Influenza infection may harm lung transplant recipients (LTR) because it potentially triggers allograft rejection. Prolonged viral shedding (PVS) is defined as positive detection of influenza A/H1N1 virus (H1N1) by real-time reverse-transcriptase polymerase chain reaction (RT-PCR) at day 7 or later after diagnosis. The aim was to quantify and characterise PVS of H1N1 infections among LTR in consecutive influenza seasons. Methods: Influenza vaccination is routinely offered at follow-up visits in our outpatient clinic. LTR are also instructed to contact and visit our clinic when signs of infection occur or home lung function deteriorates 10% or more. We then frequently perform nasopharyngeal swabs (NPS) for viral and bacterial analysis. In case of suggestive symptoms for influenza infection we start oseltamivir (Tamiflu) and moxifloxacin treatment pending NPS results. For proven H1N1 infection we continue treatment until weekly NPS return negative. Results: In winter 2009/2010 7 patients had H1N1 infection of which 2 had PVS (28%). No serious complication occurred. 2/7 LTR were vaccinated for H1N1. For 2010/2011 we have so far documented 11 H1N1 infections and PVS in 8 LTR (73%). All LTR were vaccinated with at least 1 dose containing H1N1. Three LTR were hospitalised. 5 LTR had PVS for 2-6 weeks. Quantification of viral results and drug resistance testing are being performed. Influenza B was detected in 4 other LTR. Conclusion: In this ongoing study we report an increase in frequency of PVS for H1N1 infections in LTR from 28 to 73% in consecutive influenza seasons. Most infections occurred despite vaccination and had a favourable outcome rarely requiring hospitalisation.
CMV disease (CMVD) is a recognized problem of the early post-transplant period (PTP) in renal transplant recipients. Information on CMVD in the late (< 2 years) PTP is scarce. We have observed 5 cases of CMVD during late (3–8 years) PTP during the last 15 years. Three of these patients died from CMVD. One of the patients with late-onset CMVD recovered spontaneously from mild pneumonitis, 1 patient with severe CMVD after therapy with ganciclovir/anti-CMV-IgG. CMVD was ascribed to primary infection in 4/5 patients, and transmission was attributed to blood products in 2 cases. At the time of CMVD, 4/5 patients were on stable immunosuppression with azathioprine/prednisone; 1 patient who died had received prednisone pulses 1 month prior to CMVD. Late onset CMVD is an underreported disease in renal transplant recipients, which warrants preventive measures and consideration of antiviral therapy.
Although the influence of cytochrome P450 inhibitory drugs on the area under the curve (AUC) of cyclosporine (CsA) has been described, data concerning the impact of these substances on the shape of the blood concentration curve are scarce. By assessment of CsA blood levels before and 1, 2, and 4 hr after oral intake (C0, C1, C2, and C4, respectively) CsA profiling examinations were performed in 20 lung transplant recipients taking 400 mg, 200 mg, and no itraconazole, respectively. The three groups showed comparable results for C0, C2, and AUC(0-12). Greater values were found for Cmax, Cmax-C0, peak-trough fluctuation and rise to Cmax in favor of the non-itraconazole group. Additionally, tmax was shorter in the non-itraconazole group. Comedication with the metabolic inhibitor itraconazole is associated with a flattening of the CsA blood concentration profile in lung transplant recipients. These changes cannot be assessed by isolated C0, C2, or AUC(0-12) values alone.
The present study examines the relationships between lung transplant recipients and their unknown, deceased donors. Out of 20 semi-structured interviews, eight narratives, by three female and three male recipients respectively, were identified in which the figure of the donor played a role. These narratives were examined using JAKOB, a qualitative research tool that analyses relational configurations and diagnoses psychodynamic conflicts. Analysis revealed a broad range of varying themes and relationships with equally varying wish and fear themes. All the narrators dealt either explicitly or implicitly with whether and how they are connected to their donors. In five narratives, specific personality traits were attributed to the figure of the donor; in four narratives, latent feelings of guilt concerning the donor's death were expressed. Indeed, the figure of the donor was not always perceived as an independent person, separate from the narrator's self: in two cases, the donor appears as part of the recipient's self, while in another case, the donor is presented as a transitional object for the recipient. The findings of the narrative analysis are discussed within a theoretical model of psychical organ integration.
Due to progress in lung transplantation, post-transplantation osteoporosis becomes an important problem. We determined bone mineral density (BMD) in 74 lung transplantation candidates, among them 24 patients with cystic fibrosis, 16 with chronic obstructive pulmonary disease, 14 with pulmonary fibrosis, and 11 with pulmonary hypertension. The mean T score (± SD) was − 2.6 ± 1.3 at femoral neck (FN), − 2.2 ± 1.6 at Ward's triangle (WT) and −2.3 ± 1.5 at lumbar spine (LS). Osteoporosis was found in 61% of the patients at FN, 45% at WT and 50% at LS. Patients with different underlying lung diseases were similarly affected, not only those with cystic fibrosis but also others, including patients with pulmonary hypertension. No association was found between BMD and age, gender, menstrual condition in women and testosterone level in men. A negative correlation was found between chronic glucocorticoid use and T scores. Body mass index correlated positively (p < 0.01) with T scores at any site and the correlation was also significant for the 2 largest subgroups. Loss of lung function (FEV1) also was associated with lower T scores. No correlation was found between BMD and biochemical indices of bone turnover. Multivariate analysis revealed BMI and glucocorticoid use as independent risk factors. We conclude that osteoporosis is a very common condition in patients with end-stage pulmonary disease, independent of the underlying diagnosis. In view of additional bone loss under immunosuppressive treatment after lung transplantation, early diagnosis and prevention of osteoporosis in the pretransplant period should receive high priority. Due to progress in lung transplantation, post-transplantation osteoporosis becomes an important problem. We determined bone mineral density (BMD) in 74 lung transplantation candidates, among them 24 patients with cystic fibrosis, 16 with chronic obstructive pulmonary disease, 14 with pulmonary fibrosis, and 11 with pulmonary hypertension. The mean T score (± SD) was − 2.6 ± 1.3 at femoral neck (FN), − 2.2 ± 1.6 at Ward's triangle (WT) and −2.3 ± 1.5 at lumbar spine (LS). Osteoporosis was found in 61% of the patients at FN, 45% at WT and 50% at LS. Patients with different underlying lung diseases were similarly affected, not only those with cystic fibrosis but also others, including patients with pulmonary hypertension. No association was found between BMD and age, gender, menstrual condition in women and testosterone level in men. A negative correlation was found between chronic glucocorticoid use and T scores. Body mass index correlated positively (p < 0.01) with T scores at any site and the correlation was also significant for the 2 largest subgroups. Loss of lung function (FEV1) also was associated with lower T scores. No correlation was found between BMD and biochemical indices of bone turnover. Multivariate analysis revealed BMI and glucocorticoid use as independent risk factors. We conclude that osteoporosis is a very common condition in patients with end-stage pulmonary disease, independent of the underlying diagnosis. In view of additional bone loss under immunosuppressive treatment after lung transplantation, early diagnosis and prevention of osteoporosis in the pretransplant period should receive high priority.
Although it is well known that a lung transplant enhances the recipient's quality of life, our knowledge of how it is processed mentally is limited. In this study, interviews were conducted with a lung-transplant patient two weeks, three months, and six months after surgery so as to investigate the relevant unconscious processing mechanisms. A dream reported in the first interview was analysed in accordance withapplying the Zurich Dream Process Coding System. A 'transplantation complex' was reconstructed on the basis of various sources of information (the dream and the waking narratives). The principal aspects of the transplantation complex that emerged from both the dream and the waking narratives concerned the oral-sadistic phantasy that the donor had been killed and that his lung, or soul, had been violently incorporated in the patient. The main unconscious themes involved in the processing of the transplant were found to have been already laid down in the dream and to have been presented in it in the form of visual analogues. According to our interpretation of the data analysed, powerful cannibalistic phantasies and death wishes played an important part in the processing of the transplant. These archaic phantasies may have been actualized by the transplant.
