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Kerckhof P, Ambrocio GPL, Beeckmans H, Kaes J, Geudens V, Bos S, Willems L, Vermaut A, Vermant M, Goos T, De Fays C, Aversa L, Mohamady Y, Vanstapel A, Orlitová M, Van Slambrouck J, Jin X, Varghese V, Josipovic I, Boone MN, Dupont LJ, Weynand B, Dubbeldam A, Van Raemdonck DE, Ceulemans LJ, Gayan-Ramirez G, De Sadeleer LJ, McDonough JE, Vanaudenaerde BM, Vos R. Ventilatory capacity in CLAD is driven by dysfunctional airway structure. EBioMedicine 2024; 101:105030. [PMID: 38394744 PMCID: PMC10897920 DOI: 10.1016/j.ebiom.2024.105030] [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: 11/15/2023] [Revised: 02/05/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Chronic lung allograft dysfunction (CLAD) encompasses three main phenotypes: bronchiolitis obliterans syndrome (BOS), restrictive allograft syndrome (RAS) and a Mixed phenotype combining both pathologies. How the airway structure in its entirety is affected in these phenotypes is still poorly understood. METHODS A detailed analysis of airway morphometry was applied to gain insights on the effects of airway remodelling on the distribution of alveolar ventilation in end-stage CLAD. Ex vivo whole lung μCT and tissue-core μCT scanning of six control, six BOS, three RAS and three Mixed explant lung grafts (9 male, 9 female, 2014-2021, Leuven, Belgium) were used for digital airway reconstruction and calculation of airway dimensions in relation to luminal obstructions. FINDINGS BOS and Mixed explants demonstrated airway obstructions of proximal bronchioles (starting at generation five), while RAS explants particularly had airway obstructions in the most distal bronchioles (generation >12). In BOS and Mixed explants 76% and 84% of bronchioles were obstructed, respectively, while this was 22% in RAS. Bronchiolar obstructions were mainly caused by lymphocytic inflammation of the airway wall or fibrotic remodelling, i.e. constrictive bronchiolitis. Proximal bronchiolectasis and imbalance in distal lung ventilation were present in all CLAD phenotypes and explain poor lung function and deterioration of specific lung function parameters. INTERPRETATION Alterations in the structure of conducting bronchioles revealed CLAD to affect alveolar ventilatory distribution in a regional fashion. The significance of various obstructions, particularly those associated with mucus, is highlighted. FUNDING This research was funded with the National research fund Flanders (G060322N), received by R.V.
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Affiliation(s)
- Pieterjan Kerckhof
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of CHROMETA, KU Leuven, Leuven, Belgium
| | - Gene P L Ambrocio
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of CHROMETA, KU Leuven, Leuven, Belgium; Division of Pulmonary Medicine, Department of Internal Medicine, University of the Philippines - Philippine General Hospital, Manilla, The Philippines
| | - Hanne Beeckmans
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of CHROMETA, KU Leuven, Leuven, Belgium
| | - Janne Kaes
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of CHROMETA, KU Leuven, Leuven, Belgium
| | - Vincent Geudens
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of CHROMETA, KU Leuven, Leuven, Belgium
| | - Saskia Bos
- Newcastle University, Translational and Clinical Research Institute, Newcastle upon Tyne, United Kingdom
| | - Lynn Willems
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of CHROMETA, KU Leuven, Leuven, Belgium
| | - Astrid Vermaut
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of CHROMETA, KU Leuven, Leuven, Belgium
| | - Marie Vermant
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of CHROMETA, KU Leuven, Leuven, Belgium
| | - Tinne Goos
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of CHROMETA, KU Leuven, Leuven, Belgium
| | - Charlotte De Fays
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of CHROMETA, KU Leuven, Leuven, Belgium; Pole of Pneumology, ENT, and Dermatology, Institute of Experimental and Clinical Research, Université Catholique de Louvain, Brussels, Belgium
| | - Lucia Aversa
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of CHROMETA, KU Leuven, Leuven, Belgium
| | - Yousry Mohamady
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of CHROMETA, KU Leuven, Leuven, Belgium
| | - Arno Vanstapel
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of CHROMETA, KU Leuven, Leuven, Belgium; Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | | | - Jan Van Slambrouck
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of CHROMETA, KU Leuven, Leuven, Belgium
| | - Xin Jin
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of CHROMETA, KU Leuven, Leuven, Belgium
| | - Vimi Varghese
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of CHROMETA, KU Leuven, Leuven, Belgium; Department of Heart and Lung Transplant, Yashoda Hospitals, Hyderabad, India
| | - Iván Josipovic
- Department of Physics and Astronomy, UGCT, Radiation Physics, Ghent University, Gent, Belgium
| | - Matthieu N Boone
- Department of Physics and Astronomy, UGCT, Radiation Physics, Ghent University, Gent, Belgium
| | - Lieven J Dupont
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Birgit Weynand
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Adriana Dubbeldam
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | | | - Laurens J Ceulemans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Ghislaine Gayan-Ramirez
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of CHROMETA, KU Leuven, Leuven, Belgium
| | - Laurens J De Sadeleer
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of CHROMETA, KU Leuven, Leuven, Belgium; Cell Circuits in Systems Medicine of Lung Disease (Schiller Lab), Institute of Lung Health and Immunity (LHI) / Comprehensive Pneumology Centre (CPC), German Centre for Lung Research, Helmholtz Zentrum München, München, Germany
| | - John E McDonough
- Department of Medicine, McMaster University, Firestone Institute of Respiratory Health, Hamilton, Canada
| | - Bart M Vanaudenaerde
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of CHROMETA, KU Leuven, Leuven, Belgium
| | - Robin Vos
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.
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Magnusson JM, Ericson P, Tengvall S, Stockfelt M, Brundin B, Lindén A, Riise GC. Involvement of IL-26 in bronchiolitis obliterans syndrome but not in acute rejection after lung transplantation. Respir Res 2022; 23:108. [PMID: 35501858 PMCID: PMC9063324 DOI: 10.1186/s12931-022-02036-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 04/25/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The main long-term complication after lung transplantation is bronchiolitis obliterans syndrome (BOS), a deadly condition in which neutrophils may play a critical pathophysiological role. Recent studies show that the cytokine interleukin IL-26 can facilitate neutrophil recruitment in response to pro-inflammatory stimuli in the airways. In this pilot study, we characterized the local involvement of IL-26 during BOS and acute rejection (AR) in human patients. METHOD From a biobank containing bronchoalveolar lavage (BAL) samples from 148 lung transplant recipients (LTR), clinically-matched patient pairs were identified to minimize the influence of clinical confounders. We identified ten pairs (BOS/non-BOS) with BAL samples harvested on three occasions for our longitudinal investigation and 12 pairs of patients with and without AR. The pairs were matched for age, gender, preoperative diagnosis, type of and time after surgery. Extracellular IL-26 protein was quantified in cell-free BAL samples using an enzyme-linked immunosorbent assay. Intracellular IL-26 protein in BAL cells was determined using immunocytochemistry (ICC) and flow cytometry. RESULTS The median extracellular concentration of IL-26 protein was markedly increased in BAL samples from patients with BOS (p < 0.0001) but not in samples from patients with AR. Intracellular IL-26 protein was confirmed in alveolar macrophages and lymphocytes (through ICC and flow cytometry) among BAL cells obtained from BOS patients. CONCLUSIONS Local IL-26 seems to be involved in BOS but not AR, and macrophages as well as lymphocytes constitute cellular sources in this clinical setting. The enhancement of extracellular IL-26 protein in LTRs with BOS warrants further investigation of its potential as a target for diagnosing, monitoring, and treating BOS.
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Affiliation(s)
- Jesper M Magnusson
- Department of Respiratory Medicine, Institute of Medicine Sahlgrenska Academy at the University of Gothenburg, Bruna stråket 11, 41345, Gothenburg, Sweden.
| | - Petrea Ericson
- Department of Respiratory Medicine, Institute of Medicine Sahlgrenska Academy at the University of Gothenburg, Bruna stråket 11, 41345, Gothenburg, Sweden
| | - Sara Tengvall
- Department of Respiratory Medicine, Institute of Medicine Sahlgrenska Academy at the University of Gothenburg, Bruna stråket 11, 41345, Gothenburg, Sweden.,Division for Lung and Airway Research, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Marit Stockfelt
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Bettina Brundin
- Division for Lung and Airway Research, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Anders Lindén
- Division for Lung and Airway Research, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Respiratory Medicine and Allergy, Karolinska University Hospital, Stockholm, Sweden
| | - Gerdt C Riise
- Department of Respiratory Medicine, Institute of Medicine Sahlgrenska Academy at the University of Gothenburg, Bruna stråket 11, 41345, Gothenburg, Sweden
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3
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Abstract
Lung transplantation is an accepted therapeutic option for end-stage lung diseases. Its history starts in the 1940s, initially hampered by early deaths due to perioperative problems and acute rejection. Improvement of surgical techniques and the introduction of immunosuppressive drugs resulted in longer survival. Chronic lung allograft dysfunction (CLAD), a new complication appeared and remains the most serious complication today. CLAD, the main reason why survival after lung transplantation is impaired compared to other solid-organ transplantations is characterized by a gradually increasing shortness of breath, reflected in a deterioration of pulmonary function status, respiratory insufficiency and possibly death.
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4
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Chambers DC. Bronchiolitis obliterans syndrome ‘endotypes’ in haematopoietic stem cell transplantation. Respirology 2019; 24:408-409. [DOI: 10.1111/resp.13498] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 01/22/2019] [Indexed: 12/31/2022]
Affiliation(s)
- Daniel C. Chambers
- Queensland Lung Transplant ProgramThe Prince Charles Hospital Brisbane QLD Australia
- School of Clinical MedicineThe University of Queensland Brisbane QLD Australia
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5
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Changes in serum KL-6 levels are associated with the development of chronic lung allograft dysfunction in lung transplant recipients. Transpl Immunol 2019; 52:40-44. [DOI: 10.1016/j.trim.2018.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 10/24/2018] [Accepted: 10/30/2018] [Indexed: 01/26/2023]
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6
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Cebrià I Iranzo MÀ, Vos R, Verleden GM, Gosselink R, Langer D. Evolution of Functional Exercise Capacity in Lung Transplant Patients With and Without Bronchiolitis Obliterans Syndrome: A Longitudinal Case-Control Study. Arch Bronconeumol 2018; 55:239-245. [PMID: 30595421 DOI: 10.1016/j.arbres.2018.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 11/05/2018] [Accepted: 11/12/2018] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Bronchiolitis Obliterans Syndrome (BOS) is a debilitating disease with limited treatment options that threatens both the quality of life and long-term survival of lung transplant (LTx) recipients. This retrospective longitudinal case-control study was performed to compare the long-term functional evolution of LTx recipients with and without BOS. METHODS Twenty-four LTx recipients with BOS (BOS=Cases) and 24 without BOS (NON-BOS=Controls) were selected and individually matched according to age, gender, diagnosis and LTx characteristics. Measurements of 6-minute walking distance (6MWD), symptoms of dyspnea (BORG CR-10 scale), and comprehensive pulmonary function testing were performed before LTx and at annual follow-up assessments after LTx. RESULTS Peak FEV1 after LTx was similar in both groups [FEV1 (% predicted) 101±25 vs. 101±31, p=0.96] and BOS diagnosis in cases was established 3.6±2.5 years after LTx. At the final follow-up assessment (6.5±3.2 years after LTx) FEV1 (% predicted) was 86±34 in NON-BOS vs. 44±17 in BOS (p<0.001). Evolution of 6MWD was different between groups (group by time interaction: p=0.002). Borg dyspnea scores were also significantly different between groups at the final evaluation (NON-BOS 3.3±1.7 vs. BOS 5.0±2.2; p=0.024). CONCLUSIONS We observed gradual reductions in functional exercise capacity and increasing symptoms of dyspnea in patients who developed BOS after LTx. As such, prospective studies seem warranted to explore whether rehabilitative interventions might be useful to improve symptoms and slow down deterioration of exercise capacity in these patients from the onset of BOS.
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Affiliation(s)
- Maria À Cebrià I Iranzo
- Department of Physiotherapy, University of Valencia and Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Robin Vos
- Respiratory Division, Lung Transplantation Unit, University Hospitals Leuven and Department of Clinical and Experimental Medicine, KU Leuven, Belgium
| | - Geert M Verleden
- Respiratory Division, Lung Transplantation Unit, University Hospitals Leuven and Department of Clinical and Experimental Medicine, KU Leuven, Belgium
| | - Rik Gosselink
- Respiratory Division, Respiratory Rehabilitation Unit, University Hospitals Leuven and Department of Rehabilitation Sciences, KU Leuven, Belgium
| | - Daniel Langer
- Respiratory Division, Respiratory Rehabilitation Unit, University Hospitals Leuven and Department of Rehabilitation Sciences, KU Leuven, Belgium.
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7
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Iyengar A, Kwon OJ, Sanaiha Y, Eisenring C, Biniwale R, Ross D, Ardehali A. Lung transplantation in the Lung Allocation Score era: Medium-term analysis from a single center. Clin Transplant 2018; 32:e13298. [DOI: 10.1111/ctr.13298] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2018] [Indexed: 01/18/2023]
Affiliation(s)
- Amit Iyengar
- David Geffen School of Medicine; UCLA Medical Center; Los Angeles CA USA
| | - Oh Jin Kwon
- Division of Cardiac Surgery; UCLA Medical Center; Los Angeles CA USA
| | - Yas Sanaiha
- Division of Cardiac Surgery; UCLA Medical Center; Los Angeles CA USA
| | | | - Reshma Biniwale
- Division of Cardiac Surgery; UCLA Medical Center; Los Angeles CA USA
| | - David Ross
- Division of Pulmonology; UCLA Medical Center; Los Angeles CA USA
| | - Abbas Ardehali
- Division of Cardiac Surgery; UCLA Medical Center; Los Angeles CA USA
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8
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Kuehnel M, Maegel L, Vogel-Claussen J, Robertus JL, Jonigk D. Airway remodelling in the transplanted lung. Cell Tissue Res 2016; 367:663-675. [PMID: 27837271 DOI: 10.1007/s00441-016-2529-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 10/12/2016] [Indexed: 12/22/2022]
Abstract
Following lung transplantation, fibrotic remodelling of the small airways has been recognized for almost 5 decades as the main correlate of chronic graft failure and a major obstacle to long-term survival. Mainly due to airway fibrosis, pulmonary allografts currently show the highest attrition rate of all solid organ transplants, with a 5-year survival rate of 58 % on a worldwide scale. The observation that these morphological changes are not just the hallmark of chronic rejection but rather represent a manifestation of a multitude of alloimmune-dependent and -independent injuries was made more recently, as was the discovery that chronic lung allograft dysfunction manifests in different clinical phenotypes of respiratory impairment and corresponding morphological subentities. Although recent years have seen considerable advances in identifying and categorizing these subgroups on the basis of clinical, functional and histomorphological changes, as well as susceptibility to medicinal treatment, this process is far from over. Since the actual pathophysiological mechanisms governing airway remodelling are still only poorly understood, diagnosis and therapy of chronic lung allograft dysfunction presents a major challenge to clinicians, radiologists and pathologists alike. Here, we review and discuss the current state of the literature on chronic lung allograft dysfunction and shed light on classification systems, corresponding clinical and morphological changes, key cellular players and underlying molecular pathways, as well as on emerging diagnostic and therapeutic approaches.
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Affiliation(s)
- Mark Kuehnel
- Institute of Pathology, Hannover Medical School (MHH), Carl-Neuberg-Str. 1, D-30625, Hanover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease (BREATH), The German Center for Lung Research (Deutsches Zentrum für Lungenforschung, DZL), Hanover, Germany
| | - Lavinia Maegel
- Institute of Pathology, Hannover Medical School (MHH), Carl-Neuberg-Str. 1, D-30625, Hanover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease (BREATH), The German Center for Lung Research (Deutsches Zentrum für Lungenforschung, DZL), Hanover, Germany
| | | | - Jan Lukas Robertus
- Royal Brompton & Harefield NHS Foundation Trust, Department of Histopathology, Hanover, Germany
| | - Danny Jonigk
- Institute of Pathology, Hannover Medical School (MHH), Carl-Neuberg-Str. 1, D-30625, Hanover, Germany.
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9
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Doellinger F, Weinheimer O, Zwiener I, Mayer E, Buhl R, Fahlenkamp UL, Dueber C, Achenbach T. Differences of airway dimensions between patients with and without bronchiolitis obliterans syndrome after lung transplantation-Computer-assisted quantification of computed tomography. Eur J Radiol 2016; 85:1414-20. [PMID: 27423681 DOI: 10.1016/j.ejrad.2016.05.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 04/20/2016] [Accepted: 05/26/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The aim of our retrospective study was to determine whether a dedicated software for assessment of airway morphology can detect differences in airway dimensions between patients with and without bronchiolitis obliterans syndrome (BOS), regarded as the clinical correlate of chronic lung allograft rejection. METHODS 12 patients with and 14 patients without diagnosis of BOS were enrolled in the study. Evaluation of bronchial wall area percentage (WA%) and bronchial wall thickness (WT) in all follow-up CT scans was performed using a semiautomatic airway assessment tool. We assessed temporal changes (ΔWA%, ΔWT) and compared these morphological parameters with forced expiratory volume in one second (ΔFEV1). RESULTS In patients with and without BOS, the temporal changes over the entire follow-up were 26.6% versus 16.2% for ΔFEV1 (p=0.034), 14.2% versus 5.4% for ΔWA% (p=0.003) and 0.212mm versus 0.064mm for ΔWT (p=0.011). CONCLUSIONS We detected significant differences of the temporal changes of airway dimensions (ΔWA%, ΔWT) between lung transplant recipients with and without BOS. We conclude that computer-assisted bronchial wall measurements in CT scans might complement the information from pulmonary function tests and establish as a non-invasive method to confirm BOS in lung transplant recipients in the future.
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Affiliation(s)
- Felix Doellinger
- Institute of Diagnostic and Interventional Radiology, University Medical Center, Johannes-Gutenberg University, Langenbeckstr. 1, 55131 Mainz, Germany; Institute of Radiology, Charité University Medicine, Campus Virchow Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Oliver Weinheimer
- Institute of Diagnostic and Interventional Radiology, University Medical Center, Johannes-Gutenberg University, Langenbeckstr. 1, 55131 Mainz, Germany; Institute of Diagnostic and Interventional Radiology, University Hospital, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany; Translational Lung Research Center (TLRC) Heidelberg, Member of the German Center for Lung Research (DZL), Im Neuenheimer Feld 350, 69120 Heidelberg, Germany
| | - Isabella Zwiener
- Institute for Medical Biostatistics, Epidemiology and Informatics, University Medical Center, Johannes-Gutenberg University, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Eckhard Mayer
- Division of Thoracic Surgery, Department of Cardiothoracic and Vascular Surgery, University Medical Center, Johannes-Gutenberg University, Langenbeckstr. 1, 55131 Mainz, Germany; Department of Thoracic Surgery, Kerckhoff Clinic, Benekestr. 2-8, 61231 Bad Nauheim, Germany
| | - Roland Buhl
- Pulmonary Department, University Medical Center, Johannes-Gutenberg University, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Ute Lina Fahlenkamp
- Institute of Radiology, Charité University Medicine, Campus Charité Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Christoph Dueber
- Institute of Diagnostic and Interventional Radiology, University Medical Center, Johannes-Gutenberg University, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Tobias Achenbach
- Institute of Diagnostic and Interventional Radiology, University Medical Center, Johannes-Gutenberg University, Langenbeckstr. 1, 55131 Mainz, Germany; Institute of Diagnostic and Interventional Radiology, St. Vinzenz-Hospital, Merheimer Str. 221-223, 50733 Cologne, Germany
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10
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Abstract
Lung transplantation is an established treatment for patients with end-stage lung disease. It has been observed that despite near-normal lung function, exercise intolerance and reductions in quality of life (QOL) often persist up to years after transplantation. Several modifiable pre- and posttransplant factors are known to contribute to these persisting impairments. Physiological changes associated with severe and chronic lung disease, limb muscle dysfunction, inactivity/deconditioning, and nutritional depletion can affect exercise capacity and physical functioning in candidates for lung transplantation. After transplantation, extended hospital and intensive care unit stay, prolonged sedentary time, persisting inactivity, immunosuppressant medications and episodes of organ rejection may all impact lung recipients' recovery. Available evidence will be reviewed and content will be proposed (both evidence and experience based) for rehabilitation interventions prior to transplantation, during hospitalization after transplantation, and in both the immediate (≤12 months after hospital discharge) and long-term (>12 months after hospital discharge) posttransplant phase. Outpatient rehabilitation programs including supervised exercise training have been shown to be effective in improving limb muscle dysfunction, exercise capacity, and QOL both before and after transplantation if offered appropriately. Unmet research needs included the absence of sufficiently powered randomized controlled trials measuring the effects of rehabilitation interventions on crucial long-term outcomes such as sustained improvements in QOL, participation in daily activity, survival, incidence of morbidities and cost-effectiveness. Remotely monitored (telehealth) home-based exercise or pedometer-based walking interventions might be interesting alternatives to supervised outpatient rehabilitation interventions in the long-term posttransplant phase and warrant further investigation.
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Affiliation(s)
- Daniel Langer
- Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, and Respiratory Rehabilitation and Respiratory Division, University Hospital Leuven, Leuven, Belgium
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11
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Verleden GM, Vos R, Vanaudenaerde B, Dupont L, Yserbyt J, Van Raemdonck D, Verleden S. Current views on chronic rejection after lung transplantation. Transpl Int 2015; 28:1131-9. [PMID: 25857869 DOI: 10.1111/tri.12579] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 02/28/2015] [Accepted: 04/07/2015] [Indexed: 01/01/2023]
Abstract
Chronic lung allograft dysfunction (CLAD) was recently introduced as an overarching term mainly to classify patients with chronic rejection after lung transplantation, although other conditions may also qualify for CLAD. Initially, only the development of a persistent and obstructive pulmonary function defect, clinically identified as bronchiolitis obliterans syndrome (BOS), was considered as chronic rejection, if no other cause could be identified. It became clear in recent years that some patients do not qualify for this definition, although they developed a chronic and persistent decrease in FEV1 , without another identifiable cause. As the pulmonary function decline in these patients was rather restrictive, this was called restrictive allograft syndrome (RAS). In the present review, we will further elaborate on these two CLAD phenotypes, with specific attention to the diagnostic criteria, the role of pathology and imaging, the risk factors, outcome, and the possible treatment options.
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Affiliation(s)
- Geert M Verleden
- Department of Clinical and Experimental Medicine, Laboratory for Respiratory Diseases, Lung Transplantation Unit, KU Leuven - University of Leuven, Leuven, Belgium.,Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Robin Vos
- Department of Clinical and Experimental Medicine, Laboratory for Respiratory Diseases, Lung Transplantation Unit, KU Leuven - University of Leuven, Leuven, Belgium.,Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Bart Vanaudenaerde
- Department of Clinical and Experimental Medicine, Laboratory for Respiratory Diseases, Lung Transplantation Unit, KU Leuven - University of Leuven, Leuven, Belgium
| | - Lieven Dupont
- Department of Clinical and Experimental Medicine, Laboratory for Respiratory Diseases, Lung Transplantation Unit, KU Leuven - University of Leuven, Leuven, Belgium.,Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Jonas Yserbyt
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| | | | - Stijn Verleden
- Department of Clinical and Experimental Medicine, Laboratory for Respiratory Diseases, Lung Transplantation Unit, KU Leuven - University of Leuven, Leuven, Belgium
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12
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Hartert M, Senbaklavacin O, Gohrbandt B, Fischer BM, Buhl R, Vahld CF. Lung transplantation: a treatment option in end-stage lung disease. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 111:107-16. [PMID: 24622680 DOI: 10.3238/arztebl.2014.0107] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 11/12/2013] [Accepted: 11/12/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND Lung transplantation is the final treatment option in the end stage of certain lung diseases, once all possible conservative treatments have been exhausted. Depending on the indication for which lung transplantation is performed, it can improve the patient's quality of life (e.g., in emphysema) and/ or prolong life expectancy (e.g., in cystic fibrosis, pulmonary fibrosis, and pulmonary arterial hypertension). The main selection criteria for transplant candidates, aside from the underlying pulmonary or cardiopulmonary disease, are age, degree of mobility, nutritional and muscular condition, and concurrent extrapulmonary disease. The pool of willing organ donors is shrinking, and every sixth candidate for lung transplantation now dies while on the waiting list. METHOD We reviewed pertinent articles (up to October 2013) retrieved by a selective search in Medline and other German and international databases, including those of the International Society for Heart and Lung Transplantation (ISHLT), Eurotransplant, the German Institute for Applied Quality Promotion and Research in Health-Care (Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen, AQUA-Institut), and the German Foundation for Organ Transplantation (Deutsche Stiftung Organtransplantation, DSO). RESULTS The short- and long-term results have markedly improved in recent years: the 1-year survival rate has risen from 70.9% to 82.9%, and the 5-year survival rate from 46.9% to 59.6%. The 90-day mortality is 10.0%. The postoperative complications include acute (3.4%) and chronic (29.0%) transplant rejection, infections (38.0%), transplant failure (24.7%), airway complications (15.0%), malignant tumors (15.0%), cardiovascular events (10.9%), and other secondary extrapulmonary diseases (29.8%). Bilateral lung transplantation is superior to unilateral transplantation (5-year survival rate 57.3% versus 47.4%). CONCLUSION Seamless integration of the various components of treatment will be essential for further improvements in outcome. In particular, the follow-up care of transplant recipients should always be provided in close cooperation with the transplant center.
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Affiliation(s)
- Marc Hartert
- Department of Cardiothoracic and Vascular Surgery at the University Medical Center of the Johannes Gutenberg University Mainz, Department of Hematology, Pneumology and Oncology at the University Medical Center of the Johannes Gutenberg University Mainz
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13
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Corris PA, Ryan VA, Small T, Lordan J, Fisher AJ, Meachery G, Johnson G, Ward C. A randomised controlled trial of azithromycin therapy in bronchiolitis obliterans syndrome (BOS) post lung transplantation. Thorax 2015; 70:442-50. [PMID: 25714615 PMCID: PMC4413845 DOI: 10.1136/thoraxjnl-2014-205998] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 01/23/2015] [Indexed: 01/08/2023]
Abstract
Background We conducted a placebo-controlled trial of azithromycin therapy in bronchiolitis obliterans syndrome (BOS) post lung transplantation. Methods We compared azithromycin (250 mg alternate days, 12 weeks) with placebo. Primary outcome was FEV1 change at 12 weeks. Results 48 patients were randomised; (25 azithromycin, 23 placebo). It was established, post randomisation that two did not have BOS. 46 patients were analysed as intention to treat (ITT) with 33 ‘Completers’. ITT analysis included placebo patients treated with open-label azithromycin after study withdrawal. Outcome The ITT analysis (n=46, 177 observations) estimated mean difference in FEV1 between treatments (azithromycin minus placebo) was 0.035 L, with a 95% CI of −0.112 L to 0.182 L (p=0.6). Five withdrawals, who were identified at the end of the study as having been randomised to placebo (four with rapid loss in FEV1, one withdrawn consent) had received rescue open-label azithromycin, with improvement in subsequent FEV1 at 12 weeks. Study Completers showed an estimated mean difference in FEV1 between treatment groups (azithromycin minus placebo) of 0.278 L, with 95% CI for the mean difference: 0.170 L to 0.386 L (p=<0.001). Nine of 23 ITT patients in the azithromycin group had ≥10% gain in FEV1 from baseline. No patients in the placebo group had ≥10% gain in FEV1 from baseline while on placebo (p=0.002). Seven serious adverse events, three azithromycin, four in the placebo group, were deemed unrelated to study medication. Conclusions Azithromycin therapy improves FEV1 in patients with BOS and appears superior to placebo. This study strengthens evidence for clinical practice of initiating azithromycin therapy in BOS. Trial registration number EU-CTR, 2006-000485-36/GB.
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Affiliation(s)
- Paul A Corris
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK Institute of Cellular Medicine, Newcastle upon Tyne, UK
| | - Victoria A Ryan
- Institute of Health and Society Newcastle University, Newcastle upon Tyne, UK
| | - Therese Small
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - James Lordan
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Andrew J Fisher
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK Institute of Cellular Medicine, Newcastle upon Tyne, UK
| | - Gerard Meachery
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Gail Johnson
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Chris Ward
- Institute of Cellular Medicine, Newcastle upon Tyne, UK
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14
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Jonigk D. [Aberrant reparative tissue remodeling: histopathology and molecular pathology]. DER PATHOLOGE 2014; 35 Suppl 2:254-63. [PMID: 25394975 DOI: 10.1007/s00292-014-1955-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Not only tumorous infiltrations can lead to destruction of parenchymal organs but also the aberrant proliferation and matrix production of mesenchymal cells and vessels during a dysregulated repair attempt. This fibrogenesis is the result of a complex pathogenesis, which can be investigated in animal models but also in situ to harvest new biomarkers. This article deals particularly with the second method and summarizes molecular pathological findings in various model diseases for aberrant reparative tissue reconstruction. These model diseases include plexiform vasculopathy in pulmonary arterial hypertension (PAH), Quilty lesions in heart transplantation, bronchiolitis obliterans (BO), inflammatory airway remodeling and Epstein-Barr virus (EBV) induced smooth muscle proliferation (posttransplantation smooth muscle tumor, PTSMT).Using in situ molecular pathology, we were able to dismiss an assumed involvement of myofibroblastic cells in vessel reconstruction of the lung in PAH. We could also for the first time perform a comprehensive molecular characterization of the vascular remodeling and prove that plexiform vasculopathy represents a complex-regulated epiphenomenon of excessive pulmonary hypertension. This method also allowed us to describe for the first time the miRNA expression in PAH in a compartment-specific manner and to draw conclusions regarding the damaged overriding regulatory mechanisms. In the same way, we were also able to describe the chimeric character of the complex neoangiogenesis in the donor organ after heart transplantation.After lung transplantation, we identified for the first time a group of tissue-based molecular markers, which can predict later occurrence of BO even in morphologically normal transbronchial biopsies. In addition, we have documented for the first time the molecular characteristics of the morphologically analogous airway reconstruction in lung-transplanted and non-transplanted patients. We could further elucidate the role of matrix metalloproteinases (MMP) and their antagonists in inflammatory airway reconstruction and deduce from this the resulting therapeutic implications. Accordingly, we were able to further clarify the origin, pathogenesis and the malignant potential of EBV-induced PTSMT and for the first time provide an evidence-based therapy recommendation and risk assessment.In summary, this article documents that in situ diagnostics can meet the requirements of the challenging parameters and issues of life sciences. It is to be expected that the technical possibilities will develop analogously to the increasing demands and the in situ method will move further into the focus of molecular pathology.
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Affiliation(s)
- D Jonigk
- Institut für Pathologie, Medizinische Hochschule Hannover (MHH), Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland,
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15
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Meyer KC, Raghu G, Verleden GM, Corris PA, Aurora P, Wilson KC, Brozek J, Glanville AR. An international ISHLT/ATS/ERS clinical practice guideline: diagnosis and management of bronchiolitis obliterans syndrome. Eur Respir J 2014; 44:1479-503. [PMID: 25359357 DOI: 10.1183/09031936.00107514] [Citation(s) in RCA: 382] [Impact Index Per Article: 38.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Bronchiolitis obliterans syndrome (BOS) is a major complication of lung transplantation that is associated with poor survival. The International Society for Heart and Lung Transplantation, American Thoracic Society, and European Respiratory Society convened a committee of international experts to describe and/or provide recommendations for 1) the definition of BOS, 2) the risk factors for developing BOS, 3) the diagnosis of BOS, and 4) the management and prevention of BOS. A pragmatic evidence synthesis was performed to identify all unique citations related to BOS published from 1980 through to March, 2013. The expert committee discussed the available research evidence upon which the updated definition of BOS, identified risk factors and recommendations are based. The committee followed the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) approach to develop specific clinical recommendations. The term BOS should be used to describe a delayed allograft dysfunction with persistent decline in forced expiratory volume in 1 s that is not caused by other known and potentially reversible causes of post-transplant loss of lung function. The committee formulated specific recommendations about the use of systemic corticosteroids, cyclosporine, tacrolimus, azithromycin and about re-transplantation in patients with suspected and confirmed BOS. The diagnosis of BOS requires the careful exclusion of other post-transplant complications that can cause delayed lung allograft dysfunction, and several risk factors have been identified that have a significant association with the onset of BOS. Currently available therapies have not been proven to result in significant benefit in the prevention or treatment of BOS. Adequately designed and executed randomised controlled trials that properly measure and report all patient-important outcomes are needed to identify optimal therapies for established BOS and effective strategies for its prevention.
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Affiliation(s)
- Keith C Meyer
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Ganesh Raghu
- School of Medicine, University of Washington, Seattle, WA, USA
| | | | | | - Paul Aurora
- Great Ormond Street Hospital for Children, London, UK
| | | | - Jan Brozek
- McMaster University, Hamilton, ON, Canada
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16
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Aramini B, D’Ovidio F. Gastroesophageal reflux disease and the lung transplant recipient. ACTA ACUST UNITED AC 2014. [DOI: 10.1007/s13665-014-0092-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Clajus C, Blasi F, Welte T, Greer M, Fuehner T, Mantero M. Therapeutic approach to respiratory infections in lung transplantation. Pulm Pharmacol Ther 2014; 32:149-54. [PMID: 25038552 PMCID: PMC7110868 DOI: 10.1016/j.pupt.2014.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 07/09/2014] [Indexed: 01/22/2023]
Abstract
Lung transplant recipients (LTRs) are at life-long risk for infections and disseminated diseases owing to their immunocompromised state. Besides organ failure and sepsis, infection can trigger acute and chronic graft rejection which increases mortality. Medical prophylaxis and treatment are based on comprehensive diagnostic work-up including previous history of infection and airway colonisation to reduce long-term complications and mortality. Common bacterial pathogens include Pseudomonas and Staphylococcus, whilst Aspergillus and Cytomegalovirus (CMV) are respectively the commonest fungal and viral pathogens. Clinical symptoms can be various in lung transplant recipients presenting an asymptomatic to severe progress. Regular control of infection parameters, daily lung function testing and lifelong follow-up in a specialist transplant centre are mandatory for early detection of bacterial, viral and fungal infections. After transplantation each patient receives intensive training with rules of conduct concerning preventive behaviour and to recognize early signs of post transplant complications. Early detection of infection and complications are important goals to reduce major complications after lung transplantation.
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Affiliation(s)
- Carolina Clajus
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, IRCCS Fondazione Ospedale Maggiore, Policlinico Cà Granda Milano, Italy
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Mark Greer
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Thomas Fuehner
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Marco Mantero
- Department of Pathophysiology and Transplantation, University of Milan, IRCCS Fondazione Ospedale Maggiore, Policlinico Cà Granda Milano, Italy
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18
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Berastegui C, Román J, Monforte V, Bravo C, López-Meseguer M, Montero MÁ, Culebras M, Gómez-Ollés S, Román A. Biomarkers of pulmonary rejection. Transplant Proc 2014; 45:3163-9. [PMID: 24182778 DOI: 10.1016/j.transproceed.2013.06.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 06/06/2013] [Accepted: 06/28/2013] [Indexed: 01/22/2023]
Abstract
Immunologic complications after lung transplantation (LT) include acute cellular rejection (ACR), antibody-mediated rejection (AMR), and most forms of chronic allograft dysfunction (CAD). ACR is an inflammatory process in which the reaction is mediated by the T-cell population. Most episodes of ACR fully recover with treatment, but repeated bouts are considered to be a risk factor for CAD. Biomarker cytokines interleukin (IL)-10, IL-15, IL-6, CCL5, CCR2 and IFNγ may play significant roles in this complication. Formerly bronchiolitis obliterans syndrome (BOS) or chronic rejection or most forms of CAD were considered to be immunologic complications not amenable therapeutic measures. CAD, the main limitation for long-term survival in LT, is characterized histologically by airway epithelial cell apoptosis and luminal fibrosis in the respiratory bronchioles causing airflow obstruction and, in some cases, lung parenchymal affectations causing restrictive lung disease. Several biomarkers have been studied in CAD, IL-6, IL-8, IL-17, IL-23, IL-13, IFN γ, and TGF β cytokines, pH, bile acid, and tripsine of gastroesophageal reflux and toll-like receptors of innate immunity. Herein we have reviewed the literature of biomarkers involved in lung rejection.
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Affiliation(s)
- C Berastegui
- Respiratory Department, Institute of Research, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
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Cova E, Colombo M, Inghilleri S, Morosini M, Miserere S, Peñaranda-Avila J, Santini B, Piloni D, Magni S, Gramatica F, Prosperi D, Meloni F. Antibody-engineered nanoparticles selectively inhibit mesenchymal cells isolated from patients with chronic lung allograft dysfunction. Nanomedicine (Lond) 2014; 10:9-23. [PMID: 24559038 DOI: 10.2217/nnm.13.208] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
AIMS Chronic lung allograft dysfunction represents the main cause of death after lung transplantation, and so far there is no effective therapy. Mesenchymal cells (MCs) are primarily responsible for fibrous obliteration of small airways typical of chronic lung allograft dysfunction. Here, we engineered gold nanoparticles containing a drug in the hydrophobic section to inhibit MCs, and exposing on the outer hydrophilic surface a monoclonal antibody targeting a MC-specific marker (half-chain gold nanoparticles with everolimus). MATERIALS & METHODS Half-chain gold nanoparticles with everolimus have been synthesized and incubated with MCs to evaluate the effect on proliferation and apoptosis. RESULTS & DISCUSSION Drug-loaded gold nanoparticles coated with the specific antibody were able to inhibit proliferation and induce apoptosis without stimulating an inflammatory response, as assessed by in vitro experiments. CONCLUSION These findings demonstrate the effectiveness of our nanoparticles in inhibiting MCs and open new perspectives for a local treatment of chronic lung allograft dysfunction.
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Affiliation(s)
- Emanuela Cova
- Clinica di Malattie dell'Apparato Respiratorio, IRCCS Fondazione Policlinico S Matteo, viale Golgi 19, 27100 Pavia, Italy.
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20
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Genetic variation in interleukin-17 receptor A is functionally associated with chronic rejection after lung transplantation. J Heart Lung Transplant 2013; 32:1233-40. [DOI: 10.1016/j.healun.2013.09.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 06/21/2013] [Accepted: 09/17/2013] [Indexed: 11/20/2022] Open
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21
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Keller MR, Haynes LD, Jankowska-Gan E, Sullivan JA, Agashe VV, Burlingham SR, Burlingham WJ. Epitope analysis of the collagen type V-specific T cell response in lung transplantation reveals an HLA-DRB1*15 bias in both recipient and donor. PLoS One 2013; 8:e79601. [PMID: 24265781 PMCID: PMC3827168 DOI: 10.1371/journal.pone.0079601] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 09/24/2013] [Indexed: 12/15/2022] Open
Abstract
Background IL-17-dependent cellular immune responses to the α1 chain of collagen type V are associated with development of bronchiolitis obliterans syndrome after lung transplantation, and with idiopathic pulmonary fibrosis and coronary artery disease, primary indications for lung or heart transplantation, respectively. Methodology/Principal Findings We found that 30% of the patients awaiting lung transplantation exhibited a strong cell-mediated immune response to col(V). Of these, 53% expressed HLA-DR15, compared to a 28% HLA-DR15 frequency in col(V) low-responders (p=0.02). After transplantation, patients with HLA-DR1 and -DR17, not -DR15, developed anti-col(V) responses most frequently (p=0.04 and 0.01 vs. controls, respectively). However, recipients of a lung from an HLA-DR15+donor were at significantly elevated risk of developing anti-col(V) responses (p=0.02) and BOS (p=0.03). To determine the molecular basis of this unusual pattern of DR allele bias, a peptide library comprising the collagenous region of the α1(V) protein was screened for binding to HLA-DR0101, -DR1501, -DR0301 (DR17) or to HLA-DQ2 (DQA1*0501: DQB1*0201; in linkage disequilibrium with -DR17) and -DQ6 (DQA1*0102: DQB1*0602; linked to -DR15). Eight 15-mer peptides, six DR-binding and two DQ-binding, were identified. HLA-DR15 binding to two peptides yielded the highest binding scores: 650 (where 100 = positive control) for p799 (GIRGLKGTKGEKGED), and 193 for p1439 (LRGIPGPVGEQGLPG). These peptides, which also bound weakly to HLA-DR1, elicited responses in both HLA-DR1+ and -DR15+ col(V) reactive hosts, whereas binding and immunoreactivity of p1049 (KDGPPGLRGFPGDRG) was DR15-specific. Remarkably, a col(V)-reactive HLA-DR1+DR15neg lung transplant patient, whose donor was HLA-DR15+, responded not only to p799 and p1439, but also to p1049. Conclusions/Significance HLA-DR15 and IPF disease were independently associated with pre-transplant col(V) autoimmunity. The increased risk of de novo immunity to col(V) and BOS, associated with receiving a lung transplant from an HLA-DR15+ donor, may result from presentation by donor-derived HLA- DR15, of novel self-peptides to recipient T cells.
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Affiliation(s)
- Melissa R. Keller
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, United States of America
- Cellular and Molecular Pathology Graduate Program, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Lynn D. Haynes
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Ewa Jankowska-Gan
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Jeremy A. Sullivan
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Vrushali V. Agashe
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, United States of America
- Comparative Biomedical Sciences Graduate Program, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Scott R. Burlingham
- Department of Chemistry, University of Wisconsin, Madison, Wisconsin, United States of America
| | - William J. Burlingham
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, United States of America
- * E-mail:
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22
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Effects of prophylactic use of sirolimus on bronchiolitis obliterans syndrome development in lung transplant recipients. Ann Thorac Surg 2013; 97:268-74. [PMID: 24119986 DOI: 10.1016/j.athoracsur.2013.07.072] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Revised: 07/16/2013] [Accepted: 07/22/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND Sirolimus (SIR) has been shown to stabilize the lung function in lung transplant recipients with bronchiolitis obliterans syndrome (BOS). However, there is no long-term data on the prophylactic use of SIR in lung transplant recipients. This retrospective study examines the effects of SIR in the prevention of BOS. METHODS From 1999 to 2009, 24 lung transplant recipients whose maintenance immunosuppression regimen consisted of tacrolimus (Tac), mycophenolate mofetil (MMF) or azathioprine (AZA), and prednisone (Pred), were switched to Tac, SIR, and Pred at 1 year after transplantation. From these 24 patients, 5 developed side effects that necessitated the cessation of SIR within 1 year, while 19 patients tolerated long-term use of SIR. The clinical outcomes of these 19 patients (SIR group) were compared with 22 lung transplant recipients whose immunosuppression regimen consisted of Tac, MMF or AZA, and Pred from the time of transplant (MMF group). Survival rates and freedom from BOS were calculated by the Kaplan-Meier method. RESULTS The SIR group had a lower incidence of BOS and viral infection (p = 0.05), and higher survival rates (p = 0.004). The SIR group had lower levels of Tac and received less Pred. The incidences of acute rejection, carcinoma, hypertension, and diabetes were similar between both groups. CONCLUSIONS Results from this study suggest that conversion to SIR 1 year after lung transplantation improves survival and decreases the development of BOS. Randomized studies with higher number of patients are needed to determine the prophylactic efficacy of sirolimus in preventing the development of BOS.
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Subramanian V, Mohanakumar T. Chronic rejection: a significant role for Th17-mediated autoimmune responses to self-antigens. Expert Rev Clin Immunol 2013; 8:663-72. [PMID: 23078063 DOI: 10.1586/eci.12.58] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Despite progress in the field of organ transplantation for improvement in graft survival and function, long-term graft function is still limited by the development of chronic allograft rejection. Various immune-mediated and nonimmune-mediated processes have been postulated in the pathogenesis of chronic rejection. In this review, the authors discuss the important role of alloimmune responses to donor-specific antigens and autoimmune responses to tissue restricted self-antigens in the immunopathogenesis of chronic rejection following solid organ transplantation. In particular, the authors discuss the role of induction of Th17-type autoimmune responses and the crosstalk between autoimmune and alloimmune responses. These self-perpetuate each other leading to activation of profibrotic and proinflammatory cascades that ultimately result in the development of chronic rejection.
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Affiliation(s)
- Vijay Subramanian
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
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24
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Abstract
Lung transplantation may be the only intervention that can prolong survival and improve quality of life for those individuals with advanced lung disease who are acceptable candidates for the procedure. However, these candidates may be extremely ill and require ventilator and/or circulatory support as a bridge to transplantation, and lung transplantation recipients are at risk of numerous post-transplant complications that include surgical complications, primary graft dysfunction, acute rejection, opportunistic infection, and chronic lung allograft dysfunction (CLAD), which may be caused by chronic rejection. Many advances in pre- and post-transplant management have led to improved outcomes over the past decade. These include the creation of sound guidelines for candidate selection, improved surgical techniques, advances in donor lung preservation, an improving ability to suppress and treat allograft rejection, the development of prophylaxis protocols to decrease the incidence of opportunistic infection, more effective therapies for treating infectious complications, and the development of novel therapies to treat and manage CLAD. A major obstacle to prolonged survival beyond the early post-operative time period is the development of bronchiolitis obliterans syndrome (BOS), which is the most common form of CLAD. This manuscript discusses recent and evolving advances in the field of lung transplantation.
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Meyer KC, Glanville AR. Bronchiolitis Obliterans Syndrome and Chronic Lung Allograft Dysfunction: Evolving Concepts and Nomenclature. BRONCHIOLITIS OBLITERANS SYNDROME IN LUNG TRANSPLANTATION 2013. [PMCID: PMC7122385 DOI: 10.1007/978-1-4614-7636-8_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Bronchiolitis obliterans syndrome (BOS) eventually occurs in the majority of lung transplant recipients who survive beyond 1 year, can greatly impair quality of life, and is, directly or indirectly, the major cause of delayed allograft dysfunction and recipient death. A number of associated events or conditions are strongly associated with the risk for developing BOS; these include acute rejection, gastroesophageal reflux, infections, and autoimmune reactions that can occur in the setting of alloimmune responses to the lung allograft as recipients are given intense immunosuppression to prevent allograft rejection. The term chronic lung allograft dysfunction (CLAD) is being increasingly used to refer to recipients with late allograft dysfunction that meets the spirometric criteria for the diagnosis of BOS, but clinicians should recognize that such dysfunction can occur for a variety of reasons other than BOS. The recently identified entity of restrictive allograft syndrome, which is now recognized as a relatively distinct phenotype of CLAD, has features that differentiate it from classic obstructive BOS. A number of other entities that can also significantly affect allograft function must also be considered when significant allograft dysfunction is encountered following lung transplantation.
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Vital D, Hofer M, Benden C, Holzmann D, Boehler A. Impact of Sinus Surgery on Pseudomonal Airway Colonization, Bronchiolitis Obliterans Syndrome and Survival in Cystic Fibrosis Lung Transplant Recipients. Respiration 2013; 86:25-31. [DOI: 10.1159/000339627] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Accepted: 05/21/2012] [Indexed: 11/19/2022] Open
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Emtiazjoo AM, Wilkes DS. Humoral immunity and the development of obliterative bronchiolitis after lung transplantation: is there a link? Am J Respir Cell Mol Biol 2012; 48:145-9. [PMID: 23087052 DOI: 10.1165/rcmb.2012-0349rt] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Lung transplantation is considered the definitive treatment for many end-stage lung diseases. However, the lung is rejected more commonly than other solid organ allografts. Obliterative bronchiolitis (OB) is the leading cause of chronic allograft dysfunction, and the key reason why the 5-year survival of lung transplant recipients is only 50%. The pathophysiology of OB is incompletely understood. Although a clear role for the immune response to donor antigens has been observed (also known as anti-human leukocyte antigens), evidence is emerging about the role of autoimmunity to self-antigens. This review highlights the current understanding of humoral immunity in the development of OB after lung transplantation.
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Affiliation(s)
- Amir M Emtiazjoo
- Division of Pulmonary and Critical Care, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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28
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Wilkes DS. Autoantibody formation in human and rat studies of chronic rejection and primary graft dysfunction. Semin Immunol 2012; 24:131-5. [PMID: 21925897 PMCID: PMC3873136 DOI: 10.1016/j.smim.2011.08.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 08/24/2011] [Indexed: 01/02/2023]
Abstract
Lung transplantation is considered a definitive treatment for many lung diseases. However, rejection and other pathologic entities are major causes of morbidity and mortality for lung transplant recipients. Primary graft dysfunction (PGD) and obliterative bronchiolitis (OB) are the leading causes of early and late mortality, respectively. While the immune basis of PGD has not been clearly defined, evidence is emerging about roles for autoantibodies in this process. Similarly, the pathogenesis of OB has been linked recently to autoimmunity. This review will highlight the current understanding of autoantibodies in PGD and OB post lung transplantation.
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Affiliation(s)
- David S Wilkes
- Center for Immunobiology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
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von Süßkind-Schwendi M, Ruemmele P, Schmid C, Hirt SW, Lehle K. Lung transplantation in the fischer 344–wistar kyoto strain combination is a relevant experimental model to study the development of bronchiolitis obliterans in the rat. Exp Lung Res 2012; 38:111-23. [DOI: 10.3109/01902148.2012.656820] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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30
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Tonelli AR, Timofte I, Minai OA, Baz M, Akindipe O. Pulmonary hypertension before first and second lung transplantation. Clin Transplant 2012; 26:672-8. [PMID: 22320224 DOI: 10.1111/j.1399-0012.2011.01588.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pulmonary hypertension (PH) is frequently encountered in patients with advanced lung disease before the first and second lung transplantation. We sought to determine whether there is any relationship between pulmonary hemodynamics obtained before first and second lung transplantation. We also assessed whether PH has prognostic implications in lung transplant patients going for second transplantation. METHODS We included consecutive adult (16-yr-old or older) patients who underwent lung re-transplantation, between 1997 and 2009, and had right heart catheterization before their first and second lung transplantation. RESULTS Eighteen patients were included in the study. Age at first transplantation was 50.4 (SD 10.4) yr, and bronchiolitis obliterans syndrome (BOS) in the transplanted lung was the only indication for re-transplantation. PH was observed in 39% of the patients before the first lung transplant and in 56% of the subjects before re-transplantation (p = 0.91). Pre-capillary PH was present in 28% (n = 5) and 33% (n = 6) of the patients before first and second lung transplantation, respectively. None of the hemodynamic variables obtained before the first transplant predicted the development of PH before re-transplantation. PH before re-transplantation did not predict survival or development of BOS after re-transplantation. CONCLUSIONS PH before initial lung transplantation did not predict the development of PH before the second transplantation. In our cohort, PH before second lung transplantation did not predict outcomes after re-transplantation.
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Affiliation(s)
- Adriano R Tonelli
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, OH 44195, USA.
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Roman A, Ussetti P, Zurbano F, Borro JM, Solé A, Carreño MC, Santos F. A retrospective 12-month study of conversion to everolimus in lung transplant recipients. Transplant Proc 2012; 43:2693-8. [PMID: 21911148 DOI: 10.1016/j.transproceed.2011.06.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Revised: 05/16/2011] [Accepted: 06/06/2011] [Indexed: 12/22/2022]
Abstract
BACKGROUND Everolimus has potent antifibrotic effects that may potentially affect the clinical course of bronchiolitis obliterans syndrome (BOS) or provide nephroprotective immunosuppressive regimens for lung transplantation. METHODS We retrospectively assessed the 12-month outcomes of the conversion to everolimus among lung recipients in six Spanish centers. RESULTS From March 2005 to December 2007, 65 lung recipients who were at a mean posttransplantation time of 10.2 ± 7.9 months were converted to everolimus, mainly because of BOS (64.6%) or renal insufficiency (RI; 12.3%). The initial dose of everolimus was 1.9 ± 0.6 mg/d and the mean blood trough levels were stable over time (6.4 ± 2.8 ng/mL at 12 months). Conversion to everolimus allowed us to eliminate the calcineurin inhibitor (CNI) in 21% of patients. Among the overall population, the forced expiratory volume at 1 second (FEV(1)) and renal function remained stable. Mean FEV(1) did not change among the 35 (81%) patients surviving BOS at 12 months: preconversion FEV(1): 1.449.5 ± 641.9 mL vs 12-month FEV(1): 1420.0 ± 734.6 mL (P = .866). There was a significant improvement in renal function among the RI patients with mean glomerular filtration rates of 42.2 ± 15.2 mL/min/1.73 m(2) (P = .043) at 6 and 44.4 ± 18.8 mL/min/1.73 m(2) at 12 months, (P = .063) and a decrease in the use of CNIs from 1% of RI patients preconversion to 57% at 6 and 75% at 12 months. With a mean of 8.1- months follow-up (range: 1-31.3) overall survival was 84.6% at 1 year and 50% at 22.3 months. Progressive BOS was the main cause of death. Reasons for everolimus discontinuation were patient death (n = 10), lack of efficacy (n = 4), gastrointestinal adverse events (n = 2), and edema (n = 2). CONCLUSIONS BOS and RI were the main indications for conversion to everolimus among lung recipients. Conversion to everolimus improved renal function among patients converted because of RI. The present results were inconclusive regarding effects of everolimus on BOS.
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Affiliation(s)
- A Roman
- Department of Pulmonology, University Hospital Vall d'Hebron, Barcelona, Spain.
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Morgan DL, Jokinen MP, Price HC, Gwinn WM, Palmer SM, Flake GP. Bronchial and bronchiolar fibrosis in rats exposed to 2,3-pentanedione vapors: implications for bronchiolitis obliterans in humans. Toxicol Pathol 2012; 40:448-65. [PMID: 22215510 DOI: 10.1177/0192623311431946] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
2,3-Pentanedione (PD) is a component of artificial butter flavorings. The use of PD is increasing since diacetyl, a major butter flavorant, was associated with bronchiolitis obliterans (BO) in workers and has been removed from many products. Because the toxicity of inhaled PD is unknown, these studies were conducted to characterize the toxicity of inhaled PD across a range of concentrations in rodents. Male and female Wistar-Han rats and B6C3F1 mice were exposed to 0, 50, 100, or 200 ppm PD 6 h/d, 5 d/wk for up to 2 wk. Bronchoalveolar lavage fluid (BALF) was collected after 1, 3, 5, and 10 exposures, and histopathology was evaluated after 12 exposures. MCP-1, MCP-3, CRP, FGF-9, fibrinogen, and OSM were increased 2- to 9-fold in BALF of rats exposed for 5 and 10 days to 200 ppm. In mice, only fibrinogen was increased after 5 exposures to 200 ppm. The epithelium lining the respiratory tract was the site of toxicity in all mice and rats exposed to 200 ppm. Significantly, PD also caused both intraluminal and intramural fibrotic airway lesions in rats. The histopathological and biological changes observed in rats raise concerns that PD inhalation may cause BO in exposed humans.
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Affiliation(s)
- Daniel L Morgan
- National Institute of Environmental Health Sciences, National Toxicology Program, Research Triangle Park, North Carolina 27709, USA.
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Hoppo T, Jobe BA. Diagnosis and Management of GERD Before and After Lung Transplantation. Thorac Surg Clin 2011; 21:499-510. [DOI: 10.1016/j.thorsurg.2011.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Uhlving HH, Buchvald F, Heilmann CJ, Nielsen KG, Gormsen M, Müller KG. Bronchiolitis obliterans after allo-SCT: clinical criteria and treatment options. Bone Marrow Transplant 2011; 47:1020-9. [PMID: 21874057 DOI: 10.1038/bmt.2011.161] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Bronchiolitis obliterans (BO) following allogeneic haematopoietic SCT (HSCT) is a serious complication affecting 1.7-26% of the patients, with a reported mortality rate of 21-100%. It is considered a manifestation of chronic graft-versus-host disease, but our knowledge of aetiology and pathogenesis is still limited. Diagnostic criteria are being developed, and will allow more uniform and comparable research activities between centres. At present, no randomised controlled trials have been completed that could demonstrate an effective treatment. Steroids in combination with other immunosuppressive drugs still constitute the backbone of the treatment strategy, and results from our and other centres suggest that monthly infusions of high-dose pulse i.v. methylprednisolone (HDPM) might stabilise the disease and hinder progression. This article provides an overview of the current evidence regarding treatment options for BO and presents the treatment results with HDPM in a paediatric national HSCT-cohort.
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Affiliation(s)
- H H Uhlving
- Paediatric Clinic, National University Hospital Rigshospitalet, Blegdamsvej 9, Copenhagen, Denmark.
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de Jong PA, Vos R, Verleden GM, Vanaudenaerde BM, Verschakelen JA. Thin-section computed tomography findings before and after azithromycin treatment of neutrophilic reversible lung allograft dysfunction. Eur Radiol 2011; 21:2466-74. [PMID: 21792614 PMCID: PMC3217146 DOI: 10.1007/s00330-011-2224-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Revised: 05/24/2011] [Accepted: 06/12/2011] [Indexed: 12/17/2022]
Abstract
Objectives Recently a novel subgroup of bronchiolitis obliterans syndrome (BOS) has been described in patients after lung transplantation with high neutrophil counts in broncho-alveolar lavage and recovery of lung functional decline with azithromycin treatment. We aimed to describe the thin-section computed tomography (CT) findings of these neutrophilic reversible allograft dysfunction (NRAD) patients before and after azithromycin. Methods A cohort of 100 lung transplant recipients with BOS were treated with azithromycin and underwent lung function testing, broncho-alveolar lavage and CT before azithromycin treatment and during follow-up. The 200 CT data sets were scored for bronchial dilatation, mucus plugging, centrilobular abnormalities, airway wall thickening, consolidation, ground glass and end-expiratory air trapping. Results NRAD was characterized by more centrilobular abnormalities on CT (p = 0.03 for prevalence and p = 0.06 for severity) compared to non-responders. At follow-up NRAD patients showed improvement in all CT abnormalities including air trapping, but the degree of improvement in all CT abnormalities was significantly different between responders and non-responders (who showed progression of bronchus dilatation, consolidation and air trapping). Conclusions Within BOS patients those with NRAD differ from azithromycin non-responders by more centrilobular abnormalities on CT before azithromycin and improvement in bronchus dilatation, consolidation and air trapping during treatment.
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Affiliation(s)
- Pim A de Jong
- Department of Radiology, Katholieke Universiteit Leuven, Leuven, Belgium.
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Exhaled breath condensate pH in lung transplant recipients with bronchiolitis obliterans syndrome. Transplantation 2011; 91:793-7. [PMID: 21289593 DOI: 10.1097/tp.0b013e31820d3bc3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Assessment of exhaled breath condensate (EBC) pH is a promising method for investigating airway pathology. However, inaccurate measurement techniques may bias pH readings. In this longitudinal study, we tested whether development of bronchiolitis obliterans syndrome (BOS) in lung transplant recipients is associated with acidification of EBC. METHODS EBC was collected in 15 patients with BOS and 16 stable BOS-free patients during routine clinical visits. From nine BOS patients, samples were collected before and after the onset of BOS, as well. Twenty healthy nontransplant subjects served as controls. EBC pH was measured by the carbon dioxide gas standardization method. RESULTS EBC pH in patients with and without BOS and controls was similar (BOS group: 6.40±0.04, BOS-free group: 6.45±0.03; controls: 6.39±0.02; P>0.05). In patients who developed BOS during the follow-up, EBC pH before and after the onset of BOS was comparable (pre-BOS: 6.41±0.04 vs. post-BOS: 6.41±0.04; P>0.05). Coefficient of variation for repeated pH measurements in controls and subjects with and without BOS was 2.3%±0.3%, 2.0%±0.3%, and 1.7%±0.2%, respectively (P>0.05). Similarly, the limits of agreement for between-visit variability determined by the Bland-Altman test were comparable among the study groups. CONCLUSIONS These data suggest that assessment of EBC pH is of limited value for the diagnosis of BOS.
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Abstract
Chronic, progressive, and irreversible loss of lung function is the major medium-term and long-term complication after lung transplantation and the leading cause of death. Over the past decade, progress has been made in understanding the pathogenesis of bronchiolitis obliterans. Alloimmune factors and nonalloimmune factors may contribute to its development. Understanding the precise mechanism of each type of chronic allograft dysfunction may open up the field for new preventive and therapeutic interventions. This article reviews major new insights into the clinical aspects, pathophysiology, risk factors, diagnosis, and management of chronic allograft dysfunction after lung transplantation.
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Affiliation(s)
- Christiane Knoop
- Department of Chest Medicine, Erasme University Hospital, Université Libre de Bruxelles, 808 Route de Lennik, B-1070 Brussels, Belgium.
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Jonigk D, Merk M, Hussein K, Maegel L, Theophile K, Muth M, Lehmann U, Bockmeyer CL, Mengel M, Gottlieb J, Welte T, Haverich A, Golpon H, Kreipe H, Laenger F. Obliterative airway remodeling: molecular evidence for shared pathways in transplanted and native lungs. THE AMERICAN JOURNAL OF PATHOLOGY 2011; 178:599-608. [PMID: 21281792 DOI: 10.1016/j.ajpath.2010.10.032] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Revised: 10/12/2010] [Accepted: 10/21/2010] [Indexed: 02/06/2023]
Abstract
Obliteration of the small airways is a largely unresolved challenge in pulmonary medicine. It represents either the irreversible cause of functional impairment or a morphologic disorder of limited importance in a multitude of diseases. Bronchiolitis obliterans is a key complication of lung transplantation. No predictive markers for the onset of obliterative remodeling are currently available. To further elucidate the molecular mechanisms of airway remodeling, compartment-specific expression patterns were analyzed in patients. For this purpose, remodeled and nonremodeled bronchioli were isolated from transplanted and nontransplanted lung explants using laser-assisted microdissection (n = 24). mRNA expression of 45 fibrosis-associated genes was measured using quantitative real-time RT-PCR. For 20 genes, protein expression was also analyzed by immunohistochemistry. Infiltrating cells were characterized at conventional histology and immunohistochemistry. Obliterative remodeling of the small airways in transplanted and nontransplanted lungs shared similar grades of chronic inflammation and pivotal fibrotic pathways such as transforming growth factor β signaling and increased collagen expression. Bone morphogenetic protein and thrombospondin signaling, and also matrix metalloproteinases and tissue inhibitor of metalloproteinases, were primarily up-regulated in obliterative airway remodeling in nontransplanted lungs. In transplanted lungs, clinical remodeled bone morphogenetic protein but nonremodeled bronchioli were characterized by a concordant up-regulation of matrix metalloproteinase-9, RANTES, and tissue inhibitor of metalloproteinase-1. These distinct expression patterns warrant further investigation as potential markers of impending airway remodeling, especially for prospective longitudinal molecular profiling.
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Affiliation(s)
- Danny Jonigk
- Institute of Pathology, Hannover Medical School, Hannover, Germany.
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Vanaudenaerde BM, Verleden SE, Vos R, Vleeschauwer SID, Willems-Widyastuti A, Geenens R, Raemdonck DEV, Dupont LJ, Verbeken EK, Meyts I. Innate and Adaptive Interleukin-17–producing Lymphocytes in Chronic Inflammatory Lung Disorders. Am J Respir Crit Care Med 2011; 183:977-86. [DOI: 10.1164/rccm.201007-1196pp] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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40
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Palmer SM, Flake GP, Kelly FL, Zhang HL, Nugent JL, Kirby PJ, Foley JF, Gwinn WM, Morgan DL. Severe airway epithelial injury, aberrant repair and bronchiolitis obliterans develops after diacetyl instillation in rats. PLoS One 2011; 6:e17644. [PMID: 21464978 PMCID: PMC3064568 DOI: 10.1371/journal.pone.0017644] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Accepted: 02/09/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Bronchiolitis obliterans (BO) is a fibrotic lung disease that occurs in a variety of clinical settings, including toxin exposures, autoimmunity and lung or bone marrow transplant. Despite its increasing clinical importance, little is known regarding the underlying disease mechanisms due to a lack of adequate small animal BO models. Recent epidemiological studies have implicated exposure to diacetyl (DA), a volatile component of artificial butter flavoring, as a cause of BO in otherwise healthy factory workers. Our overall hypothesis is that DA induces severe epithelial injury and aberrant repair that leads to the development of BO. Therefore, the objectives of this study were 1) to determine if DA, delivered by intratracheal instillation (ITI), would lead to the development of BO in rats and 2) to characterize epithelial regeneration and matrix repair after ITI of DA. METHODS AND MAIN RESULTS Male Sprague-Dawley rats were treated with a single dose of DA (125 mg/kg) or sterile water (vehicle control) by ITI. Instilled DA resulted in airway specific injury, followed by rapid epithelial regeneration, and extensive intraluminal airway fibrosis characteristic of BO. Increased airway resistance and lung fluid neutrophilia occurred with the development of BO, similar to human disease. Despite rapid epithelial regeneration after DA treatment, expression of the normal phenotypic markers, Clara cell secretory protein and acetylated tubulin, were diminished. In contrast, expression of the matrix component Tenascin C was significantly increased, particularly evident within the BO lesions. CONCLUSIONS We have established that ITI of DA results in BO, creating a novel chemical-induced animal model that replicates histological, biological and physiological features of the human disease. Furthermore, we demonstrate that dysregulated epithelial repair and excessive matrix Tenacin C deposition occur in BO, providing new insights into potential disease mechanisms and therapeutic targets.
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Affiliation(s)
- Scott M Palmer
- Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina, United States of America.
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Federica M, Nadia S, Monica M, Alessandro C, Tiberio O, Francesco B, Mario V, Maria FA. Clinical and immunological evaluation of 12-month azithromycin therapy in chronic lung allograft rejection. Clin Transplant 2011; 25:E381-9. [DOI: 10.1111/j.1399-0012.2011.01435.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Verleden GM, Verleden SE, Vos R, De Vleeschauwer SI, Dupont LJ, Van Raemdonck DE, Vanaudenaerde BM. Montelukast for bronchiolitis obliterans syndrome after lung transplantation: a pilot study. Transpl Int 2011; 24:651-6. [DOI: 10.1111/j.1432-2277.2011.01248.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Emaminia A, Hennessy SA, Hranjec T, LaPar DJ, Kozower BD, Jones DR, Kron IL, Lau CL. Bronchiolitis obliterans syndrome occurs earlier in the post-lung allocation score era. J Thorac Cardiovasc Surg 2011; 141:1278-82. [PMID: 21320711 DOI: 10.1016/j.jtcvs.2010.12.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Revised: 11/04/2010] [Accepted: 12/16/2010] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In 2005, the time-based waiting list for lung transplantation was replaced by an illness/benefit lung allocation score (LAS). Although short-term outcomes after transplantation have been reported to be similar before and after the new system, little is known about long-term results. The objective of this study was to evaluate the impact of LAS on the development of bronchiolitis obliterans syndrome as well as on overall 3-year and bronchiolitis obliterans syndrome-related survival. METHODS Data obtained from the United Network for Organ Sharing were used to review 8091 patients who underwent lung transplantation from 2002 to 2008. Patients were stratified according to time of transplantation into those treated before initiation of the LAS (pre-LAS group, January 2002-April 2005, n = 3729) and those treated after implementation of the score (post-LAS group, May 2005-May 2008, n = 4362). Overall, 3-year survivals for patient groups were compared using a univariate analysis, Cox proportional hazards model to generate a relative risk, and Kaplan-Meier curve analyses. RESULTS During the 3-year follow-up period, bronchiolitis obliterans syndrome developed in 22% of lung transplant recipients (n = 1801). Although the incidence of postoperative bronchiolitis obliterans syndrome development was similar between groups, post-LAS patients incurred fewer bronchiolitis obliterans syndrome-free days (609 ± 7.5 vs 682 ± 9; P <.0001; log-rank test P = .0108) than did pre-LAS patients. Overall 3-year survival was lower in post-LAS patients and approached statistical significance (P = .05). Similarly, bronchiolitis obliterans syndrome-related survival was worse for patients in the post-LAS group (log-rank test P = .01). CONCLUSIONS In the current LAS era, lung transplant recipients have significantly fewer bronchiolitis obliterans syndrome-free days after 3-year follow-up. Compared with the pre-LAS population, overall and bronchiolitis obliterans syndrome-related survival appears worse in the post-LAS era. Limitation of known risk factors for development of bronchiolitis obliterans syndrome-may prove even more important in this patient population.
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Affiliation(s)
- Abbas Emaminia
- Department of Surgery, University of Virginia, Charlottesville, Va 22908-0679, USA
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Neurohr C, Huppmann P, Leuschner S, von Wulffen W, Meis T, Leuchte H, Ihle F, Zimmermann G, Baezner C, Hatz R, Winter H, Frey L, Ueberfuhr P, Bittmann I, Behr J. Usefulness of exhaled nitric oxide to guide risk stratification for bronchiolitis obliterans syndrome after lung transplantation. Am J Transplant 2011; 11:129-37. [PMID: 21087415 DOI: 10.1111/j.1600-6143.2010.03327.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The aim of this study was to assess fractional exhaled nitric oxide (FeNO) for the early diagnosis of bronchiolitis obliterans syndrome (BOS) after lung transplantation (LTX). 611 FeNO measurements in 166 consecutive patients were classified depending on BOS stage at the time of assessment and course during minimum follow-up of 3 months: (1) stable non-BOS, (2) unstable non-BOS, (3) stable BOS and (4) unstable BOS. Unstable course was defined as new onset of BOS≥1 or progression of BOS. FeNO before unstable course was significantly increased in comparison to their stable counterparts (non-BOS: 28.9 ± 1.2 ppb, n = 40 vs. 16.4 ± 0.8 ppb, n = 131 and BOS: 32.5 ± 1.3 ppb, n = 35 vs. 15.3 ± 0.8 ppb, n = 26; p = 0.01 each). Average time from FeNO reading to onset of deterioration was 117 ± 9 days in non-BOS and 136 ± 9 days in BOS patients. The positive and negative predictive value of FeNO >20 ppb for BOS was 69.0% and 96.9%, respectively. Serial measurements demonstrated significantly lower mean individual variation in stable recipients as compared to stable patients switching to unstable course (3.2 ± 0.3 ppb vs. 12.7 ± 1.4 ppb, p = 0.02). In particular, the excellent negative predictive value of persistently low FeNO readings for future BOS make FeNO assessments a useful tool for continuous risk stratification after LTX.
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Affiliation(s)
- C Neurohr
- Department of Internal Medicine I, Division of Pulmonary Diseases, Klinikum Grosshadern, Munich, Germany.
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Abstract
Constrictive bronchiolitis is a bronchiolar airway disease that surrounds the lumen with fibrotic concentric narrowing and obliteration. The mosaic pattern seen on the expiratory high-resolution chest CT scan is diagnostic in an individual with shortness of breath, early inspiratory crackles, and irreversible airflow obstruction. Swyer-James-MacLeod syndrome is no longer considered a congenital disorder but as constrictive bronchiolitis detected in young adults who had infectious pneumonia during infancy. For lung transplant recipients, tacrolimus continues to be an important immune suppression medication, extracorporeal photopheresis may improve the decline of pulmonary function, and azithromycin may be effective in some lung transplant recipients for treatment of bronchiolitis obliterans syndrome for prevention of constrictive bronchiolitis.
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Affiliation(s)
- Gary R Epler
- Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School 75 Francis Street, Boston, MA 02115 USA
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Antihuman leukocyte antigen antibody-induced autoimmunity: role in chronic rejection. Curr Opin Organ Transplant 2010; 15:16-20. [PMID: 19898237 DOI: 10.1097/mot.0b013e3283342780] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW We provide evidence for the role of de-novo development of immune responses to self-antigens in the posttransplant period and its possible induction by alloimmunity in the pathogenesis of chronic rejection following lung, heart and kidney transplantation. The present review details recent findings for the two distinct yet interdependent immune processes in the immunopathogenesis of chronic rejection. RECENT FINDINGS The contribution of both humoral and cell-mediated alloimmune responses against mismatched donor histocompatibility antigens (HLA) in the pathogenesis of chronic rejection is well established. Recent studies have focused on development of immune responses to self-antigens during the posttransplant period and its correlation with chronic rejection. These self-antigens include myosin and vimentin in cardiac, K-alpha-1-tubulin and collagen-V in lung and angiotensin II type 1 receptor, collagen-IV and VI in kidney transplants. During the posttransplant period, the development of immune responses to self-antigens is facilitated by induction of a distinct subset of autoreactive T-helper cells referred to as Th17 cells. SUMMARY Following organ transplantation, tissue injury and remodeling inflicted by antibodies (Abs) to HLA antigens is conducive to develop autoimmunity. Abs to HLA and self-antigens are detectable in the serum of transplant recipients who develop chronic rejection. Anti-HLA Abs are often present transiently but precede the development of Abs to self-antigens.
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Lung. PATHOLOGY OF SOLID ORGAN TRANSPLANTATION 2009. [PMCID: PMC7120462 DOI: 10.1007/978-3-540-79343-4_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Experiments with animals in the 1940 and 1950s demonstrated that lung transplantation was technically possible [33]. In 1963, Dr. James Hardy performed the first human lung transplantation. The recipient survived 18 days, ultimately succumbing to renal failure and malnutrition [58]. From 1963 through 1978, multiple attempts at lung transplantation failed because of rejection and complications at the bronchial anastomosis. In the 1980s, improvements in immunosuppression, especially the introduction of cyclosporin A, and enhanced surgical techniques led to renewed interest in organ transplantation. In 1981, a 45-year-old-woman received the first successful heart–lung transplantation for idiopathic pulmonary arterial hypertension (IPAH) [106]. She survived 5 years after the procedure. Two years later the first successful single lung transplantation for idiopathic pulmonary fibrosis (IPF) [128] was reported, and in 1986 the first double lung transplantation for emphysema [25] was performed.
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