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Analysis of Early Deaths After Isolated Lung Transplantation^*

^* From the Departments of Pathology (Drs. Zander, Donnelly, and Scornik), Medicine (Dr. Baz), Pediatrics (Drs. Visner and Faro), and Surgery (Dr. Staples), University of Florida College of Medicine, Gainesville, FL.

Correspondence to: Dani S. Zander, MD, Department of Pathology, Immunology, and Laboratory Medicine, University of Florida College of Medicine, Box 100275, Gainesville, FL 32610; e-mail: zander{at}pathology.ufl.edu

Study objectives: To determine the causes of death in patients dying within 30 days after lung transplantation at the University of Florida, to assess the importance of several diagnostic modalities for determining the causes of their decline, and to construct an algorithm for the evaluation of patients with severe respiratory compromise occurring early after lung transplantation.

Design: Retrospective review of medical records and pathology slides from all patients dying within 30 days after lung transplantation, and biopsy specimen diagnoses from all lung allograft recipients at the University of Florida.

Patients: Nine deaths occurred during the first 30 days after transplantation among 117 patients undergoing 123 isolated lung transplantation operations.

Results: Infections accounted for the greatest number of deaths (bacterial pneumonia, four patients; catheter-related bacteremia, one patient). Persistent pneumonia confirmed by biopsy specimen was usually accompanied by histologic manifestations of acute cellular rejection and was associated with poor patient outcome (ie, death or subsequent development of bronchiolitis obliterans syndrome). In two patients, antibody-mediated rejection either was the immediate cause of death (hyperacute rejection, one patient) or preceded a fatal case of pneumonia (accelerated antibody-mediated rejection, one patient). Other causes of death included hypoxic-ischemic encephalopathy secondary to an intraoperative cardiac arrest (one patient), pulmonary venous thrombosis with bacterial colonization of the thrombotic material (one patient), and ischemic reperfusion injury (one patient). In most patients, more than one type of diagnostic technique was needed to ascertain the cause of the catastrophic decline.

Conclusions: The causes of early posttransplant death in our patient group included infections, antibody-mediated rejection, hypoxic-ischemic encephalopathy secondary to cardiac arrest, pulmonary venous thrombosis, and ischemic reperfusion injury. Because these processes often demonstrate overlapping clinical and morphologic features requiring multiple diagnostic techniques for resolution, a systematic multimodality approach to diagnosis is advantageous for determining the causes of decline in individual patients and for estimating the incidences of the different causes of early graft and patient loss in the lung transplant population.

Key Words: antibody-mediated rejection • death • early hyperacute rejection • lung transplantation • mortality • primary allograft failure

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