1
|
Calabrese DR, Ekstrand CA, Yellamilli S, Singer JP, Hays SR, Leard LE, Shah RJ, Venado A, Kolaitis NA, Perez A, Combes A, Greenland JR. Macrophage and CD8 T cell discordance are associated with acute lung allograft dysfunction progression. J Heart Lung Transplant 2024; 43:1074-1086. [PMID: 38367738 PMCID: PMC11230518 DOI: 10.1016/j.healun.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 02/02/2024] [Accepted: 02/06/2024] [Indexed: 02/19/2024] Open
Abstract
BACKGROUND Acute lung allograft dysfunction (ALAD) is an imprecise syndrome denoting concern for the onset of chronic lung allograft dysfunction (CLAD). Mechanistic biomarkers are needed that stratify risk of ALAD progression to CLAD. We hypothesized that single cell investigation of bronchoalveolar lavage (BAL) cells at the time of ALAD would identify immune cells linked to progressive graft dysfunction. METHODS We prospectively collected BAL from consenting lung transplant recipients for single cell RNA sequencing. ALAD was defined by a ≥10% decrease in FEV1 not caused by infection or acute rejection and samples were matched to BAL from recipients with stable lung function. We examined cell compositional and transcriptional differences across control, ALAD with decline, and ALAD with recovery groups. We also assessed cell-cell communication. RESULTS BAL was assessed for 17 ALAD cases with subsequent decline (ALAD declined), 13 ALAD cases that resolved (ALAD recovered), and 15 cases with stable lung function. We observed broad differences in frequencies of the 26 unique cell populations across groups (p = 0.02). A CD8 T cell (p = 0.04) and a macrophage cluster (p = 0.01) best identified ALAD declined from the ALAD recovered and stable groups. This macrophage cluster was distinguished by an anti-inflammatory signature and the CD8 T cell cluster resembled a Tissue Resident Memory subset. Anti-inflammatory macrophages signaled to activated CD8 T cells via class I HLA, fibronectin, and galectin pathways (p < 0.05 for each). Recipients with discordance between these cells had a nearly 5-fold increased risk of severe graft dysfunction or death (HR 4.6, 95% CI 1.1-19.2, adjusted p = 0.03). We validated these key findings in 2 public lung transplant genomic datasets. CONCLUSIONS BAL anti-inflammatory macrophages may protect against CLAD by suppressing CD8 T cells. These populations merit functional and longitudinal assessment in additional cohorts.
Collapse
Affiliation(s)
- Daniel R Calabrese
- Department of Medicine, University of California, San Francisco, California; Medical Service, Veterans Affairs Health Care System, San Francisco, California.
| | | | - Shivaram Yellamilli
- Department of Pathology, University of California, San Francisco, California
| | - Jonathan P Singer
- Department of Medicine, University of California, San Francisco, California
| | - Steven R Hays
- Department of Medicine, University of California, San Francisco, California
| | - Lorriana E Leard
- Department of Medicine, University of California, San Francisco, California
| | - Rupal J Shah
- Department of Medicine, University of California, San Francisco, California
| | - Aida Venado
- Department of Medicine, University of California, San Francisco, California
| | | | - Alyssa Perez
- Department of Medicine, University of California, San Francisco, California
| | - Alexis Combes
- Department of Pathology, University of California, San Francisco, California
| | - John R Greenland
- Department of Medicine, University of California, San Francisco, California; Medical Service, Veterans Affairs Health Care System, San Francisco, California
| |
Collapse
|
2
|
Pavlisko EN, Adam BA, Berry GJ, Calabrese F, Cortes-Santiago N, Glass CH, Goddard M, Greenland JR, Kreisel D, Levine DJ, Martinu T, Verleden SE, Weigt SS, Roux A. The 2022 Banff Meeting Lung Report. Am J Transplant 2024; 24:542-548. [PMID: 37931751 DOI: 10.1016/j.ajt.2023.10.022] [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: 08/22/2023] [Accepted: 10/11/2023] [Indexed: 11/08/2023]
Abstract
The Lung Session of the 2022 16th Banff Foundation for Allograft Pathology Conference-held in Banff, Alberta-focused on non-rejection lung allograft pathology and novel technologies for the detection of allograft injury. A multidisciplinary panel reviewed the state-of-the-art of current histopathologic entities, serologic studies, and molecular practices, as well as novel applications of digital pathology with artificial intelligence, gene expression analysis, and quantitative image analysis of chest computerized tomography. Current states of need as well as prospective integration of the aforementioned tools and technologies for complete assessment of allograft injury and its impact on lung transplant outcomes were discussed. Key conclusions from the discussion were: (1) recognition of limitations in current standard of care assessment of lung allograft dysfunction; (2) agreement on the need for a consensus regarding the standardized approach to the collection and assessment of pathologic data, inclusive of all lesions associated with graft outcome (eg, non-rejection pathology); and (3) optimism regarding promising novel diagnostic modalities, especially minimally invasive, which should be integrated into large, prospective multicenter studies to further evaluate their utility in clinical practice for directing personalized therapies to improve graft outcomes.
Collapse
Affiliation(s)
- Elizabeth N Pavlisko
- Department of Pathology, Duke University Medical Center, Durham, North Carolina, USA.
| | - Benjamin A Adam
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Canada
| | - Gerald J Berry
- Department of Pathology, Stanford University, Stanford, California, USA
| | - Fiorella Calabrese
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
| | - Nahir Cortes-Santiago
- Department of Pathology and Immunology, Texas Children's Hospital, Houston, Texas, USA
| | - Carolyn H Glass
- Department of Pathology, Duke University Medical Center, Durham, North Carolina, USA
| | - Martin Goddard
- Pathology Department, Royal Papworth Hospital, NHS Trust, Papworth Everard, Cambridge, UK
| | - John R Greenland
- Department of Medicine, University of California, San Francisco, USA; Veterans Affairs Health Care System, San Francisco, California, USA
| | - Daniel Kreisel
- Department of Surgery, Department of Pathology and Immunology, Washington University, St. Louis, Missouri, USA
| | - Deborah J Levine
- Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University, California, USA
| | - Tereza Martinu
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Stijn E Verleden
- Lung Transplant Unit, Department of Chronic Diseases and Metabolism, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium; Department of ASTARC, University of Antwerp, Wilrijk, Belgium
| | - S Sam Weigt
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Antoine Roux
- Department of Respiratory Medicine, Foch Hospital, Suresnes, France
| |
Collapse
|
3
|
Prather AA, Gao Y, Betancourt L, Kordahl RC, Sriram A, Huang CY, Hays SR, Kukreja J, Calabrese DR, Venado A, Kapse B, Greenland JR, Singer JP. Disturbed sleep after lung transplantation is associated with worse patient-reported outcomes and chronic lung allograft dysfunction. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2023.10.12.23296973. [PMID: 37873197 PMCID: PMC10593057 DOI: 10.1101/2023.10.12.23296973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Many lung transplant recipients fail to derive the expected improvements in functioning, HRQL, or long-term survival. Sleep may represent an important, albeit rarely examined, factor influencing lung transplant outcomes. Within a larger cohort study, 141 lung transplant recipients completed the Medical Outcomes Study (MOS) Sleep Scale along with a broader survey of patient-reported outcome (PRO) measures and frailty assessment. MOS Sleep yields the Sleep Problems Index (SPI); we also derived an insomnia-specific subscale. Potential perioperative predictors of disturbed sleep and time to chronic lung allograft dysfunction (CLAD) and death were derived from medical records. We investigated associations between perioperative predictors on SPI and Insomnia and associations between SPI and Insomnia on PROs and frailty by linear regressions, adjusting for age, sex, and lung function. We evaluated the associations between SPI and Insomnia on time to CLAD and death using Cox models, adjusting for age, sex, and transplant indication. Post-transplant hospital length of stay >30 days was associated with worse sleep by SPI and insomnia (SPI: p=0.01; Insomnia p=0.02). Worse sleep by SPI and insomnia was associated with worse depression, cognitive function, HRQL, physical disability, health utilities, and Fried Frailty Phenotype frailty (all p<0.01). Those in the worst quartile of SPI and insomnia exhibited increased risk of CLAD (HR 2.18; 95%CI: 1.22-3.89 ; p=0.01 for SPI and HR 1.96; 95%CI 1.09-3.53; p=0.03 for insomnia). Worsening in SPI but not insomnia was also associated with mortality (HR: 1.29; 95%CI: 1.05-1.58; p=0.01). Poor sleep after lung transplant may be a novel predictor of patient reported outcomes, frailty, CLAD, and death with potentially important screening and treatment implications.
Collapse
Affiliation(s)
- Aric A Prather
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
| | - Ying Gao
- Department of Medicine, University of California San Francisco
| | | | - Rose C Kordahl
- Department of Medicine, University of California San Francisco
| | - Anya Sriram
- Department of Medicine, University of California San Francisco
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California San Francisco
| | - Steven R Hays
- Department of Medicine, University of California San Francisco
| | - Jasleen Kukreja
- Department of Surgery, University of California San Francisco
| | - Daniel R Calabrese
- Department of Medicine, University of California San Francisco
- San Francisco Veterans Affairs Health Care System
| | - Aida Venado
- Department of Medicine, University of California San Francisco
| | - Bhavya Kapse
- Department of Medicine, University of California San Francisco
| | - John R Greenland
- Department of Medicine, University of California San Francisco
- San Francisco Veterans Affairs Health Care System
| | | |
Collapse
|
4
|
Calabrese DR, Greenland JR. Theseus and the search for an antibody-mediated rejection molecular state in lung transplant biopsies. Am J Transplant 2023; 23:1826-1827. [PMID: 37562578 PMCID: PMC10855672 DOI: 10.1016/j.ajt.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 07/19/2023] [Accepted: 08/01/2023] [Indexed: 08/12/2023]
Affiliation(s)
- Daniel R Calabrese
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA; San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.
| | - John R Greenland
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA; San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| |
Collapse
|
5
|
Santos J, Wang P, Shemesh A, Liu F, Tsao T, Aguilar OA, Cleary SJ, Singer JP, Gao Y, Hays SR, Golden JA, Leard L, Kleinhenz ME, Kolaitis NA, Shah R, Venado A, Kukreja J, Weigt SS, Belperio JA, Lanier LL, Looney MR, Greenland JR, Calabrese DR. CCR5 drives NK cell-associated airway damage in pulmonary ischemia-reperfusion injury. JCI Insight 2023; 8:e173716. [PMID: 37788115 PMCID: PMC10721259 DOI: 10.1172/jci.insight.173716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/20/2023] [Indexed: 10/05/2023] Open
Abstract
Primary graft dysfunction (PGD) limits clinical benefit after lung transplantation, a life-prolonging therapy for patients with end-stage disease. PGD is the clinical syndrome resulting from pulmonary ischemia-reperfusion injury (IRI), driven by innate immune inflammation. We recently demonstrated a key role for NK cells in the airways of mouse models and human tissue samples of IRI. Here, we used 2 mouse models paired with human lung transplant samples to investigate the mechanisms whereby NK cells migrate to the airways to mediate lung injury. We demonstrate that chemokine receptor ligand transcripts and proteins are increased in mouse and human disease. CCR5 ligand transcripts were correlated with NK cell gene signatures independently of NK cell CCR5 ligand secretion. NK cells expressing CCR5 were increased in the lung and airways during IRI and had increased markers of tissue residency and maturation. Allosteric CCR5 drug blockade reduced the migration of NK cells to the site of injury. CCR5 blockade also blunted quantitative measures of experimental IRI. Additionally, in human lung transplant bronchoalveolar lavage samples, we found that CCR5 ligand was associated with increased patient morbidity and that the CCR5 receptor was increased in expression on human NK cells following PGD. These data support a potential mechanism for NK cell migration during lung injury and identify a plausible preventative treatment for PGD.
Collapse
Affiliation(s)
- Jesse Santos
- Department of Medicine, UCSF, San Francisco, California, USA
- Department of Surgery, UCSF - East Bay, Oakland, California, USA
| | - Ping Wang
- Department of Medicine, UCSF, San Francisco, California, USA
| | - Avishai Shemesh
- Department of Medicine, UCSF, San Francisco, California, USA
- Parker Institute for Cancer Immunotherapy, San Francisco, California, USA
| | - Fengchun Liu
- Department of Medicine, UCSF, San Francisco, California, USA
| | - Tasha Tsao
- Department of Medicine, UCSF, San Francisco, California, USA
| | | | - Simon J. Cleary
- Department of Medicine, UCSF, San Francisco, California, USA
| | | | - Ying Gao
- Department of Medicine, UCSF, San Francisco, California, USA
| | - Steven R. Hays
- Department of Medicine, UCSF, San Francisco, California, USA
| | | | - Lorriana Leard
- Department of Medicine, UCSF, San Francisco, California, USA
| | | | | | - Rupal Shah
- Department of Medicine, UCSF, San Francisco, California, USA
| | - Aida Venado
- Department of Medicine, UCSF, San Francisco, California, USA
| | | | - S. Sam Weigt
- Department of Medicine, UCLA, Los Angeles, California, USA
| | | | - Lewis L. Lanier
- Parker Institute for Cancer Immunotherapy, San Francisco, California, USA
- Department of Microbiology and Immunology, and
| | - Mark R. Looney
- Department of Medicine, UCSF, San Francisco, California, USA
| | - John R. Greenland
- Department of Medicine, UCSF, San Francisco, California, USA
- Medical Service, Veterans Affairs Health Care System, San Francisco, California, USA
| | - Daniel R. Calabrese
- Department of Medicine, UCSF, San Francisco, California, USA
- Medical Service, Veterans Affairs Health Care System, San Francisco, California, USA
| |
Collapse
|
6
|
Zhang D, Wang X, Du W, Qin W, Chen W, Zuo X, Li P. Impact of statin treatment and exposure on the risk of chronic allograft dysfunction in Chinese lung transplant recipients. Pulm Pharmacol Ther 2023; 82:102243. [PMID: 37454870 DOI: 10.1016/j.pupt.2023.102243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/24/2023] [Accepted: 07/13/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE Chronic lung allograft dysfunction (CLAD) was a common complication following lung transplantation that contributed to long-term morbidity and mortality. Statin therapy had been suggested to attenuate recipient inflammation and immune response, potentially reducing the risk and severity of CLAD. This study aimed to evaluate the impact of statin use and in vivo exposure on the incidence of CLAD in lung transplant recipients (LTRs), as well as their effects on immune cells and inflammatory factors. METHODS A retrospective cohort study was conducted on patients who underwent lung transplantation between January 2017 and December 2020. The incidence of CLAD, as per the 2019 ISHLT criteria, was assessed as the clinical outcome. The plasma concentrations of statin were measured using a validated UPLC-MS/MS method, while inflammation marker levels were determined using ELISA kits. RESULTS The statin group exhibited a significantly lower rate of CLAD (P = 0.002). Patients receiving statin therapy showed lower CD4+ T-cell counts, total T-lymphocyte counts, and IL-6 levels (P = 0.017, P = 0.048, and P = 0.038, respectively). Among the CLAD groups, the atorvastatin level (2.51 ± 1.31 ng/ml) was significantly lower than that in the non-CLAD group (OR = 1.438, 95%CI (1.007-2.053), P = 0.046). CONCLUSION Statin therapy significantly reduced the incidence of CLAD, as well as immune cell counts and inflammatory cytokine levels in LTRs. Although the statin exposure was significantly lower in CLAD patients, it was not associated with the incidence of CLAD.
Collapse
Affiliation(s)
- Dan Zhang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Xiaoxing Wang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Wenwen Du
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Wei Qin
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Wenqian Chen
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Xianbo Zuo
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, 100029, China; Department of Dermatology, China-Japan Friendship Hospital, Beijing, 100029, China.
| | - Pengmei Li
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, 100029, China.
| |
Collapse
|
7
|
Singer JP, Gao Y, Huang CY, Kordahl RC, Sriram A, Hays SR, Kukreja J, Venado A, Calabrese DR, Greenland JR. The Association Between Frailty and Chronic Lung Allograft Dysfunction After Lung Transplantation. Transplantation 2023; 107:2255-2261. [PMID: 37287095 PMCID: PMC10524113 DOI: 10.1097/tp.0000000000004672] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND After lung transplantation, both frailty and chronic lung allograft dysfunction (CLAD) commonly develop, and when they do, are associated with poorer outcomes. Given their potential shared mechanisms, we sought to explore the temporal relationship between frailty and CLAD onset. METHODS In a single center, we prospectively measured frailty by the short physical performance battery (SPPB) repeatedly after transplant. Because of the nature of the relationship between frailty and CLAD is unknown, we tested the association between frailty, modeled as a time-dependent predictor, and CLAD development as well as CLAD development, modeled as a time-dependent predictor, and frailty development. To do so, we used Cox proportional cause-specific hazards and conditional logistic regression models adjusted for age, sex, race, diagnosis, cytomegalovirus serostatus, posttransplant body mass index, and acute cellular rejection episodes as time-dependent covariates. We tested SPPB frailty as a binary (≤9 points) and continuous predictor (12-point scale); as an outcome, we defined frailty as SPPB ≤9. RESULTS The 231 participants were a mean age of 55.7 y (SD 12.1). After adjusting for covariates, the development of frailty within 3 y after lung transplant was associated with cause-specific CLAD risk (adjusted cause-specific hazard ratio: 1.76; 95% confidence interval [CI], 1.05-2.92 when defining frailty as SPPB ≤9 and adjusted cause-specific hazard ratio: 1.10, 95% CI, 1.03-1.18 per 1-point worsening in SPPB). CLAD onset did not appear to be a risk factor for subsequent frailty (odds ratio, 4.0; 95% CI, 0.4-197.0). CONCLUSIONS Studying the mechanisms underlying frailty and CLAD could provide new insights into the pathobiology of both and potential targets for intervention.
Collapse
Affiliation(s)
- Jonthan P Singer
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Ying Gao
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA
| | - Rose C Kordahl
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Anya Sriram
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Steven R Hays
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Jasleen Kukreja
- San Francisco Veterans Affairs Health Care System, San Francisco, CA
| | - Aida Venado
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Daniel R Calabrese
- Department of Medicine, University of California San Francisco, San Francisco, CA
- San Francisco Veterans Affairs Health Care System, San Francisco, CA
| | - John R Greenland
- Department of Medicine, University of California San Francisco, San Francisco, CA
- San Francisco Veterans Affairs Health Care System, San Francisco, CA
| |
Collapse
|
8
|
Santos J, Hays SR, Golden JA, Calabrese DR, Kolaitis N, Kleinhenz ME, Shah R, Estrada AV, Leard LE, Kukreja J, Singer JP, Greenland JR. Decreased Lymphocytic Bronchitis Severity in the Era of Azithromycin Prophylaxis. Transplant Direct 2023; 9:e1495. [PMID: 37575951 PMCID: PMC10414707 DOI: 10.1097/txd.0000000000001495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/02/2023] [Indexed: 08/15/2023] Open
Abstract
Large-airway lymphocytic inflammation (LB), assessed on endobronchial biopsies, has been associated with acute cellular rejection and chronic lung allograft dysfunction (CLAD). Azithromycin (AZI) prophylaxis has been used to prevent airway inflammation and subsequent CLAD, with inconsistent results. We hypothesized that AZI prophylaxis would be associated with reduced LB, changes in bronchoalveolar lavage (BAL) immune cell populations, and improved CLAD-free survival. Methods We compared frequencies of LB from endobronchial biopsies before (N = 1856) and after (N = 975) protocolized initiation of AZI prophylaxis at our center. LB was classified as none, minimal, mild, or moderate by histopathologic analysis. LB grades were compared using ordinal mixed-model regression. Corresponding automated BAL leukocyte frequencies were compared using mixed-effects modeling. The effect of AZI prophylaxis on CLAD-free survival was assessed by a Cox proportional hazards model adjusted for age, sex, ethnicity, transplant indication, and cytomegalovirus serostatus. Results Biopsies in the pre-AZI era had 2-fold increased odds (95% confidence interval, 1.5-2.7; P < 0.001) of higher LB grades. LB was associated with BAL neutrophilia in both eras. However, there was no difference in risk for CLAD or death between AZI eras (hazard ratio 1.3; 95% confidence interval, 0.7-2.0; P = 0.45). Conclusions Decreased airway inflammation in the era of AZI prophylaxis may represent a direct effect of AZI therapy or reflect other practices or environmental changes. In this cohort, AZI prophylaxis was not associated with improved CLAD-free survival.
Collapse
Affiliation(s)
- Jesse Santos
- San Francisco Department of Medicine, University of California, San Francisco, CA
| | - Steven R. Hays
- San Francisco Department of Medicine, University of California, San Francisco, CA
| | - Jeffrey A. Golden
- San Francisco Department of Medicine, University of California, San Francisco, CA
| | | | - Nicholas Kolaitis
- San Francisco Department of Medicine, University of California, San Francisco, CA
| | - Mary Ellen Kleinhenz
- San Francisco Department of Medicine, University of California, San Francisco, CA
| | - Rupal Shah
- San Francisco Department of Medicine, University of California, San Francisco, CA
| | - Aida Venado Estrada
- San Francisco Department of Medicine, University of California, San Francisco, CA
| | - Lorriana E. Leard
- San Francisco Department of Medicine, University of California, San Francisco, CA
| | - Jasleen Kukreja
- San Francisco Department of Medicine, University of California, San Francisco, CA
| | - Jonathan P. Singer
- San Francisco Department of Medicine, University of California, San Francisco, CA
| | - John R. Greenland
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of California, San Francisco, CA
| |
Collapse
|
9
|
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.
Collapse
|
10
|
Lunardi F, Abbrescia DI, Vedovelli L, Pezzuto F, Fortarezza F, Comacchio GM, Guzzardo V, Ferrigno P, Loy M, Giraudo C, Fraia AS, Faccioli E, Braccioni F, Cozzi E, Gregori D, Verleden GM, Calabrese F, Schena FP, Rea F. Molecular Profiling of Tissue Samples with Chronic Rejection from Patients with Chronic Lung Allograft Dysfunction: A Pilot Study in Cystic Fibrosis Patients. Biomolecules 2023; 13:biom13010097. [PMID: 36671482 PMCID: PMC9856133 DOI: 10.3390/biom13010097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/26/2022] [Accepted: 12/29/2022] [Indexed: 01/06/2023] Open
Abstract
Chronic rejection (CR) is the main culprit for reduced survival and quality of life in patients undergoing lung transplantation (Ltx). High-throughput approaches have been used to unveil the molecular pathways of CR, mainly in the blood and/or in bronchoalveolar lavage. We hypothesized that a distinct molecular signature characterizes the biopsies of recipients with clinically confirmed histological signs of CR. Eighteen cystic fibrosis patients were included in the study and RNA sequencing was performed in 35 scheduled transbronchial biopsies (TBBs): 5 with acute cellular rejection, 9 with CR, and 13 without any sign of post-LTx complication at the time of biopsy; 8 donor lung samples were used as controls. Three networks with 33, 26, and 36 differentially expressed genes (DEGs) were found in TBBs with CR. Among these, seven genes were common to the identified pathways and possibly linked to CR and five of them (LCN2, CCL11, CX3CL1, CXCL12, MUC4) were confirmed by real-time PCR. Immunohistochemistry was significant for LCN2 and MUC4. This study identified a typical gene expression pattern in TBBs with histological signs of CR and the LCN2 gene appeared to play a central role. Thus, it could be crucial in CR pathophysiology.
Collapse
Affiliation(s)
- Francesca Lunardi
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | | | - Luca Vedovelli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Federica Pezzuto
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Francesco Fortarezza
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Giovanni Maria Comacchio
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | | | - Pia Ferrigno
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Monica Loy
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Chiara Giraudo
- Department of Medicine, University of Padova, 35128 Padova, Italy
| | - Anna Sara Fraia
- Department of Medicine, University of Padova, 35128 Padova, Italy
| | - Eleonora Faccioli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Fausto Braccioni
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Emanuele Cozzi
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Dario Gregori
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Geert M. Verleden
- Department of Respiratory Diseases, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Fiorella Calabrese
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
- Correspondence: ; Tel.: +39-049-8272268
| | | | - Federico Rea
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| |
Collapse
|
11
|
Glanville AR, Mitchell AB. New Tools for Old Problems: Gastroesophageal Reflux Disease and the Lung Allograft Microbiome. Am J Respir Crit Care Med 2022; 206:1444-1445. [PMID: 35925015 PMCID: PMC9757095 DOI: 10.1164/rccm.202207-1446ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Allan R. Glanville
- The Lung Transplant UnitSt. Vincent’s HospitalSydney, New South Wales, Australia
| | | |
Collapse
|
12
|
Halloran K, Mackova M, Parkes MD, Hirji A, Weinkauf J, Timofte IL, Snell GI, Westall GP, Lischke R, Zajacova A, Havlin J, Hachem R, Kreisel D, Levine D, Kubisa B, Piotrowska M, Juvet S, Keshavjee S, Jaksch P, Klepetko W, Halloran PF. The molecular features of chronic lung allograft dysfunction in lung transplant airway mucosa. J Heart Lung Transplant 2022; 41:1689-1699. [PMID: 36163162 DOI: 10.1016/j.healun.2022.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 07/22/2022] [Accepted: 08/17/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Many lung transplants fail due to chronic lung allograft dysfunction (CLAD). We recently showed that transbronchial biopsies (TBBs) from CLAD patients manifest severe parenchymal injury and dedifferentiation, distinct from time-dependent changes. The present study explored time-selective and CLAD-selective transcripts in mucosal biopsies from the third bronchial bifurcation (3BMBs), compared to those in TBBs. METHODS We used genome-wide microarray measurements in 324 3BMBs to identify CLAD-selective changes as well as time-dependent changes and develop a CLAD classifier. CLAD-selective transcripts were identified with linear models for microarray data (limma) and were used to build an ensemble of 12 classifiers to predict CLAD. Hazard models and random forests were then used to predict the risk of graft loss using the CLAD classifier, transcript sets associated with rejection, injury, and time. RESULTS T cell-mediated rejection and donor-specific antibody were increased in CLAD 3BMBs but most had no rejection. Like TBBs, 3BMBs showed a time-dependent increase in transcripts expressed in inflammatory cells that was not associated with CLAD or survival. Also like TBBs, the CLAD-selective transcripts in 3BMBs reflected severe parenchymal injury and dedifferentiation, not inflammation or rejection. While 3BMBs and TBBs did not overlap in their top 20 CLAD-selective transcripts, many CLAD-selective transcripts were significantly increased in both for example LOXL1, an enzyme controlling matrix remodeling. In Cox models for one-year survival, the 3BMB CLAD-selective transcripts and CLAD classifier predicted graft loss and correlated with CLAD stage. Many 3BMB CLAD-selective transcripts were also increased by injury in kidney transplants and correlated with decreased kidney survival, including LOXL1. CONCLUSIONS Mucosal and transbronchial biopsies from CLAD patients reveal a diffuse molecular injury and dedifferentiation state that impacts prognosis and correlates with the physiologic disturbances. CLAD state in lung transplants shares features with failing kidney transplants, indicating elements shared by the injury responses of distressed organs.
Collapse
Affiliation(s)
| | | | | | - Alim Hirji
- University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Greg I Snell
- Alfred Hospital Lung Transplant Service, Melbourne, Victoria, Australia
| | - Glen P Westall
- Alfred Hospital Lung Transplant Service, Melbourne, Victoria, Australia
| | | | | | - Jan Havlin
- University Hospital Motol, Prague, Czech Republic
| | - Ramsey Hachem
- Washington University in St Louis, St. Louis, Missouri
| | | | | | | | | | - Stephen Juvet
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | | | | | | |
Collapse
|
13
|
Santos J, Calabrese DR, Greenland JR. Lymphocytic Airway Inflammation in Lung Allografts. Front Immunol 2022; 13:908693. [PMID: 35911676 PMCID: PMC9335886 DOI: 10.3389/fimmu.2022.908693] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/16/2022] [Indexed: 11/16/2022] Open
Abstract
Lung transplant remains a key therapeutic option for patients with end stage lung disease but short- and long-term survival lag other solid organ transplants. Early ischemia-reperfusion injury in the form of primary graft dysfunction (PGD) and acute cellular rejection are risk factors for chronic lung allograft dysfunction (CLAD), a syndrome of airway and parenchymal fibrosis that is the major barrier to long term survival. An increasing body of research suggests lymphocytic airway inflammation plays a significant role in these important clinical syndromes. Cytotoxic T cells are observed in airway rejection, and transcriptional analysis of airways reveal common cytotoxic gene patterns across solid organ transplant rejection. Natural killer (NK) cells have also been implicated in the early allograft damage response to PGD, acute rejection, cytomegalovirus, and CLAD. This review will examine the roles of lymphocytic airway inflammation across the lifespan of the allograft, including: 1) The contribution of innate lymphocytes to PGD and the impact of PGD on the adaptive immune response. 2) Acute cellular rejection pathologies and the limitations in identifying airway inflammation by transbronchial biopsy. 3) Potentiators of airway inflammation and heterologous immunity, such as respiratory infections, aspiration, and the airway microbiome. 4) Airway contributions to CLAD pathogenesis, including epithelial to mesenchymal transition (EMT), club cell loss, and the evolution from constrictive bronchiolitis to parenchymal fibrosis. 5) Protective mechanisms of fibrosis involving regulatory T cells. In summary, this review will examine our current understanding of the complex interplay between the transplanted airway epithelium, lymphocytic airway infiltration, and rejection pathologies.
Collapse
Affiliation(s)
- Jesse Santos
- Department of Medicine University of California, San Francisco, San Francisco, CA, United States
| | - Daniel R. Calabrese
- Department of Medicine University of California, San Francisco, San Francisco, CA, United States
- Medical Service, Veterans Affairs Health Care System, San Francisco, CA, United States
- *Correspondence: Daniel Calabrese, ; John R. Greenland,
| | - John R. Greenland
- Department of Medicine University of California, San Francisco, San Francisco, CA, United States
- Medical Service, Veterans Affairs Health Care System, San Francisco, CA, United States
- *Correspondence: Daniel Calabrese, ; John R. Greenland,
| |
Collapse
|
14
|
Calabrese F, Roden AC, Pavlisko E, Lunardi F, Neil D, Adam B, Hwang D, Goddard M, Berry GJ, Ivanovic M, Thüsen JVD, Gibault L, Lin CY, Wassilew K, Glass C, Westall G, Zeevi A, Levine DJ, Roux A. LUNG ALLOGRAFT STANDARDIZED HISTOLOGICAL ANALYSIS (LASHA) TEMPLATE: A RESEARCH CONSENSUS PROPOSAL. J Heart Lung Transplant 2022; 41:1487-1500. [DOI: 10.1016/j.healun.2022.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 06/10/2022] [Accepted: 06/24/2022] [Indexed: 11/30/2022] Open
|
15
|
Glanville AR, Benden C, Bergeron A, Cheng GS, Gottlieb J, Lease ED, Perch M, Todd JL, Williams KM, Verleden GM. Bronchiolitis obliterans syndrome after lung or haematopoietic stem cell transplantation: current management and future directions. ERJ Open Res 2022; 8:00185-2022. [PMID: 35898810 PMCID: PMC9309343 DOI: 10.1183/23120541.00185-2022] [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: 04/13/2022] [Accepted: 05/18/2022] [Indexed: 11/05/2022] Open
Abstract
Bronchiolitis obliterans syndrome (BOS) may develop after either lung or haematopoietic stem cell transplantation (HSCT), with similarities in histopathological features and clinical manifestations. However, there are differences in the contributory factors and clinical trajectories between the two conditions. BOS after HSCT occurs due to systemic graft-versus-host-disease (GVHD), whereas BOS after lung transplantation is limited to the lung allograft. BOS diagnosis after HSCT is more challenging, as the lung function decline may occur due to extrapulmonary GVHD, causing sclerosis or inflammation in the fascia or muscles of the respiratory girdle. Treatment is generally empirical with no established effective therapies. This review provides rare insights and commonalities of both conditions, that are not well elaborated elsewhere in contemporary literature, and highlights the importance of cross disciplinary learning from experts in other transplant modalities. Treatment algorithms for each condition are presented, based on the published literature and consensus clinical opinion. Immunosuppression should be optimised, and other conditions or contributory factors treated where possible. When initial treatment fails, the ultimate therapeutic option is lung transplantation (or re-transplantation in the case of BOS after lung transplantation) in carefully selected candidates. Novel therapies under investigation include aerosolised liposomal cyclosporine, Janus kinase inhibitors, antifibrotic therapies, and (in patients with BOS after lung transplantation) B-cell–directed therapies. Effective novel treatments that have a tangible impact on survival and thereby avoid the need for lung transplantation or re-transplantation are urgently required.
Collapse
|
16
|
Abstract
Chronic lung allograft dysfunction (CLAD) is a syndrome of progressive lung function decline, subcategorized into obstructive, restrictive, and mixed phenotypes. The trajectory of CLAD is variable depending on the phenotype, with restrictive and mixed phenotypes having more rapid progression and lower survival. The mechanisms driving CLAD development remain unclear, though allograft injury during primary graft dysfunction, acute cellular rejection, antibody-mediated rejection, and infections trigger immune responses with long-lasting effects that can lead to CLAD months or years later. Currently, retransplantation is the only effective treatment.
Collapse
Affiliation(s)
- Aida Venado
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, 505 Parnassus Ave, M1093A, San Francisco, CA 94143-2204, USA.
| | - Jasleen Kukreja
- Division of Cardiothoracic Surgery, Univeristy of California, San Francisco, 500 Parnassus Ave, MU 405W Suite 305, San Francisco, CA 94143, USA
| | - John R Greenland
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, SF VAHCS Building 2, Room 453 (Mail stop 111D), 4150 Clement St, San Francisco CA 94121, USA
| |
Collapse
|
17
|
Greenland JR, McDyer JF. Molecular diagnostics for CLAD: When and where? Am J Transplant 2022; 22:1012-1013. [PMID: 34910363 PMCID: PMC8983448 DOI: 10.1111/ajt.16925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/01/2021] [Accepted: 12/13/2021] [Indexed: 01/25/2023]
Affiliation(s)
- John R Greenland
- University of California, San Francisco, CA; San Francisco VA Health Care System
| | | |
Collapse
|
18
|
Greenland NY, Deiter F, Calabrese DR, Hays SR, Kukreja J, Leard LE, Kolaitis NA, Golden JA, Singer JP, Greenland JR. Inflammation on bronchoalveolar lavage cytology is associated with decreased chronic lung allograft dysfunction-free survival. Clin Transplant 2022; 36:e14639. [PMID: 35246990 DOI: 10.1111/ctr.14639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 01/14/2022] [Accepted: 03/02/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Lung transplant recipients undergo bronchoalveolar lavage (BAL) to detect antecedents of chronic lung allograft dysfunction (CLAD), but routine assessment of BAL cytology is controversial. We hypothesized that inflammation on BAL cytology would predict CLAD-free survival. METHODS In a single-center retrospective cohort, associations between cytology results and clinical characteristics were compared using generalized-estimating equation-adjusted regression. The association between BAL inflammation and CLAD or death risk was assessed using time-dependent Cox models. RESULTS In 3,365 cytology reports from 451 subjects, inflammation was the most common finding (6.2%, 210 cases), followed by fungal forms (5.3%, 178 cases, including 24 cases of suspected Aspergillus). Inflammation on BAL cytology was more common in procedures for symptoms (8.5%) versus surveillance (3.2%, P<0.001). Inflammation on cytology was associated with automated neutrophil and lymphocyte counts, acute cellular rejection, infection, and portended a 2.2-fold hazard ratio (CI 1.2-4.0, P = 0.007) for CLAD or death. However, inflammation by cytology did not inform CLAD-free survival risk beyond automated BAL cell counts (P = 0.57). CONCLUSIONS Inflammation on BAL cytology is clinically significant, suggesting acute rejection or infection and increased risk of CLAD or death. However, other indicators of allograft inflammation can substitute for much of the information provided by BAL cytology. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Nancy Y Greenland
- Department of Anatomic Pathology, University of California, San Francisco, USA.,Veterans Affairs Health Care System, San Francisco, California, USA
| | - Fred Deiter
- Department of Medicine, Pulmonary, Critical Care, Allergy and Sleep Medicine Division, University of California, San Francisco, USA
| | - Daniel R Calabrese
- Veterans Affairs Health Care System, San Francisco, California, USA.,Department of Medicine, Pulmonary, Critical Care, Allergy and Sleep Medicine Division, University of California, San Francisco, USA
| | - Steven R Hays
- Department of Medicine, Pulmonary, Critical Care, Allergy and Sleep Medicine Division, University of California, San Francisco, USA
| | - Jasleen Kukreja
- Department of Surgery, University of California, San Francisco, USA
| | - Lorriana E Leard
- Department of Medicine, Pulmonary, Critical Care, Allergy and Sleep Medicine Division, University of California, San Francisco, USA
| | - Nicholas A Kolaitis
- Department of Medicine, Pulmonary, Critical Care, Allergy and Sleep Medicine Division, University of California, San Francisco, USA
| | - Jeffrey A Golden
- Department of Medicine, Pulmonary, Critical Care, Allergy and Sleep Medicine Division, University of California, San Francisco, USA
| | - Jonathan P Singer
- Department of Medicine, Pulmonary, Critical Care, Allergy and Sleep Medicine Division, University of California, San Francisco, USA
| | - John R Greenland
- Veterans Affairs Health Care System, San Francisco, California, USA.,Department of Medicine, Pulmonary, Critical Care, Allergy and Sleep Medicine Division, University of California, San Francisco, USA
| |
Collapse
|
19
|
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.
Collapse
|
20
|
Dugger DT, Calabrese DR, Gao Y, Deiter F, Tsao T, Maheshwari J, Hays SR, Leard L, Kleinhenz ME, Shah R, Golden J, Kukreja J, Gordon ED, Singer JP, Greenland JR. Lung Allograft Epithelium DNA Methylation Age Is Associated With Graft Chronologic Age and Primary Graft Dysfunction. Front Immunol 2021; 12:704172. [PMID: 34691018 PMCID: PMC8528961 DOI: 10.3389/fimmu.2021.704172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 09/09/2021] [Indexed: 02/04/2023] Open
Abstract
Advanced donor age is a risk factor for poor survival following lung transplantation. However, recent work identifying epigenetic determinants of aging has shown that biologic age may not always reflect chronologic age and that stressors can accelerate biologic aging. We hypothesized that lung allografts that experienced primary graft dysfunction (PGD), characterized by poor oxygenation in the first three post-transplant days, would have increased biologic age. We cultured airway epithelial cells isolated by transbronchial brush at 1-year bronchoscopies from 13 subjects with severe PGD and 15 controls matched on age and transplant indication. We measured epigenetic age using the Horvath epigenetic clock. Linear models were used to determine the association of airway epigenetic age with chronologic ages and PGD status, adjusted for recipient PGD risk factors. Survival models assessed the association with chronic lung allograft dysfunction (CLAD) or death. Distributions of promoter methylation within pathways were compared between groups. DNA methyltransferase (DNMT) activity was quantified in airway epithelial cells under hypoxic or normoxic conditions. Airway epigenetic age appeared younger but was strongly associated with the age of the allograft (slope 0.38 per year, 95% CI 0.27–0.48). There was no correlation between epigenetic age and recipient age (P = 0.96). Epigenetic age was 6.5 years greater (95% CI 1.7–11.2) in subjects who had experienced PGD, and this effect remained significant after adjusting for donor and recipient characteristics (P = 0.03). Epigenetic age was not associated with CLAD-free survival risk (P = 0.11). Analysis of differential methylation of promoters of key biologic pathways revealed hypomethylation in regions related to hypoxia, inflammation, and metabolism-associated pathways. Accordingly, airway epithelial cells cultured in hypoxic conditions showed suppressed DNMT activity. While airway methylation age was primarily determined by donor chronologic age, early injury in the form of PGD was associated with increased allograft epigenetic age. These data show how PGD might suppress key promoter methylation resulting in long-term impacts on the allograft.
Collapse
Affiliation(s)
- Daniel T Dugger
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Daniel R Calabrese
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States.,Medical Service, Veterans Affairs Health Care System, San Francisco, CA, United States
| | - Ying Gao
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Fred Deiter
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Tasha Tsao
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Julia Maheshwari
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Steven R Hays
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Lorriana Leard
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Mary Ellen Kleinhenz
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Rupal Shah
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Jeff Golden
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Jasleen Kukreja
- Department of Surgery, University of California at San Francisco, San Francisco, CA, United States
| | - Erin D Gordon
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Jonathan P Singer
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - John R Greenland
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States.,Medical Service, Veterans Affairs Health Care System, San Francisco, CA, United States
| |
Collapse
|
21
|
Hoover J, Mintz MA, Deiter F, Aminian E, Chen J, Hays SR, Singer JP, Calabrese DR, Kukreja J, Greenland JR. Rapid molecular detection of airway pathogens in lung transplant recipients. Transpl Infect Dis 2021; 23:e13579. [PMID: 33523538 PMCID: PMC8325716 DOI: 10.1111/tid.13579] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 01/07/2021] [Accepted: 01/16/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Airway infections are difficult to distinguish from acute rejection in lung transplant recipients. Traditional culture techniques take time that may delay treatment. We hypothesized that a rapid multiplex molecular assay could improve time to diagnosis and appropriate clinical decision making. METHODS In a prospective observational study of recipients undergoing bronchoscopy, we assessed the BioFire® FilmArray® Pneumonia Panel (BFPP) in parallel to standard of care (SOC) diagnostics. Research clinicians performed shadow (research only) clinical decision making in real time. Time to report and interpretation were reported as median and interquartile ranges and compared by Wilcoxon signed-ranked test. Agreement was defined based on detection of any species targeted in the molecular assay. RESULTS For the 150 enrolled subjects, BFPP results were available 3.8 hours (IQR 2.8-5.1) following bronchoscopy, compared to 13 hours for viral SOC (IQR 10-34, P < .001) results and 48 hours for bacterial SOC (IQR 46-70, P < .001) results. Positive BFPP results were interpreted in 9 hours (IQR 5-20) following bronchoscopy, compared to 74 hours for SOC (IQR 37-110, P < .001). Assays agreed for 138 (92%) of the 150 subjects. Of 22 BFPP diagnoses, five (23%) resulted in a shadow antibiotic recommendation. Notable BFPP deficiencies included fungal species and H parainfluenzae, accounting for 15 (27%) and 13 (23%) of the 56 actionable SOC results, respectively. CONCLUSIONS This molecular diagnostic including bacterial targets has the potential to shorten time to diagnosis and augment current clinical decision making but cannot replace SOC culture methods.
Collapse
Affiliation(s)
- Jonathan Hoover
- Department of Medicine, University of California, San Francisco CA
| | | | - Fred Deiter
- Department of Medicine, University of California, San Francisco CA
| | - Emily Aminian
- Department of Medicine, University of California, San Francisco CA
| | - Joy Chen
- Department of Surgery, University of California, San Francisco CA
| | - Steven R. Hays
- Department of Medicine, University of California, San Francisco CA
| | | | - Daniel R Calabrese
- Department of Medicine, University of California, San Francisco CA
- Medical Service, San Francisco VA Health Care System, San Francisco CA
| | - Jasleen Kukreja
- Department of Surgery, University of California, San Francisco CA
| | - John R Greenland
- Department of Medicine, University of California, San Francisco CA
- Medical Service, San Francisco VA Health Care System, San Francisco CA
| |
Collapse
|
22
|
Renaud-Picard B, Koutsokera A, Cabanero M, Martinu T. Acute Rejection in the Modern Lung Transplant Era. Semin Respir Crit Care Med 2021; 42:411-427. [PMID: 34030203 DOI: 10.1055/s-0041-1729542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Acute cellular rejection (ACR) remains a common complication after lung transplantation. Mortality directly related to ACR is low and most patients respond to first-line immunosuppressive treatment. However, a subset of patients may develop refractory or recurrent ACR leading to an accelerated lung function decline and ultimately chronic lung allograft dysfunction. Infectious complications associated with the intensification of immunosuppression can also negatively impact long-term survival. In this review, we summarize the most recent evidence on the mechanisms, risk factors, diagnosis, treatment, and prognosis of ACR. We specifically focus on novel, promising biomarkers which are under investigation for their potential to improve the diagnostic performance of transbronchial biopsies. Finally, for each topic, we highlight current gaps in knowledge and areas for future research.
Collapse
Affiliation(s)
- Benjamin Renaud-Picard
- Division of Respirology and Toronto Lung Transplant Program, University of Toronto and University Health Network, Toronto, Canada
| | - Angela Koutsokera
- Division of Pulmonology, Lung Transplant Program, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Michael Cabanero
- Department of Pathology, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Tereza Martinu
- Division of Respirology and Toronto Lung Transplant Program, University of Toronto and University Health Network, Toronto, Canada
| |
Collapse
|
23
|
Greenland JR. Transcriptome-based diagnostics for chronic lung allograft dysfunction: A socratic question revisited. J Heart Lung Transplant 2020; 39:1338-1340. [PMID: 33250117 DOI: 10.1016/j.healun.2020.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 09/04/2020] [Indexed: 10/23/2022] Open
Affiliation(s)
- John R Greenland
- Department of Medicine, University of California, San Francisco, San Francisco, California; Medical Service, San Francisco VA Health Care System, San Francisco, California.
| |
Collapse
|