%) consecutive patients (M:F⫽64:53) listed for lung transplant 1998 - 2001. SDB was defined as a respiratory disturbance index (RDI) ⱖ10 or for patients with an awake O2 saturation ⬎ 90%,ⱖ10% of total sleep time (TST) with SaO2 ⱕ 90%. Results: 80/117 patients had PSG on room air, 30/117 on oxygen and 7/117 on non-invasive ventilation. 32/79 patients (41%) room air PSG had SDB, 18/32(56%) with ⱖ10% of TST with SaO2 ⱕ 90% and RDI ⬍ 10 and 14/32 (44%) with RDI⬎10 only. 9/ 30 (30%) studied on oxygen and 1/7 studied on NIV had SDB, with 110 patients classified as indeterminate using above criteria. Room air PSG was repeated post LTx in 25 subjects. SDB resolved post transplant in 6/11, but 4/14 developed new SDB. SDB (treated or not) did not influence whether patients survived to transplant (log rank Chi-squared⫽0.1,p ⫽0.8), nor did the diagnosis of SBD prior to LTx influence post-LTx survival (log rank Chi-squared 0.8, p ⫽ 0.37). Comparison of SDB status known versus unknown, demonstrated a significant difference in survival (log rank test, p⫽0.016) estimated hazard ratio was 2.28 (95% CI 1.15-4.5) Conclusions: SDB is common before lung transplantation. A known SDB status appeared to correlate with a benefit in pre LTx survival. LTx improves oxygenation but new onset SDB may occur post transplantation. 319 DIFFERENCES IN THE DISTRIBUTION OF ISHLT PRIMARY GRAFT DYSFUNCTION GRADES: INTUBATED VS EXTUBATED PATIENTS T. Oto,1 B. Levvey,1 A. Griffiths,1 T. Higuchi,1 T. Kotsimbos,1 T. Williams,1 G. Snell,1 1Lung Transplant Service, Alfred Hospital & Monash University, Melbourne, Victoria, Australia Purpose: Standardized consensus criteria to define/grade Primary Graft Dysfunction (PGD) in lung transplantation(LTx) have been recently published. After extubation, patients on FiO2⬍0.3 (or O2 via nasal cannula) are automatically considered as grade 0 or 1. However, no specific consideration is given to patients on FiO20.3 (or facial O2 mask) and the impact of extubation on PGD grade remains unknown. This study describes the prevalence and features of PGD grading in extubated patients and the effect on early post-LTx outcomes. Methods and Materials: Using the ISHLT PGD guidelines the grades of 254 consecutive LTx were calculated. Recipients remaining intubated and already extubated were compared at multiple post-transplant time points. Results: The post-LTx intubation rate was 92% at T0, 34% at T24, 23% at T48 and 19% at T72. At T0, 71% of recipients who were extubated were classified as Grade 3, paradoxically a higher prevalence than that in the intubated patients (25%, p⫽0.0002). Extubated PGD grade 3 patients at T24 were discharged from ICU earlier than any grade of
Abstracts
The Journal of Heart and Lung Transplantation February 2007
dominant T cell clones ranged from one (i.e. clonal) to 4(oligoclonal); the identical T cell profile was maintained over time from a few months up to two years between sequential biopsy samples. The Fox P3 immunohistochemistry stain demonstrated staining of 10 to 15% of the infiltrate. Conclusions: A restricted T cell repertoire that is maintained over time is observed in the setting of lung transplantation. The molecular profile mirrors the restricted clonal T cell infiltrates seen in autoimmune disease. Regulatory T cells may play some role in reducing the extent of the emerging clonal T cell infiltrates; he main implicated cell in biopsies of cellular rejection are not of the regulatory T cell subset. The nature of the T cell epitope specifically in regards to self-antigen versus alloantigen remains to be determined. 317 A SINGLE-INSTITUTION STUDY EVALUATING THE UTILITY OF SURVEILLANCE BRONCHOSCOPY FOLLOWING LUNG TRANSPLANTATION V.G. Valentine,1 D. Weill,2 G.A. Lombard,1 S.G. LaPlace,1 L. Seoane,1 D.E. Taylor,1 G.S. Dhillon,2 1Lung Transplantation, Ochsner Medical Center, New Orleans, LA; 2Medicine, Stanford University Hospital, Stanford, CA Purpose: Most lung transplant physicians advocate surveillance bronchoscopy with transbronchial lung biopsy and bronchoalveolar lavage (TBB/BAL) to monitor the allograft, despite no evidence that this strategy improves outcomes. This report compares rates of infection (INF), acute rejection (REJ), BOS, and survival in lung allograft recipients (LARs) managed with surveillance TBB/BAL vs those with clinically indicated TBB/BAL. Methods and Materials: We reviewed 46 consecutive lung LARs transplanted between 3/2002– 8/2005. 23 LARs consented to a multi-center trial requiring surveillance TBB/BAL (SB) and 23 were managed by our usual practice of clinically indicated procedures (CIB). Clinical indications for TBB/BAL include: 10% decline in FEV1 or 20% decrease in FEF25-75 below baseline; or unexplained respiratory symptoms, signs, or fever. Freedom from treated INF, treated REJ, BOS and survival were compared between groups. Results: A total number of 237 TBB/BALs were performed. The CIB and SB groups underwent 93 (4.0 ⫾ 3.4/pt) and 144 (6.3 ⫾ 2.4) TBB/BAL, respectively. In SB group, 51 (2.2 ⫾ 1.3) TBB/BAL were true surveillance procedures, while 93 (4.0 ⫾ 2.5/pt) procedures had a clinical indication. No REJ episodes requiring treatment were detected by true surveillance procedures. Freedom from INF, REJ, BOS and survival in SB and CIB groups are compared below with no significant differences.Five pts in CIB group remain stable to date without any TBB/BAL. In addition, 4 previously asymptomatic LARs in SB group developed pneumonia 3, 5, 10, and 14 days after surveillance TBB/BAL. Table Freedom from INF (SB) (CIB) Freedom from REJ (SB) (CIB) Freedom from BOS (SB) (CIB) Survival (SB) (CIB)
3 mo
6 mo
12 mo
24 mo
58 41 82 86 100 100 96 91
42 27 72 77 96 95 96 91
28 23 72 67 82 95 83 91
12 14 64 67 73 95 75 91
Conclusions: With no obvious advantage identified, surveillance bronchoscopy may pose a risk to stable LARs. A multi-center controlled trial is required to validate the utility and safety of surveillance bronchoscopy in LT.
318 SLEEP DISORDERED BREATHING BEFORE AND AFTER LUNG TRANSPLANTATION M.A. Malouf,1 R.A. Milross,2 R.R. Grunstein,,3 P.N. Chhajed,1 D.M. Jankelson,3 C.L. Aboyoun,1 P.T. Bye,2 A.R. Glanville,1 1The Lung Transplant Unit, St. Vincent’s Hospital, Sydney, NSW, Australia; 2The Woolcock Research Institute of Medical Research, University of Sydney, Sydney, NSW, Australia; 3The Sleep Disorders Unit, St. Vincent’s Hospital, Sydney, NSW, Australia Purpose: Sleep disordered breathing (SDB) is common in patients with severe chronic respiratory failure but there are no data describing the prevalence of SDB in patients listed for lung transplantation(LTx) or the effect of transplantation on SDB. Objective: To investigate the prevalence and impact of SDB before and after lung transplantation. Methods and Materials: We performed polysomnography (PSG) on 117/183 (64%) consecutive patients (M:F⫽64:53) listed for lung transplant 1998 - 2001. SDB was defined as a respiratory disturbance index (RDI) ⱖ10 or for patients with an awake O2 saturation ⬎ 90%,ⱖ10% of total sleep time (TST) with SaO2 ⱕ 90%. Results: 80/117 patients had PSG on room air, 30/117 on oxygen and 7/117 on non-invasive ventilation. 32/79 patients (41%) room air PSG had SDB, 18/32(56%) with ⱖ10% of TST with SaO2 ⱕ 90% and RDI ⬍ 10 and 14/32 (44%) with RDI⬎10 only. 9/ 30 (30%) studied on oxygen and 1/7 studied on NIV had SDB, with 110 patients classified as indeterminate using above criteria. Room air PSG was repeated post LTx in 25 subjects. SDB resolved post transplant in 6/11, but 4/14 developed new SDB. SDB (treated or not) did not influence whether patients survived to transplant (log rank Chi-squared⫽0.1,p ⫽0.8), nor did the diagnosis of SBD prior to LTx influence post-LTx survival (log rank Chi-squared 0.8, p ⫽ 0.37). Comparison of SDB status known versus unknown, demonstrated a significant difference in survival (log rank test, p⫽0.016) estimated hazard ratio was 2.28 (95% CI 1.15-4.5) Conclusions: SDB is common before lung transplantation. A known SDB status appeared to correlate with a benefit in pre LTx survival. LTx improves oxygenation but new onset SDB may occur post transplantation. 319 DIFFERENCES IN THE DISTRIBUTION OF ISHLT PRIMARY GRAFT DYSFUNCTION GRADES: INTUBATED VS EXTUBATED PATIENTS T. Oto,1 B. Levvey,1 A. Griffiths,1 T. Higuchi,1 T. Kotsimbos,1 T. Williams,1 G. Snell,1 1Lung Transplant Service, Alfred Hospital & Monash University, Melbourne, Victoria, Australia Purpose: Standardized consensus criteria to define/grade Primary Graft Dysfunction (PGD) in lung transplantation(LTx) have been recently published. After extubation, patients on FiO2⬍0.3 (or O2 via nasal cannula) are automatically considered as grade 0 or 1. However, no specific consideration is given to patients on FiO20.3 (or facial O2 mask) and the impact of extubation on PGD grade remains unknown. This study describes the prevalence and features of PGD grading in extubated patients and the effect on early post-LTx outcomes. Methods and Materials: Using the ISHLT PGD guidelines the grades of 254 consecutive LTx were calculated. Recipients remaining intubated and already extubated were compared at multiple post-transplant time points. Results: The post-LTx intubation rate was 92% at T0, 34% at T24, 23% at T48 and 19% at T72. At T0, 71% of recipients who were extubated were classified as Grade 3, paradoxically a higher prevalence than that in the intubated patients (25%, p⫽0.0002). Extubated PGD grade 3 patients at T24 were discharged from ICU earlier than any grade of