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Abstract
BACKGROUND Activins A and B, members of the TGF-β superfamily, are produced as part of the physiological response to tissue damage and the resulting proinflammatory response. Given that lung allograft reperfusion results in an inflammatory response, it is likely that the activins and their binding protein follistatin will form part of the regulatory response. There is a need to document the response of these proteins to allograft reperfusion to determine if there is a role for the use of follistatin to control the biological actions of the activins because some of these are potentially damaging. METHODS Serum from 48 consecutive patients undergoing lung transplantation (LTx) was collected at 2, 6, 12, and 26 weeks post-LTx. The serum levels of activin A and B and follistatin were measured by enzyme-linked immunosorbent assay and specific radioimmunoassays and compared with clinical events. RESULTS Serum activin A and B levels were at the upper limit of the normal ranges at 2 weeks post-LTx decreasing thereafter to 12 weeks post-LTx (P < 0.05). In contrast, serum follistatin levels were unchanged between 2 and 12 weeks, with a late significant increase at 24 week post-LTx (P < 0.01). Patients with primary graft dysfunction had lower serum follistatin levels (7.7 vs 9.5 ng/mL; P = 0.04) and a higher activin A/follistatin ratio (13.1 vs 10.4; P = 0.02) at 2 weeks post-LTx. CONCLUSIONS Activin and follistatin levels vary with time form LTX and reflect a proinflammatory environment. Future studies will elucidate associations with chronic lung allograft dysfunction and the therapeutic potential of exogenous follistatin administration.
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Wong JY, Westall GP, Snell GI. Bronchoscopic procedures and lung biopsies in pediatric lung transplant recipients. Pediatr Pulmonol 2015; 50:1406-19. [PMID: 25940429 DOI: 10.1002/ppul.23203] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 01/07/2015] [Accepted: 01/13/2015] [Indexed: 12/19/2022]
Abstract
Bronchoscopy remains a pivotal diagnostic and therapeutic intervention in pediatric patients undergoing lung transplantation (LTx). Whether performed as part of a surveillance protocol or if clinically indicated, fibre-optic bronchoscopy allows direct visualization of the transplanted allograft, and in particular, an assessment of the patency of the bronchial anastomosis (or tracheal anastomosis following heart-lung transplantation). Additionally, bronchoscopy facilitates differentiation of infective processes from rejection episodes through collection and subsequent assessment of bronchoalveolar lavage (BAL) and transbronchial biopsy (TBBx) samples. Indeed, the diagnostic criteria for the grading of acute cellular rejection is dependent upon the histopathological assessment of biopsy samples collected at the time of bronchoscopy. Typically, performed in an out-patient setting, bronchoscopy is generally a safe procedure, although complications related to hemorrhage and pneumothorax are occasionally seen. Airway complications, including stenosis, malacia, and dehiscence are diagnosed at bronchoscopy, and subsequent management including balloon dilatation, laser therapy and stent insertion can also be performed bronchoscopically. Finally, bronchoscopy has been and continues to be an important research tool allowing a better understanding of the immuno-biology of the lung allograft through the collection and analysis of collected BAL and TBBx samples. Whilst new investigational tools continue to evolve, the simple visualization and collection of samples within the lung allograft by bronchoscopy remains the gold standard in the evaluation of the lung allograft. This review describes the use and experience of bronchoscopy following lung transplantation in the pediatric setting.
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Affiliation(s)
- Jackson Y Wong
- Division of Pediatric Respiratory Medicine, Department of Pediatrics, McMaster University, Ontario, Canada
| | - Glen P Westall
- Lung Transplant Service, Alfred Hospital and Monash University, Melbourne, Australia
| | - Gregory I Snell
- Lung Transplant Service, Alfred Hospital and Monash University, Melbourne, Australia
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Saito T, Horie M, Sato M, Nakajima D, Shoushtarizadeh H, Binnie M, Azad S, Hwang DM, Machuca TN, Waddell TK, Singer LG, Cypel M, Liu M, Paul NS, Keshavjee S. Low-dose computed tomography volumetry for subtyping chronic lung allograft dysfunction. J Heart Lung Transplant 2015; 35:59-66. [PMID: 26342441 DOI: 10.1016/j.healun.2015.07.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 07/01/2015] [Accepted: 07/17/2015] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The long-term success of lung transplantation is challenged by the development of chronic lung allograft dysfunction (CLAD) and its distinct subtypes of bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS). However, the current diagnostic criteria for CLAD subtypes rely on total lung capacity (TLC), which is not always measured during routine post-transplant assessment. Our aim was to investigate the utility of low-dose 3-dimensional computed tomography (CT) lung volumetry for differentiating RAS from BOS. METHODS This study was a retrospective evaluation of 63 patients who had developed CLAD after bilateral lung or heart‒lung transplantation between 2006 and 2011, including 44 BOS and 19 RAS cases. Median post-transplant follow-up was 65 months in BOS and 27 months in RAS. The median interval between baseline and the disease-onset time-point for CT volumetry was 11 months in both BOS and RAS. Chronologic changes and diagnostic accuracy of CT lung volume (measured as percent of baseline) were investigated. RESULTS RAS showed a significant decrease in CT lung volume at disease onset compared with baseline (mean 3,916 ml vs 3,055 ml when excluding opacities, p < 0.0001), whereas BOS showed no significant post-transplant change (mean 4,318 ml vs 4,396 ml, p = 0.214). The area under the receiver operating characteristic curve of CT lung volume for differentiating RAS from BOS was 0.959 (95% confidence interval 0.912 to 1.01, p < 0.0001) and the calculated accuracy was 0.938 at a threshold of 85%. CONCLUSION In bilateral lung or heart‒lung transplant patients with CLAD, low-dose CT volumetry is a useful tool to differentiate patients who develop RAS from those who develop BOS.
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Affiliation(s)
- Tomohito Saito
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute and Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada; Department of Thoracic and Cardiovascular Surgery, Kansai Medical University, Hirakara, Japan
| | - Miho Horie
- Cardiothoracic Division, Department of Medical Imaging, Time Resolved Imaging and Image Optimization Core Laboratory, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Masaaki Sato
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute and Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada; Department of Thoracic Surgery, Kyoto University, Kyoto, Japan
| | - Daisuke Nakajima
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute and Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada; Department of Thoracic Surgery, Kyoto University, Kyoto, Japan
| | - Hassan Shoushtarizadeh
- Cardiothoracic Division, Department of Medical Imaging, Time Resolved Imaging and Image Optimization Core Laboratory, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Matthew Binnie
- Division of Respirology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sassan Azad
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute and Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - David M Hwang
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute and Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Tiago N Machuca
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute and Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas K Waddell
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute and Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Lianne G Singer
- Division of Respirology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute and Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Mingyao Liu
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute and Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Respirology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Narinder S Paul
- Cardiothoracic Division, Department of Medical Imaging, Time Resolved Imaging and Image Optimization Core Laboratory, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute and Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada; Department of Thoracic and Cardiovascular Surgery, Kansai Medical University, Hirakara, Japan.
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Thompson BR, Westall GP, Paraskeva M, Snell GI. Lung transplantation in adults and children: putting lung function into perspective. Respirology 2014; 19:1097-105. [PMID: 25186813 DOI: 10.1111/resp.12370] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 05/22/2014] [Accepted: 06/20/2014] [Indexed: 01/13/2023]
Abstract
The number of lung transplants performed globally continues to increase year after year. Despite this growing experience, long-term outcomes following lung transplantation continue to fall far short of that described in other solid-organ transplant settings. Chronic lung allograft dysfunction (CLAD) remains common and is the end result of exposure to a multitude of potentially injurious insults that include alloreactivity and infection among others. Central to any description of the clinical performance of the transplanted lung is an assessment of its physiology by pulmonary function testing. Spirometry and the evaluation of forced expiratory volume in 1 s and forced vital capacity, remain core indices that are measured as part of routine clinical follow-up. Spirometry, while reproducible in detecting lung allograft dysfunction, lacks specificity in differentiating the different complications of lung transplantation such as rejection, infection and bronchiolitis obliterans. However, interpretation of spirometry is central to defining the different 'chronic rejection' phenotypes. It is becoming apparent that the maximal lung function achieved following transplantation, as measured by spirometry, is influenced by a number of donor and recipient factors as well as the type of surgery performed (single vs double vs lobar lung transplant). In this review, we discuss the wide range of variables that need to be considered when interpreting lung function testing in lung transplant recipients. Finally, we review a number of novel measurements of pulmonary function that may in the future serve as better biomarkers to detect and diagnose the cause of the failing lung allograft.
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Affiliation(s)
- Bruce Robert Thompson
- Lung Transplant Service, Department of Allergy, Immunology and Respiratory Medicine, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Medicine, Monash University, Melbourne, Victoria, Australia
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Fuller J, Paraskeva M, Thompson B, Snell G, Westall G. A spirometric journey following lung transplantation. Respirol Case Rep 2014; 2:120-2. [PMID: 25473588 PMCID: PMC4184745 DOI: 10.1002/rcr2.67] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 07/14/2014] [Accepted: 07/16/2014] [Indexed: 01/03/2023] Open
Abstract
Spirometry is regarded as the primary tool for the evaluation of lung function in lung transplant (LTx) recipients. Spirometry is crucial in detecting the various phenotypes of chronic lung allograft dysfunction (CLAD), including restrictive allograft syndrome (RAS) and bronchiolitis obliterans syndrome (BOS) – note that these phenotypes potentially have different etiologies and therapies. Following LTx for idiopathic pulmonary fibrosis, a 60-year-old male recipient’s lung function began to gradually improve, peaking at 5 months post-LTx. Subsequently, with increasing impairment of graft function, the diagnosis of BOS was made. A second LTx was performed and lung function subsequently began to increase again. Unfortunately, another year on, lung function deteriorated again – this time due to the development of RAS, antibody-mediated rejection was implicated as the possible underlying cause. This case report highlights the importance of spirometry in assessing the patterns of CLAD following LTx.
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Affiliation(s)
- Jeremy Fuller
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital Melbourne, Victoria, Australia
| | - Miranda Paraskeva
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital Melbourne, Victoria, Australia
| | - Bruce Thompson
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital Melbourne, Victoria, Australia
| | - Greg Snell
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital Melbourne, Victoria, Australia
| | - Glen Westall
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital Melbourne, Victoria, Australia
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Kirkby S, Hayes D. Pediatric lung transplantation: indications and outcomes. J Thorac Dis 2014; 6:1024-31. [PMID: 25132969 DOI: 10.3978/j.issn.2072-1439.2014.04.27] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 04/18/2014] [Indexed: 01/13/2023]
Abstract
Lung transplantation (LTx) is a treatment option for infants and children with untreatable and otherwise fatal pulmonary diseases. To date, over 1,800 lung transplants have been performed, most frequently in children over the age of five years. The most common indications for transplantation in children overall are cystic fibrosis (CF) and idiopathic pulmonary hypertension (PH). The surfactant protein deficiencies, other interstitial lung diseases (ILDs), and congenital heart disease are important indications among young children and infants. Re-transplantation is an option for selected recipients with chronic allograft rejection. Overall survival following pediatric LTx is similar to that encountered in adult patients, with recent registry data indicating a median survival of 4.9 years. Other outcomes such as the incidence of bronchiolitis obliterans (BO) and the presence of key post-transplant co-morbid conditions are also similar to the experience in adult lung transplant recipients.
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Affiliation(s)
- Stephen Kirkby
- Section of Pulmonary Medicine, Lung and Heart-Lung Transplant Program, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Don Hayes
- Section of Pulmonary Medicine, Lung and Heart-Lung Transplant Program, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
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Saito T, Liu M, Binnie M, Sato M, Hwang D, Azad S, Machuca TN, Zamel R, Waddell TK, Cypel M, Keshavjee S. Distinct expression patterns of alveolar "alarmins" in subtypes of chronic lung allograft dysfunction. Am J Transplant 2014; 14:1425-32. [PMID: 24787265 DOI: 10.1111/ajt.12718] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 01/27/2014] [Accepted: 02/17/2014] [Indexed: 01/25/2023]
Abstract
The long-term success of lung transplantation is limited by chronic lung allograft dysfunction (CLAD). The purpose of this study was to investigate the alveolar alarmin profiles in CLAD subtypes, restrictive allograft syndrome (RAS) and bronchiolitis obliterans syndrome (BOS). Bronchoalveolar lavage (BAL) samples were collected from 53 recipients who underwent double lung or heart-lung transplantation, including patients with RAS (n = 10), BOS (n = 18) and No CLAD (n = 25). Protein levels of alarmins such as S100A8, S100A9, S100A8/A9, S100A12, S100P, high-mobility group box 1 (HMGB1) and soluble receptor for advanced glycation end products (sRAGE) in BAL fluid were measured. RAS and BOS showed higher expressions of S100A8, S100A8/A9 and S100A12 compared with No CLAD (p < 0.0001, p < 0.0001, p < 0.0001 in RAS vs. No CLAD, p = 0.0006, p = 0.0044, p = 0.0086 in BOS vs. No CLAD, respectively). Moreover, RAS showed greater up-regulation of S100A9, S100A8/A9, S100A12, S100P and HMGB1 compared with BOS (p = 0.0094, p = 0.038, p = 0.041, p = 0.035 and p = 0.010, respectively). sRAGE did not show significant difference among the three groups (p = 0.174). Our results demonstrate distinct expression patterns of alveolar alarmins in RAS and BOS, suggesting that RAS and BOS may represent biologically different subtypes. Further refinements in biologic profiling will lead to a better understanding of CLAD.
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Affiliation(s)
- T Saito
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute, University Health Network, University of Toronto, Toronto, ON, Canada; Department of Thoracic and Cardiovascular Surgery, Kansai Medical University, Hirakara, Japan
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