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Verleden GM, Hendriks JMH, Verleden SE. The diagnosis and management of chronic lung allograft dysfunction. Curr Opin Pulm Med 2024; 30:377-381. [PMID: 38305383 DOI: 10.1097/mcp.0000000000001053] [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: 02/03/2024]
Abstract
PURPOSE OF REVIEW Chronic lung allograft dysfunction (CLAD) remains a life-threatening complication following lung transplantation. Different CLAD phenotypes have recently been defined, based on the combination of pulmonary function testing and chest computed tomography (CT) scanning and spurred renewed interests in differential diagnosis, risk factors and management of CLAD. RECENT FINDINGS Given their crucial importance in the differential diagnosis, we will discuss the latest development in assessing the pulmonary function and chest CT scan, but also their limitations in proper CLAD phenotyping, especially with regards to patients with baseline allograft dysfunction. Since no definitive treatment exists, it remains important to timely identify clinical risk factors, but also to assess the presence of specific patterns or biomarkers in tissue or in broncho alveolar lavage in relation to CLAD (phenotypes). We will provide a comprehensive overview of the latest advances in risk factors and biomarker research in CLAD. Lastly, we will also review novel preventive and curative treatment strategies for CLAD. SUMMARY Although this knowledge has significantly advanced the field of lung transplantation, more research is warranted because CLAD remains a life-threatening complication for all lung transplant recipients.
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Affiliation(s)
| | - Jeroen M H Hendriks
- Department of Thoracic and Vascular Surgery, University Hospital Antwerp, Edegem
- Department of ASTARC, University of Antwerp, Wilrijk, Belgium
| | - Stijn E Verleden
- Department of Pneumology
- Department of Thoracic and Vascular Surgery, University Hospital Antwerp, Edegem
- Department of ASTARC, University of Antwerp, Wilrijk, Belgium
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Mineura K, Tanaka S, Goda Y, Terada Y, Yoshizawa A, Umemura K, Sato A, Yamada Y, Yutaka Y, Ohsumi A, Nakajima D, Hamaji M, Mennju T, Kreisel D, Date H. Fibrotic progression from acute cellular rejection is dependent on secondary lymphoid organs in a mouse model of chronic lung allograft dysfunction. Am J Transplant 2024; 24:944-953. [PMID: 38403187 PMCID: PMC11144565 DOI: 10.1016/j.ajt.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 02/16/2024] [Accepted: 02/16/2024] [Indexed: 02/27/2024]
Abstract
Chronic lung allograft dysfunction (CLAD) remains one of the major limitations to long-term survival after lung transplantation. We modified a murine model of CLAD and transplanted left lungs from BALB/c donors into B6 recipients that were treated with intermittent cyclosporine and methylprednisolone postoperatively. In this model, the lung allograft developed acute cellular rejection on day 15 which, by day 30 after transplantation, progressed to severe pleural and peribronchovascular fibrosis, reminiscent of changes observed in restrictive allograft syndrome. Lung transplantation into splenectomized B6 alymphoplastic (aly/aly) or splenectomized B6 lymphotoxin-β receptor-deficient mice demonstrated that recipient secondary lymphoid organs, such as spleen and lymph nodes, are necessary for progression from acute cellular rejection to allograft fibrosis in this model. Our work uncovered a critical role for recipient secondary lymphoid organs in the development of CLAD after pulmonary transplantation and may provide mechanistic insights into the pathogenesis of this complication.
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Affiliation(s)
- Katsutaka Mineura
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan; Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Satona Tanaka
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Yasufumi Goda
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yuriko Terada
- Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Akihiko Yoshizawa
- Department of Diagnostic Pathology, Kyoto University Hospital, Kyoto, Japan
| | - Keisuke Umemura
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Atsuyasu Sato
- Department of Respiratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoshito Yamada
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yojiro Yutaka
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akihiro Ohsumi
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Daisuke Nakajima
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masatsugu Hamaji
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Toshi Mennju
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Daniel Kreisel
- Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA; Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Hiroshi Date
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Auner S, Hillebrand C, Boehm PM, Boecker J, Koren D, Schwarz S, Kovacs Z, Murakoezy G, Fischer G, Aigner C, Hoetzenecker K, Jaksch P, Benazzo A. Impact of Transient and Persistent Donor-Specific Antibodies in Lung Transplantation. Transpl Int 2024; 37:12774. [PMID: 38779355 PMCID: PMC11110840 DOI: 10.3389/ti.2024.12774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 04/15/2024] [Indexed: 05/25/2024]
Abstract
Lung transplantation (LuTx) is an established treatment for patients with end-stage lung diseases, however, outcomes are limited by acute and chronic rejection. One aspect that has received increasing attention is the role of the host's humoral alloresponse, particularly the formation of de novo donor-specific antibodies (dnDSAs). The aim of this study was to investigate the clinical significance of transient and persistent dnDSAs and to understand their impact on outcomes after LuTx. A retrospective analysis was conducted using DSA screening data from LuTx recipients obtained at the Medical University of Vienna between February 2016 and March 2021. Of the 405 LuTx recipients analyzed, 205 patients developed dnDSA during the follow-up period. Among these, 167 (81%) had transient dnDSA and 38 (19%) persistent dnDSA. Persistent but not transient dnDSAs were associated with chronic lung allograft dysfunction (CLAD) and antibody-mediated rejection (AMR) (p < 0.001 and p = 0.006, respectively). CLAD-free survival rates for persistent dnDSAs at 1-, 3-, and 5-year post-transplantation were significantly lower than for transient dnDSAs (89%, 59%, 56% vs. 91%, 79%, 77%; p = 0.004). Temporal dynamics of dnDSAs after LuTx have a substantial effect on patient outcomes. This study underlines that the persistence of dnDSAs poses a significant risk to graft and patient survival.
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Affiliation(s)
- S. Auner
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - C. Hillebrand
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - P. M. Boehm
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - J. Boecker
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - D. Koren
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - S. Schwarz
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Z. Kovacs
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - G. Murakoezy
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - G. Fischer
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - C. Aigner
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - K. Hoetzenecker
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - P. Jaksch
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - A. Benazzo
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
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Son BS, Lee HJ, Cho WH, So MW, Park JM, Yeo HJ. Association of positive pre-transplant angiotensin II type 1 receptor antibodies with clinical outcomes in lung transplant recipients. Transpl Immunol 2023; 80:101901. [PMID: 37442212 DOI: 10.1016/j.trim.2023.101901] [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: 04/19/2023] [Revised: 07/05/2023] [Accepted: 07/08/2023] [Indexed: 07/15/2023]
Abstract
INTRODUCTION Autoantibodies against the angiotensin II type 1 receptor (AT1R-Ab) have been previously associated with de novo donor-specific antibody (DSA) formation in lung transplantation. However, data regarding the clinical significance of AT1R-Ab in long-term graft function after lung transplantation are lacking. METHODS Seventy-one patients who underwent lung transplantation between July 2016 and January 2020 were enrolled in this study. We examined the relationship between pre-transplant AT1R-Ab levels and graft function, clinical outcomes, and human leukocyte antigen (HLA) DSA levels during the first 3 years post-transplantation. RESULTS Seventeen (23.9%) patients were AT1R-Ab-positive, and 54 (76.1%) were AT1R-Ab-negative. The median antibody value of the AT1R-Ab-positive group was 18 [18-22.5] U/mL, while that of the AT1R-Ab-negative group was 5.1 [3.5-8.0] U/mL (p < 0.001). There was no significant difference in the median acute cellular rejection (ACR) scores between the two groups (median [interquartile range] 1 [0.8-3] vs. 0.7 [0-1]; p = 0.145). However, there was a significant difference in the distribution of the ACR scores between the two groups (p = 0.015). Most (41.2%) patients in the pre-transplant AT1R-positive group scored above 1. The incidence of de novo DSA was also higher in AT1R-Ab-positive than in AT1R-Ab-negative patients (52.9% vs. 20.4%, p = 0.009). The incidence of chronic lung allograft dysfunction (CLAD) within 3 years was significantly higher in AT1R-Ab-positive than in AT1R-Ab-negative patients (58.3% vs. 11.8%; p < 0.001). In the multivariate Cox regression analysis, AT1R-Ab positivity (hazard ratio, 9.46; 95% confidence interval, 2.89-30.94; p < 0.001) was significantly associated with early CLAD. Furthermore, Kaplan-Meier analysis showed that AT1R-Ab-positive patients had a shorter survival time (χ2 = 39.62, p < 0.001). CONCLUSION High AT1R-Ab levels in the pre-transplant serum of lung recipients were associated with the development of de novo HLA-DSA, ACR, early CLAD, and short survival.
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Affiliation(s)
- Bong Soo Son
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Busan, Republic of Korea; Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Hyun Ji Lee
- Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea; Department of Laboratory Medicine, Pusan National University, School of Medicine, Busan, Republic of Korea
| | - Woo Hyun Cho
- Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea; Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea; Division of Allergy, Pulmonary and Critical Care Medicine, Department of Internal Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Min Wook So
- Division of Rheumatology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Jong Myung Park
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Busan, Republic of Korea; Department of Thoracic and Cardiovascular Surgery, Busan Medical Center, Busan, Republic of Korea
| | - Hye Ju Yeo
- Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea; Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea; Division of Allergy, Pulmonary and Critical Care Medicine, Department of Internal Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea.
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Brandon W, Dunn C, Bollineni S, Joerns J, Lawrence A, Mohanka M, Timofte I, Torres F, Kaza V. Management of donor-specific antibodies in lung transplantation. FRONTIERS IN TRANSPLANTATION 2023; 2:1248284. [PMID: 38993917 PMCID: PMC11235237 DOI: 10.3389/frtra.2023.1248284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 08/23/2023] [Indexed: 07/13/2024]
Abstract
The formation of antibodies against donor human leukocyte antigens poses a challenging problem both for donor selection as well as postoperative graft function in lung transplantation. These donor-specific antibodies limit the pool of potential donor organs and are associated with episodes of antibody-mediated rejection, chronic lung allograft dysfunction, and increased mortality. Optimal management strategies for clearance of DSAs are poorly defined and vary greatly by institution; most of the data supporting any particular strategy is limited to small-scale retrospective cohort studies. A typical approach to antibody depletion may involve the use of high-dose steroids, plasma exchange, intravenous immunoglobulin, and possibly other immunomodulators or small-molecule therapies. This review seeks to define the current understanding of the significance of DSAs in lung transplantation and outline the literature supporting strategies for their management.
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Affiliation(s)
- William Brandon
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Colin Dunn
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Srinivas Bollineni
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - John Joerns
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Adrian Lawrence
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Manish Mohanka
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Irina Timofte
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Fernando Torres
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Vaidehi Kaza
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
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