Conversion from standard cyclosporine to Neoral in lung transplant recipients.
Explore the source record for details and available documents.
Administration, Oral↗
Biomedical subjects
S Kesten
Publications and source records attributed to S Kesten.
Exhaled nitric oxide in human lung transplantation. A noninvasive marker of acute rejection.
Acute allograft rejection in animals and humans has been associated with increased nitric oxide production in the graft. Exhaled nitric oxide (ENO) measurement is a noninvasive method of assessing inflammation in airway diseases, e.g., asthma, which might be applicable to lung transplant recipients. Over 12 months, ENO of lower respiratory origin was measured in 108 lung transplant recipients with a mean time after transplant of 1,083 d. ENO (mean +/- SEM; ppb) in stable patients (19.5 +/- 1.1; p < 0.001) was not different from that of healthy controls (23.8 +/- 3.2). ENO was significantly higher in episodes of clinical acute rejection (51.1 +/- 6.3) compared with stable patients but not elevated in bronchiolitis obliterans syndrome (18.6 +/- 1.5) or pulmonary infection (25.9 +/- 4.0). A retrospective analysis of bronchoscopy findings and concurrent ENO (n = 99) showed that ENO did not vary according to histological findings (normal, acute rejection grade I, nonspecific inflammatory change) or with a positive BAL culture. ENO was not correlated with differential lymphocyte and neutrophil counts. ENO appears to be a valid marker of clinical acute rejection in human lung transplantation as distinct from infection or bronchiolitis obliterans. Furthermore, bronchoscopic findings in the absence of a clinical illness were not associated with a rise in ENO.
Adult↗
The acute effects of nasal positive pressure ventilation in patients with advanced cystic fibrosis.
OBJECTIVE: To evaluate the acute effects of noninvasive positive pressure ventilation (NPPV) in patients with stable chronic respiratory failure secondary to cystic fibrosis. PATIENTS: Eight patients (29+/-5 years of age) with severe airflow limitation (mean FEV1, 24+/-3% predicted) and chronic respiratory failure (PaO2=67+/-15 mm Hg and PaCO2=50+/-4 mm Hg) were evaluated. METHODS: Tidal volume, respiratory rate, minute ventilation, oxygen saturation, and transcutaneous CO2 (TcCO2) measurements were made over a 20-min period before and after the application of NPPV (inspiratory pressure of 10 to 12 cm H2O and expiratory pressure of 4 to 6 cm H2O). RESULTS: NPPV increased saturation from 88+/-2% to 90+/-1% (p<0.05) and decreased TcCO2 from 51+/-3 mm Hg to 50+/-2 mm Hg (p<0.05). Tidal volume increased from 219+/-20 mL to 256+/-37 mL (p=not significant [NS]) and respiratory rate decreased from 24+/-2 to 18+/-1 (p<0.01). Minute ventilation decreased from 5.3+/-0.8 L/min to 4.6+/-0.6 L/min (p=0.08). There was no change in duty cycle (32+/-5% to 34+/-5%, p=NS). In two patients, esophageal pressure measurements were also recorded. There was a decrease in pressure from -21+/-1 cm H2O to -11+/-2 cm H2O and -14+/-1 cm H2O to -7+/-1 cm H2O. CONCLUSIONS: In patients with stable, severe cystic fibrosis, NPPV (1) acutely improves gas exchange, (2) decreases minute ventilation, suggesting either a reduction in CO2 production or an increase in alveolar ventilation, and (3) reduces work of breathing.
Adult↗
Lung volume reduction surgery: an analysis of hospital costs.
OBJECTIVE: Lung volume reduction surgery (LVRS) represents a potential breakthrough in the management of advanced emphysema, although questions remain about clinical and economic implications of widespread application of LVRS. In this report, we describe hospital costs, excluding physicians' fees, for LVRS. DESIGN: Hospital charges were obtained from billing records and converted to costs by applying multiple cost-to-charge ratios. SETTING: A large, urban academic medical center. PATIENTS: Fifty-two consecutive patients who received bilateral LVRS through a median sternotomy between April 1995 and August 1996. RESULTS: Median hospital stay was 10 days (mean= 14.8+/-12.8 days; range=3 to 48 days), including 2 days (mean=6+/-9.2 days; range=1 to 35 days) in the ICU. One hospital death occurred. Hospital costs per case ranged from $11,712 to $121,829, with mean costs of $30,976 and median costs of $19,771. Costs were related significantly to duration of ICU stay and length of hospitalization. Patients who accrued the highest costs were significantly older than the remainder of the sample (69.3 years vs 62.4 years). CONCLUSIONS: Hospital costs of LVRS vary significantly but are related directly to hospital stay. Identification of factors associated with prolonged stays can be used in assessing benefits and risks of LVRS against utilization of health-care dollars.
Academic Medical Centers↗
Cytomegalovirus viremia in lung transplant recipients receiving ganciclovir and immune globulin.
BACKGROUND: Cytomegalovirus (CMV) disease is an important cause of organ transplant-related morbidity and mortality. During the last 5 years at our institution, prophylactic ganciclovir and hyperimmune globulin have been routinely administered to lung transplant recipients whenever the donor or the recipient was CMV antibody-positive. We sought to assess the efficacy of prophylaxis on viremia, CMV disease, and bronchiolitis obliterans syndrome (BOS). METHODS: A retrospective chart review of 61 consecutive lung transplants performed between recipients between January 1993 and August 1995 was performed. Fifty-six patients who survived at least 1 month were analyzed. Patients were considered at risk for CMV disease whenever pretransplant donor or recipient serology was positive. RESULTS: Fourteen of the 39 patients at risk (36%) had viremia while on prophylaxis. The rate of CMV disease was 13% during the first 6 months following transplantation. A donor whose CMV serology was positive appeared to increase the risk of BOS in a Cox regression model (relative risk=2.4; 95% confidence interval=0.86-6.74; p=0.0957). Neither age, CMV infection (viremia or a positive specimen from BAL), recipient's serology at the time of transplantation, or CMV disease was associated with BOS. None of these variables was associated with mortality on Cox regression analysis or univariate analysis. CONCLUSIONS: Administration of combination ganciclovir and hyperimmune globulin prophylactic therapy to lung transplant recipients at risk for CMV infection and disease is associated with a relatively low incidence of disease, which appears only after prophylaxis treatment with ganciclovir is completed. Ganciclovir prophylaxis does not prevent CMV viremia; however, viremia while on prophylaxis is not predictive of disease.
Adult↗
Return to work after lung transplantation.
The social rehabilitation of lung transplant recipients becomes increasingly important as the results of lung transplantation improve. Although return-to-work (RTW) rates have been published for recipients of other organ transplants, no such data are available after lung transplantation. The purpose of this study was to determine what factors influence RTW after lung transplantation. Of 99 lung transplant recipients (43 single, 56 bilateral) surveyed from Denver, Colorado, (n = 49) and Toronto, Ontario, Canada (n = 50), 22% (n = 22) were employed, 38% (n = 38) were unemployed but medically able to work, 29% (n = 29) were medically disabled, and 10% (n = 10) had retired. The RTW rate for those medically able to work was 37% (22/60), and it was identical at each center (n = 11). Only Canadian lung transplant recipients (36%, 4/11) secured new jobs, whereas all Colorado lung transplant recipients returned to their previous employment (100%, 11/11). A stepwise discriminant analysis revealed that (1) pretransplantation employment, (2) a diagnosis of emphysema, cystic fibrosis, or primary pulmonary hypertension, (3) a self-report of being physically able to work, (4) greater functional improvement as measured by post-lung transplantation percent predicted forced vital capacity, and (5) post-lung transplantation 6-minute walk > 550 m positively influenced RTW. This analysis accurately profiled 82% of the employed and 76% of the unemployed recipients for an overall effectiveness of 79%. The findings of this study are that (1) a 37% employment rate for those physically able was comparable to other types of organ transplant recipients, (2) employment was not determined by the type of lung transplantation procedure (single or bilateral), and (3) social factors remain employment barriers for some recipients, but their absence did not guarantee a better employment rate.
Adult↗
Mass media and transplantation.
Explore the source record for details and available documents.
Humans↗
Quality of life in female lung transplant candidates and recipients.
OBJECTIVE: Quality of life (QOL) studies of lung transplant recipients indicate that there are improvements following transplantation. More recently, there has been some suggestion that certain QOL issues are different for men and women. The purpose of the present study was to examine changes in QOL, body satisfaction, and sexual functioning in women lung transplant recipients. STUDY POPULATION: Seven prelung transplant (PRE) and 34 postlung transplant (POST) women. MAIN OUTCOME MEASURES: The RAND-36 Health Survey, Body Cathexis Scale, Derogatis Sexual Functioning Inventory, Hospital Depression and Anxiety Scale, Rosenberg Self-Esteem Scale, and an open-ended questionnaire. RESULTS: Higher scores were found in the POST group with respect to general health and role limitations due to physical health. We were unable to detect significant differences between the groups with respect to emotional well-being, role limitations due to emotional health, and social functioning. There were significant differences between the PRE and the POST body satisfaction scores. Although there was no significant difference in overall sexual functioning, recipients in the PRE group reported higher sex drive. Eleven of the POST recipients (52%) scored below the 10th percentile in overall sexual functioning. CONCLUSIONS: Overall QOL improves following lung transplantation; however, the lack of differences in many domains of QOL raises the concern that women lung transplant recipients may continue to have significant impairments, including those regarding sexuality and body satisfaction.
Adult↗
Lymphocytic airway infiltration as a precursor to fibrous obliteration in a rat model of bronchiolitis obliterans.
BACKGROUND: Bronchiolitis obliterans is the most significant complication adversely affecting prolonged survival of lung allograft recipients. The evolution from the initial insult to the final pathologic entity is largely unknown. The aim of this study was to characterize the evolution of transplant-induced fibrous airway obliteration in a rat tracheal transplant model of bronchiolitis obliterans. METHODS: Tracheal segments were transplanted from Brown Norway rats to Brown Norway rats (isografts) or to Lewis rats (allografts). Grafts were implanted into a subcutaneous pouch and an abdominal omental wrap. They were harvested at 14 different time points (from 1 day to 1 year after transplantation) and assessed histologically. RESULTS: The fibrous airway obliteration developed only in allografts showing a triphasic time course: an initial ischemic phase (observed in both isografts and allografts) was followed by a marked lymphocytic infiltrative phase with complete epithelial loss (observed only in allografts, P<0.01), and finally by an obliterative phase with fibrous obliteration of the allograft airway lumen (P<0.01). CONCLUSIONS: This animal model shows a distinct and reproducible triphasic time course in the development of obliterative airway lesions in allografts. It confirms that the mechanism leading to airway obliteration is immune mediated as only allografts showed this lesion and that lymphocytic infiltration is a precursor of the lesion in this model. The insights into the different phases demonstrated may lead to novel approaches regarding the type and timing of therapeutic interventions.
Animals↗
Pulmonary rehabilitation and surgery for end-stage lung disease.
Pulmonary rehabilitation is a multidisciplinary approach to the comprehensive management of patients with end-stage lung disease. Components of the pulmonary rehabilitation program include education, exercise, nutrition, and psychosocial support. Most of the information published on pulmonary rehabilitation has been from patients with COPD. There are some data on patients with cystic fibrosis but, unfortunately, there is a lack of information on other causes of end-stage lung disease. Published data almost invariably show improvements in functional capacity (i.e., walk distance) and quality of life. There are no objective physiologic changes in lung function. Because patients who attend programs regularly are a carefully selected subpopulation, conclusions from published reports may not apply to all patients with end-stage lung disease. The recommendation for pulmonary rehabilitation prior to lung volume reduction surgery or lung transplantation is based on assumptions that may not necessarily be true. No data exist that conclusively show that preoperative rehabilitation alters outcome. Nevertheless, given the relatively benign nature of pulmonary rehabilitation and the documented benefits, it is reasonable to recommend such a program to patients who are awaiting surgical intervention. Further research is required to define the role, nature, duration, intensity, and frequency of exercise training in the management of patients who are to undergo surgical treatment for advanced lung disease.
Activities of Daily Living↗
Infections in lung transplant recipients.
Advances in surgical technique and better knowledge of the physiologic and immunologic changes in the transplant population, combined with improved diagnostic tools and treatment strategies, have decreased the likelihood of early and, possibly, late mortality caused by a primary infection. Nevertheless, infection continues to be an important cause of death in both the early and late post-transplant periods. Risk of death attributable to infection after prolonged survival, however, is greatest in the setting of chronic rejection. The most significant advances in antimicrobial management have been in the area of prophylaxis. The effectiveness of prophylaxis against P carinii has virtually eliminated that organism as a cause of significant morbidity. Ganciclovir prophylaxis protocols require refinement but have been proved effective against CMV, although that virus continues to be a major pathogen in lung transplant recipients. Ultimately, a careful monitoring protocol and a high index of suspicion for infection requiring investigation and treatment are necessary in the ongoing care of lung transplant recipients. The approach to infections should be guided by the knowledge of the various factors that increase susceptibility to microorganisms and any previous culture and sensitivity results. As transplant physicians try to increase the donor pool through the use of donors who previously might have been rejected and through the potential of xeno-transplantation, vigilance and research must be maintained.
Anti-Bacterial Agents↗
Asthma and allergy avoidance knowledge and behavior in postpartum women.
OBJECTIVE: Based on family history, infants may be classified as "high risk" or "low risk" for the development of allergy or asthma. Failure to breast-feed and early exposure to cigarette smoke or aeroallergens increase the risk of developing asthma or allergy. Since we suspect that physicians seldom educate mothers on reducing environmental exposures in the postnatal period, we sought to determine the level of maternal knowledge as well as actual avoidance behaviors with respect to these risk factors in high risk and low risk families. DESIGN: Questionnaire administered by a research assistant. SETTING: Obstetrics unit of two tertiary care general hospitals. PATIENTS: A sample of 194 postpartum women with uncomplicated pregnancies, interviewed after 24-hours postpartum. MAIN OUTCOME MEASURES: (1) Parental history of asthma, allergy or eczema; (2) potential for infant exposure to environmental risk factors for asthma and allergy, as indicated by history of avoidance practices in the home; (3) parental knowledge of risk factors for asthma or allergy; and (4) physician advise on avoidance. RESULTS: Of 194 women interviewed, a history of doctor-diagnosed asthma, allergy/allergic rhinitis or eczema in either parent was reported by 122 (high risk group). The remaining 72 patients had no history of atopy (low risk group). Of those in the high risk group, 10% of mothers smoked during pregnancy, and about 25% were exposed to second hand smoke on a daily basis. Most of the mothers in the high risk group planned to breast feed (89%). A large number of patients in the high risk group reported potential risk factors for allergy/asthma in their home environments. These included animals in the household (36%), dusty environments (10%) carpeting (47%), cigarette smoke (18%), and others. Despite these risks, only 13% of patients reported being educated by their physicians on improving their home environment. Exposures to environmental risk factors were not different between low and high risk groups. Similarly, knowledge of environmental risk factors and avoidance behaviors were not significantly different between low and high risk groups. CONCLUSIONS: Many mothers whose infants are at high risk of developing asthma or allergies are not aware of and do not practice avoidance of risk factors. Physicians involved in prenatal care of women with a family history of atopy and asthma should offer advice on reducing exposure to potential risk factors and how to modify their environment in ways that can potentially decrease the risk of asthma or allergy prevalence and severity.
Adult↗
Factors associated with emergency department dependence of patients with asthma.
BACKGROUND: Dependence on crisis-oriented care rather than continuous ambulatory care for asthma is thought to contribute to asthma morbidity and mortality. We contrasted the characteristics of patients who depend on emergency department (ED) care for the management of their asthma exacerbations to the characteristics of patients employing self-management plans in an ambulatory setting. METHODS: In prospective fashion, we used a structured interview and charted information to survey two cohorts of patients suffering from an acute exacerbation of asthma; those seen in a hospital ED (n = 80) and those seen in an ambulatory asthma care facility (Asthma Center [AC]) (n = 40) at the same hospital. We looked for differences in socioeconomic characteristics, asthma severity, asthma knowledge, and asthma self-management skills between groups. RESULTS: There were no significant differences in mean age (SD) (ED vs AC: 36.65 [13.8] vs 40 [13.8] years) or female to male ratio (ED vs AC: 2/1 vs 2.5/1) between the two groups. There were no major differences in ethnic origin, educational status, marital status, smoking history, employment status, number of children in the household, possession of an extended health insurance plan, sick leave benefits, and child care availability between the two groups. Patients seeking ED care were more likely to have resided in the city for < 5 years (34% vs 8%; p < 0.05), and more likely to be living alone (35% vs 15%; p < 0.05). Significantly more patients from the ED group had a below average gross annual income (55% vs 3%; p < 0.05). There were several significant differences between groups in their knowledge of asthma and its therapy. Most striking, 79% of AC patients reported having a predetermined crisis plan vs just 23% of ED patients (p < 0.001). Although measurements of airflow (percent predicted FEV1) were significantly lower in the ED group than the AC group (mean, 50% vs 78.4%; p < 0.001), other indexes reflecting the degree of asthma severity over the long term such as past use of oral steroids, history of hospitalization, or ICU admission for asthma and the mean total days of disability within the preceding year were not significantly different between the two groups. Most of the ED patients had more than one previous visit to the ED for asthma exacerbation within the preceding year while most exacerbations of AC patients had been treated in the ambulatory care setting. Only 17% of ED patients initiated or increased inhaled or oral steroids before seeking medical care vs 89% of AC patients (p < 0.001). CONCLUSION: We conclude that a subgroup of asthmatics depends primarily on crisis-oriented care for the management of asthma. These patients are more likely to have lower income, to live alone, and to have resided at their current address for less time than patients seeking less urgent ambulatory care. Moreover, such patients are less knowledgeable about asthma and its management and are less likely to have a predetermined crisis plan.
Adult↗
Prehospitalization inhaled corticosteroid use in patients with COPD or asthma.
BACKGROUND: Guidelines for the treatment of obstructive lung diseases suggest a primary role of inhaled corticosteroids (ICs) in asthma, but only a minor role in COPD. However, surveys of physicians' prescribing habits have suggested that there is little difference in the use of ICs between these two conditions. OBJECTIVES: To determine the prevalence of IC use before and during hospitalization among patients with COPD or asthma. DESIGN: Retrospective chart review. SETTING: Tertiary care university teaching hospital. PATIENTS: Adult inpatients, aged 18 or older, with physician-diagnosed COPD or asthma. MEASUREMENTS: Patient-reported prescription drug use at hospital admission, and medical chart record of in-hospital and discharge prescriptions. RESULTS: Of 350 charts reviewed, 102 patients were admitted to the hospital for unstable COPD, 133 patients had stable COPD, 36 patients were admitted with unstable asthma, and 79 patients had stable asthma. At hospital admission, 48% of unstable COPD patients, 26% of stable COPD patients, 56% of unstable asthma patients, and 44% of stable asthma patients reported having a current prescription for ICs. The proportion of all asthmatic patients reporting a current prescription for ICs at admission (48%) was significantly higher than the proportion of all COPD patients receiving an IC at admission (35%). However, there was no significant difference in the proportion of COPD and asthma patients with a current prescription of any form of corticosteroid (oral or inhaled). The proportion of COPD patients likely to respond to IC therapy is significantly different from the observed use at hospital admission. CONCLUSIONS: The proportion of patients found to be using ICs is much higher than the proportion expected to respond. There was little difference in the use of ICs for asthma and COPD patients at hospital admission. Most COPD patients using an IC were receiving the regimen on admission to hospital, indicating that there is need for education in the community and in the hospital regarding use of ICs in COPD patients.
Administration, Inhalation↗
Lack of left ventricular dysfunction associated with sustained exposure to hyperlipidemia following lung transplantation.
OBJECTIVES: Hyperlipidemia due to standard immunosuppressive agents occurs commonly following solid organ transplantation. A decision to treat hyperlipidemias would be based on the assumption that such disorders lead to accelerated atherogenesis and ultimately to cardiac dysfunction. We therefore sought to examine whether hyperlipidemias following lung transplantation were associated with a decline in left ventricular (LV) function. STUDY DESIGN: We retrospectively reviewed serial echocardiograms, radionucleotide angiograms (RNAs), and serum lipid levels following lung transplantation. Results of cardiac studies were defined as abnormal if a decline in LV grade occurred from the best result at any time postoperatively to the most recent study. PATIENTS: A total of 184 patients with transplants between November 1983 and June 1995 were reviewed. Eighty patients were excluded owing to incomplete data. One patient was excluded because of severe perioperative myocardial dysfunction. RESULTS: Approximately 80% of patients had elevated cholesterol levels and 60% had elevated low-density lipoprotein levels. Triglyceride levels were raised in 34% of patients while only 4% had an abnormal serum high-density lipoprotein level. More than 80% of patients had no evidence of LV abnormalities in either RNA or echocardiographic studies (group 1). One patient had a change in echocardiographic LV function but no change in grade of RNA (group 2). Twenty patients had a decline in grade based on RNA but no change in the echocardiogram (group 3). There were no patients with changes in both RNA and echocardiogram (group 4). All changes in LV function were from grade I to II. The mean period of follow-up exceeded 30 months for patients in groups 1 to 3. Follow-up data at 3, 4, and 5 years were available on 47, 23, and 12 patients, respectively. There were no differences between the proportions of subjects with normal and abnormal serum lipid levels in each group. CONCLUSIONS: In the initial 5 years after lung transplantation, dyslipidemias affect the majority of patients but are not associated with evidence of deteriorating LV function.
Anticholesteremic Agents↗
Defining the asthma phenotype for the purpose of genetic analysis.
In 1991, we began a project to search for the genetic basis of asthma using linkage analysis. We encountered discord between a history of asthma and physiological measures of variable airflow obstruction and sought to examine the frequency of such occurrences and the issues surrounding phenotyping of patients with asthma. We reviewed our experience in ascertaining the asthma phenotype in 50 nuclear families comprised of 219 subjects (110 male, 109 female). Three respiratory physicians reviewed data including a questionnaire, skin testing, objective measures of variable airflow obstruction [increase in FEV1 > or = 15% following salbutamol 400 micrograms of PC20 (methacholine) < or = 4 mg/ml], and serum for IgE. Thirty-eight percent of subjects had both objective and questionnaire data consistent with asthma (++) whereas 39% had negative objective and negative questionnaire findings (--) (i.e., no asthma). A positive history but negative objective findings occurred in 7% of subjects, 2% had a negative history and positive objective findings. Retesting was requested in 13% of subjects; review of historical data was requested in 1% (i.e., childhood asthma but no present asthma). Retesting was requested for either (a) positive history, negative objective if symptoms were seasonal or the subject was using medications known to affect the challenge study, (b) viral infection within 6 weeks of a positive methacholine study, or (c) technically inadequate study. Overall, after the initial assessment, all members of only 22 families could be catagorized as either ++ or --. The diagnostic group requested at least 1 retest in 19 families and a review of historical records in 2 families. We conclude that discordance between self-reported questionnaire data and laboratory measures of variable airflow limitation is common and will increase the numbers of asthmatic subjects in studies that seek to determine the genetic basis of asthma.
Adolescent↗
The six-minute walk test: a guide to assessment for lung transplantation.
BACKGROUND: A window of opportunity exists with regard to optimal timing for lung transplantation. Performance of a transplantation too early may rob the patient of months to years of survival, whereas waiting too long increases the risk of death before transplantation. Several studies have examined specific lung function tests as predictors of death, but none have been shown to be useful across the various disorders leading to end-stage lung disease. We therefore sought to examine the usefulness of the 6-minute walk test as a guide to assessment for transplantation. METHODS: We conducted a retrospective chart review of patients who were assessed and either were accepted or died waiting acceptance by the Toronto Lung Transplant Program between January 1991 and June 1995. One hundred forty-five patients with the following lung diseases were included: emphysema (n = 38), alpha-1-antitrypsin deficiency (n = 20), idiopathic pulmonary fibrosis (n = 26), primary pulmonary hypertension (n = 10), Eisenmenger's syndrome (n = 9), and cystic fibrosis (n = 41). The sensitivity, specificity, and positive and negative predicted values for a 6-minute walk distance of 300 and 400 m as a predictor of death were calculated. RESULTS: Mortality rates were as follows: emphysema (7.9%), alpha-1-antitrypsin deficiency (15%), idiopathic pulmonary fibrosis (42.3%), primary pulmonary hypertension (50%), Eisenmenger's syndrome (11%), and cystic fibrosis (24.4%). A 6-minute walk distance of less than 400 m had the following characteristics for prediction of death: sensitivity 0.80, specificity 0.27, positive predictive value 0.27, and negative predictive value 0.91. Similar findings for a 6-minute walk distance of less than 300 m were as follows: 0.52, 0.80, 0.38, and 0.88, respectively. CONCLUSION: The 6-minute walk test is a useful tool in the assessment of when to list patients for transplantation. A 6-minute walk test result of less than 400 meters appears to be a reasonable marker with regard to when a patient should be listed for transplantation.
Adult↗