INTRODUÇÃO: O transplante pulmonar é terapia reconhecida de tratamento de doenças terminais pulmonares. Os pulmões, entretanto, são muito susceptíveis às transformações hormonais e hidroeletrolíticas ocorridas no doador após a morte encefálica. As baixas taxas de aproveitamento dos pulmões alavancam pesquisas e meios de utilizar pulmões considerados nãoideais. Um desses modelos é o recondicionamento pulmonar ex-vivo concebido por Steen, no qual se utiliza uma solução hiperosmolar (Steen Solution®) para avaliação e melhora dos pulmões doados. Consideramos que o desenvolvimento de uma solução de recondicionamento pulmonar produzida no Brasil seria conveniente aos serviços de transplante e aos pacientes. Foram comparadas a solução de recondicionamento Steen Solution® e uma solução de fabricação nacional em modelo de ex vivo de pulmões humanos não aceitos para transplante, através da avaliação da mecânica ventilatória, hemodinâmica, trocas gasosas e histologia. MÉTODOS: Foram utilizados 16 pulmões de doadores em morte encefálica, considerados inadequados para o transplante pulmonar. Os pulmões foram submetidos à captação habitual e acondicionados sob isquemia fria por 10 horas. Após este período, os pulmões foram designados, por sorteio, para reperfusão com a solução padrão (Steen solution®) ou a solução nacional por 1h em modelo ex vivo. A lesão pulmonar foi estudada através de parâmetros gasométricos, resistência pulmonar e complacência pulmonar. Foram medidos os pesos em três tempos e relação peso úmido/peso seco após a reperfusão para avaliação de edema. A partir de biópsias seriadas era calculado um score de lesão tecidual e grau de apoptose. RESULTADOS: A capacidade de oxigenação foi de 498,00 ± 37,53 mmHg no grupo STEEN e 521,00 ± 55,43 mmHg no grupo SRNac (p = 0,348). A capacidade relativa de oxigenação calculada ao final do recondicionamento foi 501,37 ± 207,77 no grupo STEEN e 470,30 ± 232,41 no grupo SRNac (p=0,782). Os pesos dos pulmões nos três momentos de avaliação foram: início da isquemia: STEEN = 1.026 ± 451 g, SRNac = 745 ± 282 g (p = 0,180); fim da isquemia: STEEN = 998 ± 391 g, SRNac = 738 ± 316 g (p = 0,184); e fim da reperfusão: STEEN = 1.097 ± 526 g, SRNac = 743 ± 248 g (p = 0,163). A relação peso úmido/peso seco foi 3,63 ± 1,26 no grupo SRNac e 2,06 ± 0,28 no grupo STEEN (p = 0,009). A resistência vascular pulmonar foi 787,99 ± 367,23 dina.s.cm-5 no grupo STEEN e 1.026,81 ± 1.112,53 dina.s.cm-5 no grupo SRNac (p = 0,575). A complacência pulmonar média foi 46,75 ± 20,99 mL/cmH2O no grupo STEEN e 49,74 ± 26,11 cmH2O no grupo SRNac (p = 0,809). O Escore de Lesão Pulmonar foi: STEEN = 4,38 ± 1,51 e SRNac = 4,50 ± 1,77 (p = 0,881). O número de células apoptóticas foi: STEEN = 2,4 ± 2,0 cel/mm2 e SRNac = 4,8 ± 6,9 cel/mm2 (p = 0,361). CONCLUSÕES: Os pulmões reperfundidos com a solução de recondicionamento de fabricação nacional apresentaram características morfológicas e funcionais similares aos que foram reperfundidos com a solução STEEN®, apesar do maior edema encontrado no grupo da solução nacional / INTRODUCTION: Lung transplantation is routine treatment of end-stage lung diseases. The lungs, however, are very susceptible to hormonal and electrolyte changes occurred in the donor after brain death. The low recovery rates of the lungs leverage researches and ways to use lungs considered non-ideal. One such model is the lung ex vivo reconditioning designed by Steen, in which using a hyperosmolar solution (Steen Solution®) for evaluation and improvement of donor lungs. We believe that the development of a pulmonary reconditioning solution produced in Brazil would be convenient to transplantation service and patients. Were compared the standard Steen Solution® and a national manufacturing solution in ex vivo model with human lungs not accepted for transplant, through the evaluation of respiratory mechanics, hemodynamics, gas exchange and histology. METHODS: 16 brain-dead donors lungs, considered unsuitable for lung transplantation, were used. The lungs were harvest as usual, packed and stored in cold ischemia for 10 hours. After this period, the lungs were appointed by randomization to reperfusion with the standard solution (Steen Solution®) or national solution for 1 h in ex vivo model. Lung injury was accessed by blood gas parameters, lung resistance and lung compliance. The weights were measured in three times and the after reperfusion wet weight / dry weight ratio for evaluation of edema. The degree of apoptosis and tissue injury score was calculated from serial biopsies. RESULTS: The oxygenation capacity was 498.00 ± 37.53mmHg in STEEN group and 521.00 ± 55.43mmHg in SRNac group (p = 0.348). The relative oxygenation capacity calculated at the end of the reconditioning was 501.37 ± 207.77 in the STEEN group and 470.30 ± 232.41 in the SRNac group (p = 0.782). The weights of lungs in the three stages of evaluation were: onset of ischemia: STEEN = 1,026 ± 451g, SRNac = 745 ± 282g (p = 0.180); end of ischemia: STEEN = 998 ± 391g, SRNac = 738 ± 316g (p = 0.184); and the end of reperfusion: STEEN = 1,097 ± 526g, SRNac = 743 ± 248g (p = 0.163). The wet weight / dry weight ratio was 3.63 ± 1.26 in SRNac group and 2.06 ± 0.28 in STEEN group (p = 0.009). Pulmonary vascular resistance was 787.99 ± 367.23dina.s.cm-5 in STEEN group and 1026.81 ± 1112.53dina.s.cm-5 in SRNac group (p = 0.575). The Lung Injury Score was: STEEN = 4.38 ± 1.51 and SRNac = 4.50 ± 1.77 (p = 0.881). The number of apoptotic cells was: STEEN = 2.4 ± 2.0 cells / mm 2 and SRNac = 4.8 ± 6.9 cells / mm2 (p = 0.361). CONCLUSIONS: The lungs reperfused with national manufacturing reconditioning solution presented morphological and functional characteristics similar to those reperfused with STEEN® solution despite the greater edema found in the group of national solution

INTRODUÇÃO: Em contraste aos bons resultados do transplante pulmonar no tratamento de pacientes com doença supurativa pulmonar avançada, a colonização por Burkholderia cepacia complex (BCC), sobretudo o genomovar III, vem sendo relacionada a pior prognóstico e, por conseguinte, uma contraindicação ao procedimento em alguns centros transplantadores. O objetivo deste estudo foi avaliar o impacto em sobrevida após o transplante pulmonar de pacientes com doença pulmonar supurativa colonizados por BCC, além de determinar a incidência da colonização e suas variantes genômicas no Instituto do Coração/HC-FMUSP. MÉTODOS: Foram analisados prospectivamente dados clínicos e amostras de culturas do trato respiratório dos pacientes que realizaram transplante pulmonar por doença supurativa entre janeiro de 2008 e dezembro de 2013. A tipagem molecular para estudar os diferentes genótipos da BCC foi realizada a partir de janeiro de 2012 por método de sequenciamento genético e análise do gene RecA. RESULTADOS: Foram realizados 132 transplantes pulmonares, 62 pacientes com doença pulmonar supurativa, sendo 28 em pacientes com Bronquiectasias e 34 com Fibrose Cística. Observou-se a colonização por BCC em 16 pacientes; em 7 amostras identificados os seguintes subtipos: três cepas B. metallica e quatro cepas B. cenocepacia. A incidência de BCC nos pacientes com Fibrose Cística foi de 38,2%, enquanto nos pacientes com Bronquiectasias foi 10,7%. Dentre os 16 pacientes colonizados por BCC, ocorreram 2 óbitos, nenhum deles relacionados à infecção pelo agente. Um óbito foi atribuído a sepse por Acinetobacter baumannii resistente a múltiplas drogas e o outro, a disfunção orgânica múltipla. O estudo desenvolvido demostrou que a colonização por BCC não gerou impacto em mortalidade nos pacientes após o transplante pulmonar, mesmo quando colonizados pelo subtipo B. cenocepacia / INTRODUCTION: Notwithstanding the good results of lung transplantation for treatment of patients with advanced lung suppurative disease, colonization by Burkholderia cepacia complex (BCC), especially genomovar III has been related to a worse prognosis in these patients and therefore contraindication to the procedure certain centers. The aim of this study was to evaluate the impact on survival after lung transplantation in patients with suppurative lung disease colonized with BCC to determine the incidence of colonization and its genomic variants at the Heart Institute / HC -FMUSP. METHODS: We prospectively analyzed clinical data and respiratory tract samples of suppurative lung disease patients that performed lung transplantation from January-2008 through November-2013. From January-2012 through December-2013, we also subtyed the different B. cepacia genotypes by DNA sequencing primers of the gene RecA. RESULTS: 132 lung transplantation were performed, 62 patients with suppurative lung disease, 28 patients with Bronchiectasis and 34 with Cystic Fibrosis. BCC was observed in 16 patients; in 7 samples we identified the following subtypes: three strains B. metallica and four strains B. cenocepacia. The incidence of BCC in patients with Cystic Fibrosis was 38.2% while in patients with Bronchiectasis was only 10.7%. Among the 16 patients colonized with BCC, there were two deaths, none of them related to infection by the agent. One death due to sepsis Acinetobacter baumannii resistant to multiple drugs and the other, multiple organ dysfunction. The study demonstrated that colonization by BCC developed no impact on the mortality rate of patients after lung transplantation, even when colonized by the subtype B. cenocepacia

Objetivo: Avaliar os efeitos do uso de dois diferentes níveis de pressão expiratória final positiva (PEEP) em porcos submetidos a transplante pulmonar unilateral através de troca gasosa [pressão parcial de oxigênio (PaO2) e pressão parcial de dióxido de carbono (PaCO2)], hemodinâmica [freqüência cardíaca (FC), pressão arterial média (PAM) e pressão da artéria pulmonar (PAP)], parâmetros ventilatórios [pressão media das vias aéreas (Pmédia); complacência estática (Cst) e resistência das vias aéreas (Rest)], resposta inflamatória [interleuina 8 (IL-8)] e estresse oxidativo [substância reativa ao ácido tiobarbitúrico (TBARS) and superóxido dismutase (SOD)]. Material e Métodos: Doze porcos pesando aproximadamente 30kg foram submetidos a transplante pulmonar esquerdo. Os animais foram randomizados em dois grupos de diferentes valores de PEEP: Grupo 1 (PEEP=5cmH2O) e Grupo 2 (PEEP=10cmH2O). Dados hemodinâmicos, troca gasosa e mecânica respiratória foram medidos em diferentes tempos após o transplante durante 210 minutos. Foi realizada análise histológica, de IL-8 e estresse oxidativo no tecido pulmonar. Resultados: O grupo 2 apresentou aumento significativo da FC (p=0,006) e Cst (p=0.001), diminuição da PAM (p=0.003) e Rest (p=0.001). Não houve diferença entre os grupos na concentração de TBARS, SOD e IL-8. Contudo, após o período de observação, o grupo 2 mostrou um aumento da concentração de TBARS (p=0,001) e IL-8 (p=0,05) e o grupo 1 um aumento da SOD (p=0,05) comparado com os valores iniciais. Conclusão: O uso de altos níveis de PEEP, após o transplante pulmonar unilateral, não resultou em melhora da troca gasosa. Embora apresentasse uma melhora da mecânica respiratória, a PEEP de 10 cmH2O teve impacto negativo nos parâmetros hemodinâmicos, e provocou um aumento da resposta inflamatória e estresse oxidativo. / Objective: Evaluate the effects of two different levels of positive end expiratory pressure (PEEP) on pigs submitted to unilateral lung transplantation through blood gas exchange [partial oxygen arterial pressure (PaO2) and partial carbon dioxide arterial pressure (PaCO2)], hemodynamics [heart rate (HR), mean arterial pressure (MAP) and pulmonary arterial pressure (PAP)], ventilatory parameters [mean airway pressure (P(aw)); static compliance (Cst) and airway resistance (Rest)], inflammatory response [interleukin 8 (IL-8)] and oxidative stress [thiobarbituric acid reactive substances (TBARS) and superoxide dismutase (SOD)]. Material and Methods: Twelve pigs were submitted to left lung transplantation. The animals were randomized into two groups of different PEEP levels: Group 1 (PEEP = 5cmH2O) and Group 2 (PEEP = 10cmH2O). Hemodynamics, gas exchange and respiratory mechanics were measured prior and after surgery for 210 minutes. Cytokines, oxidative stress and histological score were assessed in lung tissue. Results: Group 2 had significantly higher HR (p=0.006), Cst (p=0.001) and lower MAP (p=0.003) and Rest (p=0.001). There were no differences between both groups in TBARS, SOD and IL-8, concentration after transplant. However, at the end of the observation period, group 2 showed higher TBARS (p=0.001) and IL-8 (p=0.05) concentration and group 1 presented higher SOD (p=0.05) when compared to baseline. Conclusion: After unilateral lung transplantation, higher PEEP levels had no effect on gas exchange. Although, 10 cmH2O PEEP improved respiratory mechanics, it had a negative impact on hemodynamics and stimulated a high inflammatory response and production of reactive oxygen species.

INTRODUÇÃO: O transplante pulmonar é a única opção terapêutica para determinados pacientes com doença pulmonar em estágio terminal. A maioria dos transplantes de pulmão é realizada a partir de doadores em morte encefálica, condição que per si pode comprometer o sucesso do procedimento. A fisiopatologia da morte encefálica é complexa e envolve mecanismos hemodinâmicos, simpáticos e inflamatórios. A administração de metilprednisolona 60 minutos após indução da morte encefálica reduz a atividade inflamatória em pulmões de ratos. OBJETIVO: Avaliar os efeitos do tratamento com metilprednisolona em pulmões de ratos transplantados a partir de ratos doadores induzidos à morte encefálica quando administrada 60 minutos após indução da mesma. MÉTODOS: doze ratos Wistar foram randomizados e anestesiados em 2 grupos (n=6): controle: indução de morte encefálica e administração de solução salina; metilprednisolona (MET): indução de morte encefálica e administração de metilprednisolona 60 minutos após. Os animais foram observados e ventilados por 120 minutos e depois submetidos a transplante pulmonar. Foram avaliados parâmetros hemodinâmicos e gasométricos, escore histológico, dosagem de substâncias reativas ao ácido tiobarbitúrico (TBARS), superóxido dismutase (SOD), TNF-α e interleucina-1β (IL-1β). RESULTADOS: houve redução significativa dos níveis de TNF-α e IL-1β no grupo que recebeu metilprednisolona (p=0,0084; p=0,0155, respectivamente). Não houve diferença significativa na atividade do TBARS e SOD entre os grupos controle e MET (p=0,2644; p=0,7461, respectivamente). Não houve diferença significativa na gasometria, nos parâmetros hemodinâmicos, e nas alterações histológicas entre os grupos controle e MET. CONCLUSÃO: a utilização de metilprednisolona após a morte encefálica em ratos doadores reduz a atividade inflamatória em pulmões transplantados, mas não tem influencia sobre o estresse oxidativo. / INTRODUCTION: Lung transplantation is the only therapeutic option for a subset of patients with end-stage lung disease. Most lung transplantations are performed using brain-dead donors, a condition that compromises the success of the procedure. The physiopathology of brain death is complex and involves haemodynamics, the sympathetic nervous system and inflammatory mechanisms. Administering methylprednisolone 60 minutes after inducing brain death in rats has been shown to modulate pulmonary inflammatory activity. OBJECTIVE: To evaluate the effects of methylprednisolone on transplanted rat lungs from donors treated 60 minutes after brain death. METHODS: Twelve Wistar rats were anaesthetised and randomly assigned to 1 of 2 groups (n=6): a control group that underwent the induction of brain death and the administration of saline solution and a methylprednisolone (MET) group that underwent the induction of brain death and the administration of methylprednisolone after 60 minutes. All of the animals were observed and ventilated for 120 minutes and then submitted to lung transplantation. We evaluated haemodynamic and blood gas parameters, the histologic score, the lung tissue determination of thiobarbituric acid-reactive substances (TBARS), the level of superoxide dismutase (SOD), the level of TNF-α and the level of interleukin-1β (IL-1β). RESULTS: There was a significant reduction in the levels of TNF-α and IL-1β in the group that received methylprednisolone (p=0.0084 and p=0.0155, respectively). There were no significant differences in TBARS and SOD between the control and MET groups (p=0.2644 and p=0.7461, respectively). There were no significant differences in the blood gas parameters, the haemodynamic parameters and the histologic alterations between the control and MET groups. CONCLUSION: The administration of methylprednisolone after brain death in donor rats reduces inflammatory activity in transplanted lungs but has no influence on oxidative stress.

Η µεταµόσχευση πνεύµονα είναι µια αποδεκτή θεραπευτική λύση για τους ασθενείς µε πνευµονική νόσο τελικού σταδίου. Η πρώιµη δυσλειτουργία του µοσχεύµατος παραµένει µία από της κύριες αιτίες πρώιµης θνητότητας και νοσηρότητας. Το σύνδροµο ισχαιµίας – επαναιµάτωσης είναι ο υπεύθυνος κύριος παθογενετικός µηχανισµός. Η ακριβής αιτιοπαθολογία του συνδρόµου ισχαιµίας – επαναιµάτωσης δεν έχει πλήρως ερευνηθεί. Η πειραµατικές µεταµοσχεύσεις ως τώρα δεν µπόρεσαν να αποµονώσουν την κλινική εικόνα της βλάβης ισχαιµίας – επαναιµάτωσης, όπως είναι η υποξία, η σοβαρή βλάβη της ενδοθηλιακής διαπερατότητας και το γενικευµένο κυψελιδικό οίδηµα. Η ερευνητική µας οµάδα όπως και πολλές άλλες διεθνώς, χρησιµοποίησε ως τώρα το µοντέλο µεταµόσχευσης ενός πνεύµονα από το ένα ζώο σε άλλο. Ο πρώτος στόχος µας ήταν να δηµιουργήσουµε ένα σταθερό και επαναλήψιµο πειραµατικό πρωτόκολλο που θα µπορούσε να αναπαράγει τις τοπικές και συστηµατικές εκδηλώσεις του συνδρόµου ισχαιµίας- επαναιµάτωσης χωρίς όµως τη συµµετοχή της παθολογίας της απόρριψης, διατηρώντας παράλληλα τους λιγότερους χειρουργικούς χειρισµούς στο µόσχευµα. Είναι γνωστό ότι κατά τις πνευµονικές µεταµοσχεύσεις σε πειραµατικά µοντέλα εµφανίζονται αλλαγές στη σύνθεση και λειτουργικότητα του επιφανειοδραστικού παράγοντα και επιπλέον εξαγγείωση πρωτεϊνών του πλάσµατος στην κυψελίδα µε αποτέλεσµα την επιπρόσθετη επιβάρυνση της λειτουργίας του επιφανειοδραστικού παράγοντα. Οι αλλαγές στον επιφανειοδραστικό παράγοντα κατά τις πνευµονικές µεταµοσχεύσεις έχει προταθεί ότι συµµετέχουν σηµαντικά στην παθοφυσιολογία των βλαβών που σχετίζονται µε τη µεταµόσχευση. Έτσι µπορούµε να υποθέσουµε ότι διαδικασίες που θα µπορούσαν να σταθεροποιήσουν το σύστηµα του επιφανειοδραστικού παράγοντα θα οδηγούσαν πιθανότερα σε βελτίωση της λειτουργίας του µοσχεύµατος. Έχει αποδειχτεί ότι ο εξωγενώς χορηγούµενος επιφανειοδραστικός παράγοντας µιµείται τις επιφανειοδραστικές ιδιότητες του ενδογενούς. Ο δεύτερος στόχος της µελέτης µας ήταν να εξετάσουµε αν η εξωγενής χορήγηση επιφανειοδραστικού παράγοντα θα βελτίωνε τις ιδιότητες 103 του µοσχεύµατος αλλά και ποια επίδραση θα είχε η µη χορήγηση ενός ανοσοδιεγερτικού παράγοντα του επιφανειοδραστικού παράγοντα όπως είναι το SP-A επί του συνδρόµου ισχαιµίας επαναιµάτωσης. Χρησιµοποιήσαµε 14 νεαρούς χοίρους µέσου βάρους 27(±3,5) Kg εφαρµόζοντας ένα µοντέλο αυτοµεταµόσχευσης πνεύµονα in situ. Ο πνεύµονας παρασκευάστηκε και εκπλύθηκε µέσω της πνευµονικής αρτηρίας ορθόδροµα χρησιµοποιώντας διάλυµα U Wisconsin. Οι πνευµονικές φλέβες αποκλείστηκαν µετά τη συµβολή τους επί του αριστερού κόλπου και το υγρό συντήρησης παροχετεύτηκε από αντιστόµειο στον αριστερό κόλπο. Το µόσχευµα παρέµεινε σε θερµοκρασία 4-8 0C για διάστηµα 3 ωρών, διατηρώντας την κεντρική θερµοκρασία ανάµεσα 37 και 38.50 C. Ακολούθησε επαναιµάτωση του µοσχεύµατος. Στην οµάδα ελέγχου (Β) χορηγήθηκε ελεύθερος SP-A επιφανειοδραστικός παράγοντας 1.5 ml/Kg µέσω βρογχοσκοπίου, πριν τη θωρακοτοµή. Τα πειραµατόζωα θυσιάστηκαν 3 ώρες µετά την επαναιµάτωση. Μετά από 3 ώρες από την επαναιµάτωση, (οµάδα Α vs. Β) η PVRI ήταν 447.80 dyne.sec-1cm-5m-2 (±66.8) vs. 249.51(p<.001) ενώ το NO(*p<0.05,**p<0.001), η EPO και η πνευµονική ευενδοτότητα (**p<0.002) διατηρήθηκαν στατιστικά σηµαντικά. Η µέση κυψελιδική επιφάνεια ήταν 5280.84 (4991.1) µm2 vs. 3997,89 (3284.70) µm2(p<0.005). Η ιστολογική µελέτη έδειξε µικρότερη διήθηση µικροφάγων και λεµφοκυττάρων στην οµάδα χορήγησης επιφανειοδραστικού παράγοντα στο τέλος της επαναιµάτωσης. Συµπεράσµατα Το νέο αυτό µοντέλο ετερόπλευρης µεταµόσχευσης πνεύµονα αποδείχθηκε αξιόπιστο και αναπαρήγαγε όλη την παθολογία του συνδρόµου ισχαιµίας επαναιµάτωσης, χωρίς την επίδραση των µηχανισµών απόρριψης. Επιπλέον αποδείχτηκε ότι η προθεραπεία του µοσχεύµατος µε εξωγενή επιφανειοδραστικό παράγοντα µειώνει τη βλάβη ισχαιµίας-επαναιµάτωσης διατηρώντας όχι µόνο την πνευµονική ευενδοτότητα αλλά και το δείκτη πνευµονικών αντιστάσεων. Επιπλέον οι συγκεντρώσεις του NO και η 104 105 δραστηριότητα του EPO διατηρήθηκαν καλύτερα, ενώ και η µορφολογία της κυψελίδας φαίνεται να διατηρείται σηµαντικά καλύτερα. / Lung transplantation is a well accepted treatment for patients with end stage pulmonary disease. Early graft dysfunction remains one of the major causes of early morbidity and mortality, with reperfusion injury (RI) being the most responsible mechanism. The exact pathophysiology of RI in lung transplantation has not been fully evaluated and understood. Experimental transplantation after cold storage has been so far unable to duplicate the complete clinical picture of RI, such as, hypoxia, severe impairment of endothelial permeability, and frank alveolar oedema. We, among others, in our previous experimental work with pigs, had being using a single lung transplantation model. Our first aim has been to create a steady and reproducible experimental protocol that could demonstrate several parameters associated with the mechanisms of reperfusion injury, including impaired gas exchange, elevated pulmonary vascular resistant, local and systemic aspects of the reperfusion syndrome, but without the interference of the pathology concerning acute graft rejection, and with the minimal possible surgical manipulation of the graft. Animal studies have shown that lung transplantation is followed by changes to both synthesis and activity of surfactant. Surfactant alterations have been suggested to contribute significantly to the pathophysiology of transplantation-associated lung injuries. Therefore, procedures that stabilize the pulmonary surfactant system may prove to be crucial for optimal lung preservation. It has been demonstrated that exogenous surfactant mimics the surface-tension-lowering properties of natural lung surfactant. The second purpose of our study was to evaluate whether differences exist in lung preservation after pre-treatment (prior to graft retrieval) of donor lung with surfactant. We postulated that surfactant would lead to an enhanced preservation of the organ. Therefore, we used Surfactant, Beractant which is a natural bovine lung extract containing phospholipids, neutral lipids, fatty acids, and surfactantassociated proteins SP-B and SP-C to which colfosceril palmitate, palmitic acid, and tripalmiting are added in order to standardise the suspension. It should be noted that it does not contain SP-A. Furthermore, we assessed the effect of surfactant pretreatment to lung haemodynamics, respiratory parameters, serum and BALF nitric oxide and EPO levels and the microscopic morphology of the alveolar. Methods: Fourteen young female white pigs, mean weight 27(±3.5) Kg were used in a newly developed autotransplantation model with in-situ cold ischemia. The hilum was dissected free and the pericardium opened. University of Wisconsin solution was used for lung preservation flushed in an antegrade fashion through the left pulmonary artery. Pulmonary veins were clamped proximal to their origin at the left atrium and vent was created just distally to the clamp. The left main bronchus was clamped with the lung left semi-inflated. Interlobar fissure tissue temperature was monitored and maintained at 4-8 0C, while core temperature was kept between 37 and 38.50 C. After 3 hours of cold ischaemia clamps were removed and the lung was reperfused. In the study group (B, n=6) free-SP-A surfactant 1.5 ml/Kg, was administrated into the left main bronchus via flexible bronchoscopy, prior to thoracotomy. Animals were sacrificed after 3 hours of graft reperfusion. Results: At the end of reperfusion, (Control vs. study group) PVRI was 447.80 dyn.sec-1cm-5m-2 (±66.8) vs. 249.51(p<.001) and lung compliance was 14.83 ml/cm H2O (SD 1.78) vs. 18.91 (SD 0.73) (**p<0.002) were adequately preserved. Serum eosinophil peroxidase (EPO) activity persentence change was 18.6 +/- 5.6 vs. 116+/-52 p=0.001. In contrast, EPO activity in BALF was 180 +/- 21 vs 73+/-8, p=0.01. Finally, NO concentration in BALF was 0.75 μM =+/- 0. 06 vs. 0.91 +/- 0.15 p< 0,05 and serum NO were adequately preserved (*p<0.05,**p<0.001). The mean alveoli surface area estimated by computerized morphometry were 5280.84 (4991.1) μm2 vs. 3997,89 (3284.70) μm2(p<0.005). Histology revealed less macrophage and lymphocyte accumulation in the study group at the end of reperfusion. Conclusions: This new model of unilateral lung auto transplantation with a cold storage of the graft, proved to be very reliable in reproducing all aspects of ischemia/reperfusion injury, and we, therefore, propose its use in experimental studies dealing with this yet to be fully clarified clinical entity. Moreover it has demonstrated that pre-treatment of the donor lung with a surfactant agent reduced the ischemia and reperfusion injury by means of maintaining lung compliance and resulting in less respiratory and haemodynamic disturbances. Also, alveoli surface area, alveoli morphology, EPO and NO concentration were better preserved. These data supports the hypothesis that donor lung pretreatment with surfuctant has a beneficial effect on graft properties. Further studies are required before discussing potential benefits in clinical practice.

Objetivo: Avaliar os efeitos do uso de dois diferentes níveis de pressão expiratória final positiva (PEEP) em porcos submetidos a transplante pulmonar unilateral através de troca gasosa [pressão parcial de oxigênio (PaO2) e pressão parcial de dióxido de carbono (PaCO2)], hemodinâmica [freqüência cardíaca (FC), pressão arterial média (PAM) e pressão da artéria pulmonar (PAP)], parâmetros ventilatórios [pressão media das vias aéreas (Pmédia); complacência estática (Cst) e resistência das vias aéreas (Rest)], resposta inflamatória [interleuina 8 (IL-8)] e estresse oxidativo [substância reativa ao ácido tiobarbitúrico (TBARS) and superóxido dismutase (SOD)]. Material e Métodos: Doze porcos pesando aproximadamente 30kg foram submetidos a transplante pulmonar esquerdo. Os animais foram randomizados em dois grupos de diferentes valores de PEEP: Grupo 1 (PEEP=5cmH2O) e Grupo 2 (PEEP=10cmH2O). Dados hemodinâmicos, troca gasosa e mecânica respiratória foram medidos em diferentes tempos após o transplante durante 210 minutos. Foi realizada análise histológica, de IL-8 e estresse oxidativo no tecido pulmonar. Resultados: O grupo 2 apresentou aumento significativo da FC (p=0,006) e Cst (p=0.001), diminuição da PAM (p=0.003) e Rest (p=0.001). Não houve diferença entre os grupos na concentração de TBARS, SOD e IL-8. Contudo, após o período de observação, o grupo 2 mostrou um aumento da concentração de TBARS (p=0,001) e IL-8 (p=0,05) e o grupo 1 um aumento da SOD (p=0,05) comparado com os valores iniciais. Conclusão: O uso de altos níveis de PEEP, após o transplante pulmonar unilateral, não resultou em melhora da troca gasosa. Embora apresentasse uma melhora da mecânica respiratória, a PEEP de 10 cmH2O teve impacto negativo nos parâmetros hemodinâmicos, e provocou um aumento da resposta inflamatória e estresse oxidativo. / Objective: Evaluate the effects of two different levels of positive end expiratory pressure (PEEP) on pigs submitted to unilateral lung transplantation through blood gas exchange [partial oxygen arterial pressure (PaO2) and partial carbon dioxide arterial pressure (PaCO2)], hemodynamics [heart rate (HR), mean arterial pressure (MAP) and pulmonary arterial pressure (PAP)], ventilatory parameters [mean airway pressure (P(aw)); static compliance (Cst) and airway resistance (Rest)], inflammatory response [interleukin 8 (IL-8)] and oxidative stress [thiobarbituric acid reactive substances (TBARS) and superoxide dismutase (SOD)]. Material and Methods: Twelve pigs were submitted to left lung transplantation. The animals were randomized into two groups of different PEEP levels: Group 1 (PEEP = 5cmH2O) and Group 2 (PEEP = 10cmH2O). Hemodynamics, gas exchange and respiratory mechanics were measured prior and after surgery for 210 minutes. Cytokines, oxidative stress and histological score were assessed in lung tissue. Results: Group 2 had significantly higher HR (p=0.006), Cst (p=0.001) and lower MAP (p=0.003) and Rest (p=0.001). There were no differences between both groups in TBARS, SOD and IL-8, concentration after transplant. However, at the end of the observation period, group 2 showed higher TBARS (p=0.001) and IL-8 (p=0.05) concentration and group 1 presented higher SOD (p=0.05) when compared to baseline. Conclusion: After unilateral lung transplantation, higher PEEP levels had no effect on gas exchange. Although, 10 cmH2O PEEP improved respiratory mechanics, it had a negative impact on hemodynamics and stimulated a high inflammatory response and production of reactive oxygen species.

INTRODUÇÃO: O transplante pulmonar é a única opção terapêutica para determinados pacientes com doença pulmonar em estágio terminal. A maioria dos transplantes de pulmão é realizada a partir de doadores em morte encefálica, condição que per si pode comprometer o sucesso do procedimento. A fisiopatologia da morte encefálica é complexa e envolve mecanismos hemodinâmicos, simpáticos e inflamatórios. A administração de metilprednisolona 60 minutos após indução da morte encefálica reduz a atividade inflamatória em pulmões de ratos. OBJETIVO: Avaliar os efeitos do tratamento com metilprednisolona em pulmões de ratos transplantados a partir de ratos doadores induzidos à morte encefálica quando administrada 60 minutos após indução da mesma. MÉTODOS: doze ratos Wistar foram randomizados e anestesiados em 2 grupos (n=6): controle: indução de morte encefálica e administração de solução salina; metilprednisolona (MET): indução de morte encefálica e administração de metilprednisolona 60 minutos após. Os animais foram observados e ventilados por 120 minutos e depois submetidos a transplante pulmonar. Foram avaliados parâmetros hemodinâmicos e gasométricos, escore histológico, dosagem de substâncias reativas ao ácido tiobarbitúrico (TBARS), superóxido dismutase (SOD), TNF-α e interleucina-1β (IL-1β). RESULTADOS: houve redução significativa dos níveis de TNF-α e IL-1β no grupo que recebeu metilprednisolona (p=0,0084; p=0,0155, respectivamente). Não houve diferença significativa na atividade do TBARS e SOD entre os grupos controle e MET (p=0,2644; p=0,7461, respectivamente). Não houve diferença significativa na gasometria, nos parâmetros hemodinâmicos, e nas alterações histológicas entre os grupos controle e MET. CONCLUSÃO: a utilização de metilprednisolona após a morte encefálica em ratos doadores reduz a atividade inflamatória em pulmões transplantados, mas não tem influencia sobre o estresse oxidativo. / INTRODUCTION: Lung transplantation is the only therapeutic option for a subset of patients with end-stage lung disease. Most lung transplantations are performed using brain-dead donors, a condition that compromises the success of the procedure. The physiopathology of brain death is complex and involves haemodynamics, the sympathetic nervous system and inflammatory mechanisms. Administering methylprednisolone 60 minutes after inducing brain death in rats has been shown to modulate pulmonary inflammatory activity. OBJECTIVE: To evaluate the effects of methylprednisolone on transplanted rat lungs from donors treated 60 minutes after brain death. METHODS: Twelve Wistar rats were anaesthetised and randomly assigned to 1 of 2 groups (n=6): a control group that underwent the induction of brain death and the administration of saline solution and a methylprednisolone (MET) group that underwent the induction of brain death and the administration of methylprednisolone after 60 minutes. All of the animals were observed and ventilated for 120 minutes and then submitted to lung transplantation. We evaluated haemodynamic and blood gas parameters, the histologic score, the lung tissue determination of thiobarbituric acid-reactive substances (TBARS), the level of superoxide dismutase (SOD), the level of TNF-α and the level of interleukin-1β (IL-1β). RESULTS: There was a significant reduction in the levels of TNF-α and IL-1β in the group that received methylprednisolone (p=0.0084 and p=0.0155, respectively). There were no significant differences in TBARS and SOD between the control and MET groups (p=0.2644 and p=0.7461, respectively). There were no significant differences in the blood gas parameters, the haemodynamic parameters and the histologic alterations between the control and MET groups. CONCLUSION: The administration of methylprednisolone after brain death in donor rats reduces inflammatory activity in transplanted lungs but has no influence on oxidative stress.

La mucoviscidose est à ce jour une maladie malheureusement incurable. Malgré les nombreux progrès réalisés dans la recherche à ce sujet, il reste indispensable d’avoir davantage une meilleure connaissance de la maladie afin de proposer des traitements encore plus adaptés aux patients. La majorité des traitements actuels visent principalement à réduire les symptômes de la maladie sans toutefois la guérir. A ce jour, la transplantation pulmonaire reste le moyen le plus adéquat pour améliorer la qualité de vie et prolonger la vie des patients dont l’état respiratoire s’est considérablement dégradé. Cependant les critères d’identification des patients éligibles à la transplantation pulmonaire sont assez variés. Il est donc nécessaire de fournir aux cliniciens des outils d’aide à la décision pour mieux identifier les patients nécessitant une transplantation pulmonaire. Pour ce faire, il est indispensable de connaitre d’une part, les facteurs pronostics de transplantation pulmonaire et d’autre part, de savoir convenablement pronostiquer la survenue de cet événement chez les sujets atteints de mucoviscidose. L’objectif de ce travail de thèse est de développer des outils pronostiques utiles à l’évaluation des choix thérapeutiques liés à la transplantation pulmonaire. Dans la première partie de ce travail, nous avons réévalué les facteurs pronostiques de la transplantation pulmonaire ou du décès chez les adultes atteints de mucoviscidose. Suite aux progrès thérapeutiques qui ont conduit à l’amélioration du pronostic au cours des dernières années, ce travail a permis d’identifier des facteurs pronostiques en adéquation avec l’état actuel de la recherche. Un deuxième travail a consisté à développer un modèle conjoint à classes latentes fournissant des prédictions dynamiques pour la transplantation pulmonaire ou le décès. Ce modèle a permis d’identifier trois profils d’évolution de la maladie et également d’actualiser le risque de survenue de la transplantation pulmonaire ou du décès à partir des données longitudinales du marqueur VEMS. Ces modèles pronostiques ont été développés à partir des données du registre français de la mucoviscidose et ont fourni de bonnes capacités prédictives en termes de discrimination et de calibration. / Cystic Fibrosis is unfortunately an incurable inherited disorder. Despite real progress in research, it is essential to always have a better understanding of the disease in order to provide suitable treatments to patients. Current treatments mostly aim to reduce the disease symptoms without curing it. Lung transplantation is proposed to cystic fibrosis patients with terminal respiratory failure with the aim of improving life expectancy and quality of life. However, criteria for referring patients for lung transplantation still vary widely among transplant centers. It is necessary to guide clinicians in identifying in a good way patients requiring an evaluation for lung transplantation. It is thus important to clearly identify prognostic factors related to lung transplantation and to predict in a good way the occurrence of this event in patients with cystic fibrosis. The aim of this work was to develop prognostic tools to assist clinicians in the evaluation of different therapeutic options related to lung transplantation. First, we reevaluated prognostic factors of lung transplantation or death in adult with cystic fibrosis. indeed, therapeutic progress in patients with cystic fibrosis has resulted in improved prognosis over the past decades. We identified prognostic factors related to the current state of research in the cystic fibrosis field. We further developed a joint model with latent classes which provided dynamic predictions for lung transplantation or death. This model identified three profile of the evolution of the disease and was able to update the risk of lung transplantation or death taking into account the evolution of the longitudinal marker FEV1 which describes the lung function. These prognostic models were developed using the French cystic fibrosis registry and provided good predictive accuracies in terms of discrimination and calibration.

Objetivo: Avaliar os efeitos do uso de dois diferentes níveis de pressão expiratória final positiva (PEEP) em porcos submetidos a transplante pulmonar unilateral através de troca gasosa [pressão parcial de oxigênio (PaO2) e pressão parcial de dióxido de carbono (PaCO2)], hemodinâmica [freqüência cardíaca (FC), pressão arterial média (PAM) e pressão da artéria pulmonar (PAP)], parâmetros ventilatórios [pressão media das vias aéreas (Pmédia); complacência estática (Cst) e resistência das vias aéreas (Rest)], resposta inflamatória [interleuina 8 (IL-8)] e estresse oxidativo [substância reativa ao ácido tiobarbitúrico (TBARS) and superóxido dismutase (SOD)]. Material e Métodos: Doze porcos pesando aproximadamente 30kg foram submetidos a transplante pulmonar esquerdo. Os animais foram randomizados em dois grupos de diferentes valores de PEEP: Grupo 1 (PEEP=5cmH2O) e Grupo 2 (PEEP=10cmH2O). Dados hemodinâmicos, troca gasosa e mecânica respiratória foram medidos em diferentes tempos após o transplante durante 210 minutos. Foi realizada análise histológica, de IL-8 e estresse oxidativo no tecido pulmonar. Resultados: O grupo 2 apresentou aumento significativo da FC (p=0,006) e Cst (p=0.001), diminuição da PAM (p=0.003) e Rest (p=0.001). Não houve diferença entre os grupos na concentração de TBARS, SOD e IL-8. Contudo, após o período de observação, o grupo 2 mostrou um aumento da concentração de TBARS (p=0,001) e IL-8 (p=0,05) e o grupo 1 um aumento da SOD (p=0,05) comparado com os valores iniciais. Conclusão: O uso de altos níveis de PEEP, após o transplante pulmonar unilateral, não resultou em melhora da troca gasosa. Embora apresentasse uma melhora da mecânica respiratória, a PEEP de 10 cmH2O teve impacto negativo nos parâmetros hemodinâmicos, e provocou um aumento da resposta inflamatória e estresse oxidativo. / Objective: Evaluate the effects of two different levels of positive end expiratory pressure (PEEP) on pigs submitted to unilateral lung transplantation through blood gas exchange [partial oxygen arterial pressure (PaO2) and partial carbon dioxide arterial pressure (PaCO2)], hemodynamics [heart rate (HR), mean arterial pressure (MAP) and pulmonary arterial pressure (PAP)], ventilatory parameters [mean airway pressure (P(aw)); static compliance (Cst) and airway resistance (Rest)], inflammatory response [interleukin 8 (IL-8)] and oxidative stress [thiobarbituric acid reactive substances (TBARS) and superoxide dismutase (SOD)]. Material and Methods: Twelve pigs were submitted to left lung transplantation. The animals were randomized into two groups of different PEEP levels: Group 1 (PEEP = 5cmH2O) and Group 2 (PEEP = 10cmH2O). Hemodynamics, gas exchange and respiratory mechanics were measured prior and after surgery for 210 minutes. Cytokines, oxidative stress and histological score were assessed in lung tissue. Results: Group 2 had significantly higher HR (p=0.006), Cst (p=0.001) and lower MAP (p=0.003) and Rest (p=0.001). There were no differences between both groups in TBARS, SOD and IL-8, concentration after transplant. However, at the end of the observation period, group 2 showed higher TBARS (p=0.001) and IL-8 (p=0.05) concentration and group 1 presented higher SOD (p=0.05) when compared to baseline. Conclusion: After unilateral lung transplantation, higher PEEP levels had no effect on gas exchange. Although, 10 cmH2O PEEP improved respiratory mechanics, it had a negative impact on hemodynamics and stimulated a high inflammatory response and production of reactive oxygen species.

INTRODUÇÃO: O transplante pulmonar é a única opção terapêutica para determinados pacientes com doença pulmonar em estágio terminal. A maioria dos transplantes de pulmão é realizada a partir de doadores em morte encefálica, condição que per si pode comprometer o sucesso do procedimento. A fisiopatologia da morte encefálica é complexa e envolve mecanismos hemodinâmicos, simpáticos e inflamatórios. A administração de metilprednisolona 60 minutos após indução da morte encefálica reduz a atividade inflamatória em pulmões de ratos. OBJETIVO: Avaliar os efeitos do tratamento com metilprednisolona em pulmões de ratos transplantados a partir de ratos doadores induzidos à morte encefálica quando administrada 60 minutos após indução da mesma. MÉTODOS: doze ratos Wistar foram randomizados e anestesiados em 2 grupos (n=6): controle: indução de morte encefálica e administração de solução salina; metilprednisolona (MET): indução de morte encefálica e administração de metilprednisolona 60 minutos após. Os animais foram observados e ventilados por 120 minutos e depois submetidos a transplante pulmonar. Foram avaliados parâmetros hemodinâmicos e gasométricos, escore histológico, dosagem de substâncias reativas ao ácido tiobarbitúrico (TBARS), superóxido dismutase (SOD), TNF-α e interleucina-1β (IL-1β). RESULTADOS: houve redução significativa dos níveis de TNF-α e IL-1β no grupo que recebeu metilprednisolona (p=0,0084; p=0,0155, respectivamente). Não houve diferença significativa na atividade do TBARS e SOD entre os grupos controle e MET (p=0,2644; p=0,7461, respectivamente). Não houve diferença significativa na gasometria, nos parâmetros hemodinâmicos, e nas alterações histológicas entre os grupos controle e MET. CONCLUSÃO: a utilização de metilprednisolona após a morte encefálica em ratos doadores reduz a atividade inflamatória em pulmões transplantados, mas não tem influencia sobre o estresse oxidativo. / INTRODUCTION: Lung transplantation is the only therapeutic option for a subset of patients with end-stage lung disease. Most lung transplantations are performed using brain-dead donors, a condition that compromises the success of the procedure. The physiopathology of brain death is complex and involves haemodynamics, the sympathetic nervous system and inflammatory mechanisms. Administering methylprednisolone 60 minutes after inducing brain death in rats has been shown to modulate pulmonary inflammatory activity. OBJECTIVE: To evaluate the effects of methylprednisolone on transplanted rat lungs from donors treated 60 minutes after brain death. METHODS: Twelve Wistar rats were anaesthetised and randomly assigned to 1 of 2 groups (n=6): a control group that underwent the induction of brain death and the administration of saline solution and a methylprednisolone (MET) group that underwent the induction of brain death and the administration of methylprednisolone after 60 minutes. All of the animals were observed and ventilated for 120 minutes and then submitted to lung transplantation. We evaluated haemodynamic and blood gas parameters, the histologic score, the lung tissue determination of thiobarbituric acid-reactive substances (TBARS), the level of superoxide dismutase (SOD), the level of TNF-α and the level of interleukin-1β (IL-1β). RESULTS: There was a significant reduction in the levels of TNF-α and IL-1β in the group that received methylprednisolone (p=0.0084 and p=0.0155, respectively). There were no significant differences in TBARS and SOD between the control and MET groups (p=0.2644 and p=0.7461, respectively). There were no significant differences in the blood gas parameters, the haemodynamic parameters and the histologic alterations between the control and MET groups. CONCLUSION: The administration of methylprednisolone after brain death in donor rats reduces inflammatory activity in transplanted lungs but has no influence on oxidative stress.