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Todd JL, Weber JM, Kelly FL, Neely ML, Mulder H, Frankel CW, Nagler A, McCrae C, Newbold P, Kreindler J, Palmer SM. BAL Fluid Eosinophilia Associates With Chronic Lung Allograft Dysfunction Risk: A Multicenter Study. Chest 2023; 164:670-681. [PMID: 37003354 PMCID: PMC10548454 DOI: 10.1016/j.chest.2023.03.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/22/2023] [Accepted: 03/23/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Chronic lung allograft dysfunction (CLAD) is the leading cause of death among lung transplant recipients. Eosinophils, effector cells of type 2 immunity, are implicated in the pathobiology of many lung diseases, and prior studies suggest their presence associates with acute rejection or CLAD after lung transplantation. RESEARCH QUESTION Does histologic allograft injury or respiratory microbiology correlate with the presence of eosinophils in BAL fluid (BALF)? Does early posttransplant BALF eosinophilia associate with future CLAD development, including after adjustment for other known risk factors? STUDY DESIGN AND METHODS We analyzed BALF cell count, microbiology, and biopsy data from a multicenter cohort of 531 lung recipients with 2,592 bronchoscopies over the first posttransplant year. Generalized estimating equation models were used to examine the correlation of allograft histology or BALF microbiology with the presence of BALF eosinophils. Multivariable Cox regression was used to determine the association between ≥ 1% BALF eosinophils in the first posttransplant year and definite CLAD. Expression of eosinophil-relevant genes was quantified in CLAD and transplant control tissues. RESULTS The odds of BALF eosinophils being present was significantly higher at the time of acute rejection and nonrejection lung injury histologies and during pulmonary fungal detection. Early posttransplant ≥ 1% BALF eosinophils significantly and independently increased the risk for definite CLAD development (adjusted hazard ratio, 2.04; P = .009). Tissue expression of eotaxins, IL-13-related genes, and the epithelial-derived cytokines IL-33 and thymic stromal lymphoprotein were significantly increased in CLAD. INTERPRETATION BALF eosinophilia was an independent predictor of future CLAD risk across a multicenter lung recipient cohort. Additionally, type 2 inflammatory signals were induced in established CLAD. These data underscore the need for mechanistic and clinical studies to clarify the role of type 2 pathway-specific interventions in CLAD prevention or treatment.
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Affiliation(s)
- Jamie L Todd
- Department of Medicine, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC.
| | | | - Francine L Kelly
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Megan L Neely
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | | | | | - Andrew Nagler
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Christopher McCrae
- Translational Science & Experimental Medicine, Early Respiratory & Immunology, AstraZeneca, Gaithersburg, MD
| | | | | | - Scott M Palmer
- Department of Medicine, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC
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2
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Beeckmans H, Bos S, Vos R, Glanville AR. Acute Rejection and Chronic Lung Allograft Dysfunction: Obstructive and Restrictive Allograft Dysfunction. Clin Chest Med 2023; 44:137-157. [PMID: 36774160 DOI: 10.1016/j.ccm.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Lung transplantation is an established treatment of well-selected patients with end-stage respiratory diseases. However, lung transplant recipients have the highest rates of acute and chronic rejection among transplanted solid organs. Owing to ongoing alloimmune recognition and associated immune-driven airway/vascular remodeling, precipitated by multifactorial, endogenous or exogenous, post-transplant injuries to the bronchovascular axis of the secondary pulmonary lobule, most lung transplant recipients will suffer from a pathophysiological decline of their allograft, either functionally and/or structurally. This review discusses current knowledge, barriers, and gaps in acute cellular rejection and chronic lung allograft dysfunction-the greatest impediment to long-term post-transplant survival.
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Affiliation(s)
- Hanne Beeckmans
- Department of Chronic Diseases and Metabolism, KU Leuven, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Leuven, Belgium
| | - Saskia Bos
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium; Newcastle University, Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Robin Vos
- Department of Chronic Diseases and Metabolism, KU Leuven, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Leuven, Belgium; Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.
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Darley DR, Ma J, Huszti E, Fiset P, Levy L, Hwang DM, Pal P, Klement W, Zamel R, Keshavjee S, Tomlinson G, Singer LG, Tikkanen JM, Martinu T. Eosinophils in transbronchial biopsies: a predictor of chronic lung allograft dysfunction and reduced survival after lung transplantation - a retrospective single-center cohort study. Transpl Int 2020; 34:62-75. [PMID: 33025592 DOI: 10.1111/tri.13760] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 04/06/2020] [Accepted: 09/28/2020] [Indexed: 01/14/2023]
Abstract
Long-term outcomes after lung transplantation remain inferior to those of other solid organ groups. The significance of eosinophils detected on transbronchial biopsies (TBBx) after lung transplantation and their relationship to long-term outcomes remain unknown. A retrospective single-center cohort study was performed of patients transplanted between January 01, 2001, and July 31, 2018, who had at least 1 TBBx with evaluable parenchymal tissue. Multivariable Cox proportional hazard models were used to assess the associations between eosinophil detection and: all-cause mortality and Chronic Lung Allograft Dysfunction (CLAD). 8887 TBBx reports from 1440 patients were reviewed for the mention of eosinophils in the pathology report. 112 (7.8%) patients were identified with eosinophils on at least one TBBx. The median (95% CI) survival time for all patients was 8.28 (7.32-9.31) years. Multivariable analysis, adjusted for clinical variables known to affect post-transplant outcomes, showed that the detection of eosinophils was independently associated with an increased risk of death (HR 1.51, 95% CI 1.24-1.85, p < 0.01) and CLAD (HR 1.35, 95% CI 1.07-1.70, P = 0.01). Eosinophils detected in TBBx are associated with an increased risk of CLAD and death. There may be benefit in specifically reporting the presence of eosinophils in TBBx reports and incorporating their presence in clinical decision-making.
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Affiliation(s)
- David R Darley
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada.,UNSW Medicine, St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Jin Ma
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Pierre Fiset
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | | | - David M Hwang
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada.,Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Prodipto Pal
- Department of Laboratory Medicine & Pathobiology, University Health Network, Toronto, ON, Canada
| | - William Klement
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Ricardo Zamel
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - George Tomlinson
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Lianne G Singer
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Jussi M Tikkanen
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada
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Hachem RR. The role of the immune system in lung transplantation: towards improved long-term results. J Thorac Dis 2019; 11:S1721-S1731. [PMID: 31632749 DOI: 10.21037/jtd.2019.04.25] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Over the past 35 years, lung transplantation has evolved from an experimental treatment to the treatment of choice for patients with end-stage lung disease. Beyond the immediate period after lung transplantation, rejection and infection are the leading causes of death. The risk of rejection after lung transplantation is generally higher than after other solid organ transplants, and this necessitates more intensive immunosuppression. However, this more intensive treatment does not reduce the risk of rejection sufficiently, and rejection is one of the most common complications after transplantation. There are multiple forms of rejection including acute cellular rejection, antibody-mediated rejection, and chronic lung allograft dysfunction. These have posed a vexing problem for clinicians, patients, and the field of lung transplantation. Confounding matters is the inherent effect of more intensive immunosuppression on the risk of infections. Indeed, infections pose a direct problem resulting in morbidity and mortality and increase the risk of chronic lung allograft dysfunction in the ensuing weeks and months. There are complex interactions between microbes and the immune response that are the subject of ongoing studies. This review focuses on the role of the immune system in lung transplantation and highlights different forms of rejection and the impact of infections on outcomes.
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Affiliation(s)
- Ramsey R Hachem
- Division of Pulmonary & Critical Care, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
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Di Piazza A, Mamone G, Caruso S, Marrone G, Tuzzolino F, Vitulo P, Bertani A, Miraglia R. Acute rejection after lung transplantation: association between histopathological and CT findings. Radiol Med 2019; 124:1000-1005. [DOI: 10.1007/s11547-019-01059-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 06/24/2019] [Indexed: 11/30/2022]
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Abstract
Despite advances in immunosuppression over the past 25 years, acute cellular rejection remains a common complication early after lung transplantation. Although acute cellular rejection has often not resulted in clinical signs or symptoms of allograft dysfunction, it has been widely recognized as a strong independent risk factor for the development of chronic rejection, emphasizing its clinical significance. In recent years, the role of humoral immunity in lung rejection has been increasingly appreciated, and antibody-mediated rejection is now recognized as a form of rejection that may result in allograft failure.
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Affiliation(s)
- Ramsey R Hachem
- Division of Pulmonary and Critical Care, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8052, St Louis, MO 63110, USA.
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Zou J, Duffy B, Slade M, Young AL, Steward N, Hachem R, Mohanakumar T. Rapid detection of donor cell free DNA in lung transplant recipients with rejections using donor-recipient HLA mismatch. Hum Immunol 2017; 78:342-349. [PMID: 28267558 DOI: 10.1016/j.humimm.2017.03.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 02/21/2017] [Accepted: 03/02/2017] [Indexed: 12/16/2022]
Abstract
Fiberoptic bronchoscopy and transbronchial lung biopsy are currently the gold standard for detection of acute rejection following human lung transplantation (LTx). However, these surveillance procedures are expensive and invasive. Up to now, there are few new methods that have demonstrated clinical utility for detecting early stages of rejection following human lung transplantation. We optimized and technically validated a novel method to quantify donor-derived circulating cell free DNA (DcfDNA) that can be used as an early biomarker for lung allograft rejection. The method involves the initial development of a panel of probes in which each probe will specifically target a unique sequence of a human leukocyte antigen (HLA) allele. After transplantation, donor/recipient specific probes are chosen based on the mismatched HLA loci, followed by droplet digital PCR (ddPCR) used as a quantitative assay to accurately track the trace amount of DcfDNA in an ample excess of recipient DNA background. The average false positive rate noted was about 1 per 800,000 molecules. Serially 2-fold diluted cfDNA, representing donor fractions of cfDNA, were spiked into a constant level of cfDNA representing the recipient cfDNA. The fraction of spiked cfDNA was measured and quantitative linearity was observed across seven serially diluted cfDNA samples. We were able to measure the minor portion of cfDNA as low as 0.2% of total cfDNA. We subsequently applied the method to a pilot set of 18 LTx recipients grouped into biopsy-proven acute rejection, bronchiolitis obliterans syndrome (BOS) or stable groups. Serial plasma samples were used to identify the percentage of DcfDNA over total cfDNA. The level of DcfDNA was significantly elevated in patients diagnosed with acute rejection (10.30±2.80, n=18), compared to that from stable (1.71±0.50, n=24) or from BOS patients (2.52±0.62, n=20). In conclusion, we present results validating the application of digital PCR to quantify DcfDNA assay in primary clinical specimens, which demonstrate that DcfDNA can be used as an early non-invasive biomarker for acute lung allograft rejection.
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Affiliation(s)
- Jun Zou
- Department of Laboratory Medicine, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
| | - Brian Duffy
- HLA Laboratory, Barnes-Jewish Hospital, St. Louis, MO 63110, USA
| | - Michael Slade
- Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Andrew Lee Young
- Department of Pediatrics, Division of Hematology and Oncology, Washington University School of Medicine, Saint Louis, MO, USA; Center for Genome Sciences and Systems Biology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Nancy Steward
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Ramsey Hachem
- Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - T Mohanakumar
- Norton Thoracic Institute Research Laboratory, St. Joseph's Hospital & Medical Center, Phoenix, AZ 85013, USA
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8
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Abstract
Chronic, progressive, and irreversible loss of lung function is the major medium-term and long-term complication after lung transplantation and the leading cause of death. Over the past decade, progress has been made in understanding the pathogenesis of bronchiolitis obliterans. Alloimmune factors and nonalloimmune factors may contribute to its development. Understanding the precise mechanism of each type of chronic allograft dysfunction may open up the field for new preventive and therapeutic interventions. This article reviews major new insights into the clinical aspects, pathophysiology, risk factors, diagnosis, and management of chronic allograft dysfunction after lung transplantation.
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Affiliation(s)
- Christiane Knoop
- Department of Chest Medicine, Erasme University Hospital, Université Libre de Bruxelles, 808 Route de Lennik, B-1070 Brussels, Belgium.
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Discrepancias entre el diagnóstico clínico y el diagnóstico anatomopatológico en la mortalidad temprana del trasplante pulmonar. Med Intensiva 2009; 33:424-30. [DOI: 10.1016/j.medin.2009.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2009] [Revised: 06/19/2009] [Accepted: 06/22/2009] [Indexed: 11/22/2022]
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Satoda N, Shoji T, Wu Y, Fujinaga T, Chen F, Aoyama A, Zhang JT, Takahashi A, Okamoto T, Matsumoto I, Sakai H, Li Y, Zhao X, Manabe T, Kobayashi E, Sakaguchi S, Wada H, Ohe H, Uemoto S, Tottori J, Bando T, Date H, Koshiba T. Value of FOXP3 expression in peripheral blood as rejection marker after miniature swine lung transplantation. J Heart Lung Transplant 2009; 27:1293-301. [PMID: 19059109 DOI: 10.1016/j.healun.2008.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2008] [Revised: 08/01/2008] [Accepted: 08/21/2008] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Outcome for highly immunogenic lung transplantation remains unsatisfactory despite the development of potent immunosuppressants. The poor outcome may be the result of a lack of minimally invasive methods to detect early rejection. There is emerging clinical evidence that, paradoxically, expression of forkhead box P3 (FOXP3, a specific marker for the regulatory T cells) is upregulated within rejecting grafts. METHODS Orthotopic lung transplantation was performed using miniature swine without immunosuppression. Rejection was monitored by chest radiography and open lung biopsy. Expressions levels of FOXP3, perforin, Fas-L and IP-10 mRNA were quantified in the peripheral blood. In addition, rescue immunosuppressive therapy (steroid plus tacrolimus) was administered on post-operative day (POD) 4 or 6. RESULTS Early rejection was detected by open lung biopsy, but misdiagnosed by chest radiography on POD 4. Expression of FOXP3 in the peripheral blood reached its highest value as early as POD 4, followed by a decline. Such an increase of FOXP3 was not observed in recipients given high-dose tacrolimus. Neither perforin, Fas-L or IP-10 in the peripheral blood exhibited significant fluctuations in the early phase of rejection. Rescue immunosuppressive therapy from POD 4, when peak FOXP3 was seen, prolonged graft survival (27.2 days, versus 9.1 days without immunosuppression, p < 0.001), in contrast to POD 6, when rejection was suspected by chest radiography (11.5 days, p = not statistically significant [NS]). CONCLUSIONS In a miniature swine lung transplantation model, the FOXP3 mRNA level in the peripheral blood was upregulated at an early phase of rejection. The clinical implication of this finding remains to be elucidated.
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Affiliation(s)
- Naoki Satoda
- Department of Thoracic Surgery, Kyoto University, Kyoto, Japan
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12
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Lung Transplantation. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
PURPOSE OF REVIEW This article reviews current trends in pediatric lung posttransplant management, reveals pitfalls that exist, and introduces additional parameters that may have an impact on long-term survival. RECENT FINDINGS A number of parameters are monitored after transplantation to prevent or identify early complications related to lung transplantation in hope of reducing morbidity and mortality. These include routine laboratory studies, imaging, and monitoring of drug levels and lung function. Drug monitoring allows individualization of a patient's immunosuppressive therapy; however, drug levels alone may not reflect the patient's immune status. ImmuKnow is a general immune-monitoring assay that may help guide therapy. Two major complications are rejection and infection, and bronchoscopy is used to differentiate these two entities. Silent rejection may occur and increase the chance of developing bronchiolitis obliterans; therefore, many centers perform surveillance bronchoscopies. Recently, de-novo anti-histocompatibility locus antigen antibodies and gastroesophageal reflux have been associated with poor outcomes, and many centers are monitoring these entities as part of care following lung transplant. SUMMARY There has been little improvement in long-term outcomes of lung transplantation. Current monitoring methods are utilized to maintain or improve outcomes and recently additional monitoring parameters have been identified which hopefully will improve long-term outcomes.
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Affiliation(s)
- Gary A Visner
- Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, 3615 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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14
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Eleven years on: a clinical update of key areas of the 1996 lung allograft rejection working formulation. J Heart Lung Transplant 2007; 26:423-30. [PMID: 17449409 DOI: 10.1016/j.healun.2007.01.040] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2006] [Revised: 01/22/2007] [Accepted: 01/30/2007] [Indexed: 10/23/2022] Open
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Kim DW, Dacic S, Iacono A, Grgurich W, Yousem SA. Significance of a solitary perivascular mononuclear infiltrate in lung allograft recipients with mild acute cellular rejection. J Heart Lung Transplant 2006; 24:152-5. [PMID: 15701429 DOI: 10.1016/j.healun.2003.10.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2003] [Revised: 10/23/2003] [Accepted: 10/24/2003] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Although a solitary prominent perivascular mononuclear infiltrate is diagnostic of mild acute rejection (A2) in lung allograft recipients, its significance is still poorly defined. We evaluated the significance of a solitary perivascular mononuclear infiltrate and its correlation with clinical outcome in lung allograft recipients. METHODS Thirteen patients had mild acute rejection as diagnosed by the presence of a solitary perivascular mononuclear infiltrate. The patients were divided into 2 groups based on subsequent treatment: treated (Group 1) and non-treated (Group 2) patients. We analyzed the difference between the 2 groups according to clinical presentation, histologic parameters and outcome. RESULTS Nine patients were women (69%), 4 were men (31%); 12 were white and 1 was African American. Ages at the time of biopsy ranged from 20 to 68 years, with a mean of 47.2 years and a median of 52 years. Eight had a history of single-lung transplant and 5 had a history of double-lung transplant. The most common reasons for transplantation were emphysema (n = 6) and cystic fibrosis (n = 3). Nine patients (65.4%) showed decreased rejection grade or no evidence of acute rejection (Group 1) after treatment. Four patients who were untreated had persistent multifocal mild or worsening moderate rejection on subsequent biopsy (Group 2). CONCLUSIONS Treated and untreated patients with mild rejection based on a solitary perivascular infiltrate have similar clinical presentations and histologic characteristics. Solitary mononuclear infiltrates showed persistence or progression without therapy and therefore need to be treated as, not segregated from, the "usual" forms of mild acute allograft rejection.
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Affiliation(s)
- Dong-Won Kim
- Department of Pathology and Pulmonary Medicine, University of Pittsburgh Medical Center, Presbyterian University Hospital, Pittsburgh, PA 15213, USA
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Abstract
Lung transplantation has become an accepted therapy for selected patients with advanced lung disease. One of the main limitations to successful lung transplantation is rejection of the transplanted organ. This article discusses the clinical presentation, treatment, and prevention of hyperacute, acute, and chronic rejection in the lung transplant recipient.
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Affiliation(s)
- Timothy P M Whelan
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Minnesota, Minneapolis, MN 55455, USA.
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The role of surveillance transbronchial lung biopsy after lung transplantation: the potential impact of minimal acute cellular rejection or lymphocytic bronchiolitis. Curr Opin Organ Transplant 2005. [DOI: 10.1097/01.mot.0000169369.23014.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Chakinala MM, Ritter J, Gage BF, Lynch JP, Aloush A, Patterson GA, Trulock EP. Yield of surveillance bronchoscopy for acute rejection and lymphocytic bronchitis/bronchiolitis after lung transplantation. J Heart Lung Transplant 2004; 23:1396-404. [PMID: 15607670 DOI: 10.1016/j.healun.2003.09.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2003] [Revised: 09/08/2003] [Accepted: 09/10/2003] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Better understanding of the timing and pattern of surveillance bronchoscopy findings after lung transplantation could influence the timing and frequency of surveillance bronchoscopy. We present our surveillance bronchoscopy experience and test the hypothesis that patients not encountering early acute rejection or lymphocytic bronchitis/bronchiolitis are less likely to have subsequent occult occurrences in the 1st year after lung transplantation. METHODS We conducted a retrospective study of 204 patients who underword transplantation between 1996 and 2000. Based on contemporary biopsy-specimen grading in the first 100 days, we formed 2 groups: No Early Rejection and Early Rejection. We compared subsequent yields of surveillance bronchoscopy and the incidence of acute rejection or of lymphocytic bronchitis/bronchiolitis. RESULTS We reviewed 645 biopsies taken from 204 recipients during the first 100 days to classify patients into a No Early Rejection Group (n=67) or an Early Rejection Group (n=137). Yield of surveillance bronchoscopy for acute rejection or lymphocytic bronchitis/bronchiolitis was 31% with the greatest yield during the first 30 days (45%), and then decreasing to 26% (p <0.001). After Day 100, 71% of occult acute rejection episodes involved minimal (A1) lesions. Yield of surveillance bronchoscopy after Day 100 was 20% in the No Early Rejection Group and was 27% in the Early Rejection Group (p=0.22). Incidence of acute rejection or lymphocytic bronchitis/bronchiolitis after Day 100 was 41% in the No Early Rejection Group and was 50% in the Early Rejection Group (p=0.17). CONCLUSION Surveillance bronchoscopy detects occult acute rejection or lymphocytic bronchitis/bronchiolitis in approximately one-third of biopsy specimens during the 1st year, with the majority of late abnormalities being minimal (A1) rejection. The absence of acute rejection or lymphocytic bronchitis/bronchiolitis during the first 100 days does not predict freedom from such events in the remainder of the 1st year.
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Affiliation(s)
- Murali M Chakinala
- Division of Pulmonary and Critical Care Medicine, Saint Louis, Missouri 63110, USA.
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19
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Diagnostic value of transbronchial lung biopsy after lung transplantation. Curr Opin Organ Transplant 2003. [DOI: 10.1097/00075200-200309000-00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chakinala MM, Trulock EP. Acute allograft rejection after lung transplantation: diagnosis and therapy. ACTA ACUST UNITED AC 2003; 13:525-42. [PMID: 13678311 DOI: 10.1016/s1052-3359(03)00056-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Acute rejection remains a significant problem after lung transplantation. While it generally is a treatable condition, significant resources and therapies are directed toward its prevention and resolution. Its larger significance undoubtedly rests in its contribution to the pathogenesis of BOS. Significant questions regarding the origins of AR, the role of LBB, alternative histologic appearances of acute allograft injury, and optimal therapy remain. Controversy regarding the utility of surveillance bronchoscopy and preemptive treatment of occult AR persists because of lack of conclusive evidence. Future investigations might resolve these matters and provide more efficacious and less toxic therapies that will hopefully reduce the impact of chronic rejection and improve long-term outcomes.
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Affiliation(s)
- Murali M Chakinala
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box #8052, St. Louis, MO 63110, USA.
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Zuckermann A, Reichenspurner H, Birsan T, Treede H, Deviatko E, Reichart B, Klepetko W. Cyclosporine A versus tacrolimus in combination with mycophenolate mofetil and steroids as primary immunosuppression after lung transplantation: one-year results of a 2-center prospective randomized trial. J Thorac Cardiovasc Surg 2003; 125:891-900. [PMID: 12698153 DOI: 10.1067/mtc.2003.71] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Cyclosporine (INN: ciclosporin) A or tacrolimus have been used mostly in combination with azathioprine as primary immunosuppression after lung transplantation. Benefit or risk deriving from the combination with mycophenolate mofetil are yet unknown. METHODS In a prospective, 2-center, open randomized trial, the combination of cyclosporine A, mycophenolate mofetil, and steroids was compared with tacrolimus, mycophenolate mofetil, and steroids as primary therapy after primary lung transplantation. All patients underwent induction therapy with rabbit antithymocyte globulin for 3 days. The 2 groups were compared with regard to patient survival, freedom from acute rejection, bronchiolitis obliterans, infectious episodes, and side effects. RESULTS Between September 1997 and April 1999, 74 lung transplant recipients were randomized to receive either cyclosporine A (n = 37) or tacrolimus (n = 37). Groups were comparable with regard to age, sex, transplant procedure, and cytomegalovirus match. Mean follow-up was 507 +/- 258 and 508 +/- 248 days, respectively. Six- and 12-month survival was similar in both groups (89% vs 84% and 82% vs 71%, respectively; P =.748 at 12 months). Two patients from the cyclosporine A group were retransplanted. Freedom from acute rejection at 6 and 12 months was comparable between groups (46% vs 51% and 35% vs 46%, respectively; P =.774 at 12 months). The mean number of treated acute rejection episodes per 100 patient-days was higher in the cyclosporine A than in the tacrolimus group, but the difference was not statistically significant (0.32 +/- 0.42 vs 0.22 +/- 0.30, respectively; P =.097). Four patients from the cyclosporine A group had to be switched to tacrolimus to control ongoing rejection, whereas no patient from the tacrolimus group had to be switched to cyclosporine A. There was a trend toward more infections (0.7 +/- 0.36 vs 0.55 +/- 0.31, P =.059) in the cyclosporine A group. New-onset diabetes mellitus was observed in the tacrolimus group only (11% vs 0%, P =.151), whereas there was a higher incidence of hypertension (60% vs 11%, P =.03) in the cyclosporine A group. CONCLUSION This 2-center, prospective randomized study showed high immunosuppressive potency of both cyclosporine A and tacrolimus in combination with mycophenolate mofetil. No significant difference in incidence of acute rejection was observed between the 2 groups. Moreover, survival and incidence of infection were similar. Incidence of drug-related adverse events were similar, yet their spectrum was different.
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22
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Gotway MB, Dawn SK, Sellami D, Golden JA, Reddy GP, Keith FM, Webb WR. Acute rejection following lung transplantation: limitations in accuracy of thin-section CT for diagnosis. Radiology 2001; 221:207-12. [PMID: 11568342 DOI: 10.1148/radiol.2211010380] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To evaluate the sensitivity, specificity, predictive values, and accuracy of thin-section computed tomography (CT) for the diagnosis of acute rejection following lung transplantation and to determine whether any individual CT abnormalities are associated with histopathologically proved acute rejection. MATERIALS AND METHODS Thin-section CT studies from 64 lung transplant recipients were retrospectively reviewed. CT studies were temporally correlated with various grades of biopsy-proved acute rejection (n = 34); 30 other CT studies were from a control group with no histopathologic evidence of acute rejection. Acute rejection was diagnosed as present or absent, and the diagnostic was calculated. RESULTS The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of CT for the diagnosis of acute rejection were as follows: 35%, 73%, 60%, 50%, 53%, respectively. No individual CT finding was significantly associated with acute rejection. The sensitivity of CT for the detection of various grades of acute rejection was 17% for grade A1, 50% for grade A2, and 20% for grade A3. The combination of volume loss and septal thickening, with or without pleural effusion, was never seen in the absence of acute rejection. CONCLUSION Thin-section CT has limited accuracy for the diagnosis of acute rejection following lung transplantation, and no individual CT finding is significantly associated with this diagnosis.
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Affiliation(s)
- M B Gotway
- Department of Radiology, San Francisco General Hospital, University of California, San Francisco, 1001 Potrero Ave, Rm 1X 55A, Box 1325, San Francisco, CA 94110, USA.
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23
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Shomori K, Kuratate I, Sakatani T, Takeuchi K, Tei K, Mannami M, Toshino A, Oka A, Ohoka H, Ito H. Histopathology of a human allografted kidney with clinically sufficient function. Clin Transplant 2001; 14 Suppl 3:25-9. [PMID: 11092349 DOI: 10.1034/j.1399-0012.2000.0140s3025.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
To clarify the clinico-pathological significance of protocol biopsy and clinically silent rejection in the management of renal graft recipients, we selected a total of 139 (23%) from 604 biopsy specimens according to the following criteria: 1) less than 1.4 mg/dL of serum creatinine and 2) more than 1,500 mL/d of urine volume at time of biopsy. Clinical indications for the biopsy were classified into five categories: i) protocol biopsy (73 specimens), including 69 cases at discharge post-transplantation; ii) slight increase in serum creatinine (32); iii) proteinuria (20); iv) evaluation of pulse-therapy (13); and v) fever elevation (1). Except for the last category, the specimens were histopathologically diagnosed as being normal in 50 (68%), 6 (17%), 1 (5%), and 5 (38%) specimens, respectively. Even borderline changes, and mild acute rejection, as well as drug-induced nephropathy were included, implying the existence of clinically silent rejection or drug-induced nephropathy. Obvious diversity in the histopathological diagnosis was noted in category iii) showing proteinuria, which was mainly caused by chronic rejection, drug-induced nephropathy and glomerulonephritis. The graft survival rate was no different among the four categories, except for category v). These results indicate that biopsies obtained from functionally sufficient renal grafts could provide useful information in the management of the recipients. The clinical significance of protocol biopsy awaits further clarification by the analysis of a large number of cases.
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Affiliation(s)
- K Shomori
- First Department of Pathology, Faculty of Medicine, Tottori University, Japan
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24
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Mogayzel PJ, Yang SC, Wise BV, Colombani PM. Eosinophilic infiltrates in a pulmonary allograft: a case and review of the literature. J Heart Lung Transplant 2001; 20:692-5. [PMID: 11404176 DOI: 10.1016/s1053-2498(00)00218-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
An unusual case of peribronchial eosinophilic infiltrates associated with peripheral blood eosinophilia in a lung transplant patient is described. The role that eosinophils play in lung allograft rejection is reviewed. Tissue eosinophils have been associated with acute pulmonary allograft rejection. Although, eosinophils in bronchoalveolar lavage fluid (BAL) have been observed in allograft rejection, this relationship is less well defined. The role of eosinophils in the pathophysiology of allograft rejection is unclear.
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Affiliation(s)
- P J Mogayzel
- Eudowood Division of Pediatric Respiratory Sciences, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
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25
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DeVito-Haynes LD, Jankowska-Gan E, Meyer KC, Cornwell RD, Zeevi A, Griffith B, Dauber J, Iacono A, Burlingham WJ, Love RB. Soluble donor HLA class I and beta 2m-free heavy chain in serum of lung transplant recipients: steady-state levels and increases in patients with recurrent CMV infection, acute rejection episodes, and poor outcome. Hum Immunol 2000; 61:1370-82. [PMID: 11163095 DOI: 10.1016/s0198-8859(00)00210-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
We determined the concentration of donor sHLA/beta(2)m and total beta(2)m-free heavy chain (HC) in the serum of lung transplant recipients with ELISA assays. While we were unable to detect specific donor beta(2)m-free HCs due to a lack of available antibodies, we could determine if events that led to an increase in the release of beta(2)m-free HC also led to an increase in the release of donor sHLA/beta(2)m, particularly the 36 kDa, proteolytically cleaved form. We found that lung transplants constituitively release donor sHLA/beta(2)m at ng/ml levels. The levels (both of donor sHLA/beta(2)m and total beta(2)m-free HC) were significantly increased in CMV-sero-negative recipients (but not in CMV-sero-positive recipients) at the onset of post-transplant CMV disease. Acute rejection episodes were also associated with an increased release of donor sHLA/beta(2)m, but not of beta(2)m-free HC. However, in patients with particularly poor outcome (i.e., graft loss within 1 year) there was a significant release of beta(2)m-free HC. Analysis of one such patient showed a predominance of 36 kDa forms of donor-sHLA/beta(2)m. Our data are consistent with the hypothesis that the metalloproteinase that cleaves beta(2)m-free HC is active during uncontrolled CMV infection and acute rejection. However, recall responses to CMV and controlled immune responses to donor may result in little or no activation of sHLA class I release.
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Affiliation(s)
- L D DeVito-Haynes
- Department of Surgery, University of Wisconsin, Madison, Wisconsin 53792, USA.
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26
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Hausen B, Boeke K, Berry GJ, Christians U, Schüler W, Morris RE. Successful treatment of acute, ongoing rat lung allograft rejection with the novel immunosuppressant SDZ-RAD. Ann Thorac Surg 2000; 69:904-9. [PMID: 10750781 DOI: 10.1016/s0003-4975(99)01504-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Recent experimental data have shown that coadministration of microemulsion cyclosporine and the novel immunosuppressant SDZ-RAD potentiates the immunosuppressive efficacies of both drugs to suppress allograft rejection. Our study was designed to assess the potential of delayed SDZ-RAD administration, in addition to cyclosporine maintenance therapy, to reverse acute rejection in an allogeneic rat lung transplant model. METHODS Unilateral left lung transplantation was performed using Brown-Norway donors implanted into Lewis recipients. An untreated control group and a cyclosporine monotherapy group (7.5 mg/kg) were followed for 7 days. An additional cyclosporine monotherapy group (7.5 mg/kg), and a combined therapy group treated with cyclosporine (7.5 mg/kg) plus SDZ-RAD (2.5 mg/kg), were followed for 21 days. For treatment of ongoing rejection, 7.5 mg/kg cyclosporine was given as maintenance therapy, and SDZ-RAD (2.5 mg/kg) was added on postoperative day 7. Drugs were given orally, and in the combined therapy regimens, administered 6 hours apart. Outcome variables included daily weight, radiographs, and histology. RESULTS Radiographs on postoperative day 7 showed mild and moderate opacification of the left chest in the cyclosporine monotherapy groups and the untreated control group. Addition of SDZ-RAD to cyclosporine treatment on postoperative day 7 reversed opacification by postoperative days 14 and 21. Monotherapy with microemulsion CsA resulted in mild histological rejection by day 7, which progressed to moderate rejection by day 21. Addition of SDZ-RAD on postoperative day 7 reversed acute rejection, resulting in none or minimal rejection at day 21. CONCLUSIONS SDZ RAD reverses acute rejection under cyclosporine maintenance therapy in a stringent lung allotransplant model.
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Affiliation(s)
- B Hausen
- Transplantation Immunology, Department of Cardiothoracic Surgery, Stanford University, Palo Alto, California 94305-5407, USA.
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27
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Jonosono M, Fang KC, Keith FM, Turck CW, Blanc PD, Hall TS, Fukano AK, Rifkin CJ, Gold WM, Webb WR, Edinburgh KJ, Finkbeiner WE, Golden JA. Measurement of fibroblast proliferative activity in bronchoalveolar lavage fluid in the analysis of obliterative bronchiolitis among lung transplant recipients. J Heart Lung Transplant 1999; 18:972-85. [PMID: 10561108 DOI: 10.1016/s1053-2498(99)00055-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Bronchiolitis obliterans occurs in 30% to 80% of lung-transplant recipients and is a direct cause of death in more than 40% of patients with this complication. This study assessed the potential utility of measuring fibroblast-proliferative activity in bronchoalveolar lavage fluid from lung-transplant recipients to better understand the pathogenesis of this process. METHODS The capacity of bronchoalveolar lavage fluid obtained from transplant recipients, during routine surveillance bronchoscopy, to stimulate the proliferation of human lung fibroblasts in vitro was assessed retrospectively and compared to that of control subjects. For each recipient, a correlation was made between the fibroblast-proliferative activity in serial lavage samples over time and the other modalities employed for detecting post-transplant complications including spirometry, transbronchial lung biopsy, and high-resolution computed tomography. RESULTS There was a significant difference in fibroblast-proliferative activity between volunteer and transplant recipient groups (p = 0.002). Further, for each transplant recipient, the decline in the forced expired flow rate between 25% and 75% of expired volume (FEF(25%-75%)) was correlated with the mean fibroblast-proliferative activity during the period of this study (r = 0.83; p = 0.04). CONCLUSIONS A sustained increase in fibroblast-proliferative activity in lavage supernatant precedes both histologic and physiologic evidence of bronchiolitis obliterans. Relative to an increase in fibroblast-proliferative activity or abnormalities in FEF25%-75%, a decrease in forced expiratory volume in 1 second is a late finding.
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Affiliation(s)
- M Jonosono
- Cardiovascular Research Institute, University of California at San Francisco, 94143-0359, USA
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Ross DJ, Moudgil A, Bagga A, Toyoda M, Marchevsky AM, Kass RM, Jordan SC. Lung allograft dysfunction correlates with gamma-interferon gene expression in bronchoalveolar lavage. J Heart Lung Transplant 1999; 18:627-36. [PMID: 10452338 DOI: 10.1016/s1053-2498(99)00007-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Preceding episodes of acute cellular rejection (ACR) may predispose lung allografts to the subsequent development of irreversible dysfunction or bronchiolitis obliterans syndrome (BOS). Other histologic patterns such as bronchiolitis obliterans with organizing pneumonia (BOOP), organizing pneumonia, lymphocytic bronchiolitis and diffuse alveolar damage (DAD) may also adversely affect allograft function. We have previously reported the predominant expression of Th1 cytokines (IL-2 and interferon gamma) in rejecting and Th2 (IL-10) in a tolerant model of rat lung transplantation. Here we correlate the "Th1/Th2 paradigm" in clinical lung transplantation with histologic findings and assess the effect on serial spirometric function. METHODS We examined the mRNA expression of IL-2, interferon gamma, IL-10 and ICAM-1 in 53 bronchoalveolar lavage (BAL) specimens from 23 lung transplant (LT) recipients utilizing qualitative "nested" reverse transcriptase polymerase chain reaction (RT-PCR). We also measured IgG1 and IgG2 levels in 44 BAL specimens by ELISA. The mRNA expression for cytokines, ICAM-1 and the IgG2/IgG1 ratios were correlated with the presence or absence of ACR and alternate "histologic patterns". Serial spirometry were analyzed for the 2-3 month interval before bronchoscopic (FOB) assessment to derive "baseline" forced expiratory volume-one second (FEV1) values. The change in FEV1 coincident with (deltaFEV1 pre) and for the 2-3 month interval subsequent to (deltaFEV1 post) FOB were expressed relative to "baseline" spirometric indexes. RESULTS Detection of mRNA for interferon gamma and ICAM-1 correlated significantly with ACR, whereas IL-2 and IL-10 expression did not correlate. IL-10 was virtually "ubiquitous" in most BAL samples irrespective of the presence or absence of ACR. The highest correlation was observed with interferon gamma for acute cellular rejection whereupon the sensitivity was 77.7%, specificity 87.7%, positive predictive value 73.6% and negative predictive value 88.2%, although for ICAM-1 these values were 75%, 65.7%, 50.0% and 85.0%, respectively. Nevertheless, 4 of 5 episodes of respiratory tract infection (bacterial, CMV, Aspergillus spp.) were similarly associated with cytokine mRNA. The ratios of IgG2 to IgG1, a reflection of Th1/Th2 influence, were not statistically different when analyzed for the presence or absence of ACR (0.91+/-0.53 vs. 1.02+/-0.70, respectively; p = NS). By analysis of FEV1 trends, expression of interferon gamma was associated with a greater and persistent decrement (deltaFEV1 pre: -0.265+/-0.78 liters, and post: -0.236+/-0.1161; mean +/- SE) than ACR in the absence of interferon gamma expression (+0.158 +/- +0.065 and +0.236+/-0.007 liters, respectively) (Student-Newman-Keuls, p<.05). CONCLUSION Our findings suggest that interferon gamma mRNA expression and ICAM-1 may be valuable in both the diagnosis and prognosis for lung allograft ACR. IL-10, a Th2 cytokine, was locally expressed both in the presence and absence of ACR. Expression of mRNA for interferon y in BAL and, to a lesser extent ICAM-1, were associated with increased lung allograft dysfunction. Whether BAL cytokine "immunosurveillance" would complement or possibly supplant a specific "histologic pattern" and thereby direct different therapies after lung transplantation, may be potentially rewarding areas of further investigation.
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Affiliation(s)
- D J Ross
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center Lung and Heart-Lung Transplant Program, Los Angeles, California, USA.
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Moudgil A, Bagga A, Toyoda M, Nicolaidou E, Jordan SC, Ross D. Expression of gamma-IFN mRNA in bronchoalveolar lavage fluid correlates with early acute allograft rejection in lung transplant recipients. Clin Transplant 1999; 13:201-7. [PMID: 10202618 DOI: 10.1034/j.1399-0012.1999.130208.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Various cytokines are upregulated in acute allograft rejection (AR). Local production of Th-1 cytokines is suggested to play a pathogenic role in AR, and Th-2 cytokines in the development of allograft tolerance. The purpose of this study was to correlate the expression of Th-1 [interleukin-2 (IL-2) and gamma-interferon (gamma-IFN)], and Th-2 [interleukin-10 (IL-10)] cytokines in bronchoalveolar lavage (BAL) fluid with AR in lung transplant (LT) recipients. The role of Th-1 dominance expressed as IgG2/IgG1 ratio in BAL in AR was also examined. The mRNA expression for IL-2, gamma-IFN and IL-10 was examined in 64 BAL specimens from 23 LT recipients using reverse transcriptase-polymerase chain reaction (RT-PCR). IgG1 and IgG2 levels were measured in 55 BAL specimens by enzyme-linked immunosorbent assay (ELISA). The expression on mRNA for these cytokines, and the ratio of IgG2/IgG1 was correlated with AR (early AR occurring within 3 months of transplant and late AR occurring after 3 months). Ten patients had 17 episodes of biopsy proven AR. Twelve episodes of AR (6 patients) occurred within the first 3 months of transplantation. In 5 patients, AR was diagnosed 4, 5, 6, 9 and 24 months post-transplantation. Detection of gamma-IFN mRNA correlated significantly with early AR (p < 0.001), whereas it lacked correlation with late AR. Expression of IL-2 and IL-10 mRNA did not correlate with AR. IL-10 was present in most samples irrespective of the presence or absence of AR. The ratio of IgG2/IgG1 was similar in patients with or without AR. Our findings suggest that the detection of gamma-IFN mRNA in BAL by RT-PCR is useful for immune monitoring of early AR in LT recipients. Absence of elevated IgG2/IgG1 ratio, and presence of IL-10 in BAL during AR suggests that Th-1 cytokines may not be the sole mediator of rejection in LT recipients.
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Affiliation(s)
- A Moudgil
- Department of Pediatrics, Steven Spielberg Pediatric Research Center, Los Angeles, CA 90048, USA.
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Abstract
Bronchoscopy plays an indispensable role in lung transplantation. It is an essential part of the evaluation of potential lung donors, and it is the pivotal procedure in the management of lung transplant recipients. Although advances in immunodiagnostic methods may ultimately lead to noninvasive tests to detect rejection, histology will be the standard for some time, and transbronchial biopsy will remain the procedure of choice. Furthermore, the usefulness of bronchoscopy in the diagnosis of pulmonary infection after lung transplantation is unlikely to be supplanted by any emerging technique.
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Affiliation(s)
- E P Trulock
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.
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31
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Boehler A, Kesten S, Weder W, Speich R. Bronchiolitis obliterans after lung transplantation: a review. Chest 1998; 114:1411-26. [PMID: 9824023 DOI: 10.1378/chest.114.5.1411] [Citation(s) in RCA: 156] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- A Boehler
- Thoracic Surgery Research Laboratory, University of Toronto, Ontario, Canada
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32
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Levrey H, Hertz MI. Chronic lung allograft dysfunction. Transplant Rev (Orlando) 1998. [DOI: 10.1016/s0955-470x(98)80009-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Finn L, Reyes J, Bueno J, Yunis E. Epstein-Barr virus infections in children after transplantation of the small intestine. Am J Surg Pathol 1998; 22:299-309. [PMID: 9500771 DOI: 10.1097/00000478-199803000-00004] [Citation(s) in RCA: 98] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Epstein-Barr virus (EBV) infection in association with immunosuppressive drugs used for solid organ transplantation can produce a spectrum of illnesses. Forty-one children who ranged in age from 6 months to 18.5 years received small intestinal transplants alone or in combination with other organs while undergoing primary tacrolimus (FK506) immunosuppression between July 1990 and June 1995. We reviewed hematoxylin and eosin-stained sections from all biopsy, surgical, and autopsy material from these children to determine the incidence and morphology of EBV-associated disease. Nuclear staining with in situ hybridization for EBV early RNA transcript (EBER) using the EBER-1 probe confirmed the presence of EBV. The EBV lymphoproliferations were graded as 1 to 4 according to histopathology and EBV quantitation determined in the area of greatest positivity. Twenty-one patients (51%) had EBV documented histologically on one or more occasions; only 8 (38%) are alive; 5 of these had the highest grade of 2. Posttransplant lymphoproliferative disease (PTLD) developed in 13 patients. Three of 10 patients (30%) with grade 3 lesions (polymorphous PTLD) are alive with intermittent evidence of EBV infection; 6 died with PTLD. Monomorphic PTLD (grade 4) was the cause of death in the three additional patients. Thirteen of 20 patients (65%) with no histologic evidence of EBV are alive. The incidence of EBV infection in pediatric small intestinal transplant recipients is higher than reported for any other solid organ cohort. With the aid of frequent EBER staining we were able to diagnose EBV infections in 51% of 41 patients; PTLD (grade 3 or 4) developed in 32% of these children. Low-grade EBV infections often preceded the development of PTLD and were identified in gastrointestinal biopsy samples from patients with concurrent PTLD; however, results of gastrointestinal biopsy samples may be negative for EBV in some patients with PTLD and, thus, underestimate systemic EBV-associated lymphoproliferations. Rejection and EBV infection can occur simultaneously, therefore, attention to low-grade infection may be useful to patient management.
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Affiliation(s)
- L Finn
- Department of Pathology, Children's Hospital of Pittsburgh, Pennsylvania, USA
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Brézillon S, Hamm H, Heilmann M, Schäfers HJ, Hinnrasky J, Wagner TO, Puchelle E, Tümmler B. Decreased expression of the cystic fibrosis transmembrane conductance regulator protein in remodeled airway epithelium from lung transplanted patients. Hum Pathol 1997; 28:944-52. [PMID: 9269831 DOI: 10.1016/s0046-8177(97)90010-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The absence or mislocalization of cystic fibrosis transmembrane conductance regulator (CFTR) is regarded as being specific for cystic fibrosis (CF). In principle, the supply of a non-CF lung transplant to a CF patient should bring up normal CFTR expression in the lower airways. Immunolocalization of CFTR and of epithelial differentiation markers (ie, cytokeratins 13, 14, and 18, and desmoplakins 1 and 2) was carried out on 21 mucosal biopsies from the upper lobe of grafts in non-CF (n = 12) and CF patients (n = 9) retrieved between days 23 and 1,608 after lung transplantation. Biopsy specimens from seven non-CF and four CF patients presented either a pseudostratified respiratory epithelium or slight basal cell hyperplasia. CFTR was distributed at the apical membrane of the ciliated cells. In remodeled epithelia with basal cell hyperplasia or squamous metaplasia, CFTR was either weakly expressed in the cytoplasm of the superficial epithelial cells or was undetectable. The extent of epithelium remodeling was significantly correlated with an impairment of lung function. The results suggest that posttransplant airway epithelium dedifferentiation of the graft leads to the loss of properly targeted CFTR irrespective of the underlying disease of the recipient.
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Affiliation(s)
- S Brézillon
- Klinische Forschergruppe, and the Department of Pneumology, Medizinische Hochschule, Hannover, Germany
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Abstract
Rejection is a common complication following lung transplantation, and can lead to considerable short- and long-term morbidity. As numbers and survival rates of lung transplant recipients increase, it is apparent that acute rejection can occur months or years after transplantation, and may be resistant to standard therapies. Mechanisms of acute rejection have been well studied in other solid organ transplant recipients, and are beginning to be addressed in the lung recipient. This article addresses some of the common issues of diagnosis and management of acute rejection which arise frequently during the care of lung transplant recipients.
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Affiliation(s)
- M B King-Biggs
- Division of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, USA
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