301
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Todd JL, Jain R, Pavlisko EN, Finlen Copeland CA, Reynolds JM, Snyder LD, Palmer SM. Impact of forced vital capacity loss on survival after the onset of chronic lung allograft dysfunction. Am J Respir Crit Care Med 2014; 189:159-66. [PMID: 24325429 DOI: 10.1164/rccm.201306-1155oc] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
RATIONALE Emerging evidence suggests a restrictive phenotype of chronic lung allograft dysfunction (CLAD) exists; however, the optimal approach to its diagnosis and clinical significance is uncertain. OBJECTIVES To evaluate the hypothesis that spirometric indices more suggestive of a restrictive ventilatory defect, such as loss of FVC, identify patients with distinct clinical, radiographic, and pathologic features, including worse survival. METHODS Retrospective, single-center analysis of 566 consecutive first bilateral lung recipients transplanted over a 12-year period. A total of 216 patients developed CLAD during follow-up. CLAD was categorized at its onset into discrete physiologic groups based on spirometric criteria. Imaging and histologic studies were reviewed when available. Survival after CLAD diagnosis was assessed using Kaplan-Meier and Cox proportional hazards models. MEASUREMENTS AND MAIN RESULTS Among patients with CLAD, 30% demonstrated an FVC decrement at its onset. These patients were more likely to be female, have radiographic alveolar or interstitial changes, and histologic findings of interstitial fibrosis. Patients with FVC decline at CLAD onset had significantly worse survival after CLAD when compared with those with preserved FVC (P < 0.0001; 3-yr survival estimates 9% vs. 48%, respectively). The deleterious impact of CLAD accompanied by FVC loss on post-CLAD survival persisted in a multivariable model including baseline demographic and clinical factors (P < 0.0001; adjusted hazard ratio, 2.73; 95% confidence interval, 1.86-4.04). CONCLUSIONS At CLAD onset, a subset of patients demonstrating physiology more suggestive of restriction experience worse clinical outcomes. Further study of the biologic mechanisms underlying CLAD phenotypes is critical to improving long-term survival after lung transplantation.
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Affiliation(s)
- Jamie L Todd
- 1 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine
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302
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Verleden SE, de Jong PA, Ruttens D, Vandermeulen E, van Raemdonck DE, Verschakelen J, Vanaudenaerde BM, Verleden GM, Vos R. Functional and computed tomographic evolution and survival of restrictive allograft syndrome after lung transplantation. J Heart Lung Transplant 2014; 33:270-7. [DOI: 10.1016/j.healun.2013.12.011] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 10/14/2013] [Accepted: 12/11/2013] [Indexed: 11/26/2022] Open
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303
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Laporta Hernández R, Lázaro Carrasco MT, Varela de Ugarte A, Ussetti Gil P. Seguimiento a largo plazo del paciente trasplantado pulmonar. Arch Bronconeumol 2014; 50:67-72. [DOI: 10.1016/j.arbres.2013.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 10/11/2013] [Accepted: 10/14/2013] [Indexed: 10/25/2022]
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304
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Home spirometry as early detector of azithromycin refractory bronchiolitis obliterans syndrome in lung transplant recipients. Respir Med 2014; 108:405-12. [DOI: 10.1016/j.rmed.2013.12.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Revised: 12/10/2013] [Accepted: 12/30/2013] [Indexed: 11/18/2022]
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305
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306
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Verleden SE, Vasilescu DM, Willems S, Ruttens D, Vos R, Vandermeulen E, Hostens J, McDonough JE, Verbeken EK, Verschakelen J, Van Raemdonck DE, Rondelet B, Knoop C, Decramer M, Cooper J, Hogg JC, Verleden GM, Vanaudenaerde BM. The Site and Nature of Airway Obstruction after Lung Transplantation. Am J Respir Crit Care Med 2014; 189:292-300. [DOI: 10.1164/rccm.201310-1894oc] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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307
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Sommerwerck U, Rabis T, Fleimisch P, Carstens H, Teschler H, Kamler M. [Lung transplantation]. Herz 2014; 39:74-83. [PMID: 24477632 DOI: 10.1007/s00059-013-4044-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Lung transplantation is a therapeutic option for patients with end-stage lung diseases. Selection of candidates requires careful consideration of the disease-specific indications and contraindications for transplantation. Advances have been made in candidate selection via the ability to prognosticate outcomes of various lung diseases and through the implementation of the lung allocation score (LAS) with specific consideration of the degree of urgency and good postoperative survival rate, after neglecting the waiting time. This system has resulted in decreased mortality on the waiting list for lung transplantation. The availability of donor organs can possibly be increased by implementation of ex vivo lung perfusion as an alternative to conventional organ preservation. Risk factors for poor outcomes post-lung transplantation have been identified and understanding of the physiological, cellular and molecular mechanisms responsible for lung and airway damage has been extensively expanded. Primary graft dysfunction, infectious diseases, acute rejection, antibody-mediated rejection, lymphocytic bronchiolitis, obliterative bronchiolitis, restrictive allograft syndrome, and chronic lung allograft dysfunction are well defined complications and continue to be common causes of morbidity and mortality. This article provides a comprehensive update on these topics for the non-transplantation clinician.
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Affiliation(s)
- U Sommerwerck
- Abt. f. Pneumologie, Ruhrlandklinik, Westdeutsches Lungenzentrum, Universitätsklinikum Essen, Universität Duisburg-Essen, Tüschener Weg 40, 45239, Essen, Deutschland,
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308
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Elevated Bronchoalveolar Lavage Eosinophilia Correlates With Poor Outcome After Lung Transplantation. Transplantation 2014; 97:83-9. [DOI: 10.1097/tp.0b013e3182a6bae2] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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309
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Abstract
Since the first successful lung transplant 30 years ago, lung transplantation has rapidly become an established standard of care to treat end-stage lung disease in selected patients. Advances in lung preservation, surgical technique, and immunosuppression regimens have resulted in the routine performance of lung transplantation around the world for an increasing number of patients, with wider indications. Despite this, donor shortages and chronic lung allograft dysfunction continue to prevent lung transplantation from reaching its full potential. With research into the underlying mechanisms of acute and chronic lung graft dysfunction and advances in personalized diagnostic and therapeutic approaches to both the donor lung and the lung transplant recipient, there is increasing confidence that we will improve short- and long-term outcomes in the near future.
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Affiliation(s)
- Jonathan C Yeung
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario M5G 2C4, Canada
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310
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Télé-suivi des patients transplantés pulmonaires : étude de faisabilité. Rev Mal Respir 2014; 31:78-81. [DOI: 10.1016/j.rmr.2013.04.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 04/14/2013] [Indexed: 10/26/2022]
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311
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Shino MY, Weigt SS, Li N, Palchevskiy V, Derhovanessian A, Saggar R, Sayah DM, Gregson AL, Fishbein MC, Ardehali A, Ross DJ, Lynch JP, Elashoff RM, Belperio JA. CXCR3 ligands are associated with the continuum of diffuse alveolar damage to chronic lung allograft dysfunction. Am J Respir Crit Care Med 2013; 188:1117-25. [PMID: 24063316 DOI: 10.1164/rccm.201305-0861oc] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
RATIONALE After lung transplantation, insults to the allograft generally result in one of four histopathologic patterns of injury: (1) acute rejection, (2) lymphocytic bronchiolitis, (3) organizing pneumonia, and (4) diffuse alveolar damage (DAD). We hypothesized that DAD, the most severe form of acute lung injury, would lead to the highest risk of chronic lung allograft dysfunction (CLAD) and that a type I immune response would mediate this process. OBJECTIVES Determine whether DAD is associated with CLAD and explore the potential role of CXCR3/ligand biology. METHODS Transbronchial biopsies from all lung transplant recipients were reviewed. The association between the four injury patterns and subsequent outcomes were evaluated using proportional hazards models with time-dependent covariates. Bronchoalveolar lavage (BAL) concentrations of the CXCR3 ligands (CXCL9/MIG, CXCL10/IP10, and CXCL11/ITAC) were compared between allograft injury patterns and "healthy" biopsies using linear mixed-effects models. The effect of these chemokine alterations on CLAD risk was assessed using Cox models with serial BAL measurements as time-dependent covariates. MEASUREMENTS AND MAIN RESULTS There were 1,585 biopsies from 441 recipients with 62 episodes of DAD. An episode of DAD was associated with increased risk of CLAD (hazard ratio, 3.0; 95% confidence interval, 1.9-4.7) and death (hazard ratio, 2.3; 95% confidence interval, 1.7-3.0). There were marked elevations in BAL CXCR3 ligand concentrations during DAD. Furthermore, prolonged elevation of these chemokines in serial BAL fluid measurements predicted the development of CLAD. CONCLUSIONS DAD is associated with marked increases in the risk of CLAD and death after lung transplantation. This association may be mediated in part by an aberrant type I immune response involving CXCR3/ligands.
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Affiliation(s)
- Michael Y Shino
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine
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312
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Saito T, Takahashi H, Kaneda H, Binnie M, Azad S, Sato M, Waddell TK, Cypel M, Liu M, Keshavjee S. Impact of cytokine expression in the pre-implanted donor lung on the development of chronic lung allograft dysfunction subtypes. Am J Transplant 2013; 13:3192-201. [PMID: 24164971 DOI: 10.1111/ajt.12492] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 08/13/2013] [Accepted: 09/07/2013] [Indexed: 01/25/2023]
Abstract
The long-term success of lung transplantation continues to be challenged by the development of chronic lung allograft dysfunction (CLAD). The purpose of this study was to investigate the relationship between cytokine expression levels in pre-implanted donor lungs and the posttransplant development of CLAD and its subtypes, bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS). Of 109 patients who underwent bilateral lung or heart-lung transplantation and survived for more than 3 months, 50 BOS, 21 RAS and 38 patients with No CLAD were identified by pulmonary function test results. Using donor lung tissue biopsies sampled from each patient, expression levels of IL-6, IL-1β, IL-8, IL-10, interferon-γ and tumor necrosis factor-α mRNA were measured. IL-6 expression levels were significantly higher in pre-implanted lungs of patients that ultimately developed BOS compared to RAS and No CLAD (p = 0.025 and 0.011, respectively). Cox regression analysis demonstrated an association between high IL-6 expression levels and BOS development (hazard ratio = 4.98; 95% confidence interval = 2.42-10.2, p < 0.001). In conclusion, high IL-6 mRNA expression levels in pre-implanted donor lungs were associated with the development of BOS, not RAS. This association further supports the contention that early graft injury impacts on both late graft function and early graft function.
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Affiliation(s)
- T Saito
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada; Department of Thoracic and Cardiovascular Surgery, Kansai Medical University, Hirakara, Japan
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313
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Vos R, Verleden SE, Ruttens D, Vandermeulen E, Yserbyt J, Dupont LJ, Van Raemdonck DE, De Raedt N, Gheysens O, De Jong PA, Verleden GM, Vanaudenaerde BM. Pirfenidone: a potential new therapy for restrictive allograft syndrome? Am J Transplant 2013; 13:3035-40. [PMID: 24102752 DOI: 10.1111/ajt.12474] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 08/06/2013] [Indexed: 01/25/2023]
Abstract
This case report describes the evolution of pulmonary function findings (FVC, FEV1 and TLC) and CT features with pirfenidone treatment for restrictive allograft syndrome following lung transplantation. Furthermore, we herein report hypermetabolic activity on (18) F-FDG PET imaging in this setting, which could indicate active fibroproliferation and pleuroparenchymal remodeling. These findings may warrant further investigation.
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Affiliation(s)
- R Vos
- Lung Transplantation Unit, University Hospital Gasthuisberg, Leuven, Belgium
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314
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Verleden GM, Raghu G, Meyer KC, Glanville AR, Corris P. A new classification system for chronic lung allograft dysfunction. J Heart Lung Transplant 2013; 33:127-33. [PMID: 24374027 DOI: 10.1016/j.healun.2013.10.022] [Citation(s) in RCA: 401] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 10/18/2013] [Accepted: 10/23/2013] [Indexed: 11/15/2022] Open
Abstract
Although survival after lung transplantation has improved significantly during the last decade, chronic rejection is thought to be the major cause of late mortality. The physiologic hallmark of chronic rejection has been a persistent fall in forced expiratory volume in 1 second associated with an obstructive ventilatory defect, for which the term bronchiolitis obliterans syndrome (BOS) was defined to allow a uniformity of description and grading of severity throughout the world. Although BOS was generally thought to be irreversible, recent evidence suggests that some patients with BOS may respond to azithromycin with > 10% improvement in their forced expiratory volume in 1 second. In addition, a restrictive form of chronic rejection has recently been described that does not fit the strict definition of BOS as an obstructive defect. Hence, the term chronic lung allograft dysfunction (CLAD) has been introduced to cover all forms of graft dysfunction, but CLAD has yet to be defined. We propose a definition of CLAD and a flow chart that may facilitate recognition of the different phenotypes of CLAD that can complicate the clinical course of lung transplant recipients.
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Affiliation(s)
- Geert M Verleden
- University Hospital Gasthuisberg, Lung Transplantation Unit, Leuven, Belgium.
| | - Ganesh Raghu
- University of Washington School of Medicine, Seattle, Washington
| | - Keith C Meyer
- University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
| | - Allan R Glanville
- The Lung Transplant Unit, St Vincent's Hospital, Darlinghurst, Australia
| | - Paul Corris
- Department of Respiratory Medicine, Institute of Transplantation and Institute of Cellular Medicine, Newcastle University and The Newcastle upon Tyne Hospitals NHS Foundation Trust Newcastle upon Tyne, United Kingdom
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315
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Meyer KC, Nathan SD. Lung Transplantation for Idiopathic Pulmonary Fibrosis. IDIOPATHIC PULMONARY FIBROSIS 2013. [PMCID: PMC7121325 DOI: 10.1007/978-1-62703-682-5_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Despite advances in the development of novel pharmaceutical agents to treat idiopathic pulmonary fibrosis (IPF), there are no medical therapies known to resolve fibrosis or improve lung function in IPF. Therefore, lung transplantation remains the only life-saving therapy available to treat patients with IPF. However, a shortage of suitable donor organs limits the number of affected individuals who can undergo this procedure, and this shortage highlights the need to allocate donor lungs to those who are in the greatest need of a life-saving therapy yet ensure that those who undergo transplantation will have a reasonable expectation of long-term survival. Still, outcomes remain relatively poor for many patients after lung transplantation, although a sizable minority of patients can enjoy long-term survival after lung transplantation.
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Affiliation(s)
- Keith C. Meyer
- Dept. Internal Medicine, Sect. Allergy Pulmonary & Critical Care Med., University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin USA
| | - Steven D. Nathan
- Advanced Lung Disease and Lung Transplant Program, Inova Fairfax Hospital, Falls Church, Virginia USA
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316
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Preidl RHM, Eckl S, Ramsperger-Gleixner M, Koch N, Spriewald BM, Weyand M, Ensminger SM. Clopidogrel reduces post-transplant obliterative bronchiolitis. Transpl Int 2013; 26:1038-48. [DOI: 10.1111/tri.12163] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 05/13/2013] [Accepted: 07/15/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Raimund H. M. Preidl
- Department of Cardiac Surgery; Friedrich-Alexander University; Erlangen-Nürnberg Germany
| | - Sebastian Eckl
- Department of Cardiac Surgery; Friedrich-Alexander University; Erlangen-Nürnberg Germany
| | | | - Nina Koch
- Department of Cardiac Surgery; Friedrich-Alexander University; Erlangen-Nürnberg Germany
| | - Bernd M. Spriewald
- Department of Internal Medicine 5; Hematology/Oncology and Institute of Clinical Immunology; Friedrich-Alexander University; Erlangen-Nürnberg Germany
| | - Michael Weyand
- Department of Cardiac Surgery; Friedrich-Alexander University; Erlangen-Nürnberg Germany
| | - Stephan M. Ensminger
- Department of Cardiac Surgery; Friedrich-Alexander University; Erlangen-Nürnberg Germany
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317
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Hodge G, Hodge S, Ahern J, Holmes-Liew CL, Reynolds PN, Holmes M. Up-regulation of alternate co-stimulatory molecules on proinflammatory CD28null T cells in bronchiolitis obliterans syndrome. Clin Exp Immunol 2013; 173:150-60. [PMID: 23607447 DOI: 10.1111/cei.12081] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2013] [Indexed: 12/01/2022] Open
Abstract
Bronchiolitis obliterans syndrome (BOS) is associated with lack of immunosuppression of T cell proinflammatory cytokines and increased T cell granzyme B. Repeated antigen-driven proliferation down-regulates T cell CD28. We hypothesized that down-regulation of CD28 and up-regulation of alternate co-stimulatory molecules (CD134, CD137, CD152 and CD154) on T cells may be associated with BOS. Co-stimulatory molecules, granzyme B, perforin and intracellular cytokines were measured by flow cytometry on T cells from stable lung transplant patients (n = 38), patients with BOS (n = 20) and healthy controls (n = 10). There was a significant increase in the percentage of CD4/28(null) and CD8/28(null) T cells producing granzyme B, interferon (IFN)-γ and tumour necrosis factor (TNF)-α in BOS compared with stable patients. Down-regulation of CD28 was associated with steroid resistance and up-regulation of CD134, CD137, CD152 and CD154 on CD4(+) T cells and CD137 and CD152 on CD8(+) T cells. There was a significant correlation between increased CD28(null) /CD137 T cells producing IFN-γ, TNF-α with BOS grade (r = 0·861, P < 0·001 for CD28(null) /CD137 IFN-γ/CD8) and time post-transplant (r = 0·698, P < 0·001 for CD28(null) /CD137 IFN-γ/CD8). BOS is associated with down-regulation of CD28 and up-regulation of alternate co-stimulatory molecules on steroid-resistant peripheral blood proinflammatory CD4(+) and CD8(+) T cells. Therapeutic targeting of alternate co-stimulatory molecules on peripheral blood CD28(null) T cells and monitoring response using these assays may help in the management of patients with BOS.
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Affiliation(s)
- G Hodge
- Lung Research, Hanson Institute and Department of Thoracic Medicine, Royal Adelaide Hospital, Australia.
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318
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Snell GI, Paraskeva M, Westall GP. Managing bronchiolitis obliterans syndrome (BOS) and chronic lung allograft dysfunction (CLAD) in children: what does the future hold? Paediatr Drugs 2013; 15:281-9. [PMID: 23605986 DOI: 10.1007/s40272-013-0026-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The success of pediatric lung transplantation continues to be limited by long-term graft dysfunction. Historically this has been characterized as an obstructive spirometric defect in the form of the bronchiolitis obliterans syndrome (BOS). It is recognized, however, that this does not reflect many of the other acknowledged etiologies of chronic lung dysfunction-noting it is the sum of the parts that contribute to respiratory morbidity and mortality after transplant. The term chronic lung allograft dysfunction (CLAD) has been coined to reflect these other entities and, in particular, a group of relatively recently described lung disorders called the restrictive allograft syndrome (RAS). RAS is characterized by a restrictive spirometric defect. Although these entities have not yet been studied in a pediatric setting their association with poor compliance, antibody-mediated rejection (AMR), and post-infectious lung damage (particularly viral) warrants attention by pediatric lung transplant teams. Current therapy for the BOS subset of CLAD is otherwise limited to changing immunosuppressants and avoiding excessive infectious risk by avoiding over-immunosuppression. Long-term macrolide therapy in lung transplantation is not of proven efficacy. Reviewing previous BOS studies to explore restrictive spirometric cases and joint projects via groups like the International Pediatric Lung Transplant Collaborative will be the way forward to solve this pressing problem.
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Affiliation(s)
- Gregory I Snell
- National Paediatric Lung Transplant Service, Alfred Hospital and Monash University, Melbourne 3004, Australia.
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319
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Bronchiolitis obliterans syndrome and restrictive allograft syndrome: do risk factors differ? Transplantation 2013; 95:1167-72. [PMID: 23425818 DOI: 10.1097/tp.0b013e318286e076] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Chronic rejection is the major problem hampering long-term survival after lung transplantation. Recently, it became clear that patients may develop an obstructive (bronchiolitis obliterans syndrome [BOS]) or a restrictive lung function defect (restrictive allograft syndrome [RAS]), for which specific risk factors are unknown. METHODS A retrospective analysis of our lung transplantation cohort was performed (n=380). Patients with an irreversible decline in forced expiratory volume in 1 second were identified and classified as BOS or RAS. Patient characteristics, bronchoalveolar lavage (BAL) cellularity, rates of respiratory tract infection, colonization, acute rejection, and lymphocytic bronchiolitis were compared between BOS, RAS, and stable patients. RESULTS There were 103 patients suffering from chronic rejection, of which 79 had BOS and 24 were diagnosed with RAS. There were more patients with infection and pseudomonal colonizations in BOS and RAS compared with control (P=0.0090 and P=0.0034, respectively). More patients ever experienced acute and severe acute rejections (A≥2; both P<0.0001) and lymphocytic bronchiolitis (P=0.0006) in BOS and RAS versus control. There were more patients experiencing severe lymphocytic bronchiolitis in RAS compared with BOS (P=0.031). BAL neutrophilia in BOS and RAS were elevated at days 360, 540, and 720 versus control. BOS, but especially RAS patients, experienced more frequent episodes of increased BAL eosinophilia (≥2%; P<0.0001). CONCLUSION Acute rejection, lymphocytic bronchiolitis, colonization with pseudomonas, infection, and BAL eosinophilia and neutrophilia are risk factors for the later development not only of RAS but also of BOS.
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320
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Postoperative imaging after lung transplantation. Clin Imaging 2013; 37:617-23. [PMID: 23557663 DOI: 10.1016/j.clinimag.2013.02.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Accepted: 02/21/2013] [Indexed: 02/02/2023]
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321
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Paraskeva M, McLean C, Ellis S, Bailey M, Williams T, Levvey B, Snell GI, Westall GP. Acute Fibrinoid Organizing Pneumonia after Lung Transplantation. Am J Respir Crit Care Med 2013; 187:1360-8. [DOI: 10.1164/rccm.201210-1831oc] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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322
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Hirayama S, Sato M, Loisel-Meyer S, Matsuda Y, Oishi H, Guan Z, Saito T, Yeung J, Cypel M, Hwang DM, Medin JA, Liu M, Keshavjee S. Lentivirus IL-10 gene therapy down-regulates IL-17 and attenuates mouse orthotopic lung allograft rejection. Am J Transplant 2013; 13:1586-93. [PMID: 23601206 DOI: 10.1111/ajt.12230] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 02/14/2013] [Accepted: 02/14/2013] [Indexed: 01/25/2023]
Abstract
The purpose of the study was to examine the effect of lentivirus-mediated IL-10 gene therapy to target lung allograft rejection in a mouse orthotopic left lung transplantation model. IL-10 may regulate posttransplant immunity mediated by IL-17. Lentivirus-mediated trans-airway luciferase gene transfer to the donor lung resulted in persistent luciferase activity up to 6 months posttransplant in the isograft (B6 to B6); luciferase activity decreased in minor-mismatched allograft lungs (B10 to B6) in association with moderate rejection. Fully MHC-mismatched allograft transplantation (BALB/c to B6) resulted in severe rejection and complete loss of luciferase activity. In minor-mismatched allografts, IL-10-encoding lentivirus gene therapy reduced the acute rejection score compared with the lentivirus-luciferase control at posttransplant day 28 (3.0 ± 0.6 vs. 2.0 ± 0.6 (mean ± SD); p = 0.025; n = 6/group). IL-10 gene therapy also significantly reduced gene expression of IL-17, IL-23, and retinoic acid-related orphan receptor (ROR)-γt without affecting levels of IL-12 and interferon-γ (IFN-γ). Cells expressing IL-17 were dramatically reduced in the allograft lung. In conclusion, lentivirus-mediated IL-10 gene therapy significantly reduced expression of IL-17 and other associated genes in the transplanted allograft lung and attenuated posttransplant immune responses after orthotopic lung transplantation.
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Affiliation(s)
- S Hirayama
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
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323
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Abstract
Lung transplantation may be the only intervention that can prolong survival and improve quality of life for those individuals with advanced lung disease who are acceptable candidates for the procedure. However, these candidates may be extremely ill and require ventilator and/or circulatory support as a bridge to transplantation, and lung transplantation recipients are at risk of numerous post-transplant complications that include surgical complications, primary graft dysfunction, acute rejection, opportunistic infection, and chronic lung allograft dysfunction (CLAD), which may be caused by chronic rejection. Many advances in pre- and post-transplant management have led to improved outcomes over the past decade. These include the creation of sound guidelines for candidate selection, improved surgical techniques, advances in donor lung preservation, an improving ability to suppress and treat allograft rejection, the development of prophylaxis protocols to decrease the incidence of opportunistic infection, more effective therapies for treating infectious complications, and the development of novel therapies to treat and manage CLAD. A major obstacle to prolonged survival beyond the early post-operative time period is the development of bronchiolitis obliterans syndrome (BOS), which is the most common form of CLAD. This manuscript discusses recent and evolving advances in the field of lung transplantation.
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324
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Suhling H, de Wall C, Rademacher J, Greer M, Boemke A, Dettmer S, Haverich A, Warnecke G, Welte T, Gottlieb J. Low Exercise Tolerance Correlates With Reduced Inspiratory Capacity and Respiratory Muscle Function in Recipients With Advanced Chronic Lung Allograft Dysfunction. Transplantation 2013; 95:1045-50. [DOI: 10.1097/tp.0b013e31828555d0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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325
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Greer M, Dierich M, De Wall C, Suhling H, Rademacher J, Welte T, Haverich A, Warnecke G, Ivanyi P, Buchholz S, Gottlieb J, Fuehner T. Phenotyping established chronic lung allograft dysfunction predicts extracorporeal photopheresis response in lung transplant patients. Am J Transplant 2013; 13:911-918. [PMID: 23406373 DOI: 10.1111/ajt.12155] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 10/23/2012] [Accepted: 11/11/2012] [Indexed: 01/25/2023]
Abstract
Chronic lung allograft dysfunction (CLAD) remains the leading cause of mortality in lung transplant recipients after the first year. Treatment remains limited and unpredictable. Existing data suggests extracorporeal photopheresis (ECP) may be beneficial. This study aimed to identify factors predicting treatment response and the prognostic implications. A single center retrospective analysis of all patients commencing ECP for CLAD between November 1, 2007 and September 1, 2011 was performed. In total 65 patients were included, 64 of whom had deteriorated under azithromycin. Median follow-up after commencing ECP was 503 days. Upon commencing ECP, all patients were classified using proposed criteria for emerging clinical phenotypes, including "restrictive allograft syndrome (RAS)", "neutrophilic CLAD (nCLAD)" and "rapid decliners". At follow-up, 8 patients demonstrated ≥10% improvement in FEV1 , 27 patients had stabilized and 30 patients exhibited ≥10% decline in FEV1 . Patients fulfilling criteria for "rapid decliners" (n=21, p=0.005), RAS (n=22, p=0.002) and those not exhibiting neutrophilia in bronchoalveolar lavage (n=44, p=0.01) exhibited poorer outcomes. ECP appears an effective second line treatment in CLAD patients progressing under azithromycin. ECP responders demonstrated improved progression-free survival (median 401 vs. 133 days). Proposed CLAD phenotypes require refinement, but appear to predict the likelihood of ECP response.
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Affiliation(s)
- M Greer
- Department of Respiratory Medicine, Hannover Medical School, Germany
| | - M Dierich
- Department of Respiratory Medicine, Hannover Medical School, Germany
| | - C De Wall
- Department of Respiratory Medicine, Hannover Medical School, Germany
| | - H Suhling
- Department of Respiratory Medicine, Hannover Medical School, Germany
| | - J Rademacher
- Department of Respiratory Medicine, Hannover Medical School, Germany
| | - T Welte
- Department of Respiratory Medicine, Hannover Medical School, Germany
| | - A Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Germany
| | - G Warnecke
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Germany
| | - P Ivanyi
- Department of Hematology, Hemostasis, Oncology and StemCell Transplantation, Hannover Medical School, Germany
| | - S Buchholz
- Department of Hematology, Hemostasis, Oncology and StemCell Transplantation, Hannover Medical School, Germany
| | - J Gottlieb
- Department of Respiratory Medicine, Hannover Medical School, Germany
| | - T Fuehner
- Department of Respiratory Medicine, Hannover Medical School, Germany
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326
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The impact of viral respiratory tract infections on long-term morbidity and mortality following lung transplantation: a retrospective cohort study using a multiplex PCR panel. Transplantation 2013; 95:383-8. [PMID: 23444472 DOI: 10.1097/tp.0b013e318271d7f0] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The major factor affecting morbidity and mortality after lung transplantation (LTX) is bronchiolitis obliterans syndrome. Earlier studies have suggested a connection between the presence of viral agents and morbidity in this patient group, but data are somewhat conflicting. The objective of this study was to investigate the development of bronchiolitis obliterans syndrome and graft loss after LTX in relation to the presence of respiratory viruses during the first year after LTX. METHOD The study is a retrospective cohort study of 39 LTX recipients 11Y13 years after surgery. Patients were operated between January 1, 1998 and December 31, 2000 at Sahlgrenska University Hospital. The presence of virus in bronchoalveolar lavage (BAL) fluids from patients during the first year after surgery was analyzed retrospectively using a multiplex polymerase chain reaction test capable of detecting 15 respiratory agents. The time to BOS or graft loss was analyzed in relation to the positive findings in BAL during the first year after LTX. RESULTS Patients with one or more viruses detected in BAL during the first year after transplantation demonstrated a significantly faster development of BOS (P=0.005) compared with patients with no virus detected. No significant difference in graft survival was found. CONCLUSION Our results suggest that the long-term prognosis after LTX may be negatively affected by viral respiratory tract infections during the first year after LTX.
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327
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Shah RJ, Bellamy SL, Lee JC, Cantu E, Diamond JM, Mangalmurti N, Kawut SM, Ware LB, Christie JD. Early plasma soluble receptor for advanced glycation end-product levels are associated with bronchiolitis obliterans syndrome. Am J Transplant 2013; 13:754-9. [PMID: 23331756 PMCID: PMC3582806 DOI: 10.1111/ajt.12062] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 09/19/2012] [Accepted: 10/08/2012] [Indexed: 01/25/2023]
Abstract
Early epithelial injury after lung transplantation may contribute to development of bronchiolitis obliterans syndrome (BOS). We evaluated the relationship between early postoperative soluble receptor for advanced glycation end-product (sRAGE) levels, a marker of type I alveolar cell injury and BOS. We performed a cohort study of 106 lung transplant recipients between 2002 and 2006 at the University of Pennsylvania with follow-up through 2010. Plasma sRAGE was measured 6 and 24 h after transplantation. Cox proportional hazards models were used to evaluate the association between sRAGE and time to BOS, defined according to ISHLT guidelines. Sixty (57%) subjects developed BOS. The average time to BOS was 3.4 years. sRAGE levels measured at 6 h (HR per SD of sRAGE: 1.69, 95% CI: 1.11, 2.57, p = 0.02) and 24 h (HR per SD of sRAGE: 1.74, 95% CI: 1.14, 2.65, p = 0.01) were associated with an increased hazard of BOS. Multivariable Cox regression indicated this relationship was independent of potential confounders. Elevated plasma sRAGE levels measured in the immediate postoperative period are associated with the development of BOS. Early epithelial injury after transplantation may contribute to the development of fibrosis in BOS.
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Affiliation(s)
- RJ Shah
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania School of Medicine, Philadelphia, PA,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - SL Bellamy
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - JC Lee
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania School of Medicine, Philadelphia, PA,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - E Cantu
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - JM Diamond
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania School of Medicine, Philadelphia, PA,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - N Mangalmurti
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - SM Kawut
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania School of Medicine, Philadelphia, PA,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - LB Ware
- Departments of Medicine and Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - JD Christie
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania School of Medicine, Philadelphia, PA,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA
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328
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Kennedy VE, Todd JL, Palmer SM. Bronchoalveolar lavage as a tool to predict, diagnose and understand bronchiolitis obliterans syndrome. Am J Transplant 2013; 13:552-61. [PMID: 23356456 PMCID: PMC3582805 DOI: 10.1111/ajt.12091] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 12/03/2012] [Accepted: 12/08/2012] [Indexed: 01/25/2023]
Abstract
Bronchiolitis obliterans syndrome (BOS), a condition of irreversible small airway fibrosis, is the principal factor limiting long-term survival after lung transplantation. Bronchoscopy and bronchoalveolar lavage (BAL), techniques central to lung transplant clinical practice, provide a unique opportunity to interrogate the lung allograft during BOS development and identify potential disease mechanisms or biomarkers. Over the past 20 years, numerous studies have evaluated the BAL cellular composition, cytokine profiles and protein constituents in lung transplant recipients with BOS. To date, however, no summative evaluation of this literature has been reported. We developed and applied objective criteria to qualitatively rank the strength of associations between BAL parameters and BOS in order to provide a comprehensive and systematic assessment of the literature. Our analysis indicates that several BAL parameters, including neutrophil count, interleukin-8, alpha defensins and MMP-9, demonstrate highly replicable associations with BOS. Additionally, we suggest that considerable opportunity exists to increase the knowledge gained from BAL analyses in BOS through increased sample sizes, covariant adjustment and standardization of the BAL technique. Further efforts to leverage analysis of BAL constituents in BOS may offer great potential to provide additional in-depth and mechanistic insights into the pathogenesis of this complex disease.
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Affiliation(s)
- Vanessa E. Kennedy
- Division of Pulmonary, Allergy and Critical Care Medicine- Duke University Medical Center, Durham, NC
| | - Jamie L. Todd
- Division of Pulmonary, Allergy and Critical Care Medicine- Duke University Medical Center, Durham, NC,Duke Clinical Research Institute, Durham, NC
| | - Scott M. Palmer
- Division of Pulmonary, Allergy and Critical Care Medicine- Duke University Medical Center, Durham, NC,Duke Clinical Research Institute, Durham, NC
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329
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Restrictive allograft syndrome post lung transplantation is characterized by pleuroparenchymal fibroelastosis. Mod Pathol 2013; 26:350-6. [PMID: 23018877 DOI: 10.1038/modpathol.2012.171] [Citation(s) in RCA: 169] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
We previously described restrictive allograft syndrome as a form of chronic lung allograft dysfunction, demonstrating restrictive pulmonary function decline. However, the histopathological correlates of restrictive allograft syndrome have yet to be satisfactorily described. We hypothesized that pulmonary pleuroparenchymal fibroelastosis, as has recently been described in bone marrow transplant recipients, may also be present in the lungs of patients with restrictive allograft syndrome. Retrospective review of 493 patients who underwent lung transplantation between 1 January 1996 and 30 June 2009, was conducted. Out of 47 patients with clinical features of restrictive allograft syndrome, 16 had wedge biopsy, re-transplant lung explant, or autopsy lung specimens available for review. All lungs showed varying degrees of pleural fibrosis. Fifteen of 16 showed parenchymal fibroelastosis, characterized by hypocellular collagen deposition with preservation and thickening of the underlying alveolar septal elastic network. The fibroelastosis was predominantly subpleural in distribution, with some cases also showing centrilobular and paraseptal distribution. A sharp demarcation was often seen between areas of fibroelastosis and unaffected lung parenchyma, with fibroblastic foci often present at this interface. Concurrent features of obliterative bronchiolitis were present in 14 cases. Another common finding was the presence of diffuse alveolar damage (13 cases), usually in specimens obtained <1 year after clinical onset of restrictive allograft syndrome. The single specimen in which fibroelastosis was not identified was obtained before the clinical onset of chronic lung allograft dysfunction, and showed features of diffuse alveolar damage. In conclusion, pleuroparenchymal fibroelastosis is a major histopathologic correlate of restrictive allograft syndrome, and was often found concurrently with diffuse alveolar damage. Our findings support a temporal sequence of diffuse alveolar damage followed by the development of pleuroparenchymal fibroelastosis in the histopathologic evolution of restrictive allograft syndrome.
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330
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Sato M, Ohmori-Matsuda K, Saito T, Matsuda Y, Hwang DM, Waddell TK, Singer LG, Keshavjee S. Time-dependent changes in the risk of death in pure bronchiolitis obliterans syndrome (BOS). J Heart Lung Transplant 2013; 32:484-91. [PMID: 23433813 DOI: 10.1016/j.healun.2013.01.1054] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Revised: 12/21/2012] [Accepted: 01/29/2013] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The timing of disease onset may affect the prognosis in chronic lung allograft dysfunction (CLAD). The relationship between the timing of disease onset and the prognosis of CLAD and its sub-types, bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS), was examined. METHODS Clinical records and pulmonary function data of 597 patients who underwent bilateral lung transplantation from 1996 to 2010 and survived for >3 months were examined. RESULTS Among 155 patients with a final diagnosis of BOS, patient survival after disease onset was significantly different according to disease-onset timing (BOS onset/post-BOS median survival: overall/1,438 days; <1 year/511 days; 1-2 years/1,199 days; 2-3 years/1,403 days; >3 years/did not reach median survival; p < 0.0001). The prognosis of RAS was generally poorer than that of BOS (overall post-RAS median survival, 377 days). Treating non-CLAD, CLAD, BOS, and RAS as time-dependent covariates, recipient sex-adjusted and age-adjusted Cox regression analysis demonstrated an overall mortality risk of BOS (reference: no CLAD) of 6.7 (95% confidence interval, 4.6-9.9). However, when patients survived 3 years without CLAD, the mortality risk of subsequent BOS was only 1.9 (95% confidence interval, 0.8-4.4) compared with no CLAD. The number of RAS patients was too small to obtain sufficient power to estimate time-dependent mortality risk. CONCLUSION Late-onset BOS showed a better prognosis than early-onset BOS. Studies that do not distinguish BOS from RAS may overestimate the mortality risk of BOS. Multicenter studies will be required to further elucidate risk factors toward the development of better management strategies for CLAD.
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Affiliation(s)
- Masaaki Sato
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
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331
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Meyer KC, Glanville AR. Bronchiolitis Obliterans Syndrome and Chronic Lung Allograft Dysfunction: Evolving Concepts and Nomenclature. BRONCHIOLITIS OBLITERANS SYNDROME IN LUNG TRANSPLANTATION 2013. [PMCID: PMC7122385 DOI: 10.1007/978-1-4614-7636-8_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Bronchiolitis obliterans syndrome (BOS) eventually occurs in the majority of lung transplant recipients who survive beyond 1 year, can greatly impair quality of life, and is, directly or indirectly, the major cause of delayed allograft dysfunction and recipient death. A number of associated events or conditions are strongly associated with the risk for developing BOS; these include acute rejection, gastroesophageal reflux, infections, and autoimmune reactions that can occur in the setting of alloimmune responses to the lung allograft as recipients are given intense immunosuppression to prevent allograft rejection. The term chronic lung allograft dysfunction (CLAD) is being increasingly used to refer to recipients with late allograft dysfunction that meets the spirometric criteria for the diagnosis of BOS, but clinicians should recognize that such dysfunction can occur for a variety of reasons other than BOS. The recently identified entity of restrictive allograft syndrome, which is now recognized as a relatively distinct phenotype of CLAD, has features that differentiate it from classic obstructive BOS. A number of other entities that can also significantly affect allograft function must also be considered when significant allograft dysfunction is encountered following lung transplantation.
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332
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Progression pattern of restrictive allograft syndrome after lung transplantation. J Heart Lung Transplant 2013; 32:23-30. [DOI: 10.1016/j.healun.2012.09.026] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2012] [Revised: 08/12/2012] [Accepted: 09/15/2012] [Indexed: 11/20/2022] Open
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333
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de Pablo A, Santos F, Solé A, Borro JM, Cifrian JM, Laporta R, Monforte V, Román A, de la Torre M, Ussetti P, Zurbano F. Recommendations on the use of everolimus in lung transplantation. Transplant Rev (Orlando) 2012; 27:9-16. [PMID: 23276646 DOI: 10.1016/j.trre.2012.11.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 11/09/2012] [Indexed: 01/05/2023]
Abstract
The antiproliferative effect of everolimus provides a therapeutic option in the immunosuppression therapy of lung transplantation, by reducing both the risk of acute rejection and the process of progressive fibrosis that determines chronic graft rejection. However, few data on the use of everolimus in lung transplantation have been published to date, and the specific indications of the drug, along with the most adequate time for its introduction or dosing, have not been defined yet. The aim of this article is to propose recommendations for the use of everolimus in lung transplant recipients, including indications, dosing schedules and the use of concomitant immunosuppression. This consensus document has been developed by experts of all the Spanish lung transplant groups from the review of the existing literature and the clinical experience.
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Affiliation(s)
- A de Pablo
- University Hospital, Doce de Octubre, Madrid, Spain.
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334
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Shah P, Tang D, Shah K, Mehra MR. JHLT highlights 2011: cardiothoracic transplantation, pulmonary hypertension, and mechanical circulatory support. J Heart Lung Transplant 2012. [PMID: 23206983 DOI: 10.1016/j.healun.2012.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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335
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Sato M. Chronic lung allograft dysfunction after lung transplantation: the moving target. Gen Thorac Cardiovasc Surg 2012; 61:67-78. [DOI: 10.1007/s11748-012-0167-3] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2012] [Indexed: 11/29/2022]
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336
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337
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Parmar J, Dunning J, Large S. eComment. Re: Radiological patterns of primary graft dysfunction after lung transplantation. Interact Cardiovasc Thorac Surg 2012; 14:791. [PMID: 22589347 DOI: 10.1093/icvts/ivs147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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338
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Sato M, Hwang DM, Ohmori-Matsuda K, Chaparro C, Waddell TK, Singer LG, Hutcheon MA, Keshavjee S. Revisiting the pathologic finding of diffuse alveolar damage after lung transplantation. J Heart Lung Transplant 2012; 31:354-63. [PMID: 22330935 DOI: 10.1016/j.healun.2011.12.015] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Revised: 11/27/2011] [Accepted: 12/28/2011] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Diffuse alveolar damage (DAD) is a non-specific pathologic diagnosis frequently encountered after lung transplantation. We examined the relationship between DAD and different forms of chronic lung allograft dysfunction (CLAD). METHODS We reviewed the results of 4,085 transbronchial biopsies obtained from 720 lung transplant recipients. DAD detected in biopsies within 3 months and newly detected DAD after 3 months were defined as early DAD and late new-onset DAD, respectively. Among patients with CLAD (FEV(1) <80% baseline), restrictive allograft syndrome (RAS) was defined by a decline in total lung capacity to <90% baseline and bronchiolitis obliterans syndrome (BOS) as CLAD without restrictive allograft syndrome (RAS). Kaplan-Meier analyses and multivariate proportional hazard models were used. RESULTS DAD was observed in 320 of 720 (44.4%) patients at least once; early and late new-onset DAD were observed in 264 of 707 (37.3%) and 87 of 655 (13.3%) patients, respectively. Early DAD was associated with significantly higher 90-day mortality (20 of 264 [7.6%] vs 11 of 443 [2.5%]; p = 0.001). Moreover, among 502 bilateral lung transplant recipients who had sufficient pulmonary function tests to distinguish BOS and RAS, early DAD was associated with earlier BOS onset (hazard ratio [HR] 1.24; confidence interval [CI] 1.04 to 1.47; p = 0.017; median time of BOS onset: 2,902 vs 4,005 days). Conversely, treated as a time-varying covariate, late new-onset DAD was a significant risk factor for RAS in a Cox model (HR 36.8; CI 18.3 to 74.1; p < 0.0001). CONCLUSIONS Early DAD is associated with early mortality and BOS, and late new-onset DAD increases the risk of RAS.
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Affiliation(s)
- Masaaki Sato
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
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339
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Altered progenitor cell and cytokine profiles in bronchiolitis obliterans syndrome. J Heart Lung Transplant 2012; 31:222-8. [DOI: 10.1016/j.healun.2011.11.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Revised: 10/27/2011] [Accepted: 11/18/2011] [Indexed: 01/23/2023] Open
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340
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Kosanam H, Sato M, Batruch I, Smith C, Keshavjee S, Liu M, Diamandis EP. Differential proteomic analysis of bronchoalveolar lavage fluid from lung transplant patients with and without chronic graft dysfunction. Clin Biochem 2012; 45:223-30. [DOI: 10.1016/j.clinbiochem.2011.11.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 11/09/2011] [Accepted: 11/28/2011] [Indexed: 10/14/2022]
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341
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Genetic Polymorphisms and Bronchiolitis Obliterans Syndrome After Lung Transplantation. Transplantation 2012; 93:127-35. [DOI: 10.1097/tp.0b013e31823915d5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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342
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Ohshimo S, Bonella F, Sommerwerck U, Teschler H, Kamler M, Jakob HG, Kohno N, Guzman J, Costabel U. Comparison of serum KL-6 versus bronchoalveolar lavage neutrophilia for the diagnosis of bronchiolitis obliterans in lung transplantation. J Heart Lung Transplant 2011; 30:1374-80. [DOI: 10.1016/j.healun.2011.07.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Revised: 07/06/2011] [Accepted: 07/13/2011] [Indexed: 10/17/2022] Open
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343
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Abstract
BACKGROUND Chronic lung allograft dysfunction (CLAD) remains the leading cause of mortality after lung transplantation. METHODS In this retrospective single-center study, we aimed to identify different phenotypes of and risk factors for mortality after CLAD diagnosis using univariate and multivariate Cox proportional hazard survival regression analysis. RESULTS CLAD was diagnosed in 71 of 294 patients (24.2%) at 30.9±22.8 months after transplantation. Pulmonary function was obstructive in 51 (71.8%) of the CLAD patients, restrictive in 20 (28.2%) patients, of whom 17 had persistent parenchymal infiltrates on pulmonary computer tomography (CAT) scan. In univariate analysis, previous development of neutrophilic reversible allograft dysfunction (NRAD, P=0.012) and a restrictive pulmonary function (P=0.0024) were associated with a worse survival, whereas there was a strong trend for early development of CLAD and persistent parenchymal infiltrates on CAT scan (P=0.067 and 0.056, respectively). In multivariate analysis, early development of CLAD (P=0.0067), previous development of NRAD (P=0.0016), and a restrictive pulmonary function pattern (P=0.0005) or persistent parenchymal infiltrates on CAT scan (P=0.0043) remained significant. CONCLUSION Although most CLAD patients develop an obstructive pulmonary function, 28% develop a restrictive pulmonary function, compatible with the recently defined restrictive allograft syndrome phenotype. Early-onset CLAD, previous development of NRAD, and the development of restrictive allograft syndrome are associated with worse survival after CLAD has been diagnosed.
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