Kommaraju, Kavya

ABSTRACT Introduction Calcineurin inhibitors (CNIs) are the cornerstone of lung transplant immunosuppression but are associated with nephrotoxicity and other adverse effects. Although dose reduction and combination with Sirolimus, a mammalian target of rapamycin inhibitor (mTORi), have been explored, full conversion to Sirolimus remains uncommon. This study describes the characteristics and outcomes of lung transplant recipients who underwent complete CNI withdrawal and conversion to Sirolimus. Methods This retrospective case series included 52 lung transplant recipients transitioned to Sirolimus‐based immunosuppression between 2010 and 2021. Data on demographics, transplant characteristics, immunosuppression, and outcomes were collected from electronic medical records. Results The cohort included 31 males (59.6%) with a median age of 58.4 years (IQR 52.3–63.5). The primary indication for CNI withdrawal was renal dysfunction (73.1%). Sirolimus discontinuation occurred in 69.2%, most commonly due to edema (25.0%), lung toxicity (19.4%), rejection (19.4%), and surgical needs (22.2%). Clinically significant rejection occurred in 13.5%, with four patients progressing to chronic lung allograft dysfunction (CLAD) and two deaths. Sixteen patients (30.8%) tolerated CNI withdrawal for over a year. Conclusion Full conversion from CNI to Sirolimus is poorly tolerated due to side effects and has a high incidence of rejection. Further studies are needed to optimize patient selection and risk mitigation strategies.

Abstract Background In the United States, a growing number of lung transplants are performed each year, necessitating an increased number of general and transplant pulmonologists skilled in the care of these complex patients. However, pulmonary and critical care medicine (PCCM) fellowships across the country do not universally have dedicated lung transplantation curricula, and there is scarce literature in this area. We describe the generation of a content outline for curriculum development created through modified electronic Delphi methodology. Objective To identify “must know” topics in lung transplantation for a graduating PCCM fellows. Methods We developed expert consensus on “must know” lung transplant topics and subtopics (“items”) for a graduating fellow through three survey rounds from July 2023 to October 2023. Thirty-three panelists were asked to rank author-provided items as “must know,” “nice to know,” or “not necessary to know” and to generate new items in round 1 to be submitted for ranking in subsequent rounds. “Must know consensus” was defined as ≥50% must know responses. Results Survey response and completion rates across rounds were 58–70% and 96–100%, respectively. In round 1, panelists were provided eight topics and 30 subtopics for initial ranking. Panelists generated 82 new items in this round, of which 19 were included in round 2 for ranking after author review, together with one item from round 1 that required reranking. From round 2, only two items required reranking, and these items comprised round 3. Seven topics were identified as “must know”: transplant immunology, evaluation of a lung transplant candidate, surgical and peri/postoperative management, rejection, immunosuppression, infections, and other complications, together with 36 subtopics. Conclusion Self-identified lung transplantation experts obtained consensus on seven “must know” topics and 36 subtopics in lung transplantation for graduating PCCM fellows. The findings serve as a starting point for future curriculum development.

Abstract Foundational training in critical care medicine is an integral part of both undergraduate and graduate medical education. Yet, many medical school graduates enter residency underprepared to care for critically ill patients because of a lack of ubiquity of undergraduate critical care education and the heterogeneity of existing didactic and clinical experiences. This Perspective explores the importance of undergraduate critical care education, the current national and international landscape, innovative educational strategies and exemplar curricula, and recent advances in assessment that may better reflect learner-centered educational outcomes. As broad curricular reforms push medical education toward a more innovative, interactive, and collaborative future, now is the time to rethink and reimagine undergraduate critical care education.