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Transplantation
PATHOLOGIC EFFECTS OF
TOBACCO SMOKING
Tobacco smoking affects multiple organ systems in the
human body, impairing both psychologic and physical wellbeing and are summarized in other reviews and Figure 1.
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FIGURE 1. Physiological and psychological effects of smoking on humans. MAO-B, monoamine oxidase B; FEV-1, forced
expiratory volume in one second; COPD, chronic obstructive pulmonary disease; NASH, nonalcoholic steatohepatitis; PSC,
primary sclerosing cholangitis; UC, ulcerative colitis.
issues. The risks associated with these organs must be balanced against the risk of dying or becoming untransplantable
if these organs are not used (16) and potential candidates
must be appropriately consented.
Lung Transplantation
A retrospective study by Bonser et al. (17) of 1295
United Kingdom lung transplant recipients found that 39%
of the transplanted lungs were from donors with a history of
smoking. Three-year survival after transplantation in recipients of positive smoking history lungs was worse with an
adjusted hazard ratio (HR) of 1.36 (95% CI [95% confidence
interval], 1.11Y1.67) compared with nonsmokers lungs. Declining these organs, however, would have increased waitlist
mortality, so the overall patient survival would be reduced.
Statistical modeling confirmed that the potential recipient
offered a lung donated from a smoker has a better chance of
survival if the lungs are used rather than wait for the next
suitable offer.
In contrast, two smaller studies assessing 424 and
173 recipients failed to find a statistically significant impact
from the use of lungs from smokers on late mortality. There
was an increased odds of an intensive care stay for more than
2 days compared with nonsmokers donor lungs (95% CI,
1.3Y3.1; P=0.001) (12). Ventilation times were raised in
those who received organs from donors with 920 pack-years
(HR, 0.41; 95% CI, 0.22Y0.78; P=0.01) (18).
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Corbett et al.
TABLE 1.
Transplantation
Cessation
Effect on listing
Lung [13]
Contraindication
Tobacco smoking
(also includes
alcohol; narcotics;
other illegal
substances)
Kidney [15]
Tobacco smoking
Heart [14]
Tobacco smoking
Liver [15]
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Tobacco smoking
Duration of
abstinence
Management
Q 6 months
Biochemical
(in high risk)
monitoring
and smoking
cessation
signed contracts
Strongly advised;
Not specified Education; Some
not a contraindication
centres adopt
urine sampling
Relative
Contraindication
Risks of recipient
smoking compared to non
smoking recipients
Increased risk of CKD HR
1.69 (1.27Y2.24)
Allograft loss HR
1.43 (1.16Y1.76)
Death HR 2.26 (1.91Y2.66)
Transplant failure
33.3% vs. 21.2%
Cancer HR 1.12 (1.02Y1.21)
Ideally
Formal smoking
Death HR 1.6 (1.09Y2.34)
6 months
cessation programs
should be offered Renal dysfunction HR
1.97 (1.06Y4.26)
Strongly advised;
Not specified Not specified
not a contraindication
Skin cancer HR
2.25 (1.29Y3.93)
Solid organ cancer HR
4.53 (2.33Y8.78)
Biliary complications HR
1.92 (1.07Y3.43)
Hepatic Artery Thrombosis RR
2.49 (1.16Y5.33)
10-yr rate of cancer
12.7% vs. 2.1%
CKD, chronic kidney disease; HR, hazard ratio; RR, risk ratio.
RECIPIENT SMOKING
Effects of Smoking on the Immune System of
Transplanted Patients
Potential immunologic pathways have been investigated in mouse models to explain how smoking might
contribute to organ rejection. Indoleamine 2,3-dioxygenase
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171
Retrospective
Prospective
Prospective
Prospective
Prospective
Prospective
Prospective
Prospective
Prospective
Heart
Heart
Renal
Renal
Heart
Lung
Liver (ALD)
Liver
Liver
Liver
Organ
transplant
Self-report, urinary
cotinine and
exhaled CO
Self-report
Self-report
and serum cotinine
Self-report
Self-report
Self-report
Detection
method
ALD, alcoholic liver disease; CO, carbon dioxide; COPD, chronic obstructive pulmonary disease.
380
84
226
264 post-allograft
103
267
172
202
301
Prospective
Number
Study type
TABLE 2.
74%
42%
13%
0%
62% former,
38% never
34% never
10%
17%
17%
8% never
53%
Non-smokers
Active at
assessment
Smoking rates
19% G1 year
Roughly 33%
Cessation
before
transplant
17.6% in long-term
ex-smokers
40% in short-term
ex-smokers
27%
26%
12%
40%
15% (20% of
ex-smokers)
11% (23% in COPD)
20%
12%
Recidivism
after
transplantation
Corbett et al.
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Corbett et al.
TABLE 3.
985
Type
Intervention
Gum
Transdermal patch
Nasal Spray
Inhaled Nicotine
All trials
Stead 2008 [56]
Cochrane review of 132 trials and
Gum
40,00 patients
Transdermal patch
Nasal Spray
Inhaled Nicotine
Oral tablets/lozenges
Any form of NRT
Strassmann 2009 [57] Meta analysis of 6 trials and
Nicotine replacement
7372 COPD patients
therapy and counselling
vs. standard care
Nicotine replacement
therapy and counselling
vs. counselling
Nicotine replacement
therapy and counselling
vs. counselling 3.30)
Counselling vs. usual care
Eisenberg 2008 [58] Meta analysis of 69 trials
Varenicline
covering 32908 patients
Nicotine Nasal Spray
Bupropion
Nicotine patch
Tablets
Gum
Inhaled Nicotine
RR of abstinence
1.61 (1.46Y1.78)
2.07 (1.64Y2.62)
2.92 (1.49Y5.74)
3.05 (1.56Y1.87)
1.71 (1.56Y1.87)
1.43 (1.33Y1.53)
1.66 (1.53Y1.81)
2.02 (1.49Y3.73)
1.90 (1.36Y2.67)
2.00 (1.63Y2.45)
1.58 (1.50Y1.66)
5.08 (4.32Y5.97)
2.80 (1.49Y5.26)
1.53 (0.71Y3.30)
1.82 (0.96Y3.44)
2.41 (1.91Y3.12)
2.37 (1.12Y5.15)
2.07 (1.73Y2.55)
2.07 (1.69Y2.62)
2.06 (1.12Y5.13)
1.71 (1.35Y2.21)
2.17 (0.95Y5.43)
RR, risk ratio; NRT, nicotine replacement therapy; COPD, chronic obstructive pulmonary disease.
CONCLUSION
Smoking remains a preventable but addictive and
common health risk with a proven mortality and morbidity
(respiratory disease, cancers, and atherosclerotic problems)
in the general population. There are, however, greater
implications in the transplant population with increased risk
of perioperative problems such as sepsis and prolonged
hospital stay. Later complications are varied and include
graft dysfunction and possible graft loss.
Denial of transplantation to smokers, however, would
be ethically hard to defend on the grounds of distributive
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Corbett et al.
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