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Verleden SE, Vos R, Vanaudenaerde BM, Verleden GM. Chronic lung allograft dysfunction phenotypes and treatment. J Thorac Dis 2017; 9:2650-2659. [PMID: 28932572 DOI: 10.21037/jtd.2017.07.81] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Chronic lung allograft dysfunction (CLAD) remains a major hurdle limiting long-term survival post lung transplantation. Given the clinical heterogeneity of CLAD, recently two phenotypes of CLAD have been defined [bronchiolitis obliterans syndrome (BOS) vs. restrictive allograft syndrome (RAS) or restrictive CLAD (rCLAD)]. BOS is characterized by an obstructive pulmonary function, air trapping on CT and obliterative bronchiolitis (OB) on histopathology, while RAS/rCLAD patients show a restrictive pulmonary function, persistent pleuro-parenchymal infiltrates on CT and pleuroparenchymal fibro-elastosis on biopsies. Importantly, the patients with RAS/rCLAD have a severely limited survival post diagnosis of 6-18 months compared to 3-5 years after BOS diagnosis. In this review, we will review historical evidence for this heterogeneity and we will highlight the clinical, radiological, histopathological characteristics of both phenotypes, as well as their risk factors. Treatment of CLAD remains troublesome, nevertheless, we will give an overview of different treatment strategies that have been tried with some success. Adequate phenotyping remains difficult but is clearly needed for both clinical and scientific purposes.
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Affiliation(s)
- Stijn E Verleden
- Department of Clinical and Experimental Medicine, Lung Transplant Unit, KU Leuven, Leuven, Belgium
| | - Robin Vos
- Department of Clinical and Experimental Medicine, Lung Transplant Unit, KU Leuven, Leuven, Belgium
| | - Bart M Vanaudenaerde
- Department of Clinical and Experimental Medicine, Lung Transplant Unit, KU Leuven, Leuven, Belgium
| | - Geert M Verleden
- Department of Clinical and Experimental Medicine, Lung Transplant Unit, KU Leuven, Leuven, Belgium
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202
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Horie M, Saito T, Moseley J, D'Errico L, Salazar P, Nakajima D, Brock K, Yasufuku K, Binnie M, Keshavjee S, Paul N. The role of biomechanical anatomical modeling via computed tomography for identification of restrictive allograft syndrome. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.13027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2017] [Indexed: 12/26/2022]
Affiliation(s)
- Miho Horie
- Joint Department of Medical Imaging; University Health Network; University of Toronto; Toronto ON Canada
- Institute for Biomaterials and Biomedical Engineering; University of Toronto; Toronto ON Canada
| | - Tomohito Saito
- Latner Thoracic Surgery Research Laboratories; Toronto General Research Institute; University Health Network; University of Toronto; Toronto ON Canada
- Toronto Lung Transplant Program; University Health Network; University of Toronto; ON Canada
- Department of Thoracic Surgery; Kansai Medical University; Hirakara Japan
| | - Joanne Moseley
- Princess Margaret Cancer Center; University Health Network; University of Toronto; Toronto ON Canada
| | - Luigia D'Errico
- Joint Department of Medical Imaging; University Health Network; University of Toronto; Toronto ON Canada
| | | | - Daisuke Nakajima
- Latner Thoracic Surgery Research Laboratories; Toronto General Research Institute; University Health Network; University of Toronto; Toronto ON Canada
- Toronto Lung Transplant Program; University Health Network; University of Toronto; ON Canada
| | - Kristy Brock
- Department of Imaging Physics; The University of Texas M.D. Anderson Cancer Center; Houston TX USA
| | - Kazuhiro Yasufuku
- Latner Thoracic Surgery Research Laboratories; Toronto General Research Institute; University Health Network; University of Toronto; Toronto ON Canada
- Toronto Lung Transplant Program; University Health Network; University of Toronto; ON Canada
| | - Matthew Binnie
- Latner Thoracic Surgery Research Laboratories; Toronto General Research Institute; University Health Network; University of Toronto; Toronto ON Canada
- Toronto Lung Transplant Program; University Health Network; University of Toronto; ON Canada
| | - Shaf Keshavjee
- Institute for Biomaterials and Biomedical Engineering; University of Toronto; Toronto ON Canada
- Latner Thoracic Surgery Research Laboratories; Toronto General Research Institute; University Health Network; University of Toronto; Toronto ON Canada
- Toronto Lung Transplant Program; University Health Network; University of Toronto; ON Canada
- Department of Thoracic Surgery; Kansai Medical University; Hirakara Japan
| | - Narinder Paul
- Joint Department of Medical Imaging; University Health Network; University of Toronto; Toronto ON Canada
- Institute for Biomaterials and Biomedical Engineering; University of Toronto; Toronto ON Canada
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203
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Belloli EA, Degtiar I, Wang X, Yanik GA, Stuckey LJ, Verleden SE, Kazerooni EA, Ross BD, Murray S, Galbán CJ, Lama VN. Parametric Response Mapping as an Imaging Biomarker in Lung Transplant Recipients. Am J Respir Crit Care Med 2017; 195:942-952. [PMID: 27779421 DOI: 10.1164/rccm.201604-0732oc] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
RATIONALE The predominant cause of chronic lung allograft failure is small airway obstruction arising from bronchiolitis obliterans. However, clinical methodologies for evaluating presence and degree of small airway disease are lacking. OBJECTIVES To determine if parametric response mapping (PRM), a novel computed tomography voxel-wise methodology, can offer insight into chronic allograft failure phenotypes and provide prognostic information following spirometric decline. METHODS PRM-based computed tomography metrics quantifying functional small airways disease (PRMfSAD) and parenchymal disease (PRMPD) were compared between bilateral lung transplant recipients with irreversible spirometric decline and control subjects matched by time post-transplant (n = 22). PRMfSAD at spirometric decline was evaluated as a prognostic marker for mortality in a cohort study via multivariable restricted mean models (n = 52). MEASUREMENTS AND MAIN RESULTS Patients presenting with an isolated decline in FEV1 (FEV1 First) had significantly higher PRMfSAD than control subjects (28% vs. 15%; P = 0.005), whereas patients with concurrent decline in FEV1 and FVC had significantly higher PRMPD than control subjects (39% vs. 20%; P = 0.02). Over 8.3 years of follow-up, FEV1 First patients with PRMfSAD greater than or equal to 30% at spirometric decline lived on average 2.6 years less than those with PRMfSAD less than 30% (P = 0.004). In this group, PRMfSAD greater than or equal to 30% was the strongest predictor of survival in a multivariable model including bronchiolitis obliterans syndrome grade and baseline FEV1% predicted (P = 0.04). CONCLUSIONS PRM is a novel imaging tool for lung transplant recipients presenting with spirometric decline. Quantifying underlying small airway obstruction via PRMfSAD helps further stratify the risk of death in patients with diverse spirometric decline patterns.
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Affiliation(s)
| | | | - Xin Wang
- 2 Department of Biostatistics, and
| | - Gregory A Yanik
- 3 Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan; and
| | | | - Stijn E Verleden
- 5 Lung Transplant Unit, Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
| | - Ella A Kazerooni
- 6 Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Brian D Ross
- 6 Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan
| | | | - Craig J Galbán
- 6 Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Vibha N Lama
- 1 Division of Pulmonary and Critical Care Medicine
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204
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Analysis of long term CD4+CD25highCD127- T-reg cells kinetics in peripheral blood of lung transplant recipients. BMC Pulm Med 2017; 17:102. [PMID: 28720146 PMCID: PMC5516333 DOI: 10.1186/s12890-017-0446-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 07/14/2017] [Indexed: 12/26/2022] Open
Abstract
Background The role of CD4+CD25highCD127− T-reg cells in solid-organ Transplant (Tx) acceptance has been extensively studied. In previous studies on kidney and liver recipients, peripheral T-reg cell counts were associated to graft survival, while in lung Tx, there is limited evidence for similar findings. This study aims to analyze long term peripheral kinetics of T-reg-cells in a cohort of lung recipients and tests its association to several clinical variables. Methods From jan 2009 to dec 2014, 137 lung Tx recipients were submitted to an immunological follow up (median: 105.9 months (6.7–310.5)). Immunological follow up consisted of a complete blood peripheral immuno-phenotype, inclusive of CD4+CD25highCD127− T and FOXP3+ cells. We tested the association between T-reg and relevant variables by linear OR regression models for repeated measures, adjusting for time from Tx. Also, by ordered logistic models for panel data, the association between Chronic Lung Allograft Dysfuncton (CLAD) onset/progression and T-reg counts in the previous 3 months was tested. Results Among all variables analyzed at multivariate analysis: Bronchiolitis Obliterans Syndrome (OR −6.51, p < 0.001), Restrictive Allograft Syndrome (OR −5.19, p = 0.04) and Extracorporeal photopheresis (OR −5.65, p < 0.001) were significantly associated to T-reg cell. T-reg cell counts progressively decreased according to the severity of CLAD. Furthermore, patients with higher mean T-reg counts in a trimester had a significantly lower risk (OR 0.97, p = 0.012) of presenting CLAD or progressing in the graft dysfunction in the following trimester. Conclusions Our present data confirm animal observations on the possible role of T-reg in the evolution of CLAD.
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205
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Koutsokera A, Royer PJ, Antonietti JP, Fritz A, Benden C, Aubert JD, Tissot A, Botturi K, Roux A, Reynaud-Gaubert ML, Kessler R, Dromer C, Mussot S, Mal H, Mornex JF, Guillemain R, Knoop C, Dahan M, Soccal PM, Claustre J, Sage E, Gomez C, Magnan A, Pison C, Nicod LP. Development of a Multivariate Prediction Model for Early-Onset Bronchiolitis Obliterans Syndrome and Restrictive Allograft Syndrome in Lung Transplantation. Front Med (Lausanne) 2017; 4:109. [PMID: 28770204 PMCID: PMC5511826 DOI: 10.3389/fmed.2017.00109] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 06/30/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Chronic lung allograft dysfunction and its main phenotypes, bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS), are major causes of mortality after lung transplantation (LT). RAS and early-onset BOS, developing within 3 years after LT, are associated with particularly inferior clinical outcomes. Prediction models for early-onset BOS and RAS have not been previously described. METHODS LT recipients of the French and Swiss transplant cohorts were eligible for inclusion in the SysCLAD cohort if they were alive with at least 2 years of follow-up but less than 3 years, or if they died or were retransplanted at any time less than 3 years. These patients were assessed for early-onset BOS, RAS, or stable allograft function by an adjudication committee. Baseline characteristics, data on surgery, immunosuppression, and year-1 follow-up were collected. Prediction models for BOS and RAS were developed using multivariate logistic regression and multivariate multinomial analysis. RESULTS Among patients fulfilling the eligibility criteria, we identified 149 stable, 51 BOS, and 30 RAS subjects. The best prediction model for early-onset BOS and RAS included the underlying diagnosis, induction treatment, immunosuppression, and year-1 class II donor-specific antibodies (DSAs). Within this model, class II DSAs were associated with BOS and RAS, whereas pre-LT diagnoses of interstitial lung disease and chronic obstructive pulmonary disease were associated with RAS. CONCLUSION Although these findings need further validation, results indicate that specific baseline and year-1 parameters may serve as predictors of BOS or RAS by 3 years post-LT. Their identification may allow intervention or guide risk stratification, aiming for an individualized patient management approach.
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Affiliation(s)
- Angela Koutsokera
- Division of Pulmonary Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Pierre J Royer
- Institut du thorax, INSERM UMR 1087/CNRS UMR 6291, CHU de Nantes, Université de Nantes, Nantes, France
| | - Jean P Antonietti
- Division of Pulmonary Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | | | - Christian Benden
- Division of Pulmonary Medicine, University Hospital Zurich, Zurich, Switzerland
| | - John D Aubert
- Division of Pulmonary Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Adrien Tissot
- Institut du thorax, INSERM UMR 1087/CNRS UMR 6291, CHU de Nantes, Université de Nantes, Nantes, France
| | - Karine Botturi
- Institut du thorax, INSERM UMR 1087/CNRS UMR 6291, CHU de Nantes, Université de Nantes, Nantes, France
| | - Antoine Roux
- Pneumology, Adult CF Center and Lung transplantation Department, Foch Hospital, Université Versailles Saint-Quentin-en-Yvelines, UPRES EA220, Suresnes, France
| | - Martine L Reynaud-Gaubert
- Pulmonary Medicine, CF Center and Lung Transplantation Department, Centre Hospitalier Universitaire Nord, CNRS UMR 6236 Aix-Marseille Université, Marseille, France
| | - Romain Kessler
- Lung Transplant Center, Hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - Claire Dromer
- Service des Maladies respiratoires, Hôpital Haut Lévèque, Pessac, France
| | - Sacha Mussot
- Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardiopulmonaire, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Hervé Mal
- Service de Pneumologie et Transplantation pulmonaire, Hôpital Bichat, Université Denis Diderot, INSERM UMR1152, Paris, France
| | | | | | - Christiane Knoop
- Department of Chest Medicine, Erasme University Hospital, Brussels, Belgium
| | | | - Paola M Soccal
- Division of Pulmonary Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Johanna Claustre
- Clinique Universitaire de Pneumologie, Pôle Thorax et Vaisseaux, CHU Grenoble, INSERM 1055, Université Grenoble Alpes, Grenoble, France
| | - Edouard Sage
- Thoracic Surgery Department, Foch Hospital, Université Versailles Saint-Quentin-en-Yvelines, UPRES EA220, Suresnes, France
| | - Carine Gomez
- Pulmonary Medicine, CF Center and Lung Transplantation Department, Centre Hospitalier Universitaire Nord, CNRS UMR 6236 Aix-Marseille Université, Marseille, France
| | - Antoine Magnan
- Institut du thorax, INSERM UMR 1087/CNRS UMR 6291, CHU de Nantes, Université de Nantes, Nantes, France
| | - Christophe Pison
- Clinique Universitaire de Pneumologie, Pôle Thorax et Vaisseaux, CHU Grenoble, INSERM 1055, Université Grenoble Alpes, Grenoble, France
| | - Laurent P Nicod
- Division of Pulmonary Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
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206
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Shino MY, Weigt SS, Li N, Palchevskiy V, Derhovanessian A, Saggar R, Sayah DM, Huynh RH, Gregson AL, Fishbein MC, Ardehali A, Ross DJ, Lynch JP, Elashoff RM, Belperio JA. The prognostic importance of CXCR3 chemokine during organizing pneumonia on the risk of chronic lung allograft dysfunction after lung transplantation. PLoS One 2017; 12:e0180281. [PMID: 28686641 PMCID: PMC5501470 DOI: 10.1371/journal.pone.0180281] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 06/13/2017] [Indexed: 12/11/2022] Open
Abstract
RATIONALE Since the pathogenesis of chronic lung allograft dysfunction (CLAD) remains poorly defined with no known effective therapies, the identification and study of key events which increase CLAD risk is a critical step towards improving outcomes. We hypothesized that bronchoalveolar lavage fluid (BALF) CXCR3 ligand concentrations would be augmented during organizing pneumonia (OP) and that episodes of OP with marked chemokine elevations would be associated with significantly higher CLAD risk. METHODS All transbronchial biopsies (TBBX) from patients who received lung transplantation between 2000 to 2010 were reviewed. BALF concentrations of the CXCR3 ligands (CXCL9, CXCL10 and CXCL11) were compared between episodes of OP and "healthy" biopsies using linear mixed-effects models. The association between CXCR3 ligand concentrations during OP and CLAD risk was evaluated using proportional hazards models with time-dependent covariates. RESULTS There were 1894 bronchoscopies with TBBX evaluated from 441 lung transplant recipients with 169 (9%) episodes of OP and 907 (49%) non-OP histopathologic injuries. 62 (37%) episodes of OP were observed during routine surveillance bronchoscopy. Eight hundred thirty-eight (44%) TBBXs had no histopathology and were classified as "healthy" biopsies. There were marked elevations in BALF CXCR3 ligand concentrations during OP compared with "healthy" biopsies. In multivariable models adjusted for other injury patterns, OP did not significantly increase the risk of CLAD when BAL CXCR3 chemokine concentrations were not taken into account. However, OP with elevated CXCR3 ligands markedly increased CLAD risk in a dose-response manner. An episode of OP with CXCR3 concentrations greater than the 25th, 50th and 75th percentiles had HRs for CLAD of 1.5 (95% CI 1.0-2.3), 1.9 (95% CI 1.2-2.8) and 2.2 (95% CI 1.4-3.4), respectively. CONCLUSIONS This study identifies OP, a relatively uncommon histopathologic finding after lung transplantation, as a major risk factor for CLAD development when considered in the context of increased allograft expression of interferon-γ inducible ELR- CXC chemokines. We further demonstrate for the first time, the prognostic importance of BALF CXCR3 ligand concentrations during OP on subsequent CLAD risk.
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Affiliation(s)
- Michael Y. Shino
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
- * E-mail:
| | - S. Samuel Weigt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Ning Li
- Department of Biomathematics, University of California at Los Angeles, Los Angeles, California, United States of America
| | - Vyacheslav Palchevskiy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Ariss Derhovanessian
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Rajan Saggar
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - David M. Sayah
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Richard H. Huynh
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Aric L. Gregson
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Michael C. Fishbein
- Department of Pathology, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Abbas Ardehali
- Division of Cardiothoracic Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - David J. Ross
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Joseph P. Lynch
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Robert M. Elashoff
- Department of Biomathematics, University of California at Los Angeles, Los Angeles, California, United States of America
| | - John A. Belperio
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
- Department of Biomathematics, University of California at Los Angeles, Los Angeles, California, United States of America
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207
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Tangaroonsanti A, Lee AS, Crowell MD, Vela MF, Jones DR, Erasmus D, Keller C, Mallea J, Alvarez F, Almansa C, DeVault KR, Houghton LA. Impaired Esophageal Motility and Clearance Post-Lung Transplant: Risk For Chronic Allograft Failure. Clin Transl Gastroenterol 2017; 8:e102. [PMID: 28662022 PMCID: PMC5518953 DOI: 10.1038/ctg.2017.30] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 05/14/2017] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Gastroesophageal reflux is common in patients post-lung transplantation (LTx) and thus considered a risk factor for aspiration and consequently allograft rejection and the development of chronic allograft failure. However, evidence supporting this remains unclear and often contradictory. Our aim was to examine the role played by esophageal motility on gastroesophageal reflux exposure, along with its clearance and that of boluses swallowed, and the relationship to development of obstructive chronic lung allograft dysfunction (o-CLAD). METHODS Patients post-LTx (n=50, 26 female; mean age 55 years (range, 20-73 years)) completed high-resolution impedance manometry and 24-h pH/impedance. Esophageal motility abnormalities were classified based upon the Chicago Classification version 3.0. RESULTS Esophagogastric junction outflow obstruction alone (EGJOOa) (P=0.01), incomplete bolus transit (IBT) (P=0.006) and proximal reflux (P=0.042) increased the risk for o-CLAD. Patients with EGJOOa were most likely to present with o-CLAD (77%); despite being less likely to exhibit abnormal numbers of reflux events (10%) compared with those with normal motility (o-CLAD: 29%, P<0.05; abnormal reflux events: 64%, P<0.05). Patients with EGJOOa had lower total reflux bolus exposure time than those with normal motility (0.6 vs. 1.5%; P<0.05). In addition, poor esophageal clearance documented by abnormal post-reflux swallow-induced peristaltic wave index associated with o-CLAD; inversely correlating with the proportion of reflux events reaching the proximal esophagus (r=-0.251; P=0.052). CONCLUSIONS These observations support esophageal dysmotility, especially EGJOOa, and impaired clearance of swallowed bolus or refluxed contents, more so than just the presence of gastroesophageal reflux alone, as important risk factors in the development of o-CLAD.
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Affiliation(s)
| | - Augustine S Lee
- Division of Pulmonary Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Michael D Crowell
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - Marcelo F Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - Daryl R Jones
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | | | - Cesar Keller
- Lung Transplant, Mayo Clinic, Jacksonville, FL, USA
| | - Jorge Mallea
- Lung Transplant, Mayo Clinic, Jacksonville, FL, USA
| | | | - Cristina Almansa
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Kenneth R DeVault
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Lesley A Houghton
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, and Leeds Gastroenterology Institute, Leeds Teaching Hospitals Trust, Leeds, UK.,Centre for Gastrointestinal Sciences, University of Manchester, University Hospital of South Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
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208
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Salman J, Ius F, Knoefel AK, Sommer W, Siemeni T, Kuehn C, Tudorache I, Avsar M, Nakagiri T, Preissler G, Hatz R, Greer M, Welte T, Haverich A, Warnecke G. Association of Higher CD4 + CD25 high CD127 low , FoxP3 + , and IL-2 + T Cell Frequencies Early After Lung Transplantation With Less Chronic Lung Allograft Dysfunction at Two Years. Am J Transplant 2017; 17:1637-1648. [PMID: 27931084 DOI: 10.1111/ajt.14148] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 11/13/2016] [Accepted: 11/25/2016] [Indexed: 01/25/2023]
Abstract
Regulatory T cells (Treg) can regulate alloantigens and may counteract chronic lung allograft dysfunction (CLAD) in lung transplantation. We analyzed Treg in peripheral blood prospectively and correlated percentages of subpopulations with the incidence of CLAD at 2 years. Among lung-transplanted patients between January 2009 and July 2011, only patients with sufficient Treg measurements were included into the study. Tregs were measured immediately before lung transplantation, at 3 weeks and 3, 6, 12, and 24 months after transplantation and were defined as CD4+ CD25high T cells and further analyzed for CTLA4, CD127, FoxP3, and IL-2 expressions. Between January 2009 and July 2011, 264 patients were transplanted at our institution. Among the 138 (52%) patients included into the study, 31 (22%) developed CLAD within 2 years after transplantation. As soon as 3 weeks after lung transplantation, a statistically significant positive association was detected between Treg frequencies and later absence of CLAD. At the multivariate analysis, increasing frequencies of CD4+ CD25high CD127low , CD4+ CD25high FoxP3+ and CD4+ CD25high IL-2+ T cells at 3 weeks after lung transplantation emerged as protective factors against development of CLAD at 2 years. In conclusion, higher frequencies of specific Treg subpopulations early after lung transplantation are protective against CLAD development.
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Affiliation(s)
- J Salman
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - F Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - A-K Knoefel
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - W Sommer
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - T Siemeni
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - C Kuehn
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - I Tudorache
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - M Avsar
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - T Nakagiri
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - G Preissler
- Department of Surgery, Munich Lung Transplant Group, Ludwig-Maximilian's University, Munich, Germany
| | - R Hatz
- Department of Surgery, Munich Lung Transplant Group, Ludwig-Maximilian's University, Munich, Germany
| | - M Greer
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - T Welte
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - A Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - G Warnecke
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
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209
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Pain M, Royer PJ, Loy J, Girardeau A, Tissot A, Lacoste P, Roux A, Reynaud-Gaubert M, Kessler R, Mussot S, Dromer C, Brugière O, Mornex JF, Guillemain R, Dahan M, Knoop C, Botturi K, Pison C, Danger R, Brouard S, Magnan A. T Cells Promote Bronchial Epithelial Cell Secretion of Matrix Metalloproteinase-9 via a C-C Chemokine Receptor Type 2 Pathway: Implications for Chronic Lung Allograft Dysfunction. Am J Transplant 2017; 17:1502-1514. [PMID: 27982503 DOI: 10.1111/ajt.14166] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 11/30/2016] [Accepted: 12/04/2016] [Indexed: 01/25/2023]
Abstract
Chronic lung allograft dysfunction (CLAD) is the major limitation of long-term survival after lung transplantation. CLAD manifests as bronchiolitis obliterans syndrome (BOS) or restrictive allograft syndrome (RAS). Alloimmune reactions and epithelial-to-mesenchymal transition have been suggested in BOS. However, little is known regarding the role of allogenicity in epithelial cell differentiation. Primary human bronchial epithelial cells (BECs) were treated with activated T cells in the presence or absence of transforming growth factor (TGF)-β. The expression of epithelial and mesenchymal markers was investigated. The secretion of inflammatory cytokines and matrix metalloproteinase (MMP)-9 was measured in culture supernatants and in plasma from lung transplant recipients (LTRs): 49 stable, 29 with BOS, and 16 with RAS. We demonstrated that C-C motif chemokine 2 secreted by T cells supports TGF-β-induced MMP-9 production by BECs after binding to C-C chemokine receptor type 2. Longitudinal investigation in LTRs revealed a rise in plasma MMP-9 before CLAD onset. Multivariate analysis showed that plasma MMP-9 was independently associated with BOS (odds ratio [OR] = 6.19, p = 0.002) or RAS (OR = 3.9, p = 0.024) and predicted the occurrence of CLAD 12 months before the functional diagnosis. Thus, immune cells support airway remodeling through the production of MMP-9. Plasma MMP-9 is a potential predictive biomarker of CLAD.
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Affiliation(s)
- M Pain
- UMR_S 1087 CNRS UMR_6291, l'Institut du Thorax, Université de Nantes, CHU de Nantes, Centre National de Référence Mucoviscidose Nantes-Roscoff, Nantes, France
| | - P-J Royer
- UMR_S 1087 CNRS UMR_6291, l'Institut du Thorax, Université de Nantes, CHU de Nantes, Centre National de Référence Mucoviscidose Nantes-Roscoff, Nantes, France
| | - J Loy
- UMR_S 1087 CNRS UMR_6291, l'Institut du Thorax, Université de Nantes, CHU de Nantes, Centre National de Référence Mucoviscidose Nantes-Roscoff, Nantes, France
| | - A Girardeau
- UMR_S 1087 CNRS UMR_6291, l'Institut du Thorax, Université de Nantes, CHU de Nantes, Centre National de Référence Mucoviscidose Nantes-Roscoff, Nantes, France
| | - A Tissot
- UMR_S 1087 CNRS UMR_6291, l'Institut du Thorax, Université de Nantes, CHU de Nantes, Centre National de Référence Mucoviscidose Nantes-Roscoff, Nantes, France
| | - P Lacoste
- UMR_S 1087 CNRS UMR_6291, l'Institut du Thorax, Université de Nantes, CHU de Nantes, Centre National de Référence Mucoviscidose Nantes-Roscoff, Nantes, France
| | - A Roux
- Hôpital Foch, Suresnes, Université Versailles Saint-Quentin-en-Yvelines, UPRES EA220, Versailles, France
| | | | - R Kessler
- CHU de Strasbourg, Strasbourg, France
| | - S Mussot
- Centre Chirurgical Marie Lannelongue, Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardiopulmonaire, Le Plessis Robinson, France
| | - C Dromer
- CHU de Bordeaux, Bordeaux, France
| | - O Brugière
- Hôpital Bichat, Service de Pneumologie et Transplantation Pulmonaire, Paris, France
| | - J-F Mornex
- Université de Lyon, INRA, UMR754, Lyon, Hospices Civils de Lyon, Lyon, France
| | | | - M Dahan
- CHU de Toulouse, Toulouse, France
| | - C Knoop
- Hôpital Erasme, Bruxelles, Belgique
| | - K Botturi
- UMR_S 1087 CNRS UMR_6291, l'Institut du Thorax, Université de Nantes, CHU de Nantes, Centre National de Référence Mucoviscidose Nantes-Roscoff, Nantes, France
| | - C Pison
- Clinique Universitaire Pneumologie, Pôle Thorax et Vaisseaux, CHU de Grenoble, Université de Grenoble, INSERM U1055, Grenoble, France
| | - R Danger
- Université de Nantes, INSERM U1064 and Institut de Transplantation Urologie Néphrologie du Centre Hospitalier Universitaire Hôtel Dieu, Nantes, France
| | - S Brouard
- Université de Nantes, INSERM U1064 and Institut de Transplantation Urologie Néphrologie du Centre Hospitalier Universitaire Hôtel Dieu, Nantes, France
| | - A Magnan
- UMR_S 1087 CNRS UMR_6291, l'Institut du Thorax, Université de Nantes, CHU de Nantes, Centre National de Référence Mucoviscidose Nantes-Roscoff, Nantes, France
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The Lymphatic Phenotype of Lung Allografts in Patients With Bronchiolitis Obliterans Syndrome and Restrictive Allograft Syndrome. Transplantation 2017; 101:310-315. [PMID: 27163544 DOI: 10.1097/tp.0000000000001263] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Chronic lung allograft dysfunction (CLAD), presenting as bronchiolitis obliterans syndrome (BOS) or restrictive allograft syndrome (RAS) is the major limiting factor of long-term survival in lung transplantation. Its pathogenesis is still obscure. In BOS, persistent alloimmune injury and chronic airway inflammation are suggested. One of the main tasks of the lymphatic vessel (LV) system is the promotion of immune cell trafficking. The formation of new LVs has been shown to trigger chronic allograft rejection in kidney transplants. We therefore sought to address the role of lymphangiogenesis in CLAD. METHODS Formalin-fixed paraffin-embedded tissue samples of 22 patients receiving a lung retransplantation due to BOS or RAS were collected. Lymphatic vessel density (LVD) was determined by immunohistochemical staining for podoplanin. Lung tissue obtained from 13 non-CLAD patients served as control. The impact of LVD on graft survival was assessed. RESULTS Lymphatic vessel density in CLAD patients did not differ from those in control subjects (median number of LVs per bronchiole: 4.75 (BOS), 6.47 (RAS), 4.25 (control), P = 0.97). Moreover, the number of LVs was not associated with regions of cellular infiltrates (median number of LVs per bronchiole: with infiltrates, 5.00 (BOS), 9.00 (RAS), 4.00 (control), P = 0.62; without infiltrates, 4.5 (BOS), 0.00 (RAS), 4.56 (control), P = 0.74). Lymphatic vessel density did not impact the time to development of BOS or RAS in lung transplantation (low vs high LVD: 38.5 vs 86.0 months, P = 0.15 [BOS]; 60.5 vs 69.5 months, P = 0.80 [RAS]). CONCLUSIONS Unlike chronic organ failure in kidney transplantation, lymphangiogenesis is not altered in CLAD patients. Our findings highlight unique immunological processes leading to BOS and RAS.
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211
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Mariani F, Gatti B, Rocca A, Bonifazi F, Cavazza A, Fanti S, Tomassetti S, Piciucchi S, Poletti V, Zompatori M. Pleuroparenchymal fibroelastosis: the prevalence of secondary forms in hematopoietic stem cell and lung transplantation recipients. Diagn Interv Radiol 2017; 22:400-6. [PMID: 27460284 DOI: 10.5152/dir.2016.15516] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE Pleuroparenchymal fibroelastosis (PPFE) is a rare form of interstitial pneumonia, characterized by elastotic fibrosis involving the pleura and subpleural parenchyma, predominantly in the upper lobes. PPFE can be either idiopathic or secondary and mostly occurs as a late complication of lung or hematopoietic stem cell transplantation (HSCT). The aim of this study was to evaluate the prevalence of secondary forms in transplant recipients. METHODS An expert thoracic radiologist retrospectively reviewed high-resolution computed tomography exams of 700 HSCT recipients and 53 lung transplant recipients from the database of the Radiology Department of S. Orsola-Malpighi Hospital dating back from 2007. For each case that radiologically fulfilled PPFE criteria, the following details were retrieved: clinical characteristics, laboratory and functional data, pathologic findings (obtained from one patient) and metabolic data (obtained from three patients). RESULTS Six cases clinically and radiologically consistent with PPFE were identified: two HSCT recipients (0.28%) and four lung transplant recipients (7.54%). CONCLUSION In this study, PPFE was strongly associated with lung transplants as a late complication, with a prevalence of 7.54%.
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Affiliation(s)
- Francesca Mariani
- Department of Radiology, S. Orsola-Malpighi Hospital, Bologna, Italy.
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212
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Lama VN, Belperio JA, Christie JD, El-Chemaly S, Fishbein MC, Gelman AE, Hancock WW, Keshavjee S, Kreisel D, Laubach VE, Looney MR, McDyer JF, Mohanakumar T, Shilling RA, Panoskaltsis-Mortari A, Wilkes DS, Eu JP, Nicolls MR. Models of Lung Transplant Research: a consensus statement from the National Heart, Lung, and Blood Institute workshop. JCI Insight 2017; 2:93121. [PMID: 28469087 DOI: 10.1172/jci.insight.93121] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Lung transplantation, a cure for a number of end-stage lung diseases, continues to have the worst long-term outcomes when compared with other solid organ transplants. Preclinical modeling of the most common and serious lung transplantation complications are essential to better understand and mitigate the pathophysiological processes that lead to these complications. Various animal and in vitro models of lung transplant complications now exist and each of these models has unique strengths. However, significant issues, such as the required technical expertise as well as the robustness and clinical usefulness of these models, remain to be overcome or clarified. The National Heart, Lung, and Blood Institute (NHLBI) convened a workshop in March 2016 to review the state of preclinical science addressing the three most important complications of lung transplantation: primary graft dysfunction (PGD), acute rejection (AR), and chronic lung allograft dysfunction (CLAD). In addition, the participants of the workshop were tasked to make consensus recommendations on the best use of these complimentary models to close our knowledge gaps in PGD, AR, and CLAD. Their reviews and recommendations are summarized in this report. Furthermore, the participants outlined opportunities to collaborate and directions to accelerate research using these preclinical models.
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Affiliation(s)
- Vibha N Lama
- Department of Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - John A Belperio
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Jason D Christie
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Souheil El-Chemaly
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael C Fishbein
- Department of Pathology and Laboratory Medicine, UCLA Center for the Health Sciences, Los Angeles, California, USA
| | - Andrew E Gelman
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Wayne W Hancock
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Shaf Keshavjee
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Kreisel
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Victor E Laubach
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Mark R Looney
- Department of Medicine, UCSF School of Medicine, San Francisco, California, USA
| | - John F McDyer
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Rebecca A Shilling
- Department of Medicine, University of Illinois College of Medicine at Chicago, Illinois, USA
| | - Angela Panoskaltsis-Mortari
- Departments of Pediatrics, and Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - David S Wilkes
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Jerry P Eu
- National Heart, Lung and Blood Institute, NIH, Bethesda, Maryland, USA
| | - Mark R Nicolls
- Department of Medicine, Stanford University School of Medicine/VA Palo Alto Health Care System, Stanford, California, USA
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213
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Hathorn KE, Chan WW, Lo WK. Role of gastroesophageal reflux disease in lung transplantation. World J Transplant 2017; 7:103-116. [PMID: 28507913 PMCID: PMC5409910 DOI: 10.5500/wjt.v7.i2.103] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 11/16/2016] [Accepted: 02/13/2017] [Indexed: 02/05/2023] Open
Abstract
Lung transplantation is one of the highest risk solid organ transplant modalities. Recent studies have demonstrated a relationship between gastroesophageal reflux disease (GERD) and lung transplant outcomes, including acute and chronic rejection. The aim of this review is to discuss the pathophysiology, evaluation, and management of GERD in lung transplantation, as informed by the most recent publications in the field. The pathophysiology of reflux-induced lung injury includes the effects of aspiration and local immunomodulation in the development of pulmonary decline and histologic rejection, as reflective of allograft injury. Modalities of reflux and esophageal assessment, including ambulatory pH testing, impedance, and esophageal manometry, are discussed, as well as timing of these evaluations relative to transplantation. Finally, antireflux treatments are reviewed, including medical acid suppression and surgical fundoplication, as well as the safety, efficacy, and timing of such treatments relative to transplantation. Our review of the data supports an association between GERD and allograft injury, encouraging a strategy of early diagnosis and aggressive reflux management in lung transplant recipients to improve transplant outcomes. Further studies are needed to explore additional objective measures of reflux and aspiration, better compare medical and surgical antireflux treatment options, extend follow-up times to capture longer-term clinical outcomes, and investigate newer interventions including minimally invasive surgery and advanced endoscopic techniques.
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214
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Kneidinger N, Milger K, Janitza S, Ceelen F, Leuschner G, Dinkel J, Königshoff M, Weig T, Schramm R, Winter H, Behr J, Neurohr C. Lung volumes predict survival in patients with chronic lung allograft dysfunction. Eur Respir J 2017; 49:49/4/1601315. [DOI: 10.1183/13993003.01315-2016] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 12/15/2016] [Indexed: 01/09/2023]
Abstract
Identification of disease phenotypes might improve the understanding of patients with chronic lung allograft dysfunction (CLAD). The aim of the study was to assess the impact of pulmonary restriction and air trapping by lung volume measurements at the onset of CLAD.A total of 396 bilateral lung transplant recipients were analysed. At onset, CLAD was further categorised based on plethysmography. A restrictive CLAD (R-CLAD) was defined as a loss of total lung capacity from baseline. CLAD with air trapping (AT-CLAD) was defined as an increased ratio of residual volume to total lung capacity. Outcome was survival after CLAD onset. Patients with insufficient clinical information were excluded (n=95).Of 301 lung transplant recipients, 94 (31.2%) developed CLAD. Patients with R-CLAD (n=20) and AT-CLAD (n=21), respectively, had a significantly worse survival (p<0.001) than patients with non-R/AT-CLAD. Both R-CLAD and AT-CLAD were associated with increased mortality when controlling for multiple confounding variables (hazard ratio (HR) 3.57, 95% CI 1.39–9.18; p=0.008; and HR 2.65, 95% CI 1.05–6.68; p=0.039). Furthermore, measurement of lung volumes was useful to identify patients with combined phenotypes.Measurement of lung volumes in the long-term follow-up of lung transplant recipients allows the identification of patients who are at risk for worse outcome and warrant special consideration.
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215
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Müller C, Andersson-Sjöland A, Schultz HH, Eriksson LT, Andersen CB, Iversen M, Westergren-Thorsson G. Early extracellular matrix changes are associated with later development of bronchiolitis obliterans syndrome after lung transplantation. BMJ Open Respir Res 2017; 4:e000177. [PMID: 28469930 PMCID: PMC5411729 DOI: 10.1136/bmjresp-2016-000177] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 02/03/2017] [Accepted: 02/06/2017] [Indexed: 12/15/2022] Open
Abstract
Background Chronic lung allograft dysfunction in the form of bronchiolitis obliterans syndrome (BOS) is the main cause of death beyond 1-year post-lung transplantation. The disease-initiating triggers as well as the molecular changes leading to fibrotic alterations in the transplanted lung are largely unknown. The aim of this study was to identify potential early changes in the extracellular matrix (ECM) in different compartments of the transplanted lung prior to the development of BOS. Methods Transbronchial biopsies from a cohort of 58 lung transplantation patients at the Copenhagen University hospital between 2005 and 2006, with or without development of BOS in a 5-year follow-up, were obtained 3 and 12 months after transplantation. Biopsies were assessed for total collagen, collagen type IV and biglycan in the alveolar and small airway compartments using Masson's Trichrome staining and immunohistochemistry. Results A time-specific and compartment-specific pattern of ECM changes was detected. Alveolar total collagen (p=0.0190) and small airway biglycan (p=0.0199) increased between 3 and 12 months after transplantation in patients developing BOS, while collagen type IV (p=0.0124) increased in patients without BOS. Patients with early-onset BOS mirrored this increase. Patients developing grade 3 BOS showed distinct ECM changes already at 3 months. Patients with BOS with treated acute rejections displayed reduced alveolar total collagen (p=0.0501) and small airway biglycan (p=0.0485) at 3 months. Conclusions Patients with future BOS displayed distinct ECM changes compared with patients without BOS. Our data indicate an involvement of alveolar and small airway compartments in post-transplantation changes in the development of BOS.
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Affiliation(s)
- Catharina Müller
- Lung Biology Unit, Department of Experimental Medical Science, Lund University, Lund, Sweden
| | | | - Hans Henrik Schultz
- Section for Lung Transplantation, Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Leif T Eriksson
- Lung Biology Unit, Department of Experimental Medical Science, Lund University, Lund, Sweden.,Department of Respiratory Medicine and Allergology, Lund University Hospital, Lund, Sweden
| | - Claus B Andersen
- Department of Pathology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Martin Iversen
- Section for Lung Transplantation, Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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216
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Gazourian L, Ash S, Meserve EEK, Diaz A, Estepar RSJ, El-Chemaly SY, Rosas IO, Divo M, Fuhlbrigge AL, Camp PC, Ho VT, Bhatt AS, Goldberg HJ, Sholl LM, Washko GR. Quantitative computed tomography assessment of bronchiolitis obliterans syndrome after lung transplantation. Clin Transplant 2017; 31. [PMID: 28244139 DOI: 10.1111/ctr.12943] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Bronchiolitis obliterans syndrome (BOS) is a clinical manifestation of chronic allograft rejection following lung transplantation. We examined the quantitative measurements of the proximal airway and vessels and pathologic correlations in subjects with BOS. METHODS Patients who received a lung transplant at the Brigham and Women's Hospital between December 1, 2002 and December 31, 2010 were included in this study. We characterized the quantitative CT measures of proximal airways and vessels and pathological changes. RESULTS Ninety-four (46.1%) of the 204 subjects were included in the study. There was a significant increase in the airway vessel ratio in subjects who developed progressive BOS compared to controls and non-progressors. There was a significant increase in airway lumen area and decrease in vessel cross-sectional area in patients with BOS compared to controls. Patients with BOS had a significant increase in proximal airway fibrosis compared to controls. CONCLUSIONS BOS is characterized by central airway dilation and vascular remodeling, the degree of which is correlated to decrements in lung function. Our data suggest that progressive BOS is a pathologic process that affects both the central and distal airways.
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Affiliation(s)
- Lee Gazourian
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Samuel Ash
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Emily E K Meserve
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Alejandro Diaz
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Souheil Y El-Chemaly
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Ivan O Rosas
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Lung Transplant Program, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Miguel Divo
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Lung Transplant Program, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Anne L Fuhlbrigge
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Lung Transplant Program, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Phillip C Camp
- Department of Medicine, Lung Transplant Program, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Lung Transplant Program, Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Vincent T Ho
- Department of Medical Oncology, Division of Hematologic Malignancies, Dana Farber Cancer Institute, Boston, MA, USA
| | - Ami S Bhatt
- School of Medicine and Departments of Medicine and Genetics, Stanford University, Stanford, CA, USA
| | - Hilary J Goldberg
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Lung Transplant Program, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Lynette M Sholl
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - George R Washko
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
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217
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Glanville AR. Physiology of chronic lung allograft dysfunction: back to the future? Eur Respir J 2017; 49:49/4/1700187. [DOI: 10.1183/13993003.00187-2017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 01/26/2017] [Indexed: 11/05/2022]
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218
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Hall DJ, Belli EV, Gregg JA, Salgado JC, Baz MA, Staples ED, Beaver TM, Machuca TN. Two Decades of Lung Retransplantation: A Single-Center Experience. Ann Thorac Surg 2017; 103:1076-1083. [DOI: 10.1016/j.athoracsur.2016.09.107] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 09/05/2016] [Accepted: 09/29/2016] [Indexed: 11/29/2022]
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219
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Comparison of extracorporeal photopheresis and alemtuzumab for the treatment of chronic lung allograft dysfunction. J Heart Lung Transplant 2017; 37:340-348. [PMID: 28431983 DOI: 10.1016/j.healun.2017.03.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 03/10/2017] [Accepted: 03/22/2017] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Survival after lung transplantation is limited by chronic lung allograft dysfunction (CLAD). Immunomodulatory therapies such as extracorporeal photopheresis (ECP) and alemtuzumab (AL) have been described for refractory CLAD, but comparative outcomes are not well defined. METHODS We retrospectively reviewed spirometric values and clinical outcomes after therapy with ECP, AL, or no treatment (NT) in patients with CLAD who underwent transplant between January 2005 and December 2014. We used inverse probability-weighted regression adjustment (IPWRA) to adjust for potential confounders affecting treatment choice. RESULTS Of 267 patients, 31 received immunomodulatory therapies for CLAD, and 78 received NT. The slope of forced expiratory volume in 1 second (FEV1) decline significantly improved after treatment with AL and with ECP compared with pre-treatment FEV1 slope; however, there was no significant change in slope of forced vital capacity (FVC). Comparison with NT was limited because of clinical differences in treatment groups. After IPWRA, we found no significant difference in mean difference of FEV1 slope (ml/month) when comparing treatment with NT, suggesting stabilization of lung function in the treatment group. We found no difference between the 2 immunomodulatory therapies 1, 3, and 6 months post-treatment (-49.9 [95% CI -581.8, +482.0], p = 0.85; +27.7 [95% CI -167.6, +223.0], p = 0.78; -9.6 [95% CI -167.5, +148.2], p = 0.91). We found no difference in mean FVC slope or differences between ECP and AL in infection rates or survival after treatment. CONCLUSIONS Immunomodulatory therapy for CLAD with ECP or AL was associated with a significant change in FEV1 slope post-treatment compared with pre-treatment slope, with minimal effect on FVC. There was no difference between the 2 therapies in their effect on pulmonary function.
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220
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Montero MA, Osadolor T, Khiroya R, Salcedo MT, Robertus JL, Rice A, Nicholson AG, Roman A, Monforte V. Restrictive allograft syndrome and idiopathic pleuroparenchymal fibroelastosis: do they really have the same histology? Histopathology 2017; 70:1107-1113. [DOI: 10.1111/his.13171] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 01/21/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Maria A Montero
- Histopathology Department; Royal Brompton and Harefield NHS Foundation Trust; London UK
- Biomedical Respiratory Unit; Imperial College London; London UK
| | - Tina Osadolor
- Biomedical Respiratory Unit; Imperial College London; London UK
| | - Reena Khiroya
- Histopathology Department; Royal Brompton and Harefield NHS Foundation Trust; London UK
| | | | - Jan L Robertus
- Histopathology Department; Royal Brompton and Harefield NHS Foundation Trust; London UK
| | - Alexandra Rice
- Histopathology Department; Royal Brompton and Harefield NHS Foundation Trust; London UK
| | - Andrew G Nicholson
- Histopathology Department; Royal Brompton and Harefield NHS Foundation Trust; London UK
| | - Antonio Roman
- Respiratory Medicine; Vall d'Hebron University Hospitals; Barcelona Spain
| | - Victor Monforte
- Respiratory Medicine; Vall d'Hebron University Hospitals; Barcelona Spain
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221
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Berastegui C, Gómez-Ollés S, Sánchez-Vidaurre S, Culebras M, Monforte V, López-Meseguer M, Bravo C, Ramon MA, Romero L, Sole J, Cruz MJ, Román A. BALF cytokines in different phenotypes of chronic lung allograft dysfunction in lung transplant patients. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.12898] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2016] [Indexed: 12/15/2022]
Affiliation(s)
- Cristina Berastegui
- Servei de Pneumologia; Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona; Barcelona Spain
| | - Susana Gómez-Ollés
- Servei de Pneumologia; Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona; Barcelona Spain
- Ciber Enfermedades Respiratorias (Ciberes); Barcelona Spain
| | - Sara Sánchez-Vidaurre
- Servei de Pneumologia; Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona; Barcelona Spain
| | - Mario Culebras
- Servei de Pneumologia; Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona; Barcelona Spain
| | - Victor Monforte
- Servei de Pneumologia; Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona; Barcelona Spain
- Ciber Enfermedades Respiratorias (Ciberes); Barcelona Spain
| | - Manuel López-Meseguer
- Servei de Pneumologia; Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona; Barcelona Spain
| | - Carlos Bravo
- Servei de Pneumologia; Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona; Barcelona Spain
- Ciber Enfermedades Respiratorias (Ciberes); Barcelona Spain
| | - Maria-Antonia Ramon
- Servei de Pneumologia; Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona; Barcelona Spain
| | - Laura Romero
- Servei de Cirurgia Toràcica; Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona; Barcelona Spain
| | - Joan Sole
- Servei de Cirurgia Toràcica; Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona; Barcelona Spain
| | - Maria-Jesus Cruz
- Servei de Pneumologia; Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona; Barcelona Spain
- Ciber Enfermedades Respiratorias (Ciberes); Barcelona Spain
| | - Antonio Román
- Servei de Pneumologia; Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona; Barcelona Spain
- Ciber Enfermedades Respiratorias (Ciberes); Barcelona Spain
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222
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[What the family doctor must know about lung transplantation. Complications, health promotion, and outcomes (Part 2)]. Semergen 2017; 43:511-518. [PMID: 28065646 DOI: 10.1016/j.semerg.2016.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 09/23/2016] [Accepted: 11/01/2016] [Indexed: 11/23/2022]
Abstract
The lung transplantation is a therapeutic procedure indicated for lung diseases that are terminal and irreversible (except lung cancer) despite the best medical current treatment. It is an emergent procedure in medical care. In this review, an analyse is made of the most frequent complications of lung transplant related to the graft (rejection and chronic graft dysfunction), immunosuppression (infections, arterial hypertension, renal dysfunction, and diabetes), as well as others such as gastrointestinal complications, osteoporosis. The most advisable therapeutic options are also included. Specific mention is made of the reviews and follow-up for monitoring the graft and the patients, as well as the lifestyle recommended to improve the prognosis and quality of life. An analysis is also made on the outcomes in the Spanish and international registries, their historical evolution and the most frequent causes of death, in order to objectively analyse the usefulness of the transplant.
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223
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Vandermeulen E, Lammertyn E, Verleden SE, Ruttens D, Bellon H, Ricciardi M, Somers J, Bracke KR, Van Den Eynde K, Tousseyn T, Brusselle GG, Verbeken EK, Verschakelen J, Emonds MP, Van Raemdonck DE, Verleden GM, Vos R, Vanaudenaerde BM. Immunological diversity in phenotypes of chronic lung allograft dysfunction: a comprehensive immunohistochemical analysis. Transpl Int 2016; 30:134-143. [PMID: 27933655 DOI: 10.1111/tri.12882] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 08/10/2016] [Accepted: 10/28/2016] [Indexed: 11/30/2022]
Abstract
Chronic rejection after organ transplantation is defined as a humoral- and cell-mediated immune response directed against the allograft. In lung transplantation, chronic rejection is nowadays clinically defined as a cause of chronic lung allograft dysfunction (CLAD), consisting of different clinical phenotypes including restrictive allograft syndrome (RAS) and bronchiolitis obliterans syndrome (BOS). However, the differential role of humoral and cellular immunity is not investigated up to now. Explant lungs of patients with end-stage BOS (n = 19) and RAS (n = 18) were assessed for the presence of lymphoid (B and T cells) and myeloid cells (dendritic cells, eosinophils, mast cells, neutrophils, and macrophages) and compared to nontransplant control lung biopsies (n = 21). All myeloid cells, with exception of dendritic cells, were increased in RAS versus control (neutrophils, eosinophils, and mast cells: all P < 0.05, macrophages: P < 0.001). Regarding lymphoid cells, B cells and cytotoxic T cells were increased remarkably in RAS versus control (P < 0.001) and in BOS versus control (P < 0.01). Interestingly, lymphoid follicles were restricted to RAS (P < 0.001 versus control and P < 0.05 versus BOS). Our data suggest an immunological diversity between BOS and RAS, with a more pronounced involvement of the B-cell response in RAS characterized by a structural organization of lymphoid follicles. This may impact future therapeutic approaches.
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Affiliation(s)
- Elly Vandermeulen
- Lung Transplant Unit, Division of Respiratory Disease, Department of Clinical and Experimental Medicine, KULeuven, Leuven, Belgium
| | - Elise Lammertyn
- Lung Transplant Unit, Division of Respiratory Disease, Department of Clinical and Experimental Medicine, KULeuven, Leuven, Belgium
| | - Stijn E Verleden
- Lung Transplant Unit, Division of Respiratory Disease, Department of Clinical and Experimental Medicine, KULeuven, Leuven, Belgium
| | - David Ruttens
- Lung Transplant Unit, Division of Respiratory Disease, Department of Clinical and Experimental Medicine, KULeuven, Leuven, Belgium
| | - Hannelore Bellon
- Lung Transplant Unit, Division of Respiratory Disease, Department of Clinical and Experimental Medicine, KULeuven, Leuven, Belgium
| | - Mario Ricciardi
- Lung Transplant Unit, Division of Respiratory Disease, Department of Clinical and Experimental Medicine, KULeuven, Leuven, Belgium
| | - Jana Somers
- Lung Transplant Unit, Division of Respiratory Disease, Department of Clinical and Experimental Medicine, KULeuven, Leuven, Belgium
| | - Ken R Bracke
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Kathleen Van Den Eynde
- Translational Cell & Tissue Research Unit, Department of Imaging & Pathology, KULeuven, Leuven, Belgium
| | - Thomas Tousseyn
- Translational Cell & Tissue Research Unit, Department of Imaging & Pathology, KULeuven, Leuven, Belgium
| | - Guy G Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Erik K Verbeken
- Translational Cell & Tissue Research Unit, Department of Imaging & Pathology, KULeuven, Leuven, Belgium
| | - Johny Verschakelen
- Lung Transplant Unit, Division of Respiratory Disease, Department of Clinical and Experimental Medicine, KULeuven, Leuven, Belgium
| | | | - Dirk E Van Raemdonck
- Lung Transplant Unit, Division of Respiratory Disease, Department of Clinical and Experimental Medicine, KULeuven, Leuven, Belgium
| | - Geert M Verleden
- Lung Transplant Unit, Division of Respiratory Disease, Department of Clinical and Experimental Medicine, KULeuven, Leuven, Belgium
| | - Robin Vos
- Lung Transplant Unit, Division of Respiratory Disease, Department of Clinical and Experimental Medicine, KULeuven, Leuven, Belgium
| | - Bart M Vanaudenaerde
- Lung Transplant Unit, Division of Respiratory Disease, Department of Clinical and Experimental Medicine, KULeuven, Leuven, Belgium
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224
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Restrictive allograft syndrome after lung transplantation: new radiological insights. Eur Radiol 2016; 27:2810-2817. [DOI: 10.1007/s00330-016-4643-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 07/31/2016] [Accepted: 10/10/2016] [Indexed: 01/16/2023]
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225
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Kuehnel M, Maegel L, Vogel-Claussen J, Robertus JL, Jonigk D. Airway remodelling in the transplanted lung. Cell Tissue Res 2016; 367:663-675. [PMID: 27837271 DOI: 10.1007/s00441-016-2529-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 10/12/2016] [Indexed: 12/22/2022]
Abstract
Following lung transplantation, fibrotic remodelling of the small airways has been recognized for almost 5 decades as the main correlate of chronic graft failure and a major obstacle to long-term survival. Mainly due to airway fibrosis, pulmonary allografts currently show the highest attrition rate of all solid organ transplants, with a 5-year survival rate of 58 % on a worldwide scale. The observation that these morphological changes are not just the hallmark of chronic rejection but rather represent a manifestation of a multitude of alloimmune-dependent and -independent injuries was made more recently, as was the discovery that chronic lung allograft dysfunction manifests in different clinical phenotypes of respiratory impairment and corresponding morphological subentities. Although recent years have seen considerable advances in identifying and categorizing these subgroups on the basis of clinical, functional and histomorphological changes, as well as susceptibility to medicinal treatment, this process is far from over. Since the actual pathophysiological mechanisms governing airway remodelling are still only poorly understood, diagnosis and therapy of chronic lung allograft dysfunction presents a major challenge to clinicians, radiologists and pathologists alike. Here, we review and discuss the current state of the literature on chronic lung allograft dysfunction and shed light on classification systems, corresponding clinical and morphological changes, key cellular players and underlying molecular pathways, as well as on emerging diagnostic and therapeutic approaches.
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Affiliation(s)
- Mark Kuehnel
- Institute of Pathology, Hannover Medical School (MHH), Carl-Neuberg-Str. 1, D-30625, Hanover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease (BREATH), The German Center for Lung Research (Deutsches Zentrum für Lungenforschung, DZL), Hanover, Germany
| | - Lavinia Maegel
- Institute of Pathology, Hannover Medical School (MHH), Carl-Neuberg-Str. 1, D-30625, Hanover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease (BREATH), The German Center for Lung Research (Deutsches Zentrum für Lungenforschung, DZL), Hanover, Germany
| | | | - Jan Lukas Robertus
- Royal Brompton & Harefield NHS Foundation Trust, Department of Histopathology, Hanover, Germany
| | - Danny Jonigk
- Institute of Pathology, Hannover Medical School (MHH), Carl-Neuberg-Str. 1, D-30625, Hanover, Germany.
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226
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Verleden SE, Vanaudenaerde BM, Vos R, Verleden GM. Phenotypes of Chronic Lung Allograft Dysfunction: Getting Closer Step by Step? Am J Transplant 2016; 16:3071-3072. [PMID: 27305458 DOI: 10.1111/ajt.13921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 06/06/2016] [Indexed: 01/25/2023]
Affiliation(s)
- S E Verleden
- Department of Clinical and Experimental Medicine, Laboratory for Respiratory Diseases, Lung Transplantation Unit, Katholieke Universiteit Leuven (University of Leuven), Leuven, Belgium
| | - B M Vanaudenaerde
- Department of Clinical and Experimental Medicine, Laboratory for Respiratory Diseases, Lung Transplantation Unit, Katholieke Universiteit Leuven (University of Leuven), Leuven, Belgium
| | - R Vos
- Department of Respiratory Diseases, Lung Transplantation Unit, Katholieke Universiteit Leuven (University of Leuven), University Hospitals Leuven, Leuven, Belgium
| | - G M Verleden
- Department of Respiratory Diseases, Lung Transplantation Unit, Katholieke Universiteit Leuven (University of Leuven), University Hospitals Leuven, Leuven, Belgium.
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227
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Suhling H, Dettmer S, Greer M, Fuehner T, Avsar M, Haverich A, Welte T, Gottlieb J. Phenotyping Chronic Lung Allograft Dysfunction Using Body Plethysmography and Computed Tomography. Am J Transplant 2016; 16:3163-3170. [PMID: 27203799 DOI: 10.1111/ajt.13876] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Revised: 05/08/2016] [Accepted: 05/14/2016] [Indexed: 01/25/2023]
Abstract
Restrictive subtype of chronic lung allograft dysfunction (CLAD) was recently described after lung transplantation. This study compares different definitions of a restrictive phenotype in CLAD patients and impact on survival. Eighty-nine CLAD patients out of 1191 screened patients (September 1987 to July 2012) were included as complete longitudinal lung volume measurements and chest computed tomography (CT) after CLAD onset was available. CT findings and lung volumes were quantified and survival was calculated for distinctive groups and predictive factors for worse survival were investigated. Graft survival in patients with total lung capacity (TLC) between 90% and 81% of baseline (BL) (n = 13, 15%) in CLAD course was similar to those with TLC >90% BL (n = 64, 56%; log-rank test p = 0.9). Twelve patients (13%) developed a TLC ≤80% BL and 10 (11%) had significant parenchymal changes on CT, of whom 6 (46%) also had TLC ≤80% BL. CT changes correlated with TLC ≤80% BL (Φ-coefficient = 0.48, p = 0.001). Patients with either TLC ≤80% or significant CT changes (n = 16, 18%) had a significantly reduced survival (log-rank p < 0.001). Forced vital capacity loss at CLAD onset was associated with poorer survival but did not correlate with the TLC or CT changes. A restrictive subtype of CLAD may be defined by either TLC ≤80% BL or severe parenchymal changes on chest CT.
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Affiliation(s)
- H Suhling
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.
| | - S Dettmer
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - M Greer
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - T Fuehner
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - M Avsar
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - A Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - T Welte
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - J Gottlieb
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
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228
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Wallinder A, Riise GC, Ricksten SE, Silverborn M, Dellgren G. Transplantation after ex vivo lung perfusion: A midterm follow-up. J Heart Lung Transplant 2016; 35:1303-1310. [DOI: 10.1016/j.healun.2016.05.021] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 04/08/2016] [Accepted: 05/26/2016] [Indexed: 11/24/2022] Open
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229
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Verleden SE, Vos R, Vandermeulen E, Ruttens D, Bellon H, Heigl T, Van Raemdonck DE, Verleden GM, Lama V, Ross BD, Galbán CJ, Vanaudenaerde BM. Parametric Response Mapping of Bronchiolitis Obliterans Syndrome Progression After Lung Transplantation. Am J Transplant 2016; 16:3262-3269. [PMID: 27367568 PMCID: PMC5083149 DOI: 10.1111/ajt.13945] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 06/07/2016] [Accepted: 06/12/2016] [Indexed: 01/25/2023]
Abstract
Bronchiolitis obliterans syndrome (BOS) remains a major complication after lung transplantation. Air trapping and mosaic attenuation are typical radiological features of BOS; however, quantitative evaluation remains troublesome. We evaluated parametric response mapping (PRM, voxel-to-voxel comparison of inspiratory and expiratory computed tomography [CT] scans) in lung transplant recipients diagnosed with BOS (n = 20) and time-matched stable lung transplant recipients (n = 20). Serial PRM measurements were performed prediagnosis, at time of BOS diagnosis, and postdiagnosis (Tpre , T0 , and Tpost , respectively), or at a postoperatively matched time in stable patients. PRM results were correlated with pulmonary function and confirmed by microCT analysis of end-stage explanted lung tissue. Using PRM, we observed an increase in functional small airway disease (fSAD), from Tpre to T0 (p = 0.006) and a concurrent decrease in healthy parenchyma (p = 0.02) in the BOS group. This change in PRM continued to Tpost , which was significantly different compared to the stable patients (p = 0.0002). At BOS diagnosis, the increase in fSAD was strongly associated with a decrease in forced expiratory volume in 1 s (p = 0.011). Micro-CT confirmed the presence of airway obliteration in a sample of a BOS patient identified with 67% fSAD by PRM. We demonstrated the use of PRM as an adequate output to monitor BOS progression in lung transplant recipients.
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Affiliation(s)
- Stijn E Verleden
- Lung transplant Unit, Department of Clinical and Experimental Medicine, KU Leuven, Leuven Belgium
| | - Robin Vos
- Lung transplant Unit, Department of Clinical and Experimental Medicine, KU Leuven, Leuven Belgium
| | - Elly Vandermeulen
- Lung transplant Unit, Department of Clinical and Experimental Medicine, KU Leuven, Leuven Belgium
| | - David Ruttens
- Lung transplant Unit, Department of Clinical and Experimental Medicine, KU Leuven, Leuven Belgium
| | - Hannelore Bellon
- Lung transplant Unit, Department of Clinical and Experimental Medicine, KU Leuven, Leuven Belgium
| | - Tobias Heigl
- Lung transplant Unit, Department of Clinical and Experimental Medicine, KU Leuven, Leuven Belgium
| | - Dirk E Van Raemdonck
- Lung transplant Unit, Department of Clinical and Experimental Medicine, KU Leuven, Leuven Belgium
| | - Geert M Verleden
- Lung transplant Unit, Department of Clinical and Experimental Medicine, KU Leuven, Leuven Belgium
| | - Vibha Lama
- Pneumology Department, University of Michigan, Ann Arbor, MI, USA
| | - Brian D Ross
- Radiology Department, University of Michigan, Ann Arbor, MI, USA
| | - Craig J Galbán
- Radiology Department, University of Michigan, Ann Arbor, MI, USA
| | - Bart M Vanaudenaerde
- Lung transplant Unit, Department of Clinical and Experimental Medicine, KU Leuven, Leuven Belgium
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230
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Affiliation(s)
- Song Yee Kim
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Institute of Chest Diseases, Yonsei University College of Medicine, Seoul, Korea
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231
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232
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Walton DC, Hiho SJ, Cantwell LS, Diviney MB, Wright ST, Snell GI, Paraskeva MA, Westall GP. HLA Matching at the Eplet Level Protects Against Chronic Lung Allograft Dysfunction. Am J Transplant 2016; 16:2695-703. [PMID: 27002311 DOI: 10.1111/ajt.13798] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 03/13/2016] [Accepted: 03/13/2016] [Indexed: 01/25/2023]
Abstract
Donor selection in lung transplantation (LTx) is historically based upon clinical urgency, ABO compatibility, and donor size. HLA matching is not routinely considered; however, the presence or later development of anti-HLA antibodies is associated with poorer outcomes, particularly chronic lung allograft dysfunction (CLAD). Using eplet mismatches, we aimed to determine whether donor/recipient HLA incompatibility was a significant predictor of CLAD. One hundred seventy-five LTx undertaken at the Alfred Hospital between 2008 and 2012 met criteria. Post-LTx monitoring was continued for at least 12 months, or until patient death. HLA typing was performed by sequence-based typing and Luminex sequence-specific oligonucleotide. Using HLAMatchmaker, eplet mismatches between each donor/recipient pairing were analyzed and correlated against incidences of CLAD. HLA-DRB1/3/4/5+DQA/B eplet mismatch was a significant predictor of CLAD (hazard ratio [HR] 3.77, 95% confidence interval [CI]: 1.71-8.29 p < 0.001). When bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS) were analyzed independently, HLA-DRB1/3/4/5 + DQA/B eplet mismatch was shown to significantly predict RAS (HR 8.3, 95% CI: 2.46-27.97 p < 0.001) but not BOS (HR 1.92, 95% CI: 0.64-5.72, p = 0.237). HLA-A/B eplet mismatch was shown not to be a significant predictor when analyzed independently but did provide additional stratification of results. This study illustrates the importance of epitope immunogenicity in defining donor-recipient immune compatibility in LTx.
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Affiliation(s)
- D C Walton
- Victorian Transplantation and Immunogenetics Service, Australian Red Cross Blood Service, Melbourne, Australia
| | - S J Hiho
- Victorian Transplantation and Immunogenetics Service, Australian Red Cross Blood Service, Melbourne, Australia
| | - L S Cantwell
- Victorian Transplantation and Immunogenetics Service, Australian Red Cross Blood Service, Melbourne, Australia
| | - M B Diviney
- Victorian Transplantation and Immunogenetics Service, Australian Red Cross Blood Service, Melbourne, Australia
| | - S T Wright
- Research and Development, Australian Red Cross Blood Service, Sydney, Australia.,Mathematical and Physical Sciences, University of Technology Sydney, Sydney, Australia
| | - G I Snell
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia
| | - M A Paraskeva
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia
| | - G P Westall
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia
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233
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Apoptosis of the Tracheal Epithelium Can Increase the Number of Recipient Bone Marrow–Derived Myofibroblasts in Allografts and Exacerbate Obliterative Bronchiolitis After Tracheal Transplantation in Mice. Transplantation 2016; 100:1880-8. [DOI: 10.1097/tp.0000000000001230] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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234
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Lung Transplant Rejection and Surveillance in 2016: Newer Options. CURRENT TRANSPLANTATION REPORTS 2016. [DOI: 10.1007/s40472-016-0104-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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235
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Gauthier JM, Hachem RR, Kreisel D. Update on Chronic Lung Allograft Dysfunction. CURRENT TRANSPLANTATION REPORTS 2016; 3:185-191. [PMID: 28090432 DOI: 10.1007/s40472-016-0112-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Chronic lung allograft dysfunction (CLAD) encompasses a range of pathologies that cause a transplanted lung to not achieve or maintain normal function. CLAD manifests as airflow restriction and/or obstruction and is predominantly a result of chronic rejection. Three distinct phenotypes of chronic rejection are now recognized: bronchiolitis obliterans, neutrophilic reversible allograft dysfunction, and restrictive allograft syndrome. Recent investigations have revealed that each phenotype has a unique pathology and histopathological findings, suggesting that treatment regimens should be tailored to the underlying etiology. CLAD is poorly responsive to treatment once diagnosed, and therefore the prevention of the factors that predispose a patient to develop CLAD is critically important. Small and large animal models have contributed significantly to our understanding of CLAD and more studies are needed to develop treatment regimens that are effective in humans.
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Affiliation(s)
- Jason M Gauthier
- Department of Surgery, Washington University in St. Louis, Saint Louis, MO
| | - Ramsey R Hachem
- Department of Medicine, Washington University in St. Louis, Saint Louis, MO
| | - Daniel Kreisel
- Department of Surgery, Washington University in St. Louis, Saint Louis, MO ; Department of Pathology & Immunology, Washington University in St. Louis, Saint Louis, MO
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236
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Abstract
Despite improvement in median life expectancy and overall health, some children with cystic fibrosis (CF) progress to end-stage lung or liver disease and become candidates for transplant. Transplants for children with CF hold the promise to extend and improve the quality of life, but barriers to successful long-term outcomes include shortage of suitable donor organs; potential complications from the surgical procedure and immunosuppressants; risk of rejection and infection; and the need for lifelong, strict adherence to a complex medical regimen. This article reviews the indications and complications of lung and liver transplantation in children with CF.
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Affiliation(s)
- Albert Faro
- Department of Pediatrics, Washington University in St. Louis, Campus Box 8116, 660 South Euclid Avenue, St Louis, MO 63110, USA.
| | - Alexander Weymann
- Department of Pediatrics, Washington University in St. Louis, Campus Box 8116, 660 South Euclid Avenue, St Louis, MO 63110, USA
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237
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Abstract
CONTEXT Lung transplantation has become a viable option for definitive treatment of several end-stage lung diseases for which there are no other options available. However, long-term survival continues to be limited by chronic lung allograft dysfunction, which primarily affects the airways. OBJECTIVE To highlight the complications occurring mainly in the airways of the lung transplant recipient from the early to late posttransplant periods. DATA SOURCES Review literature focusing on the airways in patients with lung transplants and clinical experience of the authors. CONCLUSIONS Postsurgical complications and infections of the airways have decreased because of better techniques and management. Acute cellular rejection of the airways can be distinguished from infection pathologically and on cultures. Separating small from large airways need not be an issue because both are risk factors for bronchiolitis obliterans. Grading of airway rejection needs to be standardized. Chronic lung allograft dysfunction consists of both bronchiolitis obliterans and restrictive allograft syndrome, neither of which can be treated very effectively at present.
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Affiliation(s)
- Aliya N Husain
- From the Departments of Pathology (Dr Husain) and Medicine (Dr Garrity), University of Chicago, Chicago, Illinois
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238
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Wood RK. Esophageal Dysmotility, Gastro-esophageal Reflux Disease, and Lung Transplantation: What Is the Evidence? Curr Gastroenterol Rep 2016; 17:48. [PMID: 26454656 DOI: 10.1007/s11894-015-0474-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Lung transplantation is an effective and life-prolonging therapy for patients with advanced lung disease (ALD). However, long-term patient survival following lung transplantation is primarily limited by development of an inflammatory and fibrotic process involving the lung allograft known as bronchiolitis obliterans syndrome (BOS). Although the precise cause of BOS remains uncertain and is likely multifactorial, chronic aspiration of gastro-duodenal contents is one possible contributing factor. Multiple small, cross-sectional studies performed over the past two decades have reported a high prevalence of gastro-esophageal reflux disease (GERD) and esophageal dysmotility in the ALD population and several investigations suggest the prevalence may increase following lung transplantation. More recent studies evaluating the direct effect of gastro-duodenal contents on airways have demonstrated a possible biologic link between GERD and BOS. Despite the recent advances in our understanding of BOS, further investigations are needed to establish GERD as a causative factor in its development. This review will discuss the existing literature that has identified an association of GERD with ALD and post-transplant populations, with a focus on recent advances in the field.
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Affiliation(s)
- Richard K Wood
- Division of Gastroenterology, Duke University Medical Center, DUMC 3662, Durham, NC, 27710, USA.
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239
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Suhling H, Bollmann B, Gottlieb J. Nintedanib in restrictive chronic lung allograft dysfunction after lung transplantation. J Heart Lung Transplant 2016; 35:939-40. [DOI: 10.1016/j.healun.2016.01.1220] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 01/12/2016] [Accepted: 01/26/2016] [Indexed: 12/31/2022] Open
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240
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Daimiel Naranjo I, Alonso Charterina S. What can happen after lung transplantation and the importance of the time since transplantation: Radiological review of post-transplantation complications. RADIOLOGIA 2016. [DOI: 10.1016/j.rxeng.2016.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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241
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Le Pavec J, Suberbielle C, Lamrani L, Feuillet S, Savale L, Dorfmüller P, Stephan F, Mussot S, Mercier O, Fadel E. De-novo donor-specific anti-HLA antibodies 30 days after lung transplantation are associated with a worse outcome. J Heart Lung Transplant 2016; 35:1067-77. [PMID: 27373824 DOI: 10.1016/j.healun.2016.05.020] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 03/18/2016] [Accepted: 05/26/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The impact of de-novo donor-specific anti-HLA antibodies (DSA) on patient and graft survival after lung transplantation remains controversial. We analyzed DSA that developed at Day 7 and Month (M) 1, M3, M6 and M12 after lung transplantation and evaluated their impact on chronic lung allograft dysfunction (CLAD) development and survival. METHODS One hundred thirty-four patients who underwent lung transplantation at our institution between November 2007 and August 2013 were included in this study. During the first post-transplant year, 82 (61%) patients developed de novo DSA and 52 (39%) patients did not. Three mean fluorescence intensity (MFI) intervals were used to define scores of anti-HLA antibody positivity: score 4 if MFI was 500 to 1,000; score 6 if MFI was 1,000 to 3,000; and score 8 if MFI was ≥3,000. Patients' records were retrospectively reviewed. RESULTS DSA with MFI scores of ≥4 (hazard ratio [HR] 2.21, 95% confidence interval [CI] 1.08 to 4.54, p = 0.03), 6 (HR 2.63, 95% CI 1.27 to 5.20, p < 0.01) and 8 (HR 2.83, 95% CI 1.42 to 5.67, p < 0.01) at M1; female gender (HR 0.49, 95% CI 0.28 to 0.87, P = 0.01); and with post-operative extracorporeal membrane oxygenation (HR 0.09, 95% CI 0.01 to 0.28, p = 0.02) were significantly associated with CLAD. Multivariate analysis identified score 8 at M1 (HR 2.71, 95% CI 1.34 to 5.47, p < 0.01) as an independent risk factor for mortality. Overall, 1-, 3- and 5-year survival rates were 76%, 52% and 41% compared with 84%, 74% and 70% for patients with or without de-novo DSA at M1, respectively (p = 0.02). CONCLUSION Early de-novo DSA may significantly impact long-term outcomes after lung transplantation and should therefore prompt regular screening.
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Affiliation(s)
- Jérôme Le Pavec
- Université Paris-Sud, Faculté de Médecine, Université Paris Saclay, Le Kremlin Bicêtre, France; Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France; UMR-S 999, Universitaire Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France.
| | | | - Lilia Lamrani
- Université Paris-Sud, Faculté de Médecine, Université Paris Saclay, Le Kremlin Bicêtre, France; UMR-S 999, Universitaire Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Séverine Feuillet
- Université Paris-Sud, Faculté de Médecine, Université Paris Saclay, Le Kremlin Bicêtre, France; Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France; UMR-S 999, Universitaire Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Laurent Savale
- Université Paris-Sud, Faculté de Médecine, Université Paris Saclay, Le Kremlin Bicêtre, France; UMR-S 999, Universitaire Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France; AP-HP, Service de Pneumologie, Hôpital de Bicêtre, Le Kremlin Bicêtre, France
| | - Peter Dorfmüller
- Université Paris-Sud, Faculté de Médecine, Université Paris Saclay, Le Kremlin Bicêtre, France; UMR-S 999, Universitaire Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Service d'Anatomie Pathologique, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - François Stephan
- Université Paris-Sud, Faculté de Médecine, Université Paris Saclay, Le Kremlin Bicêtre, France; UMR-S 999, Universitaire Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Service de Réanimation, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Sacha Mussot
- Université Paris-Sud, Faculté de Médecine, Université Paris Saclay, Le Kremlin Bicêtre, France; Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France; UMR-S 999, Universitaire Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Olaf Mercier
- Université Paris-Sud, Faculté de Médecine, Université Paris Saclay, Le Kremlin Bicêtre, France; Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France; UMR-S 999, Universitaire Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Elie Fadel
- Université Paris-Sud, Faculté de Médecine, Université Paris Saclay, Le Kremlin Bicêtre, France; Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France; UMR-S 999, Universitaire Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France
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Piloni D, Magni S, Oggionni T, Benazzo A, Stella G, Scudeller L, Morosini M, Cova E, Meloni F. Clinical utility of CD4+ function assessment (ViraCor-IBT ImmuKnow test) in lung recipients. Transpl Immunol 2016; 37:35-39. [PMID: 27095000 DOI: 10.1016/j.trim.2016.04.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 04/12/2016] [Accepted: 04/15/2016] [Indexed: 11/19/2022]
Abstract
The ImmuKnow assay measures cell-mediated immunity, quantifying ATP production from peripheral blood CD4+T-cells in solid-organ transplant patients who undergo immunosuppressive therapy. We aimed to measure functional immunity in lung transplant recipients and correlate Immuknow values with immunosuppression levels, presence of chronic lung allograft dysfunction (CLAD) and infections. We evaluated 61 lung recipients who underwent follow-up for lung transplantation between 2010 and 2014. Rejection and infection were retrospectively analyzed. The association between over-immunosuppression and a number of predictors was assessed by means of univariate and multivariate logistic regression models. 71 out of 127 samples (56%) showed an over-immunosuppression with an ImmuKnow assay mean level of 112.92ng/ml (SD±58.2), vs. 406.14ng/ml (SD±167.7) of the rest of our cohort. In the over-immunosuppression group we found 51 episodes of infection (71%) (OR 2.754, 95% CI 1.40-5.39; P-value 0.003). In the other group, only 25 samples (44%) were taken during an infectious episode. The mean absolute ATP level was significantly different between patients with or without infection (202.38±139.06ng/ml vs. 315.51±221.60ng/ml; P<0.001). RAS (Restrictive allograft syndrome) was associated to low ImmuKnow level (P<0.001). These results were confirmed by the multivariate analysis. The ImmuKnow assay levels were significantly lower in infected lung transplant recipients compared with non-infected recipients and in RAS patients.
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Affiliation(s)
- Davide Piloni
- Department of Internal Medicine, PhD in Experimental Medicine, University of Pavia, Pavia, Italy.
| | - Sara Magni
- Cardiothoracic and Vascular Department, Pneumology Unit, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Tiberio Oggionni
- Cardiothoracic and Vascular Department, Pneumology Unit, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Alberto Benazzo
- Cardiothoracic and Vascular Department, Pneumology Unit, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Giulia Stella
- Cardiothoracic and Vascular Department, Pneumology Unit, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Luigia Scudeller
- Clinical Epidemiology and Biometric Unit, Scientific Direction, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Monica Morosini
- Cardiothoracic and Vascular Department, Pneumology Unit, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Emanuela Cova
- Cardiothoracic and Vascular Department, Pneumology Unit, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Federica Meloni
- Department of Internal Medicine, University of Pavia, Pavia, Italy
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243
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Verleden SE, Ruttens D, Vandermeulen E, Bellon H, Dubbeldam A, De Wever W, Dupont LJ, Van Raemdonck DE, Vanaudenaerde BM, Verleden GM, Benden C, Vos R. Predictors of survival in restrictive chronic lung allograft dysfunction after lung transplantation. J Heart Lung Transplant 2016; 35:1078-84. [PMID: 27212563 DOI: 10.1016/j.healun.2016.03.022] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 03/21/2016] [Accepted: 03/30/2016] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Chronic lung allograft dysfunction (CLAD) is the main factor limiting long-term survival after lung transplantation. Besides bronchiolitis obliterans syndrome, a restrictive phenotype of CLAD (rCLAD) exists, which is associated with poor prognosis after diagnosis. However, survival determinants for rCLAD remain to be elucidated. Our aim in this study was to establish parameters predicting survival in patients with rCLAD. METHODS All patients diagnosed with rCLAD in 2 lung transplant centers were assessed in a retrospective manner. Various clinical parameters [demography, pulmonary function, bronchoalveolar lavage (BAL), histopathology, radiology and blood differentials] at rCLAD diagnosis were correlated with graft survival using unadjusted and adjusted analysis. RESULTS A total of 53 patients with rCLAD were included with a median graft survival after diagnosis of 1.1 years. Univariate analysis demonstrated that lower-lobe-dominant or diffuse infiltrates on chest computed tomography, presence of an identifiable trigger before rCLAD onset, lymphocytic bronchiolitis, increased BAL neutrophilia, increased BAL eosinophilia and increased blood eosinophils were associated with inferior graft survival after rCLAD diagnosis. Multivariate analysis confirmed the association of location of infiltrates and blood eosinophilia on graft survival. CONCLUSION In this study we have identified parameters associated with graft survival after rCLAD diagnosis that may be useful to predict prognosis.
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Affiliation(s)
- Stijn E Verleden
- Leuven Lung Transplant Unit, Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium.
| | - David Ruttens
- Leuven Lung Transplant Unit, Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
| | - Elly Vandermeulen
- Leuven Lung Transplant Unit, Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
| | - Hannelore Bellon
- Leuven Lung Transplant Unit, Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
| | | | | | - Lieven J Dupont
- Leuven Lung Transplant Unit, Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
| | - Dirk E Van Raemdonck
- Leuven Lung Transplant Unit, Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
| | - Bart M Vanaudenaerde
- Leuven Lung Transplant Unit, Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
| | - Geert M Verleden
- Leuven Lung Transplant Unit, Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
| | - Christian Benden
- Division of Pulmonary Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Robin Vos
- Leuven Lung Transplant Unit, Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
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Halofuginone treatment reduces interleukin-17A and ameliorates features of chronic lung allograft dysfunction in a mouse orthotopic lung transplant model. J Heart Lung Transplant 2016; 35:518-27. [DOI: 10.1016/j.healun.2015.12.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 11/17/2015] [Accepted: 12/04/2015] [Indexed: 11/23/2022] Open
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245
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Daimiel Naranjo I, Alonso Charterina S. What can happen after lung transplantation and the importance of the time since transplantation: radiological review of post-transplantation complications. RADIOLOGIA 2016; 58:257-67. [PMID: 27017046 DOI: 10.1016/j.rx.2016.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Revised: 02/10/2016] [Accepted: 02/13/2016] [Indexed: 11/18/2022]
Abstract
Lung transplantation is the best treatment option in the final stages of diseases such as cystic fibrosis, pulmonary hypertension, chronic obstructive pulmonary disease, or idiopathic pulmonary fibrosis. Better surgical techniques and advances in immunosuppressor treatments have increased survival in lung transplant recipients, making longer follow-up necessary because complications can occur at any time after transplantation. For practical purposes, complications can be classified as early (those that normally occur within two months after transplantation), late (those that normally occur more than two months after transplantation), or time-independent (those that can occur at any time after transplantation). Many complications have nonspecific clinical and radiological manifestations, so the time factor is key to narrow the differential diagnosis. Imaging can guide interventional procedures and can detect complications early. This article aims to describe and illustrate the complications that can occur after lung transplantation from the clinical and radiological viewpoints so that they can be detected as early as possible.
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Affiliation(s)
- I Daimiel Naranjo
- Servicio de Radiodiagnóstico, Hospital Universitario 12 de Octubre, Madrid, España.
| | - S Alonso Charterina
- Servicio de Radiodiagnóstico, Hospital Universitario 12 de Octubre, Madrid, España
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Abstract
PURPOSE OF REVIEW Chronic lung allograft dysfunction (CLAD) was recently introduced as an overarching term covering different phenotypes of chronic allograft dysfunction, including obstructive CLAD (bronchiolitis obliterans syndrome), restrictive CLAD (restrictive allograft syndrome) and graft dysfunction due to causes not related to chronic rejection. In the present review, we will highlight the latest insights and current controversies regarding the new CLAD terminology, underlying pathophysiologic mechanisms, diagnostic approach and possible treatment options. RECENT FINDINGS Different pathophysiological mechanisms are clearly involved in clinically distinct phenotypes of chronic rejection, as is reflected by differences in histology, allograft function and imaging. Therefore, not all CLAD patients may equally benefit from specific therapies. SUMMARY The recent introduction of CLAD importantly changed the clinical practice in lung transplant recipients. Given the relative low accuracy of the current diagnostic tools, future research should focus on specific biomarkers, more sensitive pulmonary function parameters and imaging techniques for timely CLAD diagnosis and phenotyping. Personalized or targeted therapeutic options for adequate prevention and treatment of CLAD are required.
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Singer LG, Chowdhury NA, Faughnan ME, Granton J, Keshavjee S, Marras TK, Tullis DE, Waddell TK, Tomlinson G. Effects of Recipient Age and Diagnosis on Health-related Quality-of-Life Benefit of Lung Transplantation. Am J Respir Crit Care Med 2016; 192:965-73. [PMID: 26131729 DOI: 10.1164/rccm.201501-0126oc] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
RATIONALE The average age of lung transplant recipients is increasing, and the mix of recipient indications for transplantation is changing. OBJECTIVES To determine whether the health-related quality-of-life (HRQL) benefit of lung transplantation differs by recipient age and diagnosis. METHODS In this prospective cohort study, we obtained serial HRQL measurements in adults with advanced lung disease who subsequently underwent lung transplantation (2004-2012). HRQL assessments included the St. George's Respiratory Questionnaire, 36-Item Short-Form Health Survey (SF-36), EQ-5D, Standard Gamble, and Visual Analog Scale for current health. We used linear mixed effects models for associations between age or diagnosis and changes in HRQL with transplantation. To address potential survivorship bias, we fitted Markov models to the distribution of discrete post-transplant health states (HRQL better than pretransplant, not better, or dead) and estimated quality-adjusted life-years post-transplant. MEASUREMENTS AND MAIN RESULTS A total of 430 subjects were listed, 387 were transplanted, and 326 provided both pretransplant and post-transplant data. Transplantation conferred large improvements in all HRQL measures: St. George's change of -47 units (95% confidence interval, -48 to -44), 36-Item Short-Form Health Survey physical component summary score of 17.7 (16.5-18.9), EQ-5D of 0.27 (0.24-0.30), Standard Gamble of 0.48 (0.44-0.51), and Visual Analog of 44 (42-47). Age was not associated with meaningful differences in the HRQL benefits of transplantation. There was less HRQL benefit in interstitial lung disease than in cystic fibrosis. CONCLUSIONS Lung transplantation confers large HRQL benefits, which vary by recipient diagnosis, but do not differ substantially in older recipients.
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Affiliation(s)
- Lianne G Singer
- 1 Department of Medicine and.,2 University Health Network, Toronto, Ontario, Canada
| | | | - Marie E Faughnan
- 1 Department of Medicine and.,3 St. Michael's Hospital, Toronto, Ontario, Canada; and.,4 Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - John Granton
- 1 Department of Medicine and.,2 University Health Network, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- 5 Department of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada.,2 University Health Network, Toronto, Ontario, Canada
| | - Theodore K Marras
- 1 Department of Medicine and.,2 University Health Network, Toronto, Ontario, Canada
| | - D Elizabeth Tullis
- 1 Department of Medicine and.,3 St. Michael's Hospital, Toronto, Ontario, Canada; and
| | - Thomas K Waddell
- 5 Department of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada.,2 University Health Network, Toronto, Ontario, Canada
| | - George Tomlinson
- 1 Department of Medicine and.,2 University Health Network, Toronto, Ontario, Canada
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250
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Lung Transplantation. PATHOLOGY OF TRANSPLANTATION 2016. [PMCID: PMC7153460 DOI: 10.1007/978-3-319-29683-8_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The therapeutic options for patients with advanced pulmonary parenchymal or vascular disorders are currently limited. Lung transplantation remains one of the few viable interventions, but on account of the insufficient donor pool only a minority of these patients actually undergo the procedure each year. Following transplantation there are a number of early and late allograft complications such as primary graft dysfunction, allograft rejection, infection, post-transplant lymphoproliferative disorder and late injury that is now classified as chronic lung allograft dysfunction. The pathologist plays an essential role in the diagnosis and classification of these myriad complications. Although the transplant procedures are performed in selected centers patients typically return to their local centers. When complications arise it is often the responsibility of the local pathologist to evaluate specimens. Therefore familiarity with the pathology of lung transplantation is important.
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