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Kubo Y, Sugimoto S, Shiotani T, Matsubara K, Hashimoto K, Tanaka S, Shien K, Suzawa K, Miyoshi K, Yamamoto H, Okazaki M, Toyooka S. Percentage of low attenuation area on computed tomography detects chronic lung allograft dysfunction, especially bronchiolitis obliterans syndrome, after bilateral lung transplantation. Clin Transplant 2023; 37:e15077. [PMID: 37461238 DOI: 10.1111/ctr.15077] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 07/04/2023] [Accepted: 07/06/2023] [Indexed: 09/18/2023]
Abstract
INTRODUCTION The percentage of low attenuation area (%LAA) on computed tomography (CT) is useful for evaluating lung emphysema, and higher %LAA was observed in patients with chronic lung allograft dysfunction (CLAD). This study investigated the relationship between the %LAA and the development of CLAD after bilateral lung transplantation (LT). METHODS We conducted a single-center retrospective study of 75 recipients who underwent bilateral LT; the recipients were divided into a CLAD group (n = 30) and a non-CLAD group (n = 45). The %LAA was calculated using CT and compared between the two groups from 4 years before to 4 years after the diagnosis of CLAD. The relationships between the %LAA and the percent baseline values of the pulmonary function test parameters were also calculated. RESULTS The %LAA was significantly higher in the CLAD group than in the non-CLAD group from 2 years before to 2 years after the diagnosis of CLAD (P < .05). In particular, patients with bronchiolitis obliterans syndrome (BOS) exhibited significant differences even from 4 years before to 4 years after diagnosis (P < .05). Significant negative correlations between the %LAA and the percent baseline values of the forced expiratory volume in 1 s (r = -.36, P = .0031), the forced vital capacity (r = -.27, P = .027), and the total lung capacity (r = -.40, P < .001) were seen at the time of CLAD diagnosis. CONCLUSION The %LAA on CT was associated with the development of CLAD and appears to have the potential to predict CLAD, especially BOS, after bilateral LT.
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Affiliation(s)
- Yujiro Kubo
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Seiichiro Sugimoto
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Toshio Shiotani
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kei Matsubara
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kohei Hashimoto
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shin Tanaka
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kazuhiko Shien
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Ken Suzawa
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kentaroh Miyoshi
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiromasa Yamamoto
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Mikio Okazaki
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shinichi Toyooka
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Halitim P, Tissot A. [Chronic lung allograft dysfunction in 2022, past and updates]. Rev Mal Respir 2023; 40:324-334. [PMID: 36858879 DOI: 10.1016/j.rmr.2023.01.025] [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: 09/21/2022] [Accepted: 01/24/2023] [Indexed: 03/03/2023]
Abstract
INTRODUCTION While short-term results of lung transplantation have improved considerably, long-term survival remains below that achieved for other solid organ transplants. CURRENT KNOWLEDGE The main cause of late mortality is chronic lung allograft dysfunction (CLAD), which affects nearly half of the recipients 5 years after transplantation. Immunological and non-immune risk factors have been identified. These factors activate the innate and adaptive immune system, leading to lesional and altered wound-healing processes, which result in fibrosis affecting the small airways or interstitial tissue. Several phenotypes of CLAD have been identified based on respiratory function and imaging pattern. Aside from retransplantation, which is possible for only small number of patients, no treatment can reverse the CLAD process. PERSPECTIVES Current therapeutic research is focused on anti-fibrotic treatments and photopheresis. Basic research has identified numerous biomarkers that could prove to be relevant as therapeutic targets. CONCLUSION While the pathophysiological mechanisms of CLAD are better understood than before, a major therapeutic challenge remains.
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Affiliation(s)
- P Halitim
- Service de pneumologie et soins intensifs, Hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, 75015 Paris, France; Service de pneumologie, CHU de Nantes, l'Institut du thorax, Nantes Université, Inserm, Center for Research in Transplantation and Translational Immunology, UMR 1064, 44093 Nantes cedex, France
| | - A Tissot
- Service de pneumologie, CHU de Nantes, l'Institut du thorax, Nantes Université, Inserm, Center for Research in Transplantation and Translational Immunology, UMR 1064, 44093 Nantes cedex, France.
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3
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Biomarkers for Chronic Lung Allograft Dysfunction: Ready for Prime Time? Transplantation 2023; 107:341-350. [PMID: 35980878 PMCID: PMC9875844 DOI: 10.1097/tp.0000000000004270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Chronic lung allograft dysfunction (CLAD) remains a major hurdle impairing lung transplant outcome. Parallel to the better clinical identification and characterization of CLAD and CLAD phenotypes, there is an increasing urge to find adequate biomarkers that could assist in the earlier detection and differential diagnosis of CLAD phenotypes, as well as disease prognostication. The current status and state-of-the-art of biomarker research in CLAD will be discussed with a particular focus on radiological biomarkers or biomarkers found in peripheral tissue, bronchoalveolar lavage' and circulating blood' in which significant progress has been made over the last years. Ultimately, although a growing number of biomarkers are currently being embedded in the follow-up of lung transplant patients, it is clear that one size does not fit all. The future of biomarker research probably lies in the rigorous combination of clinical information with findings in tissue, bronchoalveolar lavage' or blood. Only by doing so, the ultimate goal of biomarker research can be achieved, which is the earlier identification of CLAD before its clinical manifestation. This is desperately needed to improve the prognosis of patients with CLAD after lung transplantation.
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Peräkylä L, Nykänen A, Piilonen A, Kesävuori R, Halme M, Raivio P. Transition from BOS to RAS impairs prognosis after lung transplantation-CLAD subtype analysis by CT volumetry. PLoS One 2022; 17:e0275563. [PMID: 36223371 PMCID: PMC9555659 DOI: 10.1371/journal.pone.0275563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 09/19/2022] [Indexed: 11/05/2022] Open
Abstract
Background Chronic lung allograft dysfunction (CLAD), subclassified into bronchiolitis obliterans syndrome (BOS) or restrictive allograft syndrome (RAS), limits survival after lung transplantation. Information concerning transition from BOS to RAS is limited. We aimed to characterize the lung volume change after BOS diagnosis by computed tomography (CT) volumetry and to determine the incidence, risk factors and clinical significance of BOS to RAS transition. Methods CT volumetry measurements were performed from 63 patients with CLAD initially classified as BOS by CT volumetry. BOS patients with lung volume remaining >85% of baseline were classified as persistent BOS, whereas BOS patients whose lung volume permanently decreased to ≤85% of baseline were classified as BOS to RAS transition. Results During follow-up (median 9.8 years) eight patients (12.7%) were classified as BOS to RAS transition, which decreased recipient (p = 0.004) and graft survival (p = 0.020) in comparison to patients with persistent BOS. Opacities on chest imaging preceded BOS to RAS transition in 88% of patients. Opacities on chest imaging at BOS diagnosis and early CLAD diagnosis after transplantation were risk factors for transition. Conclusion Based on lung volume decrease measured by CT volumetry, a small proportion of BOS patients transitioned to RAS which had an adverse effect on recipient and graft survival.
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Affiliation(s)
- Laura Peräkylä
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- * E-mail:
| | - Antti Nykänen
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Anneli Piilonen
- Department of Radiology, Medical Imaging Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Risto Kesävuori
- Department of Radiology, Medical Imaging Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Maija Halme
- Department of Pulmonary Medicine, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Peter Raivio
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Shalmon T, Salazar P, Horie M, Hanneman K, Pakkal M, Anwari V, Fratesi J. Predefined and data driven CT densitometric features predict critical illness and hospital length of stay in COVID-19 patients. Sci Rep 2022; 12:8143. [PMID: 35581369 PMCID: PMC9114017 DOI: 10.1038/s41598-022-12311-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 05/09/2022] [Indexed: 11/09/2022] Open
Abstract
The aim of this study was to compare whole lung CT density histograms to predict critical illness outcome and hospital length of stay in a cohort of 80 COVID-19 patients. CT chest images on segmented lungs were retrospectively analyzed. Functional Principal Component Analysis (FPCA) was used to find the main modes of variations on CT density histograms. CT density features, the CT severity score, the COVID-GRAM score and the patient clinical data were assessed for predicting the patient outcome using logistic regression models and survival analysis. ROC analysis predictors of critically ill status: 87.5th percentile CT density (Q875)—AUC 0.88 95% CI (0.79 0.94), F1-CT—AUC 0.87 (0.77 0.93) Standard Deviation (SD-CT)—AUC 0.86 (0.73, 0.93). Multivariate models combining CT-density predictors and Neutrophil–Lymphocyte Ratio showed the highest accuracy. SD-CT, Q875 and F1 score were significant predictors of hospital length of stay (LOS) while controlling for hospital death using competing risks models. Moreover, two multivariate Fine-Gray regression models combining the clinical variables: age, NLR, Contrast CT factor with either Q875 or F1 CT-density predictors revealed significant effects for the prediction of LOS incidence in presence of a competing risk (death) and acceptable predictive performances (Bootstrapped C-index 0.74 [0.70 0.78]).
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Affiliation(s)
- Tamar Shalmon
- Joint Department of Medical Imaging, University of Toronto, Toronto, ON, Canada.,University Health Network, Toronto General Hospital, 200 Elizabeth St, Toronto, ON, M5G 2C4, Canada
| | | | - Miho Horie
- Joint Department of Medical Imaging, University of Toronto, Toronto, ON, Canada.,University Health Network, Toronto General Hospital, 200 Elizabeth St, Toronto, ON, M5G 2C4, Canada
| | - Kate Hanneman
- Joint Department of Medical Imaging, University of Toronto, Toronto, ON, Canada.,University Health Network, Toronto General Hospital, 200 Elizabeth St, Toronto, ON, M5G 2C4, Canada
| | - Mini Pakkal
- Joint Department of Medical Imaging, University of Toronto, Toronto, ON, Canada.,University Health Network, Toronto General Hospital, 200 Elizabeth St, Toronto, ON, M5G 2C4, Canada
| | - Vahid Anwari
- Joint Department of Medical Imaging, University of Toronto, Toronto, ON, Canada.,University Health Network, Toronto General Hospital, 200 Elizabeth St, Toronto, ON, M5G 2C4, Canada
| | - Jennifer Fratesi
- Joint Department of Medical Imaging, University of Toronto, Toronto, ON, Canada. .,University Health Network, Toronto General Hospital, 200 Elizabeth St, Toronto, ON, M5G 2C4, Canada.
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6
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Novel biomarkers of chronic lung allograft dysfunction: is there anything reliable? Curr Opin Organ Transplant 2022; 27:1-6. [PMID: 34939958 DOI: 10.1097/mot.0000000000000944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Chronic lung allograft dysfunction (CLAD) remains a major barrier preventing long-term survival following lung transplantation. As our clinical knowledge regarding its definition and presentation has significantly improved over the last years, adequate biomarkers to predict development of CLAD, phenotype of CLAD or prognosis post-CLAD diagnosis are definitely needed. RECENT FINDINGS Radiological and physiological markers are gradually entering routine clinical practice. In-depth investigation of biological samples including broncho-alveolar lavage, biopsy and serum has generated potential biomarkers involved in fibrogenesis, airway injury and inflammation but none of these are universally accepted or implemented although progress has been made, specifically regarding donor-derived cell-free DNA and donor-specific antibodies. SUMMARY Although a lot of promising biomarkers have been put forward, a very limited number has made it to routine clinical practice. Nevertheless, a biomarker that leads to earlier detection or more adequate disease phenotyping would advance the field enormously.
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7
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McInnis MC, Ma J, Karur GR, Houbois C, Levy L, Havlin J, Fuchs E, Tikkanen J, Chow CW, Huszti E, Martinu T. Chronic lung allograft dysfunction phenotype and prognosis by machine learning CT analysis. Eur Respir J 2021; 60:13993003.01652-2021. [PMID: 34949699 DOI: 10.1183/13993003.01652-2021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 11/23/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Chronic lung allograft dysfunction (CLAD) is the principal cause of graft failure in lung transplant recipients and prognosis depends on CLAD phenotype. We used machine learning computed tomography (CT) lung texture analysis tool at CLAD diagnosis for phenotyping and prognostication compared to radiologists' scoring. METHODS This retrospective study included all adult first double-lung transplant patients (01/2010-12/2015) with CLAD (censored 12/2019) and inspiratory CT near CLAD diagnosis. The machine learning tool quantified ground-glass opacity, reticulation, hyperlucent lung, and pulmonary vessel volume (PVV). Two radiologists scored for ground-glass opacity, reticulation, consolidation, pleural effusion, air trapping and bronchiectasis. Receiver operating characteristic curve analysis was used to evaluate the diagnostic performance of machine learning and radiologist for CLAD phenotype. Multivariable Cox proportional-hazards regression analysis for allograft survival controlled for age, sex, native lung disease, cytomegalovirus serostatus, and CLAD phenotype (bronchiolitis obliterans syndrome [BOS] and restrictive allograft syndrome [RAS]/mixed). RESULTS 88 patients were included (57 BOS, 20 RAS/mixed, and 11 unclassified/undefined) with CT a median 9.5 days from CLAD onset. Radiologist and machine learning parameters phenotyped RAS/mixed with PVV as the strongest indicator (AUC 0.85). Machine learning hyperlucent lung phenotyped BOS using only inspiratory CT (AUC=0.76). Radiologist and machine learning parameters predicted graft failure in the multivariable analysis, best with PVV (HR=1.23, 95%CI 1.05-1.44, p=0.01). CONCLUSIONS Machine learning discriminated between CLAD phenotypes on CT. Both radiologist and machine learning scoring were associated with graft failure, independent of CLAD phenotype. PVV, unique to machine learning, was the strongest in phenotyping and prognostication.
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Affiliation(s)
- Micheal C McInnis
- Department of Medical Imaging, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Jin Ma
- Biostatistics Research Unit, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Gauri Rani Karur
- Department of Medical Imaging, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Christian Houbois
- Department of Medical Imaging, University Health Network, University of Toronto, Toronto, ON, Canada.,Department of Diagnostic and Interventional Radiology, University of Cologne, Cologne, Germany
| | - Liran Levy
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Jan Havlin
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Eyal Fuchs
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Jussi Tikkanen
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Chung-Wai Chow
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada.,Division of Respirology, Department of Medicine, University of Toronto, ON, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada.,Division of Respirology, Department of Medicine, University of Toronto, ON, Canada
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8
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Chronic lung allograft dysfunction. Indian J Thorac Cardiovasc Surg 2021; 38:318-325. [DOI: 10.1007/s12055-021-01228-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 06/11/2021] [Accepted: 06/21/2021] [Indexed: 10/19/2022] Open
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9
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Peräkylä LH, Raivio PM, Kesävuori RI, Piilonen AK, Stark CK, Halme MK, Nykänen AI. Chronic lung allograft dysfunction subtype analysis by computed tomography volumetry. Clin Transplant 2021; 36:e14507. [PMID: 34634164 DOI: 10.1111/ctr.14507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 10/03/2021] [Accepted: 10/05/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND Chronic lung allograft dysfunction (CLAD) limits long-term survival after lung transplantation. Of the two subtypes, restrictive allograft syndrome (RAS) is characterized by a larger lung volume decrease and worse prognosis than bronchiolitis obliterans syndrome (BOS). We used computed tomography (CT) volumetry to classify CLAD subtypes and determined their clinical impact. METHODS Adult primary lung transplants performed 2003-2015 (n = 167) were retrospectively evaluated for CLAD and subclassified with CT volumetry. Lung volume decrease of < 15% from baseline resulted in BOSCT-vol and ≥15% resulted in RASCT-vol diagnosis. Clinical impact of CLAD subtypes was defined, and the prognostic value of different lung function, radiological, and lung volume parameters present at the time of CLAD diagnosis were compared. RESULTS CLAD affected 43% of patients and was classified with CT volumetry as BOSCT-vol in 89% and RASCT-vol in 11%. Median graft survival estimate in RASCT-vol was significantly decreased compared to BOSCT-vol (1.6 vs. 9.7 years, P = .038). At CLAD onset, RASCT-vol diagnosis (P = .05), increased lung density (P = .007), and more severe FEV1 (P = .004) decline from baseline, increased graft loss risk in multivariate analysis. CONCLUSIONS CT volumetry serves to identify lung transplant patients with a poor clinical outcome but should be validated in prospective trials.
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Affiliation(s)
- Laura H Peräkylä
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Peter M Raivio
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Risto I Kesävuori
- Department of Radiology, Medical Imaging Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Anneli K Piilonen
- Department of Radiology, Medical Imaging Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Christoffer K Stark
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Maija K Halme
- Department of Pulmonology, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Antti I Nykänen
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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10
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Belloli EA, Gu T, Wang Y, Vummidi D, Lyu DM, Combs MP, Chughtai A, Murray S, Galbán CJ, Lama VN. Radiographic Graft Surveillance in Lung Transplantation: Prognostic Role of Parametric Response Mapping. Am J Respir Crit Care Med 2021; 204:967-976. [PMID: 34319850 DOI: 10.1164/rccm.202012-4528oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Chronic lung allograft dysfunction (CLAD) results in significant morbidity following lung transplantation. Potential CLAD occurs when lung function declines to 80-90% of baseline. Better non-invasive tools to prognosticate at potential CLAD are needed. OBJECTIVES To determine if parametric response mapping (PRM), a CT voxel-wise methodology, applied to high resolution CT scans can identify patients at risk of progression to CLAD or death. METHODS Radiographic features and PRM-based CT metrics quantifying functional small airways disease (PRMfSAD) and parenchymal disease (PRMPD) were studied at potential CLAD (n=61). High PRMfSAD and high PRMPD were defined as ≥ 30%. Restricted mean modeling was performed to compare CLAD-free survival among groups. MEASUREMENTS AND MAIN RESULTS PRM metrics identified 3 unique signatures: high PRMfSAD (11.5%), high PRMPD (41%) and neither (PRMNormal; 47.5%). Patients with high PRMfSAD or PRMPD had shorter CLAD-free median survival times (0.46 years and 0.50 years) compared to patients with predominantly PRMNormal (2.03 years; p=0.004 and 0.007 compared to PRMfSAD and PRMPD groups, respectively). In multivariate modeling adjusting for single versus double lung transplant, age at transplant, BMI at potential CLAD, and time from transplant to CT, PRMfSAD or PRMPD ≥ 30% continue to be statistically significant predictors of shorter CLAD-free survival. Air trapping by radiologist interpretation was common (66%), similar across PRM groups, and was not predictive of CLAD-free survival. Ground glass opacities by radiologist read occurred in 16% of cases and was associated with decreased CLAD-free survival (p<0.001). CONCLUSIONS PRM analysis offers valuable prognostic information at potential CLAD, identifying patients most at risk of developing CLAD or death.
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Affiliation(s)
- Elizabeth A Belloli
- University of Michigan, Pulmonary & Critical Care Medicine, Ann Arbor, Michigan, United States;
| | - Tian Gu
- University of Michigan, Biostatistics, Ann Arbor, Michigan, United States
| | - Yizhuo Wang
- University of Michigan School of Public Health, 51329, Biostatistics, Ann Arbor, Michigan, United States
| | - Dharshan Vummidi
- University of Michigan, Radiology, Ann Arbor, Michigan, United States
| | - Dennis M Lyu
- University of Michigan, Internal Medicine, Division Pulmonary & Critical Care, Ann Arbor, Michigan, United States
| | - Michael P Combs
- University of Michigan, Internal Medicine, Ann Arbor, Michigan, United States
| | - Aamer Chughtai
- University of Michigan, Radiology, Ann Arbor, Michigan, United States
| | - Susan Murray
- University of Michigan, School of Public Health, Biostatistics, Ann Arbor, Michigan, United States
| | - Craig J Galbán
- Center for Molecular Imaging, Michigan, Michigan, United States
| | - Vibha N Lama
- University of Michigan, 1259, Pulmonary and Critical Care Medicine, Ann Arbor, Michigan, United States
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11
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Amubieya O, Ramsey A, DerHovanessian A, Fishbein GA, Lynch JP, Belperio JA, Weigt SS. Chronic Lung Allograft Dysfunction: Evolving Concepts and Therapies. Semin Respir Crit Care Med 2021; 42:392-410. [PMID: 34030202 DOI: 10.1055/s-0041-1729175] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The primary factor that limits long-term survival after lung transplantation is chronic lung allograft dysfunction (CLAD). CLAD also impairs quality of life and increases the costs of medical care. Our understanding of CLAD continues to evolve. Consensus definitions of CLAD and the major CLAD phenotypes were recently updated and clarified, but it remains to be seen whether the current definitions will lead to advances in management or impact care. Understanding the potential differences in pathogenesis for each CLAD phenotype may lead to novel therapeutic strategies, including precision medicine. Recognition of CLAD risk factors may lead to earlier interventions to mitigate risk, or to avoid risk factors all together, to prevent the development of CLAD. Unfortunately, currently available therapies for CLAD are usually not effective. However, novel therapeutics aimed at both prevention and treatment are currently under investigation. We provide an overview of the updates to CLAD-related terminology, clinical phenotypes and their diagnosis, natural history, pathogenesis, and potential strategies to treat and prevent CLAD.
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Affiliation(s)
- Olawale Amubieya
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Allison Ramsey
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ariss DerHovanessian
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Gregory A Fishbein
- Department of Pathology, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Joseph P Lynch
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - John A Belperio
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - S Samuel Weigt
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
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12
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Brun AL, Chabi ML, Picard C, Mellot F, Grenier PA. Lung Transplantation: CT Assessment of Chronic Lung Allograft Dysfunction (CLAD). Diagnostics (Basel) 2021; 11:diagnostics11050817. [PMID: 33946544 PMCID: PMC8147203 DOI: 10.3390/diagnostics11050817] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 04/27/2021] [Accepted: 04/28/2021] [Indexed: 01/05/2023] Open
Abstract
Chronic lung allograft rejection remains one of the major causes of morbi-mortality after lung transplantation. The term Chronic Lung Allograft Dysfunction (CLAD) has been proposed to describe the different processes that lead to a significant and persistent deterioration in lung function without identifiable causes. The two main phenotypes of CLAD are Bronchiolitis Obliterans Syndrome (BOS) and Restrictive Allograft Syndrome (RAS), each of them characterized by particular functional and imaging features. These entities can be associated (mixed phenotype) or switched from one to the other. If CLAD remains a clinical diagnosis based on spirometry, computed tomography (CT) scan plays an important role in the diagnosis and follow-up of CLAD patients, to exclude identifiable causes of functional decline when CLAD is first suspected, to detect early abnormalities that can precede the diagnosis of CLAD (particularly RAS), to differentiate between the obstructive and restrictive phenotypes, and to detect exacerbations and evolution from one phenotype to the other. Recognition of early signs of rejection is crucial for better understanding of physiopathologic pathways and optimal management of patients.
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Affiliation(s)
- Anne-Laure Brun
- Radiology Department, Hôpital Foch, 92150 Suresnes, France; (M.-L.C.); (F.M.)
- Correspondence: (A.-L.B.); (P.A.G.)
| | - Marie-Laure Chabi
- Radiology Department, Hôpital Foch, 92150 Suresnes, France; (M.-L.C.); (F.M.)
| | - Clément Picard
- Respiratory Department, Hôpital Foch, 92150 Suresnes, France;
| | - François Mellot
- Radiology Department, Hôpital Foch, 92150 Suresnes, France; (M.-L.C.); (F.M.)
| | - Philippe A. Grenier
- Department of Clinical Research and Innovation, Hôpital Foch, 92150 Suresnes, France
- Correspondence: (A.-L.B.); (P.A.G.)
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13
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Hoang-Thi TN, Chassagnon G, Hua-Huy T, Boussaud V, Dinh-Xuan AT, Revel MP. Chronic Lung Allograft Dysfunction Post Lung Transplantation: A Review of Computed Tomography Quantitative Methods for Detection and Follow-Up. J Clin Med 2021; 10:jcm10081608. [PMID: 33920108 PMCID: PMC8069908 DOI: 10.3390/jcm10081608] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 12/27/2022] Open
Abstract
Chronic lung allograft dysfunction (CLAD) remains the leading cause of morbidity and mortality after lung transplantation. The term encompasses both obstructive and restrictive phenotypes, as well as mixed and undefined phenotypes. Imaging, in addition to pulmonary function tests, plays a major role in identifying the CLAD phenotype and is essential for follow-up after lung transplantation. Quantitative imaging allows for the performing of reader-independent precise evaluation of CT examinations. In this review article, we will discuss the role of quantitative imaging methods for evaluating the airways and the lung parenchyma on computed tomography (CT) images, for an early identification of CLAD and for prognostic estimation. We will also discuss their limits and the need for novel approaches to predict, understand, and identify CLAD in its early stages.
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Affiliation(s)
- Trieu-Nghi Hoang-Thi
- AP-HP.Centre, Hôpital Cochin, Department of Radiology, Université de Paris, 75014 Paris, France; (T.-N.H.-T.); (G.C.)
- Department of Diagnostic Imaging, Vinmec Central Park Hospital, Ho Chi Minh City 70000, Vietnam
- AP-HP.Centre, Hôpital Cochin, Department of Respiratory Physiology, Université de Paris, 75014 Paris, France; (T.H.-H.); (A.-T.D.-X.)
| | - Guillaume Chassagnon
- AP-HP.Centre, Hôpital Cochin, Department of Radiology, Université de Paris, 75014 Paris, France; (T.-N.H.-T.); (G.C.)
| | - Thong Hua-Huy
- AP-HP.Centre, Hôpital Cochin, Department of Respiratory Physiology, Université de Paris, 75014 Paris, France; (T.H.-H.); (A.-T.D.-X.)
| | - Veronique Boussaud
- AP-HP.Centre, Hôpital Cochin, Department of Pneumology, Université de Paris, 75014 Paris, France;
| | - Anh-Tuan Dinh-Xuan
- AP-HP.Centre, Hôpital Cochin, Department of Respiratory Physiology, Université de Paris, 75014 Paris, France; (T.H.-H.); (A.-T.D.-X.)
| | - Marie-Pierre Revel
- AP-HP.Centre, Hôpital Cochin, Department of Radiology, Université de Paris, 75014 Paris, France; (T.-N.H.-T.); (G.C.)
- Correspondence: ; Tel.: +33-1-5841-2471
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14
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Lv M, Zhou Z, Tang Q, Xu J, Huang Q, Lu L, Duan S, Zhu J, Li H. Differentiation of usual vertebral compression fractures using CT histogram analysis as quantitative biomarkers: A proof-of-principle study. Eur J Radiol 2020; 131:109264. [PMID: 32920220 DOI: 10.1016/j.ejrad.2020.109264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/19/2020] [Accepted: 08/24/2020] [Indexed: 01/20/2023]
Abstract
PURPOSE To investigate the utility of CT histogram analysis (CTHA) for discrimination of traumatic, osteoporotic and malignant fractures in patients with vertebral compression fractures (VCFs). To evaluate the feasibility and accuracy of CTHA in differentiating non-malignant (traumatic and osteoporotic) from malignant VCFs. MATERIALS AND METHODS Totally, 235 patients with VCFs were enrolled in the current experimental study. There were 132 patients with traumatic VCFs, 51 with osteoporotic VCFs and 52 with malignant VCFs, with MRI and histology as the standard references. All the patients underwent unenhanced CT scans. Nineteen histogram-based parameters were derived using Omni-Kinetics software (Omni-Kinetics, GE Healthcare). The reproducibility of those parameters was evaluated using two independent delineations conducted by two observers. These histogram parameters were compared among the three different VCFs using Kruskal-Wallis H test. Traumatic VCFs and osteoporotic VCFs were combined as non-malignant VCFs and compared with malignant VCFs using Mann-Whitney U test Multivariable logistic regression analysis was performed on the significantly different features and built a diagnosis model. Receiver operating characteristic (ROC) curve was carried out to observe the difference of diagnostic performance between the single positive parameter and the combination of parameters. RESULTS All the 19 parameters presented excellent reproducibility, with intraclass correlation coefficient values from 0.789 to 0.997. At quantitative evaluation, the best predictive histogram parameters in discrimination of the three different types of VCFs were relative min intensity (p = 0.022), relative entropy (p = 0.043), and relative frequency size (p < 0.001). Relative frequency size (p < 0.001) and relative quantile5 (p = 0.012) resulted in statistically significant difference between non-malignant and malignant VCFs. The area under ROC curve indicated that relative frequency size combined with relative quantile5 (0.754; 95 % confidence intervals: 0.661∼0.829; p < 0.001) was of best performance in differentiating malignant from non-malignant VCFs. CONCLUSIONS Our results are encouraging and suggest that histogram parameters derived from unenhanced CT could be reliable quantitative biomarkers for diff ;erential diagnosis of usual VCFs.
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Affiliation(s)
- Mu Lv
- The Second Clinical Medical College of Nanjing Medical University, Nan Jing, China
| | - Zhichao Zhou
- The Second Clinical Medical College of Nanjing Medical University, Nan Jing, China
| | - Qingkun Tang
- The Second Clinical Medical College of Nanjing Medical University, Nan Jing, China; Department of Radiology, the Second Affiliated Hospital of Nanjing Medical University, Nan Jing, China
| | - Jie Xu
- The Second Clinical Medical College of Nanjing Medical University, Nan Jing, China; Department of Radiology, the Second Affiliated Hospital of Nanjing Medical University, Nan Jing, China
| | - Qiao Huang
- Department of Radiology, Mayo Clinic, Rochester, United States
| | - Lin Lu
- Department of Radiology, Columbia University Medical Center, New York, United States
| | | | - Jianguo Zhu
- The Second Clinical Medical College of Nanjing Medical University, Nan Jing, China; Department of Radiology, the Second Affiliated Hospital of Nanjing Medical University, Nan Jing, China.
| | - Haige Li
- The Second Clinical Medical College of Nanjing Medical University, Nan Jing, China; Department of Radiology, the Second Affiliated Hospital of Nanjing Medical University, Nan Jing, China
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15
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Courtwright AM, Lamattina AM, Takahashi M, Trindade AJ, Hunninghake GM, Rosas IO, Agarwal S, Raby BA, Goldberg HJ, El-Chemaly S. Shorter telomere length following lung transplantation is associated with clinically significant leukopenia and decreased chronic lung allograft dysfunction-free survival. ERJ Open Res 2020; 6:00003-2020. [PMID: 32577419 PMCID: PMC7293991 DOI: 10.1183/23120541.00003-2020] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 03/26/2020] [Indexed: 01/11/2023] Open
Abstract
Patients with short telomeres and interstitial lung disease may have decreased chronic lung allograft dysfunction (CLAD)-free survival following lung transplantation. The relationship between post-transplant telomere length and outcomes following lung transplantation has not been characterised among all recipients, regardless of native lung disease. This was a single-centre prospective cohort study. Consenting transplant recipients had their telomere length measured using quantitative real-time PCR assays on peripheral blood collected at the time of surveillance bronchoscopy. We assessed the association between early post-transplant telomere length (as measured in the first 100 days) and CLAD-free survival, time to clinically significant leukopenia, cytomegalovirus (CMV) viraemia, chronic kidney disease, and acute cellular rejection. We also assessed the association between rate of telomere shortening and CLAD-free survival. Telomere lengths were available for 98 out of 215 (45.6%) recipients who underwent lung transplant during the study period (median measurement per patient=2 (interquartile range, 1–3)). Shorter telomere length was associated with decreased CLAD-free survival (hazard ratio (HR)=1.24; 95% CI=1.03–1.48; p=0.02), leukopenia requiring granulocyte colony-stimulating factor (HR=1.17, 95% CI=1.01–1.35, p=0.03), and CMV viraemia among CMV-mismatch recipients (HR=4.04, 95% CI=1.05–15.5, p=0.04). Telomere length was not associated with acute cellular rejection or chronic kidney disease. Recipients with more rapid loss in telomere length (defined as the highest tertile of telomere shortening) did not have worse subsequent CLAD-free survival than those without rapid loss (HR=1.38, 95% CI=0.27–7.01, p=0.70). Shorter early post-transplant telomere length is associated with decreased CLAD-free survival and clinically significant leukopenia in lung transplant recipients, regardless of native lung disease. Shorter recipient telomere length following lung transplantation is associated with clinically significant leukopenia and decreased chronic lung allograft dysfunction-free survivalhttps://bit.ly/2ytymXc
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Affiliation(s)
- Andrew M Courtwright
- Dept of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Anthony M Lamattina
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Mai Takahashi
- Harvard T.H. Chen School of Public Health, Boston, MA, USA
| | - Anil J Trindade
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Gary M Hunninghake
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Ivan O Rosas
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Suneet Agarwal
- Division of Hematology/Oncology, Dana-Farber Boston Children's Cancer and Blood Disorders Center, Boston Children's Hospital, Boston, MA, USA
| | - Benjamin A Raby
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, MA, USA.,Division of Pulmonary Medicine, Boston Children's Hospital, Boston, MA, USA.,Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Hilary J Goldberg
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Souheil El-Chemaly
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, MA, USA
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16
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Kotecha S, Paraskeva MA, Levin K, Snell GI. An update on chronic lung allograft dysfunction. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:417. [PMID: 32355861 PMCID: PMC7186740 DOI: 10.21037/atm.2020.01.05] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Chronic lung allograft dysfunction (CLAD) remains a significant challenge and the major determinant of morbidity and mortality post lung transplantation (LTx). The definition of CLAD has evolved significantly over the last ten years, reflecting better understanding of pathophysiology and different phenotypes. While there is an agreed consensus approach to CLAD, questions remain regarding the limitations of lung function parameters as well as the role of imaging and histopathology. Here we present a current snapshot of the definition of CLAD, its evolution and future directions.
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Affiliation(s)
- Sakhee Kotecha
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia
| | | | - Kovi Levin
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia
| | - Gregory I Snell
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia
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