Chest -- eLetters for Christie et al., 127 (1) 161-165

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LUNG TRANSPLANTATION:
Jason D. Christie, Jeffrey S. Sager, Stephen E. Kimmel, Vivek N. Ahya, Christina Gaughan, Nancy P. Blumenthal, and Robert M. Kotloff
Impact of Primary Graft Failure on Outcomes Following Lung Transplantation
Chest 2005; 127: 161-165 [Abstract] [Full text] [PDF]

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Novel approaches to preventing PGF.: Richard G Fiddian-Green (15 March 2005)

Novel approaches to preventing PGF. 15 March 2005

Richard G Fiddian-Green,
FRCS, FACS
None
Send letter to journal:
Re: Novel approaches to preventing PGF.

richardfg{at}hotmail.com Richard G Fiddian-Green

Cylosporin A closes the permeability transition pore on te mitochondria when opened by, for example, free radicals. If accompanied by a systemic decline in efficiency of ATP resynthesis, induced by a fall in thermogenesis and reversed Q10 effect, this could be an important cause of graft failure, other organ dysfunctions and nosocominal infections in the PGF group (1). Indeed immunosuppression per se might be a failure of the immune system induced either directly and/or indirectly by a decline in Daniel Atkinson energy charge (2). If so the lower the dose of cyclosporin A and/or other immunosuppresive agents, which might have similar effects on the itochondria, the less likely the risk of developing organ dysfunctions.
If ischaemia/reperfusion injury of gut mucosa can induce pulmonary iflammation that is clinically indistinguishale from AGR might attention to the gut mucosa (3) aid in keeping the dose of immunosuppressive agents as low as safely possible? Soddium tungstate (xanthine oxidase inhibitor) prevented the pulmonary and hepatic consequences of ischaemia/reperfusion injury in gut mucosa in a small animal model (4).
Of additonal benefit to the lungs of these patients might, however, be supplemetary oxygenation delivered by enteral and/or peritoneal routes (5). In an animal model we were able to eliminate the complementory increase in cardiac output induced by decreasing the FiO2 to 0.15 (6). Portal venous and even arterial oxygenation were also significantly increased. Graft viability might be better preserved if increasing the FiO2 above 0.20 and even reducing it below 0.20 could be achieved without causing organ dysfunctions by limiting free radical generation in the alveolae and aidng in the prevention of free radical-induced lung injury.
Of particular value in achieving thse objectives should be using the arterial and intra-alveolar pH, measured by either direct (7) or indirect means (8), as a means of detecting a very early decline in intrapulmonary energy charge before pulmonary dysfunction has occurred.
1. Jason D. Christie, Jeffrey S. Sager, Stephen E. Kimmel, Vivek N. Ahya, Christina Gaughan, Nancy P. Blumenthal, and Robert M. Kotloff Impact of Primary Graft Failure on Outcomes Following Lung Transplantation Chest 2005; 127: 161-165
2.Hardie DG, Hawley SA. AMP-activated protein kinase: the energy charge hypothesis revisited. Bioessays. 2001 Dec;23(12):1112-9.
3. Fiddian-Green RG, Baker S. Nosocomial pneumonia in the critically ill: product of aspiration or translocation? Crit Care Med. 1991 Jun;19(6):763-9.
4. Nielsen VG, Tan S, Baird MS, McCammon AT, Parks DA. Gastric intramucosal pH and multiple organ injury: impact of ischemia-reperfusion and xanthine oxidase. Crit Care Med. 1996 Aug;24(8):1339-44.
5. Haglund U. Therapeutic potential of intraluminal oxygenation. Crit Care Med. 1993 Feb;21(2 Suppl):S69-71.
6. Gross BD, Sacristan E, Peura RA, Shahnarian A, Devereaux D, Wang HL, Fiddian-Green R. Supplemental systemic oxygen support using an intestinal intraluminal membrane oxygenator. Artif Organs. 2000 Nov;24(11):864-9.
7. Direct vs indirect measurements of alveolar tissue pH. Richard G Fiddian-Green Chest Online, 2 Jul 2004 eLetter re: Giovanna E. Carpagnano, Peter J. Barnes, Jackie Francis, Nicola Wilson, Andrew Bush, and Sergei A. Kharitonov Breath Condensate pH in Children With Cystic Fibrosis and Asthma: A New Noninvasive Marker of Airway Inflammation? Chest 2004; 125: 2005-2010
8. Lebuffe G, Vallet B, Takala J, Hartstein G, Lamy M, Mythen M, Bakker J, Bennett D, Boyd O, Webb A. A european, multicenter, observational study to assess the value of gastric-to-end tidal PCO2 difference in predicting postoperative complications. Anesth Analg. 2004 Jul;99(1):166-72