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Ann Thorac Surg 1996;62:1472-1473
© 1996 The Society of Thoracic Surgeons
DR R. MORTON BOLMAN III (Minneapolis, MN): Doctor Reichenspurner, I congratulate you on a really important study. Stanford has the longest experience in North America with lung transplantation and, I think, can give us data that really are not available anywhere else. For those of us involved in lung transplantation, this is a tremendously important and depressing problem. It seems as if every week at our conference we have new patients who have turned up with this diagnosis and it brings up a number of interesting ethical concerns.
First of all, could you tell me, in terms of treatment, do you base your treatment or decision to treat or not to treat at all on the histology? In other words, if there is an active lymphocytic infiltrate with the OB, are you more likely to treat with an antilymphocytic agent? If it has burned out and just turned into scar, do you think the treatment is less effective? Do you differentiate at all based on histology in terms of your decision to treat and your type of treatment?
DR REICHENSPURNER: Yes, I think it is very important to look at the histology very carefully. If there is any presence of a concurrent acute rejection, or what is called active OB, which means presence of mononuclear cells, then we do think it is necessary to initiate a very aggressive antirejection treatment, which mainly, at least at our department, consists of steroid pulse therapy. We did use antilymphocyte preparations in a few cases. If inactive OB is found on biopsy, then we go ahead and increase the oral steroid dose and taper it according to the pulmonary function. In addition, I think that is also very important to administer maximum doses of cyclosporine and azathioprine. That is a policy that we have followed now for more than 10 years, and this may be the reason why there are reasonable survival rates still in the affected patient group.
DR BOLMAN: I have another question. We have just reviewed our experience in about 185 lung and heart-lung patients, and in looking at risk factors for OB, we found that the only thing that we could identify on multivariate analysis was cytomegalovirus infection and age between 18 and 50 years. In other words, because we do not have that many pediatric patients, basically the patients younger than 50 years seemed to be at higher risk. Did you identify any such association?
DR REICHENSPURNER: We have done the risk factor analysis according to age. We did not find any correlation. Regarding cytomegalovirus, as I told you, in the multivariate two and three risk factor model, it was an additional risk factor when it appeared in addition to acute rejection, but on its own we saw just a trend.
DR BOLMAN: I have just one last question. What is your policy on retransplantation? I think this is one of the most difficult situations that we face. Are you actively performing retransplantation in these individuals? When do you decide to reintervene?
DR REICHENSPURNER: Our attitude toward retransplantation is very conservative, which means it must really be an ideal transplant candidate with no contraindication whatsoever. However, in selected cases we think it can be done. We have a limited experience of only four retransplants in cases of OB with 2 survivors longer than 2 years; 1 patient has survived for up to 5 years, and OB developed again after 4
years. So retransplantation is a possible treatment option, but it shows inferior results and should only be done in carefully selected patients.
DR JOSEPH E. BAVARIA (Philadelphia, PA): I, too, congratulate you on a fantastic paper, and that was a beautiful discussion.
I have three questions. First of all, was there any difference in your OB rates and the severity of the OB in your single-lung versus your double-lung or bilateral sequential lung patients? I know you only had about 30 or 40. The second question is, have you used rapamycin, and how do you think that is going to affect your current and future immunosuppression management? Finally, do you have a routine protocol or some sort of a schedule for transbronchial biopsies, and could you outline how you approach the transbronchial biopsy question?
DR REICHENSPURNER: Regarding your first question, we did analyze single-lung versus bilateral lung transplantation. When we looked at the histology of transbronchial biopsy specimens, we did not find a difference in the incidence and prevalence data. We believe that the single-lung transplants show symptoms earlier. This is probably due to the severe impaired ventilation-perfusion mismatch.
Regarding rapamycin, we have not yet used it in our patients. We are working on it, and we hope to be able to use rapamycin within the next few years for prevention of OB. Regarding a transbronchial biopsy schedule, there is a fixed schedule: we do transbronchial biopsies after 2 and 6 weeks, 3 and 6 months, and 1 year.
DR CHARLES B. HUDDLESTON (St. Louis, MO): One of our patients by histology and pulmonary function tests has carried the diagnosis of bronchiolitis obliterans syndrome. At any rate, he was treated in a fashion similar to what you have done, and, interestingly, has had over the course of a somewhat delayed response after his treatment a complete rebound to normal pulmonary function tests. He has not undergone another biopsy since then. He is the only one in our series of patients with bronchiolitis obliterans who has done this. I wonder whether or not you have also observed this in anecdotal cases.
The other comment is that some of the preliminary results from our very young patients who have received transplants, and I mean by that less than 2 years of age, have shown some protection against this syndrome. Part of the problem with their evaluation has been that we are not able to do pulmonary function tests, and all of their evaluation has been by histologic and clinical evaluation.
This was a very good paper and interesting results.
DR REICHENSPURNER: This is very interesting. We only observed similar results in our patients with BOS stage 1. In these patients, if you start the treatment early, the patients do not deteriorate further. We did not find similar results for BOS stages 2 or 3.
Related Article
Ann. Thorac. Surg. 1996 62: 1467-1472.
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