Review: immunosuppression for the lung transplant patient

Kotecha, Sakhee; Ivulich, S.; Snell, Gregory I

doi:10.21037/jtd-2021-11

Cited by 14 publications

(8 citation statements)

References 97 publications

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“…The resultant inflammation, alongside the effects of humoral and innate immunity, yields a prognosis for graft function in DLT that differs significantly from that of other transplants. 4,7 Moreover, DLT recipients’ increased susceptibility to viral infections, which are frequently associated with carcinogenesis, further heightens the risk of Post-TM. The use of calcineurin inhibitors, which is known to promote cancer progression more so than mTOR inhibitors, remains prevalent among DLT recipients, adding another layer of risk.…”

Section: Discussionmentioning

confidence: 99%

Rethinking the Impact of Pretransplant Malignancy (Pre-TM) on Double Lung Transplantation (DLT) Eligibility: An Analysis of 23,291 DLT Recipients

Woo,

Kim,

Bharat

et al. 2024

Preprint

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Background: Given the increasing need for lung transplants among older patients with a history of cancer, this study analyzed database registry to assess outcomes for DLT recipients with Pre-TM. Methods: This study evaluated the United Network for Organ Sharing (UNOS) registry for adult DLT performed between 2005 and 2023. Patients with a history of previous or multi-organ transplants, and those with donors who had cancer history, were excluded. Propensity-score matching was used to compare patients with or without Pre-TM. Overall and Post-TM-free survival were analyzed. Results: Among the 23,291 recipients of DLT, 8.0%(1,870) had Pre-TM. Compared to those without Pre-TM, patients with Pre-TM had worse overall (hazard ratio[HR] 1.20, 95% confidence interval[CI] 1.12-1.29, p<0.001) and Post-TM-free survival (HR 1.32, 95% CI 1.24-1.41, p<0.001). However, after adjusting for age, sex, and race through propensity-score matching, the survival difference between the groups became non-significant (HR 1.05, 95% CI 0.97-1.13, p=0.229). While the Pre-TM group still had worse Post-TM-free survival, this difference diminished after excluding cutaneous Post-TM (HR 1.06, 95% CI 0.99-1.15, p=0.116). Additionally, the recurrence rate of Pre-TM after transplant wasn't higher than de novo cancers in patients without Pre-TM. Conclusion: Patients with Pre-TM had similar overall survival rates after DLT as those without Pre-TM. Importantly, there is no increased risk of the primary Pre-TM type recurring post-transplant compared to patients without Pre-TM. These findings highlight the necessity for a more nuanced evaluation of transplant candidacy to prevent premature exclusion of Pre-TM patients from life-saving surgeries.

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Section: Discussionmentioning

confidence: 99%

Rethinking the Impact of Pretransplant Malignancy (Pre-TM) on Double Lung Transplantation (DLT) Eligibility: An Analysis of 23,291 DLT Recipients

Woo,

Kim,

Bharat

et al. 2024

Preprint

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“…Lung transplant recipients have a higher risk of osteoporosis and pathologic fractures than kidney, liver, and heart transplant recipients ( 13 ). This may be because lung transplant recipients are required more intensive administration of high doses of immunosuppressants to improve patient survival ( 40 ).…”

Section: Discussionmentioning

confidence: 99%

High risk of osteoporosis and fracture following solid organ transplantation: a population-based study

et al. 2023

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BackgroundOsteoporosis and fractures increase morbidity and mortality rates after solid organ transplantation (SOT), but few studies have analyzed the risk of osteoporosis and related fractures after SOT. In this retrospective cohort study, we investigated the risk of osteoporosis and fractures in different SOT recipients.MethodsThis study was a retrospective cohort study using a nationally representative database in Taiwan. We collected the data of SOT recipients and used the propensity score matching method to obtain a comparison cohort. To reduce bias, we excluded patients who had been diagnosed with osteoporosis or fracture before inclusion. All participants were followed up until the date of diagnosis as having a pathological fracture, death, or the end of 2018, whichever occurred first. The Cox proportional hazards model was used to investigate the risk of osteoporosis and pathological fracture in SOT recipients.ResultsAfter adjustment for the aforementioned variables, SOT recipients were observed to have a higher risk of osteoporosis (hazard ratio (HR) = 1.46, 95% confidence interval (CI): 1.29–1.65) and fracture (HR: 1.19, 95% CI: 1.01–1.39) than the general individuals. Among the different SOT recipients, the highest risk of fractures was noted in heart or lung transplant recipients, with a HR of 4.62 (95% CI: 2.05–10.44). Among the age groups, patients aged >61 years had the highest HRs for osteoporosis (HR: 11.51; 95% CI, 9.10–14.56) and fracture (HR: 11.75, 95% CI: 8.97–15.40).ConclusionSOT recipients had a higher risk of osteoporosis and related fractures than the general population, with the highest risks observed in patients receiving heart or lung transplants, older patients, and patients with CCI scores of >3.

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“…One additional thought at this point is whether the patient is a lung transplant candidate, as this may preclude the use of certain medications in the peri-transplant period. 95…”

Section: Additional Therapymentioning

confidence: 99%

Overview of Rheumatoid Arthritis-Associated Interstitial Lung Disease and Its Treatment

Pugashetti,

Lee

2024

Semin Respir Crit Care Med

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Interstitial lung disease (ILD) is a common pulmonary complication of rheumatoid arthritis (RA), causing significant morbidity and mortality. Optimal treatment for RA-ILD is not yet well defined. Reliable prognostic indicators are largely byproducts of prior ILD progression, including low or decreasing forced vital capacity and extensive or worsening fibrosis on imaging. In the absence of validated tools to predict treatment response, decisions about whether to initiate or augment treatment are instead based on clinical judgment. In general, treatment should be initiated in patients who are symptomatic, progressing, or at high risk of poor outcomes. Retrospective data suggest that mycophenolate mofetil, azathioprine, and rituximab are likely effective therapies for RA-ILD. Abatacept is also emerging as a potential first-line treatment option for patients with RA-ILD. Further, recent data demonstrate that immunosuppression may be beneficial even in patients with a usual interstitial pneumonia (UIP) pattern on imaging, suggesting that immunosuppression should be considered irrespective of imaging pattern. Recent randomized controlled trials have shown that antifibrotic medications, such as nintedanib and likely pirfenidone, slow forced vital capacity decline in RA-ILD. Consideration can be given to antifibrotic initiation in patients progressing despite immunosuppression, particularly in patients with a UIP pattern. Future research directions include developing tools to predict which patients will remain stable from patients who will progress, discriminating patients who will respond to treatment from nonresponders, and developing algorithms for starting immunosuppression, antifibrotics, or both as first-line therapies.

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Review: immunosuppression for the lung transplant patient

Cited by 14 publications

References 97 publications

Rethinking the Impact of Pretransplant Malignancy (Pre-TM) on Double Lung Transplantation (DLT) Eligibility: An Analysis of 23,291 DLT Recipients

Rethinking the Impact of Pretransplant Malignancy (Pre-TM) on Double Lung Transplantation (DLT) Eligibility: An Analysis of 23,291 DLT Recipients

High risk of osteoporosis and fracture following solid organ transplantation: a population-based study

Overview of Rheumatoid Arthritis-Associated Interstitial Lung Disease and Its Treatment

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