Original clinical science
Non-tuberculous mycobacterium infection after lung transplantation is associated with increased mortality

https://doi.org/10.1016/j.healun.2011.02.007Get rights and content

Background

Pulmonary non-tuberculous mycobacterial (NTM) infection is relatively common after lung transplantation, but the effect on mortality remains undetermined. Herein we describe our experience with pulmonary NTM infection after lung transplantation and hypothesized that non-tuberculous mycobacterial infection after lung transplantation would be associated with increased mortality.

Methods

We retrospectively evaluated 201 primary lung transplant recipients transplanted between January 2000 and August 2006. Serial bronchoscopies with bronchoalveolar lavage and transbronchial biopsy were performed according to a surveillance protocol and when clinically indicated. The diagnosis NTM infection was established by a positive NTM culture in a bronchoalveolar lavage sample or in at least two separate expectorated sputum samples. NTM infections were further classified as “disease” or “colonization,” based on whether or not NTM infection patients developed symptoms and characteristic radiographic findings.

Results

Thirty-six (18%) recipients were diagnosed with pulmonary NTM infection at a median of 97 days post-transplantation: 9 were classified as NTM disease and the remaining 27 as NTM colonization cases. Single lung transplant was a significant risk factor for NTM infection (HR 2.25, p = 0.02). NTM colonization was a risk factor for NTM disease (HR 8.39, p = 0.003). NTM infection significantly increased the risk of death after lung transplantation (HR 2.61, p = 0.001) and persisted in multivariate models controlling for single lung transplant and bronchiolitis obliterans syndrome. The increased risk was seen for both NTM colonization and NTM disease. Among the patients who died, non-NTM infection was a more common contributing factor in the cause of death for the NTM infection group (44% vs 12%, p = 0.04).

Conclusions

Non-tuberculous mycobacterial infection is common after lung transplantation. NTM colonization and treated acute rejection are risk factors for NTM disease. NTM infection is associated with increased risk of mortality independent of bronchiolitis obliterans syndrome.

Section snippets

Recipient cohort

This study cohort consisted of all primary adult lung transplant recipients transplanted at UCLA between January 1, 2000 and August 30, 2006. Of the 207 consecutive lung transplant operations performed, 201 recipients met the inclusion criteria and their follow-up data were collected through December 2009. Five retransplant recipients were excluded from the final cohort. One additional patient with intra-operative death was also excluded. The study was approved by the institutional review board

Study cohort characteristics

The final study cohort included 201 primary lung transplant recipients (65 single, 133 bilateral, 3 heart–lung). The NTM infection group (n = 36) included all patients diagnosed with NTM colonization (n = 27) or NTM disease (n = 9) at any point after lung transplantation. The non-NTM group (n = 165) consisted of all the remaining patients, including patients with a BAL culture positive for M gordonae (n = 4), which was considered to be a contaminant in accordance with ATS/IDSA guidelines.29

Discussion

Infections and BOS are the two most important factors limiting long-term survival post-transplant. Data regarding NTM infection complicating lung transplantation are sparse and limited to only one series comprising 23 cases,23 a few reviews19, 21, 22 and isolated case reports.18, 20, 24, 25, 26, 27, 28 The role of NTM in mortality has not been appreciated. We hypothesized that NTM infection after lung transplantation may be an independent risk factor for increased mortality after lung

Disclosure statement

The first two authors (H.C.H. and S.S.W.) contributed equally to this study. This study was supported in part by the National Institutes of Health (HL 080206 to J.A.B. and HL 094746 to S.S.W.).

The authors have no conflicts of interest to disclose.

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