American Journal of Transplantation Images in Transplantation – Continuing Medical Education (CME) Each month, the American Journal of Transplantation will feature Images in Transplantation, a journal-based CME activity, chosen to educate participants on current developments in the science and imaging of transplantation. Participants can earn 1 AMA PRA Category 1 Credit™ per article at their own pace. This month’s feature article is titled: “Early Graft Dysfunction After Lung Transplantation.” Accreditation and Designation Statement This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Blackwell Futura Media Services, the American Society of Transplant Surgeons and the American Society of Transplantation. Blackwell Futura Media Services is accredited by the ACCME to provide continuing medical education for physicians. Blackwell Futura Media Services designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Statement of Need Primary graft dysfunction (PGD) occurs within the first 72 h after lung transplantation (LTx) and is the leading cause of death within 30 days of LTx. Early identification and aggressive management is paramount to patient salvage. Purpose of Activity The purpose of this activity is to improve clinical competency in the diagnosis and management of lung transplant patients with severe PGD. Identification of Practice Gap Mortality for patients with severe PGD has historically been high. Extracorporeal membrane oxygenation (ECMO) support for these patients has markedly improved survival. It is important for transplant physicians to recognize the indications and outcomes for patients requiring ECMO support for PGD. Learning Objectives Upon completion of this educational activity, participants will be able to: • Understand the differential diagnosis for PGD in the postoperative period. • Understand criteria for the diagnosis and grading of PGD. • Recognize PGD on chest radiograph. • Identify risk factors for PGD. • Explain the indication for ECMO support in refractory cases. Target Audience This activity has been designed to meet the educational needs of physicians and surgeons in the field of transplantation. Disclosures No commercial support has been accepted related to the development or publication of this activity. Blackwell Futura Media Services has reviewed all disclosures and resolved or managed all identified conflicts of interest, as applicable. Editor-in-Chief Allan D. Kirk, MD, PhD, FACS, has no relevant financial relationships to disclose. Editors Sandy Feng, MD, PhD, has no relevant financial relationships to disclose. Douglas W. Hanto, MD, PhD, has no relevant financial relationships to disclose. Authors Chase R. Brown, MD, Marie M. Budev, DO, and David P. Mason, MD, have no relevant financial relationships to disclose. This manuscript underwent peer review in line with the standards of editorial integrity and publication ethics maintained by the American Journal of Transplantation. The peer reviewers have no relevant financial relationships to disclose. The peer review process for the American Journal of Transplantation is blinded. As such, the identities of the reviewers are not disclosed in line with the standard accepted practices of medical journal peer review. Instructions on Receiving CME Credit This activity is designed to be completed within an hour. Physicians should claim only those credits that reflect the time actually spent in the activity. This activity will be available for CME credit for twelve months following its publication date. At that time, it will be reviewed and potentially updated and extended for an additional twelve months. Follow these steps to participate, answer the questions and claim your CME credit: • Log on to https://www.wileyhealthlearning.com/ajt • Read the learning objectives, target audience, and activity disclosures. • Read the article in print or online format. • Reflect on the article. • Access the CME Exam, and choose the best answer to each question. • Complete the required evaluation and print your CME certificate.
American Journal of Transplantation 2015; 15: 569–571
569
Continuing Medical Education
Early Graft Dysfunction After Lung Transplantation A 60-year-old G7P2 Caucasian female with end-stage lung disease secondary to usual interstitial pneumonitis with calculated panel reactive antibody Class I and II of 0% underwent bilateral lung transplantation (LTx). The donor was a 35-year-old female nonsmoker with excellent gas exchange (PaO2=380 mmHg), clear radiograph and no evidence of infection on bronchoscopy. Virtual crossmatch appeared acceptable without evidence of donor specific antibodies. Initial graft function in the operating room was excellent with SPO2 100% on 60% FiO2, normal lung compliance (peak airway pressures 18 mmHg) and normal pulmonary artery (PA) pressures (25/16). Total ischemic time was 7 h and 41 min. Approximately 45 min following chest closure, graft function gradually worsened and was manifested by rising PA pressures (70/45 mmHg) and diminishing lung compliance (plateau pressures 45 mmHg). PaO2 to FiO2 ratio (P/F) was 80 whereas previous P/F ratio was 360. Intraoperative transesophageal echocardiography revealed normal ventricular function and patent atrial anastomoses. Inhaled nitric oxide administered intraoperatively at 40 parts per million failed to improve oxygenation. Due to progressive hypoxemia, the patient was placed on veno-venous extracorporeal membrane oxygenation (ECMO) support with improvement of oxygenation. Chest radiograph (CXR) immediately following LTx revealed diffuse bilateral infiltrates consistent with severe primary graft dysfunction (PGD) (Figure 1). The patient continued to have evidence of PGD for 72 h and was supported on ECMO until her oxygen requirements on the ventilator were 30% FiO2 with a PaO2 above 100 mmHg. Pulmonary compliance and gas exchange improved over the next days with gradual clearance of the CXR (Figure 2) and normalization of PA pressures (28/16). ECMO support was discontinued on postoperative day (POD) 9 and she was discharged on POD 58. At 1 year posttransplant, she had good pulmonary function (FEV1 of 66% of predicted) with excellent quality of life and normal CXR (Figure 3). C. R. Brown1, M. M. Budev1 and D. P. Mason2,* Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, OH 2 Department of Thoracic Surgery, Baylor University Medical Center, Dallas, TX *Corresponding author: David P. Mason, [email protected] 1
Figure 1: CXR 6 h after bilateral LTx demonstrating dense pulmonary infiltrates.
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American Journal of Transplantation 2015; 15: 569–571
Figure 2: CXR 9 days after LTx demonstrating gradual clearance of bilateral infiltrates.
Figure 3: Normal CXR 1 year after LTx.
Questions 1.
All of the following can cause severe graft dysfunction in the immediate postoperative period except?
a. b. c. d. e.
Hyperacute rejection Venous anastomosis occlusion Aspiration pneumonia Pulmonary edema Accelerated bronchiolitis obliterans
2.
What is the grade of this patient’s PGD and the criteria that support this?
a. b. c. d. e.
Grade 0 PGD due to diffuse bilateral infiltrates on CXR Grade 2 PGD due to P/F ratio < 300 It is impossible to determine the grade of PGD without a bronchoscopic biopsy Grade 3 PGD due to the patient’s requirement for ECMO Grade 4 PGD due to bilateral infiltrate and P/F ratio < 200
3.
Studies have demonstrated that patients with PGD have a greater likelihood of developing which of the following sequelae?
a. b. c. d. e.
Bronchiolitis obliterans syndrome Acute rejection Pulmonary infections Congestive heart failure Tracheal stenosis
4.
Which of the following donor characteristics is a clinical risk factor for the development of PGD?
a. b. c. d. e.
African American race Age > 35 Male gender History of alcohol abuse History of diabetes
5.
Which of the following statements regarding the treatment of patients with PGD is correct?
a. b. c. d. e.
All patients with Grade 3 PGD require ECMO support Use of inhaled nitric oxide has demonstrated the greatest survival benefit for patients with PGD Patients with Grade 3 PGD should be immediately listed for retransplantation Anti-rejection medications should be increased to prevent acute rejection Treatment is supportive and based upon protocols designed for patients with acute respiratory distress syndrome To complete this activity and earn credit, please go to https://www.wileyhealthlearning.com/ajt
American Journal of Transplantation 2015; 15: 569–571
571
Copyright of American Journal of Transplantation is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
American Journal of Transplantation 2015; 15: 569–571
569
Continuing Medical Education
Early Graft Dysfunction After Lung Transplantation A 60-year-old G7P2 Caucasian female with end-stage lung disease secondary to usual interstitial pneumonitis with calculated panel reactive antibody Class I and II of 0% underwent bilateral lung transplantation (LTx). The donor was a 35-year-old female nonsmoker with excellent gas exchange (PaO2=380 mmHg), clear radiograph and no evidence of infection on bronchoscopy. Virtual crossmatch appeared acceptable without evidence of donor specific antibodies. Initial graft function in the operating room was excellent with SPO2 100% on 60% FiO2, normal lung compliance (peak airway pressures 18 mmHg) and normal pulmonary artery (PA) pressures (25/16). Total ischemic time was 7 h and 41 min. Approximately 45 min following chest closure, graft function gradually worsened and was manifested by rising PA pressures (70/45 mmHg) and diminishing lung compliance (plateau pressures 45 mmHg). PaO2 to FiO2 ratio (P/F) was 80 whereas previous P/F ratio was 360. Intraoperative transesophageal echocardiography revealed normal ventricular function and patent atrial anastomoses. Inhaled nitric oxide administered intraoperatively at 40 parts per million failed to improve oxygenation. Due to progressive hypoxemia, the patient was placed on veno-venous extracorporeal membrane oxygenation (ECMO) support with improvement of oxygenation. Chest radiograph (CXR) immediately following LTx revealed diffuse bilateral infiltrates consistent with severe primary graft dysfunction (PGD) (Figure 1). The patient continued to have evidence of PGD for 72 h and was supported on ECMO until her oxygen requirements on the ventilator were 30% FiO2 with a PaO2 above 100 mmHg. Pulmonary compliance and gas exchange improved over the next days with gradual clearance of the CXR (Figure 2) and normalization of PA pressures (28/16). ECMO support was discontinued on postoperative day (POD) 9 and she was discharged on POD 58. At 1 year posttransplant, she had good pulmonary function (FEV1 of 66% of predicted) with excellent quality of life and normal CXR (Figure 3). C. R. Brown1, M. M. Budev1 and D. P. Mason2,* Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, OH 2 Department of Thoracic Surgery, Baylor University Medical Center, Dallas, TX *Corresponding author: David P. Mason, [email protected] 1
Figure 1: CXR 6 h after bilateral LTx demonstrating dense pulmonary infiltrates.
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American Journal of Transplantation 2015; 15: 569–571
Figure 2: CXR 9 days after LTx demonstrating gradual clearance of bilateral infiltrates.
Figure 3: Normal CXR 1 year after LTx.
Questions 1.
All of the following can cause severe graft dysfunction in the immediate postoperative period except?
a. b. c. d. e.
Hyperacute rejection Venous anastomosis occlusion Aspiration pneumonia Pulmonary edema Accelerated bronchiolitis obliterans
2.
What is the grade of this patient’s PGD and the criteria that support this?
a. b. c. d. e.
Grade 0 PGD due to diffuse bilateral infiltrates on CXR Grade 2 PGD due to P/F ratio < 300 It is impossible to determine the grade of PGD without a bronchoscopic biopsy Grade 3 PGD due to the patient’s requirement for ECMO Grade 4 PGD due to bilateral infiltrate and P/F ratio < 200
3.
Studies have demonstrated that patients with PGD have a greater likelihood of developing which of the following sequelae?
a. b. c. d. e.
Bronchiolitis obliterans syndrome Acute rejection Pulmonary infections Congestive heart failure Tracheal stenosis
4.
Which of the following donor characteristics is a clinical risk factor for the development of PGD?
a. b. c. d. e.
African American race Age > 35 Male gender History of alcohol abuse History of diabetes
5.
Which of the following statements regarding the treatment of patients with PGD is correct?
a. b. c. d. e.
All patients with Grade 3 PGD require ECMO support Use of inhaled nitric oxide has demonstrated the greatest survival benefit for patients with PGD Patients with Grade 3 PGD should be immediately listed for retransplantation Anti-rejection medications should be increased to prevent acute rejection Treatment is supportive and based upon protocols designed for patients with acute respiratory distress syndrome To complete this activity and earn credit, please go to https://www.wileyhealthlearning.com/ajt
American Journal of Transplantation 2015; 15: 569–571
571
Copyright of American Journal of Transplantation is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
