Since the advent of the lung allocation score (LAS), idiopathic pulmonary fibrosis (IPF) has become the most common indication for lung transplant. An acute exacerbation of IPF (AE-IPF) is defined as an acute, clinically significant respiratory deterioration characterized by evidence of new widespread alveolar abnormality, not explained by cardiac dysfunction. By virtue of clinical features, AE-IPF increases LAS to the point that transplant priority rises. The impact of AE-IPF on lung transplant outcomes remains unclear.METHODS: All patients with IPF listed for lung transplant between July 2005 and October 2020 at Loyola University Medical Center were included. Retrospective chart review was performed to gather patient characteristics, including demographics, primary graft dysfunction (PGD), acute cellular rejection (ACR) within the first year, lung allocation score (LAS), and mortality. Continuous measures were compared using two-sample t-tests or Wilcoxon rank sum tests, and nominal characteristics were compared using chi-square or Fisher's exact tests as appropriate. Age and sex-adjusted odds ratios for acute exacerbation status associated with outcomes were estimated from multivariable logistic regression models. A Kaplan Meier plot was used to display survival time by acute exacerbation status.RESULTS: In total, 159 patients were included in this study, of which 17.6% (n¼28) had an acute exacerbation at time of transplantation. Compared to patients with stable IPF at transplant, those with AE-IPF were more likely to have comorbidities (93% vs 74%, p¼0.03), receive a bilateral transplant (61% vs 37%, p¼0.02), and have higher oxygen and LAS (p<0.01 for all comparisons). Those with AE-IPF were also more likely to be intubated or on ECMO (p<0.001).Survival probabilities by AE status at transplant were similar throughout follow-up and did not differ at 90 days, 1-year or 3-year post-transplantation. Similarly, rates of grade 3 PGD or ACR within one year did not differ significantly and even trended lower for those with AE.CONCLUSIONS: Patients with AE-IPF are more likely to have higher oxygenation requirements and higher LAS at time of lung transplantation than those with stable IPF. Despite this, there were no differences in survival at 90 days, one year, and three years, or differences in incidence of severe PGD or ACR.CLINICAL IMPLICATIONS: Transplantation of patients with AE-IPF is associated with comparable clinical outcomes to transplantation of patients with stable IPF, including survival and incidence of PGD or acute rejection. This is in contrast with limited previous studies examining lung transplant in AE-IPF.
Aspiration is the diversion of food or liquid into the trachea, and the high incidence and potentially detrimental impact in lung transplant recipients has been documented. (Atkins J Heart Lung Transpl 2007; 26:1144-8) Currently, imaging and endoscopic techniques are used to diagnose aspiration, however the sensitivity of such techniques is not well studied. We evaluated the sensitivity of these techniques to diagnose aspiration as compared with lung tissue examination in a population of lung transplant recipients with and without aspiration. METHODS:A retrospective evaluation of 193 consecutive patients who underwent lung transplantation between January 1, 2015 and June 30, 2019 was performed. All patients underwent surveillance bronchoscopy with transbronchial biopsy as tolerated at 1, 3, 6, 9, and 12 months post-transplantation and as clinically indicated. Two pulmonary pathologists reviewed all specimens. The following features identified in either explanted lungs or transbronchial biopsies were considered consistent with pathologic aspiration: 1) granulomas with vegetable matter, 2) multinucleated giant cell with intracytoplasmic lipids, or 3) lipogranulomas. Videofluoroscopic swallow, barium esophagram and fiberoptic endoscopic evaluation of swallowing (FEES) were performed when clinically indicated.RESULTS: Pathologic review identified aspiration in 40 patients (20.7%); 153 patients (79.3%) had no evidence of aspiration. Pathologic aspiration was present in 12/52 (23.1%) patients in whom videofluoroscopic swallow was performed. Sensitivity, specificity, positive and negative predictive value of any aspiration (thin, thick or puree) for the diagnosis of pathologic aspiration was 25%, 67%, 18% and 75%, respectively. Pathologic aspiration was present in 15/60 (25%) patients in whom barium esophagram was performed. Sensitivity, specificity, positive and negative predictive value of radiographic reflux for the diagnosis of pathologic aspiration was 13%, 88%, 28% and 75%, respectively. Pathologic aspiration was present in 9/49 (18.3%) patients in whom FEES was performed. Sensitivity, specificity, positive and negative predictive value of thin liquid aspiration for the diagnosis of pathologic aspiration was 44%, 45%, 15% and 78%, respectively. CONCLUSIONS: Imaging and endoscopic techniques have suboptimal sensitivity for the diagnosis of biopsy proven aspiration in lung transplant recipients. Bronchoscopy and transbronchial biopsy for pathologic review may be appropriate for patients in whom aspiration is undiagnosed but strongly suspected.CLINICAL IMPLICATIONS: Aspiration has a high incidence in lung transplant recipients with the potential to adversely impact otucomes. Standard imaging and endoscopic techniques may have reduced sensitivity for the diagnosis of aspiration in lung transplant recipients. A high index of suspicion for undiagnosed aspiration may be warranted in this population.
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