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Correspondence |

Distinct Phenotypes of Primary Graft Dysfunction After Lung TransplantationPrimary Graft Dysfunction After Lung Transplant FREE TO VIEW

Wenjun Mao, MD; Wei Xia, MD; Jingyu Chen, MD
Author and Funding Information

From the Division of Cardiothoracic Surgery (Drs Mao and Chen) and Intensive Care Unit (Dr Xia), Wuxi People’s Hospital, Nanjing Medical University.

Correspondence to: Wenjun Mao, MD, Division of Cardiothoracic Surgery, Wuxi People’s Hospital, No. 299, Qing Yang Rd, Wuxi City, Jiangsu, China; e-mail: maowenjun1@126.com


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(1):192-193. doi:10.1378/chest.13-1957
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To the Editor:

We read with great interest the article by Shah et al1 in a recent issue of CHEST (August 2013). Three distinct phenotypes of grade 3 primary graft dysfunction (PGD) were identified by latent class analysis, bringing new insights into the mechanism and treatment of severe PGD. However, a few issues need to be clarified after deeper analysis of the article.

The hypothesis introduced by the authors was that distinct phenotypes of PGD are associated with different prognoses identified by latent class analysis. However, the results may be produced by the evolution of PGD per se and the risk factors for exacerbation of PGD rather than by the distinct phenotypes. By analogy, it is not difficult to recognize that individuals with the same stage of non-small cell lung cancer often have disparate manifestations of the disease and different prognoses. The authors compared different characteristics among classes in the three-class model to identify risk factors for severe PGD. However, if all the factors were included in multivariable logistic regression, independent risk factors for PGD may be discriminated from those presented by the authors (donor age, donor smoking, donor mode of death, cardiopulmonary bypass, intraoperative crystalloids, tidal volume, packed RBC use, pulmonary artery pressure). Previous studies have demonstrated more risk factors, including Fio2 during allograft reperfusion, single lung transplant, recipient BMI indicating overweight or obesity, preoperative sarcoidosis, or pulmonary arterial hypertension2 and black donors and female donors.3 PGD was a significant predictor for lung transplant outcomes. Thus, patients could benefit from preventive strategies aimed at reducing reperfusion injury and decreasing the hazardness of risk factors for PGD.

PGD has a reported incidence of between 11% and 57%4 and accounts for 26% of causes of death within the first 30 days after lung transplant and for 17% within 1 year.5 Extracorporeal membrane oxygenation (ECMO) provides reliable support for PGD, with acceptable outcomes during the postoperative period.6 Analysis of the Extracorporeal Life Support Organization registry (January 1987-December 2005) showed that PGD requiring postoperative ECMO support developed in 151 patients, of whom 93 (61.6%) were weaned from ECMO as a result of lung recovery.6 However, the authors did not provide data on ECMO for all patients with PGD from the 10 participating centers. Such data are important because ECMO can facilitate lung recovery from severe PGD, and ECMO as a confounding factor complicated latent class analysis in the study.

PGD as a form of ischemia/reperfusion injury can present immediately postoperatively and 48 to 72 h later. In the latent class analysis, the authors divided 361 patients with PGD into three classes, with the same morbidity onset time, time zero1; however, PGD developed at other time points after 24 h and up to 72 h postoperatively may be omitted. Thus, we argue that PGD developing at different time points should be taken into account when planning the latent class analysis.

References

Shah RJ, Diamond JM, Cantu E, et al. Latent class analysis identifies distinct phenotypes of primary graft dysfunction after lung transplantation. Chest. 2013;144(2):616-622. [CrossRef] [PubMed]
 
Diamond JM, Lee JC, Kawut SM, et al; Lung Transplant Outcomes Group. Clinical risk factors for primary graft dysfunction after lung transplantation. Am J Respir Crit Care Med. 2013;187(5):527-534. [CrossRef] [PubMed]
 
Christie JD, Kotloff RM, Pochettino A, et al. Clinical risk factors for primary graft failure following lung transplantation. Chest. 2003;124(4):1232-1241. [CrossRef] [PubMed]
 
Arcasoy SM, Fisher A, Hachem RR, Scavuzzo M, Ware LB; ISHLT Working Group on Primary Lung Graft Dysfunction. Report of the ISHLT Working Group on Primary Lung Graft Dysfunction part V: predictors and outcomes. J Heart Lung Transplant. 2005;24(10):1483-1488. [CrossRef] [PubMed]
 
Christie JD, Edwards LB, Kucheryavaya AY, et al; International Society of Heart and Lung Transplantation. The Registry of the International Society for Heart and Lung Transplantation: 29th adult lung and heart-lung transplant report-2012. J Heart Lung Transplant. 2012;31(10):1073-1086. [CrossRef] [PubMed]
 
Fischer S, Bohn D, Rycus P, et al. Extracorporeal membrane oxygenation for primary graft dysfunction after lung transplantation: analysis of the Extracorporeal Life Support Organization (ELSO) registry. J Heart Lung Transplant. 2007;26(5):472-477. [CrossRef] [PubMed]
 

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References

Shah RJ, Diamond JM, Cantu E, et al. Latent class analysis identifies distinct phenotypes of primary graft dysfunction after lung transplantation. Chest. 2013;144(2):616-622. [CrossRef] [PubMed]
 
Diamond JM, Lee JC, Kawut SM, et al; Lung Transplant Outcomes Group. Clinical risk factors for primary graft dysfunction after lung transplantation. Am J Respir Crit Care Med. 2013;187(5):527-534. [CrossRef] [PubMed]
 
Christie JD, Kotloff RM, Pochettino A, et al. Clinical risk factors for primary graft failure following lung transplantation. Chest. 2003;124(4):1232-1241. [CrossRef] [PubMed]
 
Arcasoy SM, Fisher A, Hachem RR, Scavuzzo M, Ware LB; ISHLT Working Group on Primary Lung Graft Dysfunction. Report of the ISHLT Working Group on Primary Lung Graft Dysfunction part V: predictors and outcomes. J Heart Lung Transplant. 2005;24(10):1483-1488. [CrossRef] [PubMed]
 
Christie JD, Edwards LB, Kucheryavaya AY, et al; International Society of Heart and Lung Transplantation. The Registry of the International Society for Heart and Lung Transplantation: 29th adult lung and heart-lung transplant report-2012. J Heart Lung Transplant. 2012;31(10):1073-1086. [CrossRef] [PubMed]
 
Fischer S, Bohn D, Rycus P, et al. Extracorporeal membrane oxygenation for primary graft dysfunction after lung transplantation: analysis of the Extracorporeal Life Support Organization (ELSO) registry. J Heart Lung Transplant. 2007;26(5):472-477. [CrossRef] [PubMed]
 
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