View Abstract

A5330 - Post Lung Transplant Status Asthmaticus Complicating Severe Primary Graft Dysfunction Necessitating Urgent Redo-Bilateral Lung Transplantation
Author Block: T. Thaniyavarn1, E. N. Pavlisko2, C. R. Rackley1, H. A. Ali1; 1Pulmonary and Critical Care Medicine, Duke University Hospital, Durham, NC, United States, 2Pathology, Duke University Hospital, Durham, NC, United States.
Introduction: Primary graft dysfunction (PGD) is a well-known post-operative complication of lung transplantation. However, non-infectious donor-related disorders are rare and diagnosis can be elusive. Here we report a case of severe PGD suspected to be due to status asthmaticus leading to urgent re-transplantation. Case Description: A 45-year-old male underwent bilateral lung transplant with veno-venous extracorporeal membrane oxygenation (VV-ECMO) support for chronic hypersensitivity pneumonitis. VV-ECMO could not be weaned post-transplant due to difficulty with ventilation. With a tidal volume (Vt) of 50 mL, his peak inspiratory pressure (PIP) was 30 cm H2O and plateau pressure (PPlat) was 10 cm H2O consistent with increased airway resistance. Bronchoscopy showed intact anastomoses and patent large airways without plugs. A chest x-ray showed mild, diffuse pulmonary opacities with fair aeration inconsistent with patient’s Vt, suggesting dynamic hyperinflation. Patient was treated as status asthmaticus as no other explanation for increased airway resistance was found. Scheduled bronchodilators followed by IV aminophylline and IV magnesium were started with improvement in airflow obstruction. Patient was also receiving high dose steroid as part of our standard immunosuppressive regimen. Following these interventions, at a Vt of 300 mL his PIP was 30 cm H2O and PPlat was 20 cm H2O. According to information on UNOS DonorNet, his donor had a cardiac arrest at home and no diagnosis of asthma or COPD was recorded. However, the donor had upper respiratory complaints and was using albuterol more frequently before his death. Despite aggressive therapy, his PGD continued to progress and he required constant bronchodilators to maintain acceptable airway resistance. The committee decision was made to urgently re-transplant him. Patient was re-transplanted 5 days after the initial transplant. The explant allograft histopathology showed evidence of chronic bronchitis/bronchiolitis with prominent goblet cell hyperplasia, basement membrane thickening, squamous metaplasia with superimposed acute inflammation, favored being related to aspiration. Conclusion: Large transplant centers are now accepting more increased risk donors. Most donor-related risks are infectious. However, non-infectious disease as demonstrated in our case is also very important as this can severely impact post-transplant care. Some of the non-infectious diseases such as asthma, especially if not seeking ongoing care, may not be adequately documented on DonorNet. Transplant physicians evaluating potential donors should maintain a high index of suspicion and look for clues of these potentially important diagnoses.