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Diabetes Dramatically Decreases Survival in Lung Transplant Recipients
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The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2013
older recipients 47(35-55) vs 39(20-53); p¼0.034. Recipients with s-rPGD were more likely to have previous cardiac surgery and be in hospital on inotropes.[table1]The 90-day allograft mortality following VAD use were 17/48(35%). Conclusions: Self-reported PGD is a reliable outcome measure characterised by high inotrope and VAD use and capturing all graft failure-related deaths. We believe our definition can be used in prospective studies to reduce the high 30-day mortality rate of this condition.
Results: Thirteen patients (2.5% incidence) were noted to have explant NSCLC. Listing diagnosis was UIP in 9 (69%) and COPD in 4 (31%) with 8 undergoing double LTx and 5 undergoing single LTx. Mean age at transplantation was 63 ⫾ 6 years. Time from the last chest CT scan to transplantation was 103 ⫾ 83 days. All malignancies were primary NSCLC with adenocarcinoma in 9 (69%) and squamous cell carcinoma in 4 (31%). 8 patients were Stage I, 4 Stage II and 1 Stage IV. 7 (53%) patients underwent post-transplant cancer treatment. Progression of disease occurred in 8 (62%) patients at a mean followup of 9.9 ⫾ 6.5 months, with overall survival 14% at 2 years.
582 Diabetes Dramatically Decreases Survival in Lung Transplant Recipients K.L. Hackman,1,2 G.I. Snell,1,2 L.A. Bach.1,2 1The Alfred Hospital, Melbourne, Australia; 2Monash University, Melbourne, Australia. Purpose: Diabetes (DM) is a known risk factor for morbidity and mortality following lung transplantation (LTx) but few studies have determined patients’ DM status both before and after LTx and assessed its effect on survival. We sought to determine the effect of DM on patient survival following LTx. Methods and Materials: All patients who underwent LTx at our institution between 1/1/2001– 31/7/2010 (n¼386) were retrospectively assessed for DM both prior to and following LTx using patient files and all available pathology results. Patients who died within 90 days of LTx (n¼24), whose DM status was unknown (n¼9), who had DM for a period but which then resolved (n¼10) and those diagnosed with DM within 2 weeks of death (n¼11) were excluded from analyses. KaplanMeier and Cox regression analyses were used to determine median survival of the remaining 332 patients with and without DM and to determine whether DM affected survival after allowing for underlying lung disease, CMV matching, transplant type, patient age, sex and BMI. Results: Of the 332 patients analysed, 170 did not have DM and 66 (39%) of these patients died. Forty-six patients had DM both pre- and post LTx and 116 developed DM post LTx. Of these 162 patients, 89 (55%) died and there was no significant difference in survival between these 2 groups of patients with DM. Patients without DM had an estimated median survival of 3699 days. Those with DM prior to LTx and those who developed DM following LTx had significantly shorter median survivals of 1834 (95% CI 1081–2587) and 1583 (1159–2007) days respectively (Log rank po0.001). Following multivariate analysis, DM status remained an independent predictor of mortality, as was CMV matching and transplant type. In contrast, underlying lung disease, patient age, sex and BMI were not predictors of survival. The estimated odds ratios for death in patients with pre- and post Tx DM was 1.66 (1.01-2.75) whereas it was 1.96 (1.39-2.77) in patients with post-Tx DM. Conclusions: Diabetes is an important and potentially modifiable risk factor for mortality following lung transplantation. 583 Losing the War before the First Battle: Explant Malignancy in Lung Transplantation C.R. Brown,1 A.E. Shafii,1 S.C. Murthy,1 G.B. Pettersson,1 M.M. Budev,2 D.P. Mason.1 1Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH; 2Department of Pulmonary, Allergy, and Critical Care Medicine, Cleveland Clinic, Cleveland, OH. Purpose: Despite thorough radiologic evaluation prior to lung transplantation (LTx), explanted lungs occasionally harbor nonsmall cell lung cancer (NSCLC). However, the incidence and outcomes for this phenomenon are unknown. We describe our center’s experience with unexpected explant NSCLC and its impact on posttransplant survival. Methods and Materials: From April 2007 to April 2012, 522 patients underwent LTx at the Cleveland Clinic. Review of medical records was performed which included surgical pathology of the explanted lung(s), pathologic cancer staging and postoperative course. Specific attention was given to cancer progression and recurrence. Overall survival was determined using Kaplan-Meier method.
Conclusions: Despite heightened screening, incidence of unsuspected NSCLC is surprisingly high. Moreover, despite the complete resection afforded by native pneumonectomy and adjuvant therapy, overall survival is poor due to rapid malignant progression. A unique pretransplant surveillance screening program needs to be devised for this high risk population. 584 Estimation of Minimal Important Differences in Health-Related Quality of Life Measures for Lung Transplant Recipients L.G. Singer,1,2 N. Chowdhury.1 1Toronto Lung Transplant Program, University Health Network, Toronto, Canada; 2Medicine, University of Toronto, Toronto, Canada. Purpose: Changes in health-relayed quality of life (HRQL) after lung transplantation must be interpreted in the context of the minimal important difference (MID), which is the smallest positive or negative change which can be perceived by a patient. MID can be estimated using anchor or distribution based methods. MID estimates for HRQL instruments have not been reported for lung transplant recipients. Methods and Materials: Stable lung transplant recipients at a single center completed HRQL measures on 2 clinic visits separated by at least 3 months. These included the St George’s Respiratory Questionnaire (SGRQ), Short Form-36 (SF-36), Visual Analog Scale (0-100) for current health (VAS), and Euroqol 5D (EQ-5D). On the second visit, participants indicated the magnitude of change in their overall health compared with the prior visit using a Global Rating of Change questionnaire (GRC). For instruments where change in HRQL showed adequate (40.3) correlation with GRC, we used GRC as an anchor to estimate the MID based on receiver operating characteristic curve analysis of change in HRQL. For all instruments, we used ½ of the standard deviation of change in HRQL as a distribution-based estimate of MID. Results: 137 subjects were included; 50% female. Mean subject age was 55 yrs (SD¼14), and median time since transplant 61 months at the second assessment (range 6-243). 66 subjects reported a detectable change in overall health. Correlation between GRC and change in
The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2013
older recipients 47(35-55) vs 39(20-53); p¼0.034. Recipients with s-rPGD were more likely to have previous cardiac surgery and be in hospital on inotropes.[table1]The 90-day allograft mortality following VAD use were 17/48(35%). Conclusions: Self-reported PGD is a reliable outcome measure characterised by high inotrope and VAD use and capturing all graft failure-related deaths. We believe our definition can be used in prospective studies to reduce the high 30-day mortality rate of this condition.
Results: Thirteen patients (2.5% incidence) were noted to have explant NSCLC. Listing diagnosis was UIP in 9 (69%) and COPD in 4 (31%) with 8 undergoing double LTx and 5 undergoing single LTx. Mean age at transplantation was 63 ⫾ 6 years. Time from the last chest CT scan to transplantation was 103 ⫾ 83 days. All malignancies were primary NSCLC with adenocarcinoma in 9 (69%) and squamous cell carcinoma in 4 (31%). 8 patients were Stage I, 4 Stage II and 1 Stage IV. 7 (53%) patients underwent post-transplant cancer treatment. Progression of disease occurred in 8 (62%) patients at a mean followup of 9.9 ⫾ 6.5 months, with overall survival 14% at 2 years.
582 Diabetes Dramatically Decreases Survival in Lung Transplant Recipients K.L. Hackman,1,2 G.I. Snell,1,2 L.A. Bach.1,2 1The Alfred Hospital, Melbourne, Australia; 2Monash University, Melbourne, Australia. Purpose: Diabetes (DM) is a known risk factor for morbidity and mortality following lung transplantation (LTx) but few studies have determined patients’ DM status both before and after LTx and assessed its effect on survival. We sought to determine the effect of DM on patient survival following LTx. Methods and Materials: All patients who underwent LTx at our institution between 1/1/2001– 31/7/2010 (n¼386) were retrospectively assessed for DM both prior to and following LTx using patient files and all available pathology results. Patients who died within 90 days of LTx (n¼24), whose DM status was unknown (n¼9), who had DM for a period but which then resolved (n¼10) and those diagnosed with DM within 2 weeks of death (n¼11) were excluded from analyses. KaplanMeier and Cox regression analyses were used to determine median survival of the remaining 332 patients with and without DM and to determine whether DM affected survival after allowing for underlying lung disease, CMV matching, transplant type, patient age, sex and BMI. Results: Of the 332 patients analysed, 170 did not have DM and 66 (39%) of these patients died. Forty-six patients had DM both pre- and post LTx and 116 developed DM post LTx. Of these 162 patients, 89 (55%) died and there was no significant difference in survival between these 2 groups of patients with DM. Patients without DM had an estimated median survival of 3699 days. Those with DM prior to LTx and those who developed DM following LTx had significantly shorter median survivals of 1834 (95% CI 1081–2587) and 1583 (1159–2007) days respectively (Log rank po0.001). Following multivariate analysis, DM status remained an independent predictor of mortality, as was CMV matching and transplant type. In contrast, underlying lung disease, patient age, sex and BMI were not predictors of survival. The estimated odds ratios for death in patients with pre- and post Tx DM was 1.66 (1.01-2.75) whereas it was 1.96 (1.39-2.77) in patients with post-Tx DM. Conclusions: Diabetes is an important and potentially modifiable risk factor for mortality following lung transplantation. 583 Losing the War before the First Battle: Explant Malignancy in Lung Transplantation C.R. Brown,1 A.E. Shafii,1 S.C. Murthy,1 G.B. Pettersson,1 M.M. Budev,2 D.P. Mason.1 1Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH; 2Department of Pulmonary, Allergy, and Critical Care Medicine, Cleveland Clinic, Cleveland, OH. Purpose: Despite thorough radiologic evaluation prior to lung transplantation (LTx), explanted lungs occasionally harbor nonsmall cell lung cancer (NSCLC). However, the incidence and outcomes for this phenomenon are unknown. We describe our center’s experience with unexpected explant NSCLC and its impact on posttransplant survival. Methods and Materials: From April 2007 to April 2012, 522 patients underwent LTx at the Cleveland Clinic. Review of medical records was performed which included surgical pathology of the explanted lung(s), pathologic cancer staging and postoperative course. Specific attention was given to cancer progression and recurrence. Overall survival was determined using Kaplan-Meier method.
Conclusions: Despite heightened screening, incidence of unsuspected NSCLC is surprisingly high. Moreover, despite the complete resection afforded by native pneumonectomy and adjuvant therapy, overall survival is poor due to rapid malignant progression. A unique pretransplant surveillance screening program needs to be devised for this high risk population. 584 Estimation of Minimal Important Differences in Health-Related Quality of Life Measures for Lung Transplant Recipients L.G. Singer,1,2 N. Chowdhury.1 1Toronto Lung Transplant Program, University Health Network, Toronto, Canada; 2Medicine, University of Toronto, Toronto, Canada. Purpose: Changes in health-relayed quality of life (HRQL) after lung transplantation must be interpreted in the context of the minimal important difference (MID), which is the smallest positive or negative change which can be perceived by a patient. MID can be estimated using anchor or distribution based methods. MID estimates for HRQL instruments have not been reported for lung transplant recipients. Methods and Materials: Stable lung transplant recipients at a single center completed HRQL measures on 2 clinic visits separated by at least 3 months. These included the St George’s Respiratory Questionnaire (SGRQ), Short Form-36 (SF-36), Visual Analog Scale (0-100) for current health (VAS), and Euroqol 5D (EQ-5D). On the second visit, participants indicated the magnitude of change in their overall health compared with the prior visit using a Global Rating of Change questionnaire (GRC). For instruments where change in HRQL showed adequate (40.3) correlation with GRC, we used GRC as an anchor to estimate the MID based on receiver operating characteristic curve analysis of change in HRQL. For all instruments, we used ½ of the standard deviation of change in HRQL as a distribution-based estimate of MID. Results: 137 subjects were included; 50% female. Mean subject age was 55 yrs (SD¼14), and median time since transplant 61 months at the second assessment (range 6-243). 66 subjects reported a detectable change in overall health. Correlation between GRC and change in