1
|
Friedlander S, Pogatchnik B, Furuya Y, Allen T. Pulmonary transplant complications: a radiologic review. J Cardiothorac Surg 2024; 19:270. [PMID: 38702686 PMCID: PMC11067284 DOI: 10.1186/s13019-024-02731-w] [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: 12/19/2023] [Accepted: 03/29/2024] [Indexed: 05/06/2024] Open
Abstract
Lung transplantation has become the definitive treatment for end stage respiratory disease. Numbers and survival rates have increased over the past decade, with transplant recipients living longer and with greater comorbidities, resulting in greater complexity of care. Common and uncommon complications that occur in the immediate, early, intermediate, and late periods can have significant impact on the course of the transplant. Fortunately, advancements in surgery, medical care, and imaging as well as other diagnostics work to prevent, identify, and manage complications that would otherwise have a negative impact on survivability. This review will focus on contextualizing complications both categorically and chronologically, with highlights of specific imaging and clinical features in order to inform both radiologists and clinicians involved in post-transplant care.
Collapse
Affiliation(s)
- Samuel Friedlander
- Department of Radiology, University of Minnesota Medical School, Minneapolis, MN, 55455, USA.
| | - Brian Pogatchnik
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Yuka Furuya
- Medical Director of Lung Transplant, CareDX, Inc, Brisbane, CA, 94005, USA
| | - Tadashi Allen
- Department of Radiology, University of Minnesota Medical School, Minneapolis, MN, 55455, USA
| |
Collapse
|
2
|
Kim JS, Gupta R. Lung transplantation in pulmonary sarcoidosis. J Autoimmun 2023:103135. [PMID: 37923622 DOI: 10.1016/j.jaut.2023.103135] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/12/2023] [Accepted: 10/18/2023] [Indexed: 11/07/2023]
Abstract
Sarcoidosis is a systemic inflammatory disease of unknown etiology and variable clinical course. Pulmonary sarcoidosis is the most common presentation and accounts for most morbidity and mortality related to sarcoidosis. While sarcoidosis generally has good outcomes, few patients experience chronic disease. A minority of patients progress to a specific phenotype of sarcoidosis referred to advanced pulmonary sarcoidosis (APS) which includes advanced fibrosis, pulmonary hypertension and respiratory failure, leading to high morbidity and mortality. In patients with advanced disease despite medical therapy, lung transplantation may be the last viable option for improvement in quality of life. Though post-transplant survival is similar to that of other end-stage lung diseases, it is imperative that patients are evaluated and referred early to transplant centers with experience in APS. A multidisciplinary approach and clinical experience are crucial in detecting the optimal timing of referral, initiating comprehensive transplantation evaluation and listing, discussing surgical approach, and managing perioperative and post-transplant care. This review article seeks to address these aspects of lung transplantation in APS.
Collapse
Affiliation(s)
- Jin Sun Kim
- Lewis Katz School of Medicine, Department of Thoracic Medicine and Surgery, Philadelphia, PA, USA.
| | - Rohit Gupta
- Lewis Katz School of Medicine, Department of Thoracic Medicine and Surgery, Philadelphia, PA, USA
| |
Collapse
|
3
|
Lu L, Wein AN, Villanueva A, Jones C, Anderson A, Ritter J, Lin CY. Clinical and Histopathologic Characteristics of Recurrent Sarcoidosis in Posttransplant Lungs: 25 Years of Experience. Am J Surg Pathol 2023; 47:1034-1038. [PMID: 37317999 DOI: 10.1097/pas.0000000000002074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Lung transplantation is the definitive therapy for end-stage pulmonary sarcoidosis. While recurrent sarcoidosis in allografts has been described in several case reports, the incidence and clinicopathologic characteristics remain unclear. In this study, we characterize the clinical and histopathologic features of recurrent sarcoidosis diagnosed in posttransplant lung surveillance transbronchial biopsies (TBBx). We identified 35 patients who underwent lung transplant for pulmonary sarcoidosis during the study period. Among them, 18 patients (51%) experienced recurrent sarcoidosis posttransplant. These included 7 females and 11 males with mean age at recurrence of 51.6 years. The average time interval from transplant to recurrence was 252 days (22 to 984 d). All TBBx contained >4 pieces of alveolated lung tissue with no evidence of International Society for Heart and Lung Transplantation (ISHLT) grade A2, A3, or A4 acute cellular rejection; chronic rejection; or antibody-mediated rejection. There were 33 surveillance TBBx that contained granulomatous inflammation with a mean of 3.6 well-formed granulomas per TBBx (range: 1 to >20). Multinucleated giant cells were identified in 11 TBBx (33.3%), with 1 case containing asteroid bodies. While most of the granulomas were "naked granulomas," 5 cases (15.2%) showed prominent lymphoid cuffing. Two cases showed evidence of fibrosis. One of the granulomas had focal necrosis; however, no infectious organisms were identified by special stains and clinical correlation suggested this case represented recurrent sarcoidosis. Biopsies of recurrent sarcoidosis usually show multiple well-formed granulomas with giant cells in more than half of the cases, while lymphoid cuffing, fibrosis, asteroid bodies, and necrotizing granulomas are uncommon findings. Pathologists should be aware of these features, as recurrence of sarcoidosis following lung transplant occurs in more than half of patients.
Collapse
Affiliation(s)
- Liang Lu
- Department of Pathology and Immunology, Washington University School of Medicine
| | - Alexander N Wein
- Department of Pathology and Immunology, Washington University School of Medicine
| | - Ana Villanueva
- Department of Pathology and Immunology, Washington University School of Medicine
| | - Christopher Jones
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Adam Anderson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Jon Ritter
- Department of Pathology and Immunology, Washington University School of Medicine
| | - Chieh-Yu Lin
- Department of Pathology and Immunology, Washington University School of Medicine
| |
Collapse
|
4
|
Kang J, Digumarthy SR. Imaging in Lung Transplantation: Surgical Techniques and Complications. Radiol Clin North Am 2023; 61:833-846. [PMID: 37495291 DOI: 10.1016/j.rcl.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
Lung transplant is an established treatment for patients with end-stage lung disease. As a result, there is increased demand for transplants. Despite improvements in pretransplant evaluation, surgical techniques, and postsurgical care, the average posttransplant life expectancy is only around 6.5 years. Early recognition of complications on imaging and treatment can improve survival. Knowledge of surgical techniques and imaging findings of surgical and nonsurgical complications is essential. This review covers surgical techniques and imaging appearance of postsurgical and nonsurgical complications, including allograft dysfunction, infections, neoplasms, and recurrence of primary lung disease.
Collapse
Affiliation(s)
- Jiyoon Kang
- Division of Thoracic Imaging and Intervention, Massachusetts General Hospital, 55 Fruit Street, Founders 202, Boston, MA 02114, USA; Harvard Medical School, Boston, MA, USA
| | - Subba R Digumarthy
- Division of Thoracic Imaging and Intervention, Massachusetts General Hospital, 55 Fruit Street, Founders 202, Boston, MA 02114, USA; Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
5
|
Sweis JJG, Sweis NWG, Alnaimat F, Jansz J, Liao TWE, Alsakaty A, Azam A, Elmergawy H, Hanson HA, Ascoli C, Rubinstein I, Sweiss N. Immune-mediated lung diseases: A narrative review. Front Med (Lausanne) 2023; 10:1160755. [PMID: 37089604 PMCID: PMC10117988 DOI: 10.3389/fmed.2023.1160755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 03/20/2023] [Indexed: 04/25/2023] Open
Abstract
The role of immunity in the pathogenesis of various pulmonary diseases, particularly interstitial lung diseases (ILDs), is being increasingly appreciated as mechanistic discoveries advance our knowledge in the field. Immune-mediated lung diseases demonstrate clinical and immunological heterogeneity and can be etiologically categorized into connective tissue disease (CTD)-associated, exposure-related, idiopathic, and other miscellaneous lung diseases including sarcoidosis, and post-lung transplant ILD. The immunopathogenesis of many of these diseases remains poorly defined and possibly involves either immune dysregulation, abnormal healing, chronic inflammation, or a combination of these, often in a background of genetic susceptibility. The heterogeneity and complex immunopathogenesis of ILDs complicate management, and thus a collaborative treatment team should work toward an individualized approach to address the unique needs of each patient. Current management of immune-mediated lung diseases is challenging; the choice of therapy is etiology-driven and includes corticosteroids, immunomodulatory drugs such as methotrexate, cyclophosphamide and mycophenolate mofetil, rituximab, or other measures such as discontinuation or avoidance of the inciting agent in exposure-related ILDs. Antifibrotic therapy is approved for some of the ILDs (e.g., idiopathic pulmonary fibrosis) and is being investigated for many others and has shown promising preliminary results. A dire need for advances in the management of immune-mediated lung disease persists in the absence of standardized management guidelines.
Collapse
Affiliation(s)
| | | | - Fatima Alnaimat
- Division of Rheumatology, Department of Internal Medicine, The University of Jordan, Amman, Jordan
| | - Jacqueline Jansz
- Department of Medicine, University of Illinois Chicago, Chicago, IL, United States
| | - Ting-Wei Ernie Liao
- School of Medicine, Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Alaa Alsakaty
- Division of Rheumatology, Department of Medicine, University of Illinois Chicago, Chicago, IL, United States
| | - Abeera Azam
- Department of Internal Medicine, The University of Texas Health Science Center at Tyler, Tyler, TX, United States
| | - Hesham Elmergawy
- Division of Rheumatology, Department of Medicine, University of Illinois Chicago, Chicago, IL, United States
| | - Hali A. Hanson
- UIC College of Pharmacy, University of Illinois Chicago, Chicago, IL, United States
| | - Christian Ascoli
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois Chicago, Chicago, IL, United States
| | - Israel Rubinstein
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois Chicago, Chicago, IL, United States
- Research Service, Jesse Brown VA Medical Center, Chicago, IL, United States
| | - Nadera Sweiss
- Division of Rheumatology, Department of Medicine, University of Illinois Chicago, Chicago, IL, United States
| |
Collapse
|
6
|
Olland A, Valeyre D, Nunes H, Le Pavec J. [Lung transplantation for sarcoidosis]. Rev Mal Respir 2023; 40 Suppl 1:e58-e61. [PMID: 36639340 DOI: 10.1016/j.rmr.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- A Olland
- Lung Transplantation Group, University Hospital Strasbourg, Strasbourg, France; INSERM (French institute for health and medical research) 1260 Regenerative Nanomedecine, Translational Medicine Federation of Strasbourg, University of Strasbourg, Strasbourg, France
| | - D Valeyre
- Service de Pneumologie, Inserm UMR 1272, Université Sorbonne Paris Nord, AP-HP, Hôpital Avicenne, Bobigny, France; Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - H Nunes
- Service de Pneumologie, Inserm UMR 1272, Université Sorbonne Paris Nord, AP-HP, Hôpital Avicenne, Bobigny, France; Service de Pneumologie, Hôpital Avicenne, Assistance Publique Hôpitaux de Paris, Paris, France
| | - J Le Pavec
- Service de Pneumologie et de Transplantation Pulmonaire, Groupe Hospitalier Marie-Lannelongue -Paris Saint Joseph, Le Plessis-Robinson, France; Université Paris-Saclay, Le Kremlin Bicêtre, France; UMR_S 999, Université Paris-Sud, Inserm, Groupe hospitalier Marie-Lannelongue-Saint Joseph, Le Plessis-Robinson, France.
| |
Collapse
|
7
|
Lilburn P, Pillutla D, Sivasubramaniam V, Plit M. Inescapable Fibrosis: The Development of Desquamative Interstitial Pneumonia Post-Lung Transplantation Performed for a Patient with Idiopathic Pulmonary Fibrosis. Case Rep Transplant 2023; 2023:1737309. [PMID: 37090840 PMCID: PMC10115523 DOI: 10.1155/2023/1737309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 11/18/2022] [Accepted: 02/21/2023] [Indexed: 04/25/2023] Open
Abstract
Interstitial lung disease is characterised by a combination of cellular proliferation, inflammation of the interstitium and fibrosis within the alveolar wall. A 58-year-old man was referred for lung transplantation after developing worsening dyspnoea and progressive hypoxaemic respiratory failure from idiopathic pulmonary fibrosis. Three years later, he developed desquamative interstitial pneumonia in his transplanted lungs, and despite augmentation of immune suppression, he had a progressive decline in his lung function and exercise capacity. Interestingly, in our case, the histopathology obtained post transplant strongly goes against the recurrence of usual interstitial pneumonia/idiopathic pulmonary fibrosis; rather, two separate interstitial disease processes have been identified.
Collapse
Affiliation(s)
- Paul Lilburn
- University of New South Wales, Kensington, NSW 2052, Australia
- Macquarie University Hospital, 3 Technology Place, North Ryde, NSW 2109, Australia
- Department of Respiratory Medicine, Prince of Wales Hospital, Randwick, NSW 2031, Australia
| | - Divya Pillutla
- St. Vincent's Hospital, 390 Victoria Street, Darlinghurst, NSW 2010, Australia
| | - Vanathi Sivasubramaniam
- University of New South Wales, Kensington, NSW 2052, Australia
- St. Vincent's Hospital, 390 Victoria Street, Darlinghurst, NSW 2010, Australia
| | - Marshall Plit
- University of New South Wales, Kensington, NSW 2052, Australia
- St. Vincent's Hospital, 390 Victoria Street, Darlinghurst, NSW 2010, Australia
| |
Collapse
|
8
|
Rama Esendagli D, Ntiamoah P, Kupeli E, Bhardwaj A, Ghosh S, Mukhopadhyay S, Mehta AC. Recurrence of primary disease following lung transplantation. ERJ Open Res 2022; 8:00038-2022. [PMID: 35651363 PMCID: PMC9149385 DOI: 10.1183/23120541.00038-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/12/2022] [Indexed: 11/17/2022] Open
Abstract
Lung transplant has become definitive treatment for patients with several end-stage lung diseases. Since the first attempted lung transplantation in 1963, survival has significantly improved due to advancement in immunosuppression, organ procurement, ex vivo lung perfusion, surgical techniques, prevention of chronic lung allograft dysfunction and bridging to transplant using extracorporeal membrane oxygenation. Despite a steady increase in number of lung transplantations each year, there is still a huge gap between demand and supply of organs available, and work continues to select recipients with potential for best outcomes. According to review of the literature, there are some rare primary diseases that may recur following transplantation. As the number of lung transplants increase, we continue to identify disease processes at highest risk for recurrence, thus shaping our future approaches. While the aim of lung transplantation is improving survival and quality of life, choosing the best recipients is crucial due to a shortage of donated organs. Here we discuss the common disease processes that recur and highlight its impact on overall outcome following lung transplantation. This article reviews the underlying conditions leading to lung transplant with potential for recurrence and the impact of such recurrences on the overall outcome following transplanthttps://bit.ly/3v3gSvJ
Collapse
|
9
|
Saha BK, Chong WH. Lung transplant to manage end-stage lung disease due to idiopathic pulmonary hemosiderosis: A review of the literature. Respir Investig 2022; 60:82-89. [PMID: 34312096 DOI: 10.1016/j.resinv.2021.06.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/05/2021] [Accepted: 06/19/2021] [Indexed: 06/13/2023]
Abstract
Idiopathic pulmonary hemosiderosis (IPH) is a rare immunological disease with a genetic predisposition. It is characterized by recurrent episodes of diffuse alveolar hemorrhage (DAH). Timely use of immunosuppressive medications has significantly improved overall outcomes, including mortality. Still, uncontrolled and frequent episodes of DAH can eventually cause pulmonary fibrosis, leading to end-stage lung disease (ESLD). The objective of the present project was to scrutinize the literature and summarize the demographic, clinical, radiological, and histopathological features, as well as the overall outcomes, in this patient population following lung transplant. The Medline database was searched using the PubMed platform. Articles published in English between 1960 and 2020 were included in the search. Different search terms were used to identify all patients who underwent lung transplantation to manage ESLD due to IPH. Only four cases of lung transplantation have been reported in the literature in patients with IPH. All but one of these underwent deceased donor lung transplant; recurrence was reported in two of these patients and suspected in the third. One patient received living donor lung transplant and had no recurrence during a five-year follow-up. Patients with IPH should not be excluded from lung transplantation because the disease may not recur in all patients, and even when it does recur it can be promptly treated by increasing immunosuppression.
Collapse
Affiliation(s)
- Biplab K Saha
- Division of Pulmonary and Critical Care Medicine, Ozarks Medical Center, 1100 N Kentucky Avenue, West Plains, MO, 65775, USA.
| | - Woon H Chong
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, 43 New Scotland Avenue, Albany, NY, 12208, USA
| |
Collapse
|
10
|
DeFreitas MR, McAdams HP, Azfar Ali H, Iranmanesh AM, Chalian H. Complications of Lung Transplantation: Update on Imaging Manifestations and Management. Radiol Cardiothorac Imaging 2021; 3:e190252. [PMID: 34505059 DOI: 10.1148/ryct.2021190252] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 04/02/2021] [Accepted: 07/12/2021] [Indexed: 12/23/2022]
Abstract
As lung transplantation has become the most effective definitive treatment option for end-stage chronic respiratory diseases, yearly rates of this surgery have been steadily increasing. Despite improvement in surgical techniques and medical management of transplant recipients, complications from lung transplantation are a major cause of morbidity and mortality. Some of these complications can be classified on the basis of the time they typically occur after lung transplantation, while others may occur at any time. Imaging studies, in conjunction with clinical and laboratory evaluation, are key components in diagnosing and monitoring these conditions. Therefore, radiologists play a critical role in recognizing and communicating findings suggestive of lung transplantation complications. A description of imaging features of the most common lung transplantation complications, including surgical, medical, immunologic, and infectious complications, as well as an update on their management, will be reviewed here. Keywords: Pulmonary, Thorax, Surgery, Transplantation Supplemental material is available for this article. © RSNA, 2021.
Collapse
Affiliation(s)
- Mariana R DeFreitas
- Department of Radiology, Division of Cardiothoracic Imaging (M.R.D., H.P.M., A.M.I., H.C.), and Department of Medicine, Division of Pulmonary, Allergy and Critical Care (H.A.A.), Duke University Medical Center, Durham, NC
| | - Holman Page McAdams
- Department of Radiology, Division of Cardiothoracic Imaging (M.R.D., H.P.M., A.M.I., H.C.), and Department of Medicine, Division of Pulmonary, Allergy and Critical Care (H.A.A.), Duke University Medical Center, Durham, NC
| | - Hakim Azfar Ali
- Department of Radiology, Division of Cardiothoracic Imaging (M.R.D., H.P.M., A.M.I., H.C.), and Department of Medicine, Division of Pulmonary, Allergy and Critical Care (H.A.A.), Duke University Medical Center, Durham, NC
| | - Arya M Iranmanesh
- Department of Radiology, Division of Cardiothoracic Imaging (M.R.D., H.P.M., A.M.I., H.C.), and Department of Medicine, Division of Pulmonary, Allergy and Critical Care (H.A.A.), Duke University Medical Center, Durham, NC
| | - Hamid Chalian
- Department of Radiology, Division of Cardiothoracic Imaging (M.R.D., H.P.M., A.M.I., H.C.), and Department of Medicine, Division of Pulmonary, Allergy and Critical Care (H.A.A.), Duke University Medical Center, Durham, NC
| |
Collapse
|
11
|
Kapnadak SG, Raghu G. Lung transplantation for interstitial lung disease. Eur Respir Rev 2021; 30:30/161/210017. [PMID: 34348979 DOI: 10.1183/16000617.0017-2021] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/02/2021] [Indexed: 01/18/2023] Open
Abstract
Lung transplantation (LTx) can be a life-extending treatment option for patients with advanced and/or progressive fibrotic interstitial lung disease (ILD), especially idiopathic pulmonary fibrosis (IPF), fibrotic hypersensitivity pneumonitis, sarcoidosis and connective tissue disease-associated ILD. IPF is now the most common indication for LTx worldwide. Several unique features in patients with ILD can impact optimal timing of referral or listing for LTx, pre- or post-transplant risks, candidacy and post-transplant management. As the epidemiology of LTx and community practices have evolved, recent literature describes outcomes and approaches in higher-risk candidates. In this review, we discuss the unique and important clinical findings, course, monitoring and management of patients with IPF and other progressive fibrotic ILDs during pre-LTx evaluation and up to the day of transplantation; the need for co-management with clinical experts in ILD and LTx is emphasised. Some post-LTx complications are unique in these patient cohorts, which require prompt detection and appropriate management by experts in multiple disciplines familiar with telomere biology disorders and infectious, haematological, oncological and cardiac complications to enhance the likelihood of improved outcomes and survival of LTx recipients with IPF and other ILDs.
Collapse
Affiliation(s)
- Siddhartha G Kapnadak
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, University of Washington, Seattle, WA, USA
| | - Ganesh Raghu
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, University of Washington, Seattle, WA, USA .,Dept of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| |
Collapse
|
12
|
Kim SJ, Azour L, Hutchinson BD, Shirsat H, Zhou F, Narula N, Moreira AL, Angel L, Ko JP, Moore WH. Imaging Course of Lung Transplantation: From Patient Selection to Postoperative Complications. Radiographics 2021; 41:1043-1063. [PMID: 34197245 DOI: 10.1148/rg.2021200173] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Lung transplant is increasingly performed for the treatment of end-stage lung disease. As the number of lung transplants and transplant centers continues to rise, radiologists will more frequently participate in the care of patients undergoing lung transplant, both before and after transplant. Potential donors and recipients undergo chest radiography and CT as part of their pretransplant assessment to evaluate for contraindications to transplant and to aid in surgical planning. After transplant, recipients undergo imaging during the postoperative hospitalization and also in the long-term outpatient setting. Radiologists encounter a wide variety of conditions leading to end-stage lung disease and a myriad of posttransplant complications, some of which are unique to lung transplantation. Familiarity with these pathologic conditions, including their imaging findings and their temporal relationship to the transplant, is crucial to accurate radiologic interpretation. Knowledge of the surgical techniques and expected postoperative appearance prevents confusing normal posttransplant imaging findings with complications. A basic understanding of the indications, contraindications, and surgical considerations of lung transplant aids in imaging interpretation and protocoling and also facilitates communication between radiologists and transplant physicians. Despite medical and surgical advances over the past several decades, lung transplant recipients currently have an average posttransplant life expectancy of only 6.7 years. As members of the transplant team, radiologists can help maximize patient survival and hopefully increase posttransplant life expectancy and quality of life in the coming decades. ©RSNA, 2021 An invited commentary by Bierhals is available online. Online supplemental material is available for this article.
Collapse
Affiliation(s)
- Stacy J Kim
- From the Department of Radiology (S.J.K., L.A., J.P.K., W.H.M.), Department of Pathology (F.Z., N.N., A.L.M.), Department of Pulmonology, Critical Care, and Sleep Medicine (L.A.), and Transplant Institute (L.A.), New York University, New York, NY; Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.D.H.); and Department of Pathology, Vancouver Island Health Authority and University of British Columbia, Victoria, British Columbia, Canada (H.S.)
| | - Lea Azour
- From the Department of Radiology (S.J.K., L.A., J.P.K., W.H.M.), Department of Pathology (F.Z., N.N., A.L.M.), Department of Pulmonology, Critical Care, and Sleep Medicine (L.A.), and Transplant Institute (L.A.), New York University, New York, NY; Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.D.H.); and Department of Pathology, Vancouver Island Health Authority and University of British Columbia, Victoria, British Columbia, Canada (H.S.)
| | - Barry D Hutchinson
- From the Department of Radiology (S.J.K., L.A., J.P.K., W.H.M.), Department of Pathology (F.Z., N.N., A.L.M.), Department of Pulmonology, Critical Care, and Sleep Medicine (L.A.), and Transplant Institute (L.A.), New York University, New York, NY; Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.D.H.); and Department of Pathology, Vancouver Island Health Authority and University of British Columbia, Victoria, British Columbia, Canada (H.S.)
| | - Hemlata Shirsat
- From the Department of Radiology (S.J.K., L.A., J.P.K., W.H.M.), Department of Pathology (F.Z., N.N., A.L.M.), Department of Pulmonology, Critical Care, and Sleep Medicine (L.A.), and Transplant Institute (L.A.), New York University, New York, NY; Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.D.H.); and Department of Pathology, Vancouver Island Health Authority and University of British Columbia, Victoria, British Columbia, Canada (H.S.)
| | - Fang Zhou
- From the Department of Radiology (S.J.K., L.A., J.P.K., W.H.M.), Department of Pathology (F.Z., N.N., A.L.M.), Department of Pulmonology, Critical Care, and Sleep Medicine (L.A.), and Transplant Institute (L.A.), New York University, New York, NY; Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.D.H.); and Department of Pathology, Vancouver Island Health Authority and University of British Columbia, Victoria, British Columbia, Canada (H.S.)
| | - Navneet Narula
- From the Department of Radiology (S.J.K., L.A., J.P.K., W.H.M.), Department of Pathology (F.Z., N.N., A.L.M.), Department of Pulmonology, Critical Care, and Sleep Medicine (L.A.), and Transplant Institute (L.A.), New York University, New York, NY; Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.D.H.); and Department of Pathology, Vancouver Island Health Authority and University of British Columbia, Victoria, British Columbia, Canada (H.S.)
| | - Andre L Moreira
- From the Department of Radiology (S.J.K., L.A., J.P.K., W.H.M.), Department of Pathology (F.Z., N.N., A.L.M.), Department of Pulmonology, Critical Care, and Sleep Medicine (L.A.), and Transplant Institute (L.A.), New York University, New York, NY; Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.D.H.); and Department of Pathology, Vancouver Island Health Authority and University of British Columbia, Victoria, British Columbia, Canada (H.S.)
| | - Luis Angel
- From the Department of Radiology (S.J.K., L.A., J.P.K., W.H.M.), Department of Pathology (F.Z., N.N., A.L.M.), Department of Pulmonology, Critical Care, and Sleep Medicine (L.A.), and Transplant Institute (L.A.), New York University, New York, NY; Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.D.H.); and Department of Pathology, Vancouver Island Health Authority and University of British Columbia, Victoria, British Columbia, Canada (H.S.)
| | - Jane P Ko
- From the Department of Radiology (S.J.K., L.A., J.P.K., W.H.M.), Department of Pathology (F.Z., N.N., A.L.M.), Department of Pulmonology, Critical Care, and Sleep Medicine (L.A.), and Transplant Institute (L.A.), New York University, New York, NY; Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.D.H.); and Department of Pathology, Vancouver Island Health Authority and University of British Columbia, Victoria, British Columbia, Canada (H.S.)
| | - William H Moore
- From the Department of Radiology (S.J.K., L.A., J.P.K., W.H.M.), Department of Pathology (F.Z., N.N., A.L.M.), Department of Pulmonology, Critical Care, and Sleep Medicine (L.A.), and Transplant Institute (L.A.), New York University, New York, NY; Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.D.H.); and Department of Pathology, Vancouver Island Health Authority and University of British Columbia, Victoria, British Columbia, Canada (H.S.)
| |
Collapse
|
13
|
Le Pavec J, Valeyre D, Gazengel P, Holm AM, Schultz HH, Perch M, Le Borgne A, Reynaud-Gaubert M, Knoop C, Godinas L, Hirschi S, Bunel V, Laporta R, Harari S, Blanchard E, Magnusson JM, Tissot A, Mornex JF, Picard C, Savale L, Bernaudin JF, Brillet PY, Nunes H, Humbert M, Fadel E, Gottlieb J. Lung transplantation for sarcoidosis: outcome and prognostic factors. Eur Respir J 2021; 58:13993003.03358-2020. [DOI: 10.1183/13993003.03358-2020] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 12/25/2020] [Indexed: 01/20/2023]
Abstract
Study questionIn patients with sarcoidosis, past and ongoing immunosuppressive regimens, recurrent disease in the transplant and extrapulmonary involvement may affect outcomes of lung transplantation. We asked whether sarcoidosis lung phenotypes can be differentiated and, if so, how they relate to outcomes in patients with pulmonary sarcoidosis treated by lung transplantation.Patients and methodsWe retrospectively reviewed data from 112 patients who met international diagnostic criteria for sarcoidosis and underwent lung or heart–lung transplantation between 2006 and 2019 at 16 European centres.ResultsPatient survival was the main outcome measure. At transplantation, median (interaquartile range (IQR)) age was 52 (46–59) years; 71 (64%) were male. Lung phenotypes were individualised as follows: 1) extended fibrosis only; 2) airflow obstruction; 3) severe pulmonary hypertension (sPH) and airflow obstruction; 4) sPH, airflow obstruction and fibrosis; 5) sPH and fibrosis; 6) airflow obstruction and fibrosis; 7) sPH; and 8) none of these criteria, in 17%, 16%, 17%, 14%, 11%, 9%, 5% and 11% of patients, respectively. Post-transplant survival rates after 1, 3, and 5 years were 86%, 76% and 69%, respectively. During follow-up (median (IQR) 46 (16–89) months), 31% of patients developed chronic lung allograft dysfunction. Age and extended lung fibrosis were associated with increased mortality. Pulmonary fibrosis predominating peripherally was associated with short-term complications.Answer to the study questionPost-transplant survival in patients with pulmonary sarcoidosis was similar to that in patients with other indications for lung transplantation. The main factors associated with worse survival were older age and extensive pre-operative lung fibrosis.
Collapse
|
14
|
Gerke AK. Treatment of Sarcoidosis: A Multidisciplinary Approach. Front Immunol 2020; 11:545413. [PMID: 33329511 PMCID: PMC7732561 DOI: 10.3389/fimmu.2020.545413] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 10/22/2020] [Indexed: 12/12/2022] Open
Abstract
Sarcoidosis is a systemic disease of unknown etiology defined by the presence of noncaseating granulomatous inflammation that can cause organ damage and diminished quality of life. Treatment is indicated to protect organ function and decrease symptomatic burden. Current treatment options focus on interruption of granuloma formation and propagation. Clinical trials guiding evidence for treatment are lacking due to the rarity of disease, heterogeneous clinical course, and lack of prognostic biomarkers, all of which contribute to difficulty in clinical trial design and implementation. In this review, a multidisciplinary treatment approach is summarized, addressing immunuosuppressive drugs, managing complications of chronic granulomatous inflammation, and assessing treatment toxicity. Discovery of new therapies will depend on research into pathogenesis of antigen presentation and granulomatous inflammation. Future treatment approaches may also include personalized decisions based on pharmacogenomics and sarcoidosis phenotype, as well as patient-centered approaches to manage immunosuppression, symptom control, and treatment of comorbid conditions.
Collapse
Affiliation(s)
- Alicia K Gerke
- Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Iowa, Iowa City, IA, United States
| |
Collapse
|
15
|
Recurrent Pulmonary Fibrosis in a Lung Allograft Secondary to De Novo Antisynthetase Syndrome. Ann Am Thorac Soc 2020; 17:901-904. [PMID: 32437253 DOI: 10.1513/annalsats.202002-126rl] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
16
|
Meyer KC. Lung transplantation for pulmonary sarcoidosis. SARCOIDOSIS VASCULITIS AND DIFFUSE LUNG DISEASES 2019; 36:92-107. [PMID: 32476942 DOI: 10.36141/svdld.v36i2.7163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 02/04/2019] [Indexed: 01/15/2023]
Abstract
Although relatively few patients with pulmonary sarcoidosis develop advanced disease that progresses to respiratory insufficiency despite receiving best practice pharmacologic interventions, lung transplantation may be the only therapeutic option for such patients to both prolong survival and provide improved quality of life. Lung transplant can be successfully performed for patients with end-stage pulmonary sarcoidosis, and post-transplant survival is similar to that for other transplant indications such as idiopathic pulmonary fibrosis. However, appropriate timing of referral, comprehensive assessment of potential candidates for lung transplant, placement of patients on the lung transplant waiting list when within the transplant window as appropriate, choosing the best procedure (bilateral versus single lung transplant), and optimal peri-operative and post-transplant management are key to successful lung transplant outcomes for patients with sarcoidosis.
Collapse
Affiliation(s)
- Keith C Meyer
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
| |
Collapse
|
17
|
Abstract
Sarcoidosis is a multi-system disease of unknown etiology, usually affecting the respiratory tract and other organs, and is characterized by the formation of nonnecrotizing epithelioid granulomas. The diagnosis depends on a combination of a typical clinicoradiological presentation, the finding of nonnecrotizing epithelioid granulomas in a tissue biopsy, and exclusion of other possible diseases, especially those of infectious etiology. The granulomas contain epithelioid cells, giant cells, CD4+ T cells in their center, and CD8+ T lymphocytes and B lymphocytes at their periphery. The granulomas are present in a lymphatic pattern around bronchovascular structures and, because of this, may show angioinvasion. The bronchial involvement produces a high diagnostic yield for transbronchial and endobronchial biopsies in this disease. Finally, small amounts of fibrinoid necrosis may occur within granulomas of sarcoidosis and do not exclude the diagnosis. Larger amounts suggest either infection or the rare disease necrotizing sarcoid granulomatosis (NSG). A number of cytoplasmic structures/inclusions can be identified within the granulomas of sarcoidosis, including asteroid bodies, Schaumann's bodies, calcium oxalate crystals, and Hamazaki-Wesenberg bodies; the last two of these can cause difficulties in differential diagnosis. Extra-pulmonary sarcoid can be an important factor in prognosis. Involved sites include (in decreasing frequency): skin, endocrine organs, extra-thoracic lymph nodes, neurologic sites, eyes, liver, spleen, bone marrow, cardiac, ear/nose/throat, parotid/salivary, muscles, bones/joint, and kidney. NSG is a controversial variant of sarcoidosis consisting of granulomatous pneumonitis with sarcoid-like granulomas, variable amounts of necrosis, and granulomatous vasculitis. The lesions are most often confined to lung, and they usually appear as multiple nodules or nodular infiltrates, but occasionally as solitary or unilateral nodules ranging up to 5 cm in diameter. Nodular sarcoidosis is rare, varying from 1.6% to 4% of patients with sarcoidosis, and, as the name suggests, it shows radiographic nodules measuring 1 to 5 cm in diameter that typically consist of coalescent granulomas. Lung transplantation can be used in selected patients with fibrotic late-stage sarcoidosis. There is a high reported frequency of recurrence of disease in the pulmonary allograft, ranging from 47% to 67%, but recurrence is usually not clinically significant. Studies of the pathogenesis of sarcoidosis suggest that it is a chronic immunological response produced by a genetic susceptibility and exposure to specific environmental factors.
Collapse
Affiliation(s)
- YanLing Ma
- Department of Lung Pathologist, KEck Medical Center of USC, Los Angeles, California
| | - Anthony Gal
- Department of Pathology, Emory School of Medicine, Atlanta, Georgia
| | - Michael Koss
- Department of Lung Pathologist, KEck Medical Center of USC, Los Angeles, California.
| |
Collapse
|
18
|
Raghu G, Carbone RG. Imaging of Lung Transplantation. LUNG TRANSPLANTATION 2018. [PMCID: PMC7121182 DOI: 10.1007/978-3-319-91184-7_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Lung transplantation has become a viable treatment option for end-stage lung disease. Common indications for lung transplantation are chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis, cystic fibrosis, alpha-1 antitrypsin deficiency, and pulmonary arterial hypertension. Either single or bilateral lung transplantation can be performed, but bilateral lung recipients appear to have a better median survival than single lung recipients. Complications after lung transplantation are common and may have nonspecific clinical and radiologic manifestations. The time point at which these complications occur relative to the date of transplant is crucial in formulating a differential diagnosis and recognizing them accurately. Significant advances in imaging techniques and recognition of air trapping in exhalation images and other patterns /distribution of parenchymal abnormalities have led to routine use of HRCT for diagnostic evaluation in patients manifesting respiratory decline in the lung transplant recipient.
Collapse
Affiliation(s)
- Ganesh Raghu
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine University of Washington, Seattle, Washington USA
| | | |
Collapse
|
19
|
Chia E, Babawale SN. Imaging features of intrathoracic complications of lung transplantation: What the radiologists need to know. World J Radiol 2017; 9:438-447. [PMID: 29354209 PMCID: PMC5746647 DOI: 10.4329/wjr.v9.i12.438] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 08/21/2017] [Accepted: 11/08/2017] [Indexed: 02/06/2023] Open
Abstract
Lung transplantation has been a method for treating end stage lung disease for decades. Despite improvements in the preoperative assessment of recipients and donors as well as improved surgical techniques, lung transplant recipients are still at a high risk of developing post-operative complications which tend to impact negatively the patients’ outcome if not recognised early. The recognised complications post lung transplantation can be broadly categorised into acute and chronic complications. Recognising the radiological features of these complications has a significant positive impact on patients’ survival post transplantation. This manuscript provides a comprehensive review of the radiological features of post lung transplantations complications over a time continuum.
Collapse
Affiliation(s)
- Elisa Chia
- Department of Radiology, Royal Perth Hospital, Wellington Street Campus, Perth, WA 6001, Australia
| | - Simeon Niyi Babawale
- Department of Radiology, Royal Perth Hospital, Wellington Street Campus, Perth, WA 6001, Australia
| |
Collapse
|
20
|
Abstract
The term interstitial lung diseases (ILD) comprises a diverse group of diseases that lead to inflammation and fibrosis of the alveoli, distal airways, and septal interstitium of the lungs. The ILD consist of disorders of known cause (e.g., collagen vascular diseases, drug-related diseases) as well as disorders of unknown etiology. The latter include idiopathic interstitial pneumonias (IIPs), and a group of miscellaneous, rare, but nonetheless interesting, diseases. In patients with ILD, MDCT enriches the diagnostic armamentarium by allowing volumetric high-resolution scanning, i.e., continuous data acquisition with thin collimation and a high spatial frequency reconstruction algorithm. CT is a key method in the identification and management of patients with ILD. It not only improves the detection and characterization of parenchymal abnormalities, but also increases the accuracy of diagnosis. The spectrum of morphologic characteristics that are indicative of interstitial lung disease is relatively limited and includes the linear and reticular pattern, the nodular pattern, the increased attenuation pattern (such as ground-glass opacities and consolidation), and the low attenuation pattern (such as emphysema and cystic lung diseases). In the correct clinical context, some patterns or combination of patterns, together with the anatomic distribution of the abnormality, i.e., from the lung apex to the base, or peripheral subpleural versus central bronchovascular, can lead the interpreter to a specific diagnosis. However, due to an overlap of the CT morphology between the various entities, the final diagnosis of many ILD requires close cooperation between clinicians and radiologists and complementary lung biopsy is recommended in many cases.
Collapse
Affiliation(s)
- Konstantin Nikolaou
- Department of Radiology, University Hospitals Tübingen, Tübingen, Baden-Württemberg Germany
| | - Fabian Bamberg
- Department of Diagnostic and Interventional Radiology, University of Freiburg, Freiburg, Germany
| | - Andrea Laghi
- Department of Surgical and Medical Sciences and Translational Medicine, “Sapienza” – University of Rome, Rome, Italy
| | - Geoffrey D. Rubin
- Department of Radiology, Duke University School of Medicine, Durham, NC USA
| |
Collapse
|
21
|
Sarcoïdose pulmonaire : aspects cliniques et modalités thérapeutiques. Rev Med Interne 2016; 37:594-607. [DOI: 10.1016/j.revmed.2016.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 01/18/2016] [Indexed: 11/22/2022]
|
22
|
Daimiel Naranjo I, Alonso Charterina S. What can happen after lung transplantation and the importance of the time since transplantation: Radiological review of post-transplantation complications. RADIOLOGIA 2016. [DOI: 10.1016/j.rxeng.2016.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
23
|
Tejwani V, Panchabhai TS, Kotloff RM, Mehta AC. Complications of Lung Transplantation. Chest 2016; 149:1535-45. [DOI: 10.1016/j.chest.2015.12.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Revised: 11/16/2015] [Accepted: 12/11/2015] [Indexed: 01/30/2023] Open
|
24
|
Daimiel Naranjo I, Alonso Charterina S. What can happen after lung transplantation and the importance of the time since transplantation: radiological review of post-transplantation complications. RADIOLOGIA 2016; 58:257-67. [PMID: 27017046 DOI: 10.1016/j.rx.2016.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Revised: 02/10/2016] [Accepted: 02/13/2016] [Indexed: 11/18/2022]
Abstract
Lung transplantation is the best treatment option in the final stages of diseases such as cystic fibrosis, pulmonary hypertension, chronic obstructive pulmonary disease, or idiopathic pulmonary fibrosis. Better surgical techniques and advances in immunosuppressor treatments have increased survival in lung transplant recipients, making longer follow-up necessary because complications can occur at any time after transplantation. For practical purposes, complications can be classified as early (those that normally occur within two months after transplantation), late (those that normally occur more than two months after transplantation), or time-independent (those that can occur at any time after transplantation). Many complications have nonspecific clinical and radiological manifestations, so the time factor is key to narrow the differential diagnosis. Imaging can guide interventional procedures and can detect complications early. This article aims to describe and illustrate the complications that can occur after lung transplantation from the clinical and radiological viewpoints so that they can be detected as early as possible.
Collapse
Affiliation(s)
- I Daimiel Naranjo
- Servicio de Radiodiagnóstico, Hospital Universitario 12 de Octubre, Madrid, España.
| | - S Alonso Charterina
- Servicio de Radiodiagnóstico, Hospital Universitario 12 de Octubre, Madrid, España
| |
Collapse
|
25
|
|
26
|
Abstract
PURPOSE OF REVIEW To present an update on the most recent contributions in advanced pulmonary sarcoidosis (APS). RECENT FINDINGS Pathology is better described and the differences between fibrosing pulmonary sarcoidosis and usual interstitial pneumonia (UIP) are clarified. Serial spirometry is the most reliable tool for monitoring evolution. Survival may be predicted by an integrative algorithm based on pulmonary function and computed tomography (CT). SUMMARY APS is characterized by significant fibrocystic pulmonary lesions at CT and pathology. There are two main patterns of APS, one with predominant central bronchovascular distortion, often associated with airflow limitation, and the other with predominant honeycombing with a different location than in UIP with severe restrictive impairment and very low diffusion capacity of the lung for carbon monoxide. APS may be burnt out but is most often still active as evidenced by several findings, including on F-fluorodeoxyglucose-PET. There is an increased mortality and morbidity with chronic respiratory insufficiency, pulmonary hypertension stemming from multiple mechanisms, chronic pulmonary aspergillosis and extra infections. Acute worsening episodes are frequent. Serial spirometry, particularly forced vital capacity, is the most reliable tool for monitoring evolution. A new elegant algorithm based on pulmonary function and CT may predict survival. Despite important stakes, there is still a lack of therapeutic recommendations. However, the use of antisarcoidosis treatment is most often required at least as a temporary trial. Finally, the effect of pulmonary hypertension treatment has recently been the object of further evaluation.
Collapse
|
27
|
Disease Recurrence and Acute Cellular Rejection Episodes During the First Year After Lung Transplantation Among Patients With Sarcoidosis. Transplantation 2015; 99:1940-5. [PMID: 25757213 DOI: 10.1097/tp.0000000000000673] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Sarcoidosis is reported to recur after lung transplantation (LT). We sought to determine the frequency of recurrent disease after LT and predictors of recurrence. We also evaluated the incidence and severity of acute cellular rejection (ACR) episodes among these patients. METHODS The database of LT patients at Cleveland Clinic was interrogated for sarcoidosis patients who underwent LT between May 1993 and 2011. Charts were reviewed for demographics, type of transplant, posttransplant biopsy findings, and outcomes. RESULTS Data were available for 30 patients (mean age, 50 ± 9.3 years; range, 30-65 years; M-to-F ratio, 17:13; single-to-double-to-heart lung ratio, 5:24:1). Recurrence of sarcoidosis was noted among 7 patients (pathological recurrence in all and radiological findings suggesting recurrence in 1 patient) with no impact on overall outcomes. Presence of granulomas on explanted lungs was the only predictor of recurrence (85.7% vs 30.4%, odds ratio, 13.7; 1.4-136.2; P = 0.02).Overall burden of ACR episodes on all bronchoscopies was significantly lower in patients with disease recurrence (7.6 % vs 21.3% of biopsies, P = 0.038). Among patients with recurrent disease, ACR did not develop once disease recurrence had been seen on transbronchial biopsy. CONCLUSIONS A significant proportion of sarcoidosis patients have disease recurrence after LT and presence of active granulomas on explant is associated with subsequent recurrence. There may be an association of recurrence with lower frequency of ACR episodes. There does not appear to be any impact of sarcoidosis recurrence on 1-, 3-, or 5-year survivals.
Collapse
|
28
|
Primary disease recurrence after single lung transplantation in a patient with prior hard metal exposure. J Heart Lung Transplant 2015; 34:1216-8. [DOI: 10.1016/j.healun.2015.05.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 05/02/2015] [Accepted: 05/28/2015] [Indexed: 11/19/2022] Open
|
29
|
Kern RM, Singer JP, Koth L, Mooney J, Golden J, Hays S, Greenland J, Wolters P, Ghio E, Jones KD, Leard L, Kukreja J, Blanc PD. Lung transplantation for hypersensitivity pneumonitis. Chest 2015; 147:1558-1565. [PMID: 25412059 PMCID: PMC4451710 DOI: 10.1378/chest.14-1543] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 10/10/2014] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Hypersensitivity pneumonitis (HP) is an inhaled antigen-mediated interstitial lung disease (ILD). Advanced disease may necessitate the need for lung transplantation. There are no published studies addressing lung transplant outcomes in HP. We characterized HP outcomes compared with referents undergoing lung transplantation for idiopathic pulmonary fibrosis (IPF). METHODS To identify HP cases, we reviewed records for all ILD lung transplantation cases at our institution from 2000 to 2013. We compared clinical characteristics, survival, and acute and chronic rejection for lung transplant recipients with HP to referents with IPF. We also reviewed diagnoses of HP discovered only by explant pathology and looked for evidence of recurrent HP after transplant. Survival was compared using Kaplan-Meier methods and Cox proportional hazard modeling. RESULTS We analyzed 31 subjects with HP and 91 with IPF among 183 cases undergoing lung transplantation for ILD. Survival at 1, 3, and 5 years after lung transplant in HP compared with IPF was 96%, 89%, and 89% vs 86%, 67%, and 49%, respectively. Subjects with HP manifested a reduced adjusted risk for death compared with subjects with IPF (hazard ratio, 0.25; 95% CI, 0.08-0.74; P = .013). Of the 31 cases, the diagnosis of HP was unexpectedly made at explant in five (16%). Two subjects developed recurrent HP in their allografts. CONCLUSIONS Overall, subjects with HP have excellent medium-term survival after lung transplantation and, relative to IPF, a reduced risk for death. HP may be initially discovered only by review of the explant pathology. Notably, HP may recur in the allograft.
Collapse
Affiliation(s)
- Ryan M Kern
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California San Francisco, San Francisco.
| | - Jonathan P Singer
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California San Francisco, San Francisco
| | - Laura Koth
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California San Francisco, San Francisco
| | - Joshua Mooney
- Division of Pulmonary and Critical Care Medicine, Stanford University, Palo Alto, CA
| | - Jeff Golden
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California San Francisco, San Francisco
| | - Steven Hays
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California San Francisco, San Francisco
| | - John Greenland
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California San Francisco, San Francisco
| | - Paul Wolters
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California San Francisco, San Francisco
| | - Emily Ghio
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California San Francisco, San Francisco
| | - Kirk D Jones
- Department of Pathology, Pulmonary Pathology and Cytopathology University of California San Francisco, San Francisco
| | - Lorriana Leard
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California San Francisco, San Francisco
| | - Jasleen Kukreja
- Division of Pulmonary and Critical Care Medicine, Stanford University, Palo Alto, CA
| | - Paul D Blanc
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California San Francisco, San Francisco; Division of Occupational and Environmental Medicine, University of California San Francisco; Division of Pulmonary and Critical Care Medicine, Stanford University, Palo Alto, CA
| |
Collapse
|
30
|
Arboleda R, Gonzalez O, Cortes M, Perez-Cerda F. Recurrent polymyositis-associated lung disease after lung transplantation. Interact Cardiovasc Thorac Surg 2015; 20:560-2. [PMID: 25574033 DOI: 10.1093/icvts/ivu423] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The association between interstitial lung disease and polymyositis/dermatomyositis is well known. It severely affects patients' quality of life, worsens prognosis and represents a major risk factor for premature death. Current treatment is unclear and therapeutic options are based on case series. We report the case of a 15-year old female diagnosed with end-stage lung disease associated to polymyositis who received a double lung transplant after 20 days of extracorporeal membrane oxygenation. She died 9 months later and microscopic post-mortem findings revealed recurrence of interstitial lung disease. This is the first time that recurrence of polymyositis-associated lung disease following lung transplantation is described in the literature.
Collapse
Affiliation(s)
- Rafael Arboleda
- Department of Anaesthesia, Hospital '12 de Octubre', Madrid, Spain
| | - Olga Gonzalez
- Department of Anaesthesia, Hospital '12 de Octubre', Madrid, Spain
| | - Manuel Cortes
- Department of Anaesthesia, Hospital '12 de Octubre', Madrid, Spain
| | | |
Collapse
|
31
|
Madan R, Chansakul T, Goldberg HJ. Imaging in lung transplants: Checklist for the radiologist. Indian J Radiol Imaging 2014; 24:318-26. [PMID: 25489125 PMCID: PMC4247501 DOI: 10.4103/0971-3026.143894] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Post lung transplant complications can have overlapping clinical and imaging features, and hence, the time point at which they occur is a key distinguisher. Complications of lung transplantation may occur along a continuum in the immediate or longer postoperative period, including surgical and mechanical problems due to size mismatch and vascular as well as airway anastomotic complication, injuries from ischemia and reperfusion, acute and chronic rejection, pulmonary infections, and post-transplantation lymphoproliferative disorder. Life expectancy after lung transplantation has been limited primarily by chronic rejection and infection. Multiple detector computed tomography (MDCT) is critical for evaluation and early diagnosis of complications to enable selection of effective therapy and decrease morbidity and mortality among lung transplant recipients.
Collapse
Affiliation(s)
- Rachna Madan
- Department of Thoracic Imaging, Lung Transplant Program, Brigham and Women's Hospital, Harvard Medical School, Massachusetts, USA
| | - Thanissara Chansakul
- Department of Radiology, Lung Transplant Program, Brigham and Women's Hospital, Harvard Medical School, Massachusetts, USA
| | - Hilary J Goldberg
- Department of Medicine, Lung Transplant Program, Brigham and Women's Hospital, Harvard Medical School, Massachusetts, USA
| |
Collapse
|
32
|
Shino MY, Lynch Iii JP, Fishbein MC, McGraw C, Oyama J, Belperio JA, Saggar R. Sarcoidosis-associated pulmonary hypertension and lung transplantation for sarcoidosis. Semin Respir Crit Care Med 2014; 35:362-71. [PMID: 25007088 DOI: 10.1055/s-0034-1376863] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Pulmonary hypertension (PH) is a significant complication of sarcoidosis, occurring in approximately 6 to > 20% of cases, and markedly increases mortality among these patients. The clinician should exercise a high index of suspicion for sarcoidosis-associated PH (SAPH) given the nonspecific symptomatology and the limitations of echocardiography in this patient population. The pathophysiology of PH in sarcoidosis is complex and multifactorial. Importantly, there are inherent differences in the pathogenesis of SAPH compared with idiopathic pulmonary arterial hypertension, making the optimal management of SAPH controversial. In this article, we review the epidemiology, diagnosis, prognosis, and treatment considerations for SAPH. Lung transplantation (LT) is a viable therapeutic option for sarcoid patients with severe pulmonary fibrocystic sarcoidosis or SAPH refractory to medical therapy. We discuss the role for LT in patients with sarcoidosis, review the global experience with LT in this population, and discuss indications and contraindications to LT.
Collapse
Affiliation(s)
- Michael Y Shino
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Joseph P Lynch Iii
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Michael C Fishbein
- Department of Pathology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Charles McGraw
- Department of Radiological Sciences, UCLA Medical Center, Los Angeles, California
| | - Jared Oyama
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - John A Belperio
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Rajan Saggar
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| |
Collapse
|
33
|
Hemmert C, Ohana M, Jeung MY, Labani A, Dhar A, Kessler R, Roy C. Imaging of lung transplant complications. Diagn Interv Imaging 2014; 95:399-409. [DOI: 10.1016/j.diii.2013.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
34
|
Abstract
Sarcoidosis is a systemic disease of unknown cause that is characterised by the formation of immune granulomas in various organs, mainly the lungs and the lymphatic system. Studies show that sarcoidosis might be the result of an exaggerated granulomatous reaction after exposure to unidentified antigens in individuals who are genetically susceptible. Several new insights have been made, particularly with regards to the diagnosis and care of some important manifestations of sarcoidosis. The indications for endobronchial ultrasound in diagnosis and for PET in the assessment of inflammatory activity are now better specified. Recognition of unexplained persistent disabling symptoms, fatigue, small-fibre neurological impairment, cognitive failure, and changes to health state and quality of life, has improved. Mortality in patients with sarcoidosis is higher than that of the general population, mainly due to pulmonary fibrosis. Predicted advances for the future are finding the cause of sarcoidosis, and the elucidation of relevant biomarkers, reliable endpoints, and new efficient treatments, particularly in patients with refractory sarcoidosis, lung fibrosis, and those with persistent disabling symptoms.
Collapse
Affiliation(s)
- Dominique Valeyre
- Department of Pneumology, Assistance Publique Hôpitaux de Paris, Avicenne University Hospital, Bobigny, France; University Paris 13, Sorbonne Paris Cité, Bobigny, France.
| | - Antje Prasse
- Department of Pneumology, University Hospital, Freiburg, Germany
| | - Hilario Nunes
- Department of Pneumology, Assistance Publique Hôpitaux de Paris, Avicenne University Hospital, Bobigny, France; University Paris 13, Sorbonne Paris Cité, Bobigny, France
| | - Yurdagul Uzunhan
- Department of Pneumology, Assistance Publique Hôpitaux de Paris, Avicenne University Hospital, Bobigny, France; University Paris 13, Sorbonne Paris Cité, Bobigny, France
| | - Pierre-Yves Brillet
- Department of Radiology, Assistance Publique Hôpitaux de Paris, Avicenne University Hospital, Bobigny, France; University Paris 13, Sorbonne Paris Cité, Bobigny, France
| | | |
Collapse
|
35
|
Abstract
Exacerbations of sarcoidosis are common. In particular, exacerbations of pulmonary sarcoidosis are reported in more than one-third of patients. Despite their frequent occurrence, there is little medical evidence concerning the definition, diagnosis, and treatment of pulmonary exacerbations of sarcoidosis. In this article, we propose a definition of acute pulmonary exacerbations of sarcoidosis (APES). We review the meager medical literature concerning the risk factors, diagnosis, and treatment of this condition. Given the limited information concerning APES, we acknowledge that this article is not a definitive resource but, rather, a position paper that will encourage greater consideration of the pathogenesis, diagnostic challenges, and treatment approaches to this condition. We believe that further focus on APES will improve the quality of care of patients with pulmonary sarcoidosis.
Collapse
Affiliation(s)
| | - Marc A Judson
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY.
| |
Collapse
|
36
|
Amesur NB, Orons PD, Iacono AT. Interventional techniques in the management of airway complications following lung transplantation. Semin Intervent Radiol 2011; 21:283-95. [PMID: 21331140 DOI: 10.1055/s-2004-861563] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The last four decades have seen tremendous advances in the field of pulmonary transplantation. Vast improvements in the areas of surgical transplantation techniques, immunosuppressive agents, and postoperative care have all contributed to improved survival of patients. Advances in noninvasive imaging and bronchoscopy have allowed the pulmonary transplant team to intervene early in patients presenting with airway complications, often using minimally invasive procedures such as endobronchial balloon dilation or stent placement, or both. Stent technology itself has also improved and stents may sometimes be customized for treatment of short airway lesions or to optimize continued airflow through the sides of stents by creating openings using balloons or bronchoscopically directed laser. Preliminary work with brachytherapy may be decreasing the need for secondary reinterventions. The authors present an overview of some of these conventional and novel approaches to the treatment of airway complications after lung transplantation.
Collapse
Affiliation(s)
- Nikhil B Amesur
- Assistant Professor of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | |
Collapse
|
37
|
Abstract
SARCOIDOSIS IS A SYSTEMIC INFLAMMATORY CONDITION WITH AN UNEXPLAINED PREDILECTION FOR THE LUNG: over 90% of patients have radiographic or physiological abnormalities. Respiratory physicians therefore often manage patients, but any organ may be involved, with noncaseating granulomas the characteristic feature. Sarcoidosis is the commonest interstitial lung disease (ILD), differing from most other ILDs in that many patients remain asymptomatic or improve spontaneously. Careful baseline assessment of disease distribution and severity is thus central to initial management. Subsequently, the unpredictable clinical course necessitates regular monitoring. Sarcoidosis occurs worldwide, with a high prevalence in Afro-Caribbeans and those of Swedish or Danish origin. African Americans also tend to have severe disease. Oral corticosteroids have been used since the 1950s, with evidence of short to medium response; more recent studies have examined the role of inhaled steroids. Long-term benefits of steroids remain uncertain. International guidelines published in 1999 represent a consensus view endorsed by North American and European respiratory societies. Updated British guidelines on interstitial lung disease, including sarcoidosis, were published in 2008. This review describes current management strategies for pulmonary disease, including oral and inhaled steroids, commonly used alternative immunosuppressant agents, and lung transplantation. Tumor necrosis factor alpha inhibitors are briefly discussed.
Collapse
Affiliation(s)
- Robina Kate Coker
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| |
Collapse
|
38
|
|
39
|
Abstract
Sarcoidosis is a multi-system disease of unknown etiology, usually affecting the respiratory tract and other organs, and is characterized by the formation of nonnecrotizing epithelioid granulomas. The diagnosis depends on a combination of a typical clinicoradiological presentation, the finding of nonnecrotizing epithelioid granulomas in a tissue biopsy, and exclusion of other possible diseases, especially those of infectious etiology. The granulomas contain epithelioid cells, giant cells, CD4+ T cells in their center, and CD8 + T lymphocytes and B lymphocytes at their periphery. The granulomas are present in a lymphatic pattern around bronchovascular structures and, because of this, may show angioinvasion. The bronchial involvement produces a high diagnostic yield for transbronchial and endobronchial biopsies in this disease. Finally, small amounts of fibrinoid necrosis may occur within granulomas of sarcoidosis and do not exclude the diagnosis. Larger amounts suggest either infection or the rare disease necrotizing sarcoid granulomatosis (NSG). A number of cytoplasmic structures/inclusions can be identified within the granulomas of sarcoidosis, including asteroid bodies, Schaumann's bodies, calcium oxalate crystals, and Hamazaki-Wesenberg bodies; the last two of these can cause difficulties in differential diagnosis. Extra-pulmonary sarcoid can be an important factor in prognosis. Involved sites include (in decreasing frequency): skin, endocrine organs, extra-thoracic lymph nodes, neurologic sites, eyes, liver, spleen, bone marrow, cardiac, ear/nose/throat, parotid/ salivary, muscles, bones/joint, and kidney. NSG is a controversial variant of sarcoidosis consisting of granulomatous pneumonitis with sarcoid-like granulomas, variable amounts of necrosis, and granulomatous vasculitis. The lesions are most often confined to lung, and they usually appear as multiple nodules or nodular infiltrates, but occasionally as solitary or unilateral nodules ranging up to 5 cm in diameter. Nodular sarcoidosis is rare, varying from 1.6% to 4% of patients with sarcoidosis, and, as the name suggests, it shows radiographic nodules measuring 1 to 5 cm in diameter that typically consist of coalescent granulomas. Lung transplantation can be used in selected patients with fibrotic late-stage sarcoidosis. There is a high reported frequency of recurrence of disease in the pulmonary allograft, ranging from 47% to 67%, but recurrence is usually not clinically significant. Studies of the pathogenesis of sarcoidosis suggest that it is a chronic immunological response produced by a genetic susceptibility and exposure to specific environmental factors.
Collapse
Affiliation(s)
- YanLing Ma
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | | | | |
Collapse
|
40
|
Krishnam MS, Suh RD, Tomasian A, Goldin JG, Lai C, Brown K, Batra P, Aberle DR. Postoperative complications of lung transplantation: radiologic findings along a time continuum. Radiographics 2007; 27:957-74. [PMID: 17620461 DOI: 10.1148/rg.274065141] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In the past decade, lung transplantation has become established as an accepted therapy for end-stage pulmonary disease. Complications of lung transplantation that may occur in the immediate or longer postoperative term include mechanical problems due to a size mismatch between the donor lung and the recipient thoracic cage; malposition of monitoring tubes and lines; injuries from ischemia and reperfusion; acute pleural events; hyperacute, acute, and chronic rejection; pulmonary infections; bronchial anastomotic complications; pulmonary thromboembolism; upper-lobe fibrosis; primary disease recurrence; posttransplantation lymphoproliferative disorder; and native lung complications such as hyperinflation, malignancy, and infection. Radiologic imaging--particularly chest radiography, computed tomography (CT), and high-resolution CT--is critical for the early detection, evaluation, and diagnosis of complications after lung transplantation. To enable the selection of an effective and relevant course of therapy and, ultimately, to decrease morbidity and mortality among lung transplant recipients, radiologists at all levels of experience must be able to recognize and understand the imaging manifestations of posttransplantation complications.
Collapse
Affiliation(s)
- Mayil S Krishnam
- Department of Radiological Sciences, David Geffen School of Medicine, University of California at Los Angeles, Peter V. Ueberroth Bldg, Suite 3371, 10945 LeConte Ave, Los Angeles, CA 90095-7206, USA.
| | | | | | | | | | | | | | | |
Collapse
|
41
|
Isnard J, Trogrlic S, Haloun A, Sagan C, Germaud P, Bommart S, Dupas B. [Heart and heart-lung transplants thorax complications: major radiologic forms]. ACTA ACUST UNITED AC 2007; 88:339-48. [PMID: 17457265 DOI: 10.1016/s0221-0363(07)89830-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Bipulmonary and cardiopulmonary transplantations are among the most difficult to perform, with a 10-year survival rate estimated at 33%. This low rate can be attributed to thoracic complications that can be classified into three distinct groups: 1) early complications, occurring in the first 30 days after transplantation (hemothorax, diaphragmatic paralysis, reperfusion edema, hydric overloading, acute rejection); 2) late complications that occur beyond the first month (bronchiolitis obliterans syndrome, bronchic stenosis, sirolimus-induced lung disorders, initial disease recurrence); and 3) infections classed separately because of their high morbidity and mortality (thoracic wall abscess, bacterial and viral pneumonia, CMV, pneumocystosis, Aspergillus necrotizing bronchitis). Imaging is essential in screening and diagnosing these complications as part of the clinician's monitoring throughout the rest of the transplant recipient's life. In diagnosis, combined with clinical and biological data, imaging has its place in delaying the onset of these diseases.
Collapse
Affiliation(s)
- J Isnard
- Service de Radiologie Générale, Site Hospitalier Nord, Boulevard Jean Monod, Saint Herblain Cedex, France.
| | | | | | | | | | | | | |
Collapse
|
42
|
Chen F, Hasegawa S, Bando T, Kitaichi M, Hiratsuka T, Kawashima M, Hanaoka N, Yoshimura T, Tanaka F, Trulock EP, Wada H. Recurrence of bilateral diffuse bronchiectasis after bilateral lung transplantation. Respirology 2007; 11:666-8. [PMID: 16916346 DOI: 10.1111/j.1440-1843.2006.00904.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
We report two cases of bilateral diffuse bronchiectasis in which early recurrence of the original lung disease occurred after bilateral lung transplantation (LT). Patient 1 underwent cadaveric LT. Recurrent bronchiectasis occurred 4 months later, and he died 6 years after LT. Patient 2 underwent living-related lobar LT, bronchiectasis relapsed 4 months later, and he died 13 months after LT. Both cases were finally diagnosed as bilateral diffuse bronchiectasis by the pathological features of the explanted lungs: infiltration of inflammatory cells predominantly in the conducting airways with dilation of the bronchi of bilateral lungs and scarcity of foamy macrophages in the wall of the respiratory bronchioles. Similar pathological features were seen in autopsy specimens from patient 1 and a transbronchial biopsy specimen from patient 2. LT should be carried out with caution in patients with bilateral diffuse bronchiectasis. When performing LT in such patients, it is suggested that sinusitis should be controlled perioperatively.
Collapse
Affiliation(s)
- Fengshi Chen
- Department of Thoracic Surgery, Kyoto University Hospital, Kyoto, Japan
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Recurrent and de novo disease in kidney, heart, lung, pancreas and intestinal transplants. Curr Opin Organ Transplant 2006. [DOI: 10.1097/01.mot.0000227848.67570.50] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
44
|
Pakhale SS, Hadjiliadis D, Howell DN, Palmer SM, Gutierrez C, Waddell TK, Chaparro C, Davis RD, Keshavjee S, Hutcheon MA, Singer LG. Upper lobe fibrosis: a novel manifestation of chronic allograft dysfunction in lung transplantation. J Heart Lung Transplant 2006; 24:1260-8. [PMID: 16143243 DOI: 10.1016/j.healun.2004.08.026] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2003] [Revised: 07/25/2004] [Accepted: 08/14/2004] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Lung transplantation is an established treatment modality for a number of chronic lung diseases. Long-term survival after lung transplantation is limited by chronic allograft dysfunction, usually manifested by bronchiolitis obliterans syndrome. We describe a case series with upper lobe fibrosis, a novel presentation of chronic allograft dysfunction. METHODS We reviewed lung transplants at the Toronto General Hospital and Duke University Hospital from 1990 to 2002 and identified patients with upper lobe fibrosis. RESULTS Thirteen of 686 patients (6 women) developed upper lobe fibrosis (Toronto, 9; Duke, 4); 12 of 13 had bilateral transplants. The median age at diagnosis was 42 years (range, 19-70). Primary diagnoses were cystic fibrosis, 6; emphysema, 4; sarcoidosis, 1; and pulmonary fibrosis, 2 patients. Radiographic diagnosis was made at a median of 700 days post-transplant (range, 150-2,920). Pulmonary function tests demonstrated predominantly a progressively worsening restrictive pattern. Open lung biopsy specimens revealed dense interstitial fibrosis, with occasional features of obliterative bronchitis, bronchiolitis obliterans obstructive pneumonia, and aspiration. Nine patients died at a median follow-up of 2,310 days (range, 266-3,740), 8 due to respiratory failure. CONCLUSION Upper lobe fibrosis is a novel presentation of chronic allograft dysfunction in lung transplant recipients and is differentiated from bronchiolitis obliterans syndrome on the basis of physiologic and radiologic findings.
Collapse
Affiliation(s)
- Smita Sakha Pakhale
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Chughtai A, Cronin P, Kelly AM, Kazerooni EA. Lung transplantation imaging in the adult. Semin Roentgenol 2006; 41:26-35. [PMID: 16376169 DOI: 10.1053/j.ro.2005.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Aamer Chughtai
- Department of Radiology, Division of Thoracic Radiology, University of Michigan Medical Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | | | | | | |
Collapse
|
46
|
Ionescu DN, Hunt JL, Lomago D, Yousem SA. Recurrent sarcoidosis in lung transplant allografts: granulomas are of recipient origin. ACTA ACUST UNITED AC 2005; 14:140-5. [PMID: 16106194 DOI: 10.1097/01.pas.0000176765.26047.6f] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Sarcoidosis accounts for only 2.8% of lung transplants in the United States. It is, however, the most commonly reported disease to recur after lung transplantation. In most cases, recurrence is diagnosed as an incidental finding in transbronchial lung allograft biopsy (TBLAB) and is unrelated to clinical or radiologic abnormalities. The origin of the histiocytes composing the noncaseating granulomas in the allograft lung in patients with recurrent sarcoidosis (RS) was analyzed using DNA identity testing in 4 cases. MATERIAL AND METHODS Native lung resections and corresponding transbronchial biopsies from patients who underwent lung transplantation for sarcoidosis between 1990 and 2004 and who developed RS were gathered from the paraffin block archives of University of Pittsburgh Medical Center. Clinical parameters including age, sex, grade of rejection, number of episodes of RS, and follow-up were recorded. Native lungs and corresponding TBLAB showing granulomas consistent with RS were microdissected in cases where adequate material was available. DNA was extracted, and an ABI AmpflSTR commercial kit was used to simultaneously amplify 15 short tandem repeat (STR) loci as well as 1 marker for the XY chromosomes. The informative STR loci in native lung (pure recipient), nongranulomatous donor lung, and granulomas in donor lung were analyzed in 4 patients. The relative proportion of donor and recipient cells in the chimera was quantified using the fluorescence intensity of each peak on an electropherogram. FISH analysis using probes targeted to X and Y chromosomes was performed in a case of sex-mismatched lung transplantation. RESULTS Eight patients with RS were identified. Two had bilateral lung transplantation, and the remaining 6 had single-lung transplantation. The age at transplantation ranged between 39 and 53. Five were females and 3 were men. Recurrent disease was diagnosed in 1 to 11 biopsies per patient and occurred first in the first 6 months following transplantation in 2 cases (25%), between 6 months and 1 year in 2 other cases (25%), and between 1 and 2 years in 4 cases (50%). In 4 patients, sufficient material allowed for DNA analysis. Amplification failed in 1 of the 4 cases, while the other 3 were successful. Patient 1 showed no ACR and granulomatous inflammation of RS in TBLAB. Donor (D) to recipient (R) profile changed from "normal" donor lung (37% D, 63% R) to 15% D and 85% R DNA in the granuloma. In patient 2, the TBLAB showed minimal ACR and granulomatous inflammation. D to R profile changed from 75% D and 25% R in the "normal" D lung to 54% D and 46% R in the granuloma. Patient 3 showed no ACR and RS in TBLAB. D to R profile changed from 85% D and 15% R in the "normal" D lung to 71% D and 29% R in the granuloma. FISH analysis showed a predominance of male cells of recipient origin. CONCLUSIONS DNA analysis of 3 cases of RS suggests that the presence of recurrent granulomas in the graft is associated with an increase in the percentage of recipient DNA in the epithelioid cell clusters, as confirmed by the FISH analysis of 1 case.
Collapse
Affiliation(s)
- Diana N Ionescu
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA 15213, USA.
| | | | | | | |
Collapse
|
47
|
Abstract
The aim of this article is to clarify radiographic definitions associated with common parenchymal patterns encountered in the transplant population and to discuss the most common pathologic causes responsible for each pattern. The article also touches on radiographic findings signifying complications of other intrathoracic structures, including the airways, pleural space, and mediastinum.
Collapse
Affiliation(s)
- Rosita M Shah
- Division of Thoracic Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA 19107, USA.
| | | |
Collapse
|
48
|
Lederer DJ, Kawut SM, Sonett JR, Vakiani E, Seward SL, White JG, Wilt JS, Marboe CC, Gahl WA, Arcasoy SM. Successful Bilateral Lung Transplantation for Pulmonary Fibrosis Associated With the Hermansky-Pudlak Syndrome. J Heart Lung Transplant 2005; 24:1697-9. [PMID: 16210149 DOI: 10.1016/j.healun.2004.11.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2004] [Revised: 10/12/2004] [Accepted: 11/12/2004] [Indexed: 10/25/2022] Open
Abstract
Hermansky-Pudlak syndrome (HPS) is a genetic disorder characterized by oculocutaneous albinism, a bleeding diathesis, and in a subset of patients, pulmonary fibrosis. Lung transplantation, the only curative therapy for pulmonary fibrosis, has not been previously reported as a successful treatment strategy for patients with HPS because the bleeding diathesis was thought to contraindicate major thoracic surgery. We successfully performed bilateral sequential lung transplantation in a patient with pulmonary fibrosis and HPS after transfusion of 6 units of platelets. Lung transplantation is a viable therapeutic option in patients with pulmonary fibrosis and only a mild bleeding diathesis associated with HPS.
Collapse
Affiliation(s)
- David J Lederer
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Abstract
Sarcoidosis is a multisystemic disease of unknown aetiology characterized by the formation of immune granulomas in involved organs. It is a worldwide disease that mainly affects 25-40 years old people with a lifetime incidence rate of 0.85-2.4%. Multiple clinical phenotypes are observed according to presentation, involved organs, disease duration and severity. Sarcoidosis primarily affects the lungs and the lymphatic system. The prevailing pathogenic hypothesis is that various antigens could promote sarcoidosis in genetically susceptible hosts, both these factors modulating the incidence and the clinical phenotype of sarcoidosis. So far, environmental agents have been suspected, including possible mycobacteria and propionibacteria. Interferon-gamma, tumour necrosis factor (TNF)-alpha, interleukin (IL)-12 and IL-18 play a critical role in driving the Th1 commitment in the course of granulomatous process. Evolution of sarcoidosis is often marked by spontaneous resolution within 12-36 months, but can be severe because of chronic cases with pulmonary fibrosis or involving other organs, including heart, central nervous system and eyes. Mortality, ranging between 0.5 and 5%, is most often related to pulmonary fibrosis. Corticosteroids can reverse the granulomatous process, but are only suspensive, and their long-term benefit remains under question. Corticosteroids are recommended when sarcoidosis shows unfavourable clinical tolerance and evolution. Alternative and corticosteroid-sparing therapies are of increased interest in difficult cases, while targeted new drugs such as anti-TNF-alpha are still under investigation.
Collapse
Affiliation(s)
- H Nunes
- Service de Pneumologie, Hôpital Avicenne, GHU Nord, Assistance Publique Hôpitaux de Paris et Faculté de Médecine, Université Paris, Bobigny, France
| | | | | |
Collapse
|
50
|
Abstract
Although a rare condition, pulmonary alveolar proteinosis (PAP) can be a very devastating diagnosis with life-altering consequences. This case study follows the path of a young woman who is currently undergoing whole lung lavage as treatment for pulmonary alveolar proteinosis. The entire concept of flooding a lung with large quantities of saline as a treatment for lung disease is contrary to normal respiratory care. Caring for the patient with PAP provides many challenges for the perianesthesia nurse. Management of the postanesthesia airway, oxygen administration and maintenance of oxygen saturation, and pain relief skills are all of high importance to the patient with PAP. These skills plus the emotional support provided by the experienced perianesthesia nurse can ensure a safe recovery from this unusual procedure.
Collapse
Affiliation(s)
- Kathleen J Menard
- UM Memorial UMass Memorial Medical Center, Worcester, MA 01605, USA.
| |
Collapse
|