The Journal of Heart and Lung Transplantation, Vol 36, No 4S, April 2017
(9%) having recurring (range 2-5) or persistent leucopenia. Increasing CMV risk was associated with higher rates of leucopenia (p< 0.001) and a refractory course (p= 0.018), independent of CMV reactivation. Whilst not associated with leucopenia incidence, persisting leucopenia was more common when using tacrolimus rather than ciclosporin (23/195 vs. 6/144, OR 2.15 95%CI 1.04-4.44; p= 0.017). Use of rituximab post-operatively increased risk of persistent leucopenia (OR 1.43 95%CI 1.05-1.94; p= 0.002). Leucopenia increased the risk of fatal sepsis (8/89 vs. 7/243, OR 1.67 95%CI 1.07-2.77; p= 0.03), overall 4-year graft survival rates (81 vs. 83% 4-year survival; p= 0.83) were similar. Conclusion: Persistent leucopenia occurred in 10%. CMV status, tacrolimus and rituximab all increased likelihood of persistent leucopenia. Whilst fatal sepsis rates were higher, overall graft survival was not influenced by leucopenia.
Impact of Elevated Pulmonary Artery Pressure in Lung Recipients Transplanted for COPD E. Poli ,1 P. Yerly,2 T. Krueger,3 M. Gonzalez,3 H.F. Ris,3 L.P. Nicod,4 P.M. Soccal,5 A. Brill,6 M. Tamm,7 J.D. Aubert.8 1Medical School, University of Lausanne, Lausanne, Switzerland; 2Cardiology, Lausanne University Hospital, Lausanne, Switzerland; 3Thoracic Surgery, Lausanne University Hospital, Lausanne, Switzerland; 4Pulmonary Medicine, Lausanne University Hospital, Lausanne, Switzerland; 5Pulmonary Medicine, Geneva University Hospital, Geneva, Switzerland; 6Pulmonary Medicine, Bern University Hospital, Bern, Switzerland; 7Pulmonary Medicine, Basel University Hospital, Basel, Switzerland; 8Lausanne-Geneva Lung Transplantation Center, Lausanne, Switzerland. Purpose: Pulmonary hypertension (PH) is frequent among patients with COPD awaiting lung transplantation. PH is usually of group 3 (hypoxic lung disorders) but can also be associated with left ventricular dysfunction (group 2) or less frequently with chronic thromboembolic disease. Pulmonary arterial hypertension has been associated with more frequent primary graft dysfunction (PGD) and early mortality. We aimed to investigate the impact of PH after lung transplantation in patients with COPD as the main diagnosis. Methods: This is a single center retrospective analysis of 68 consecutive patients with COPD, excluding alpha1-antitrypsin deficiency, who were transplanted in the Centre Universitaire Romand de Transplantation, Lausanne, Switzerland between 2004 and 2015. Results: 65 patients had right heart catheter data available for analysis. PH, defined as a mean PAP > 25 mmHg was diagnosed in 41 (63%). Of these 24 had a precapillary PH (group 3), 6 a postcapillary PH (group 2), and 11 a mixed or unclassified pattern. The presence of PH was not associated with a difference in 30 day survival (100 vs 92%), the use of perioperative cardiopulmonary bypass (CPB) (7.3% vs 12.5%), and the duration of mechanical ventilation (median: 2 vs 1 day). A weak correlation was found however between the mPAP value and the length of ICU stay (p= 0.013). PGD (any grade) was not associated with a higher mPAP (PGD+ n= 19: 27 mmHg vs no PGD: 26 mmHg). In addition the use of posttransplant ECMO was not correlated with mPAP (ECMO+:n= 6, 23 mmHg vs no ECMO: 26 mmHg). Long term survival, measured by Kaplan-Meier, was also similar in recipients with or without PH (5 years survival: 74% vs 64%). The analysis restricted to a subgroup of patients with severe PH, defined as a mPAP > 35 mmHg (n= 5), shows a reasonable outcome with 1/5 CPB, 2/5 PGD, 1/5 postoperative ECMO, and a median ICU stay of 9 days without mortality. Conclusion: We conclude that, contrary to pulmonary arterial hypertension (group 1), PH in COPD lung recipients does not jeopardize the outcome after lung transplantation, with short and long term results similar to COPD recipients without PH. 1( 253) Leucopenia After Lung Transplantation: Incidence & Outcomes M. Greer ,1 F. Ius,2 T. Steinberg,1 I. Tudorache,2 T. Welte,1 J. Gottlieb.1 1Respiratory Medicine, Hanover Medical School, Hannover, Germany; 2Heart, Thoracic, Transplantation & Vascular Surgery, Hanover Medical School, Hannover, Germany. Purpose: Adequate immunosuppression after lung transplantation (LTx) is vital to ensure graft survival. Due to higher rejection rates, the levels of immunosuppression needed surpass other solid organ transplantations. Various anti-infective agents commonly used to avoid opportunistic infection can increase bone marrow toxicity. This study evaluates the incidence, causes and effect of severe leucopenia on outcomes after LTx. Methods: Retrospective analysis of all LTx performed at our centre between 01.01.2012 - 31.12.2014. Leucopenia ≤ 2.5 Tsd/µl for > 1 week was taken as the cut-off, with duration being the time taken to return to ≥ 4.0 Tsd/µl. Cumulative Leucopenia ≥ 4 weeks was considered persistent. Calcineurin inhibitor and CMV antigen levels were included. Drug history and subsequent treatment were reviewed. Distributions were assumed non-parametric. Values are median [interquartile range] unless otherwise stated. Results: A total of 7300 attendances in 339 LTx patients (51% male) were reviewed. Follow-up 36 [27-45] months. No patients received LTx induction. Pre-emptive oral valganciclovir was given for 1, 3 or 12 months depending on risk profile. Leucopenia occurred in 89/341 (26%) patients, with 29/341
1( 254) Three Years Experience with an IgM Enriched Human Intravenous Immunoglobulins Based Treatment for Patients with Early Donor Specific Antibodies After Lung Transplantation F. Ius ,1 W. Sommer,1 M. Verboom,2 C. Kühn,1 M. Avsar,1 A. Knöfel,1 T. Siemeni,1 J. Salman,1 D. Böthig,1 M. Hallensleben,2 T. Welte,3 N. Schwerk,4 C. Müller,4 A. Haverich,1 I. Tudorache,1 G. Warnecke.1 1Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany; 2Department of Transfusion Medicine, Hannover Medical School, Hannover, Germany; 3Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany; 4Department of Paediatric Pneumology, Hannover Medical School, Hannover, Germany. Purpose: We employed a pre-emptive treatment protocol based on IgM enriched intravenous immunoglobulins (IVIG) and a single dose of Rituximab since March 2013 for treatment of early donor specific antibodies (eDSA) after lung transplantation. IVIG treatment was repeated every 4 weeks until eDSA clearance. Since March 2015, immunoadsorption was added before the first IVIG infusion, in an attempt to shorten overall treatment time. Methods: This retrospective study was designed to present the 3-year results of the eDSA treatment with IVIG and Rituximab in lung transplantation as well as to evaluate the impact of the addition of immunoadsorption to the original protocol. Patients who developed eDSA and were treated formed Group A, the remaining patients without eDSA formed Group B. Follow-up amounted to a median of 20 months. Results: Among the 468 lung transplanted patients between March 2013 and October 2016, 97 (21%) developed eDSA (median time 14 days after transplantation), 71 (73%) being treated with IVIG and Rituximab and 26 (27%) with additional 2 immunoadsorptions since March 2015. Among the 85 (88%) patients discharged from hospital alive and who had completed the eDSA treatment, eDSA cleared in 79 (93%) patients. Treatment time amounted to a median of 4 months, with 68 (80%) requiring at least one additional IVIG treatment (median 3 additional admissions). Among the 79 successfully treated patients, 8 (10%) patients showed eDSA recurrence 11 months after treatment end. There was no difference in treatment time (p= 0.20) and number of admissions for IVIG infusions (p= 0.20) after the addition of 2 immunoadsorptions. In Group A vs. B patients and at 3-year follow-up, respectively, survival (%) was 83±5 vs. 89±2 (p= 0.74), freedom (%) from biopsy-confirmed rejection 58±6 vs. 54±4 (p= 0.42) and from CLAD 84±5 vs. 82±3 (p= 0.86). In group A, frequencies (%) of CD4+CD25+CD127low T regulatory cells in peripheral blood increased after eDSA treatment (65±20 vs. 77±21, p= 0.046). Conclusion: After lung transplantation, a treatment protocol for eDSA based on IVIG and Rituximab yielded optimal eDSA clearance. The addition of 2 immunoadsorptions did not reduce treatment time or the number of admissions for IVIG infusion. Patients with eDSA have good 3-year survival similar to contemporary patients without eDSA. 1( 255) Successful Maintenance Belatacept-Based Immunosuppression in Lung Transplantation Recipients Who Failed Calcineurin Inhibitors C.J. Iasella , R.J. Winstead, C.A. Moore, B.A. Johnson, M.R. Morrell, J. Hayanga, A. Zeevi, E.A. Lendermon, J.F. McDyer, C.R. Ensor. University of Pittsburgh, Pittsburgh, PA.