Recurrence of sarcoidosis in pulmonary allograft recipients

Lung transplantation in pulmonary sarcoidosis

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.

Clinical and Histopathologic Characteristics of Recurrent Sarcoidosis in Posttransplant Lungs: 25 Years of Experience

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.

An expert overview of pulmonary fibrosis in sarcoidosis

INTRODUCTION

Advanced pulmonary sarcoidosis refers to phenotypes of pulmonary sarcoidosis that often lead to significant loss of lung function, respiratory failure, or death. Around 20% of patients with sarcoidosis may progress to this state which is mainly driven by advanced pulmonary fibrosis. Advanced fibrosis often presents with associated complications of sarcoidosis including infections, bronchiectasis, and pulmonary hypertension.

AREAS COVERED

This article will focus on the pathogenesis, natural history of disease, diagnosis, and potential treatment options of pulmonary fibrosis in sarcoidosis. In the expert opinion section, we will discuss the prognosis and management of patients with significant disease.

EXPERT OPINION

While some patients with pulmonary sarcoidosis remain stable or improve with anti-inflammatory therapies, others develop pulmonary fibrosis and further complications. Although advanced pulmonary fibrosis is the leading cause of death in sarcoidosis, there are no evidence-based guidelines for the management of fibrotic sarcoidosis. Current recommendations are based on expert consensus and often include multidisciplinary discussions with experts in sarcoidosis, pulmonary hypertension, and lung transplantation to facilitate care for such complex patients. Current works evaluating treatments include the use of antifibrotic therapies for treatment in advanced pulmonary sarcoidosis.

Recurrence of primary disease following lung transplantation

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

Living Kidney Donation From a Donor With Pulmonary Sarcoidosis: A Case Report and Review of the Literature

BACKGROUND

Sarcoidosis is a chronic systemic disease that is characterized by the formation of noncaseating granuloma and whose etiology is unclear. It is unclear whether patients with sarcoidosis are suitable organ donors.

CASE

We treated a 56-year-old woman with pulmonary sarcoidosis who donated her kidney. She was previously in good health and was diagnosed with pulmonary sarcoidosis during her preoperative examination. Because she presented with no symptoms and was otherwise in good condition, donor nephrectomy was performed.

RESULTS

Baseline biopsy examination showed no evidence of sarcoidosis. One year after transplantation, both the donor and the recipient had not developed kidney dysfunction or recurrence of sarcoidosis.

CONCLUSION

This is a rare case in which a patient with pulmonary sarcoidosis donated a kidney for transplantation, and both the recipient and the donor were clinically healthy. A patient with sarcoidosis and no kidney lesion can donate a living kidney, because transplantation appears to be safe for both the recipient and the donor.

Etiologies of Sarcoidosis

Since sarcoidosis was first described more than a century ago, the etiologic determinants causing this disease remain uncertain. Studies suggest that genetic, host immunologic, and environmental factors interact together to cause sarcoidosis. Immunologic characteristics of sarcoidosis include non-caseating granulomas, enhanced local expression of T helper-1 (and often Th17) cytokines and chemokines, dysfunctional regulatory T-cell responses, dysregulated Toll-like receptor signaling, and oligoclonal expansion of CD4+ T cells consistent with chronic antigenic stimulation. Multiple environmental agents have been suggested to cause sarcoidosis. Studies from several groups implicate mycobacterial or propionibacterial organisms in the etiology of sarcoidosis based on tissue analyses and immunologic responses in sarcoidosis patients. Despite these studies, there is no consensus on the nature of a microbial pathogenesis of sarcoidosis. Some groups postulate sarcoidosis is caused by an active viable replicating infection while other groups contend there is no clinical, pathologic, or microbiologic evidence for such a pathogenic mechanism. The authors posit a novel hypothesis that proposes that sarcoidosis is triggered by a hyperimmune Th1 response to pathogenic microbial and tissue antigens associated with the aberrant aggregation of serum amyloid A within granulomas, which promotes progressive chronic granulomatous inflammation in the absence of ongoing infection.

Neurosarcoidosis Presenting as Aseptic Meningitis in an Immunosuppressed Renal Transplant Recipient

BACKGROUND

Sarcoidosis is a presumptive autoimmune disorder characterized by the presence of noncaseating granulomas and is usually treated successfully with immunosuppression.

METHODS AND RESULTS

Here, we describe the case of a 63-year-old male renal transplant recipient with a remote history of pulmonary sarcoidosis on chronic immunosuppression who developed recurrent aseptic meningitis and underwent brain biopsy revealing a diagnosis of neurosarcoidosis.

CONCLUSIONS

This case highlights the possibility of recurrence of sarcoidosis in the setting of maintenance immunosuppression, the need for heightened awareness of alternative sites of recurrence of autoimmune disease, and future studies to determine the underlying mechanism of recurrence in organ transplant recipients.

Disease Recurrence and Acute Cellular Rejection Episodes During the First Year After Lung Transplantation Among Patients With Sarcoidosis

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.

Pulmonary fibrosis in sarcoidosis. Clinical features and outcomes

Sarcoidosis is a systemic inflammatory disease with a predilection for the respiratory system. Although most patients enter remission and have good long-term outcomes, up to 20% develop fibrotic lung disease, whereby granulomatous inflammation evolves to pulmonary fibrosis. There are several radiographic patterns of pulmonary fibrosis in sarcoidosis; bronchial distortion is common, and other patterns, including honeycombing, are variably observed. The development of pulmonary fibrosis is associated with significant morbidity and can be fatal. Dyspnea, cough, and hypoxemia are frequent clinical manifestations. Pulmonary function testing often demonstrates restriction from parenchymal involvement, although airflow obstruction from airway-centric fibrosis is also recognized. Complications of fibrotic pulmonary sarcoidosis include pulmonary hypertension from capillary obliteration and chronic aspergillus disease, with hemoptysis a common and potentially life-threatening manifestation. Immunosuppression is not always indicated in end-stage sarcoidosis. Lung transplantation should be considered for patients with severe fibrotic pulmonary sarcoidosis, as mortality is high in these patients.

Acute pulmonary exacerbations of sarcoidosis

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.

Lung transplantation for interstitial lung disease

For selected parenchymal lung disease patients who fail to respond to medical therapy and demonstrate declines in function that place them at increased risk for mortality, lung transplantation should be considered. Lung transplantation remains a complex medical intervention that requires a dedicated recipient and medical team. Despite the challenges, lung transplantation affords appropriate patients a reasonable chance at increased survival and improved quality of life. Lung transplantation remains an appropriate therapeutic option for selected patients with parenchymal lung disease.

Comparison between referral diagnosis of patients requiring transplantation and pathologic diagnosis of native lungs

BACKGROUND

The donor organs available for lung transplantation remain far fewer than the number of recipients. Therefore, it is of primary importance to optimize this resource, especially by carefully selecting potential recipients. The diagnosis of end-stage diseases referred for transplantation is mainly based on clinical/radiologic assessment and rarely on histology.

METHODS

A clinicopathologic study was performed on 175 patients who underwent lung transplantation over a 12-year period (1995 to 2007). Diagnoses on native lungs were compared with referral diagnoses to assess the presence of discrepancies. In particular, major discrepancies included complete mismatch between referral and pathologic diagnoses and other additional findings likely to affect patient management.

RESULTS

Major discrepancies were found in 18 of 175 cases (10%). The highest percentage of discordance was found in diffuse parenchymal lung diseases, more frequently idiopathic pulmonary fibrosis (IPF). In the majority of IPF and other non-IPF idiopathic forms, there was often an imprecise nosographic definition of the diseases. Unsuspected additional findings included Aspergillus and mycobacterial infections, carcinomas and carcinoids. Short-term survival is significantly lower in patients with discrepancies than in those without.

CONCLUSIONS

On the basis of the high rate and importance of discrepancies, more accurate and repeated clinicopathologic investigations should be planned in the waiting list period.

The intricacies of cardiac sarcoidosis: a case report involving the coronary arteries and a review of the literature

BACKGROUND

Primary cardiac sarcoidosis (CS) is rare, and concomitant involvement of the coronary arteries is rarer still. Successful diagnosis of this disease is difficult due to its nonspecific symptoms which mimic those of idiopathic dilated cardiomyopathy (IDCM).

METHODS AND RESULTS

We describe a 47-year-old Caucasian male who underwent orthotopic heart transplant for presumed IDCM. Examination of the explanted heart revealed numerous nonnecrotizing granulomata throughout, similar granulomata in the walls of the large coronary arteries, and large areas of fibrosis.

CONCLUSIONS

In cases of IDCM with symptoms of angina or acute coronary syndrome, the possibility of CS should be considered. Herein, we present this case and a review of the relevant literature.

Recurrent sarcoidosis in lung transplant allografts: granulomas are of recipient origin

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.

Lung transplantation and interstitial lung disease

PURPOSE OF REVIEW

Interstitial lung disease includes a heterogeneous group of disorders that leads to respiratory insufficiency and death in a significant number of patients. Lung transplantation is a therapeutic option in select candidates.

RECENT FINDINGS

The indications, transplant procedure options, and outcomes continue to evolve. Various recipient comorbidities influence the choice of procedure in patients with interstitial lung disease. Single lung transplants are used as the procedure of choice and bilateral transplants are reserved for patients with suppurative lung disease and patients with pulmonary hypertension. Issues unique to patients with interstitial lung disease affect the morbidity, mortality and recurrence of the disease.

SUMMARY

Lung transplantation is an effective therapy for respiratory failure in interstitial lung disease with survival following transplant being similar to that achieved in transplant recipients with other diseases.

Lung transplantation for interstitial lung disease

Lung transplantation remains the only therapeutic option shown to improve survival for many end-stage interstitial lung diseases. Although idiopathic pulmonary fibrosis is the most common indication, transplantation has been performed for many other diseases. This article reviews the current indications and outcomes for the procedure and problems encountered in lung transplantation for interstitial lung diseases. The role of transplant for specific diseases also is discussed.

Pathology of interstitial lung disease

A large and diverse group of pathologic conditions manifests clinically and radiologically as diffuse parenchymal lung disease. Diffuse interstitial lung diseases (ILDs) encompass mainly inflammatory processes that involve the structural elements of this organ. Some ILDs are caused by infections, but most are the result of immunologic, environmental, or toxic mechanisms. Currently, less morbid sampling techniques have increased dramatically the probability that pulmonologists will be faced with establishing a specific and clinically relevant diagnosis using surgical lung biopsy material. Most of the concepts presented in this article have been established using this type of specimen. In the early years of surgical lung biopsy, a small number of diffuse inflammatory conditions came to light that exclusively involved the lungs and did not seem to be caused by infection, toxin, sarcoidosis, pneumoconiosis, or neoplasm. In this article, these idiopathic disorders are discussed in the context of their dominant pathologic findings rather than presented as a separate group of entities.

Recurrence of Pulmonary Emphysema in an α-1 Proteinase Inhibitor-deficient Lung Transplant Recipient

Several types of primary disease may recur after lung transplantation, but recurrence of pulmonary emphysema has so far never been published. We report the case of a 49-year-old white male who underwent single lung transplantation for emphysema related to alpha-1 antitrypsin deficiency and to superimposed smoking. The postoperative course was complicated by several rejection episodes. Subsequently, the patient remained stable without evidence of graft dysfunction for more than 10 years, but he resumed light smoking at 8 years after transplant. At 11 years after transplant, although the patient was still asymptomatic and had a stable lung function, recurrence of emphysema on the grafted side was diagnosed on computerized tomography of the thorax. One year later, the patient began to experience a moderate decline in lung function. Two separate bronchoalveolar lavages performed after the onset of the recurrence disclosed a significant elastolytic activity related to neutrophil serine-elastase in lavage fluid. In summary, we describe a case of recurrence of pulmonary emphysema in a patient with alpha-1 antitrypsin deficiency. The resumption of smoking has probably played a central role in the presence of elastolytic activity in lavage fluid and in the recurrence of emphysema.

Bronchoalveolar lavage in a patient with recurrence of sarcoidosis after lung transplantation

End-stage pulmonary disease due to sarcoidosis rarely leads to lung transplantation. Once a patient has undergone lung transplantation, sarcoidosis often recurs in the lung allograft. In this case report we show, for the first time, the utility of bronchoalveolar lavage fluid in diagnosing the recurrence of sarcoidosis in the transplanted allograft.

Obstructive sarcoidosis

Sarcoidosis is a systemic granulomatous disease that frequently involves the lung. Although classically thought of as a restrictive lung disease, airway obstruction has become a recognized feature of the disease in the past years. Sarcoidosis can affect the airway at any level and when the involvement includes small airways, it can resemble more common obstructive airway diseases, such as asthma and chronic bronchitis. Pulmonary function testing and high-resolution computerized tomography of the chest are two important tools to evaluate the presence and extent of airway obstruction in sarcoidosis. Pharmacologic options for the treatment of obstructive sarcoidosis are, in large part, not supported by large, randomized clinical trials. In severe cases of bronchostenosis owing to sarcoidosis granuloma or extrinsic compression from intrathoracic lymphadenopathy, interventional bronchoscopy has successfully been performed, although repeated procedures are usually required. Lung transplantation is an ultimate option in selected patients with late-stage fibrotic disease.

Selection of patients and techniques of heart transplantation

Cardiac transplantation remains the primary therapeutic choice for most patients under 65 years of age with advanced heart failure who remain symptomatic despite maximal medical therapy. Cardiac transplantation should be reserved for those patients most likely to benefit in terms of both life expectancy and quality of life. The concept of survival benefit margin must be balanced with the principles of utility in the selection process. A critical component of outcomes research for advanced heart failure will be the generation of accurate data and analyses which predict long-term survival and quality of life with various therapeutic modalities. Patients with multiple comorbidities have inferior survival and might be considered for alternative therapies. We currently recommend the bicaval techniques as the transplant technique of choice except in small infants and children.

Recurrence of idiopathic pulmonary hemosiderosis in a young adult patient after bilateral single-lung transplantation

BACKGROUND

Idiopathic pulmonary hemosiderosis (IPH) is a rare disease of unknown etiology characterized by hemoptysis, diffuse pulmonary infiltration, and anemia. Diagnosis requires a detailed clinical history and transbronchial lung biopsy (TLB).

METHODS AND RESULTS

A 19-year-old man developed progressive dyspnea, hemoptysis, and anemia. The chest x-rays showed bilateral opacities. IPH was diagnosed on the basis of clinical findings and TLB. The patient was treated with corticosteroidal therapy. His respiratory function worsened, and he underwent lung transplantation in 1997. The pathological examination on native lungs confirmed the previous histologic diagnosis. In 2000, the patient again developed hemoptysis, fever, and hypoxemia. A recurrence of the disease was established by TLB.

CONCLUSIONS

This is the first report of recurring IPH. The possibility of recurrent IPH raises the question whether these patients should be disqualified from lung transplantation. This question is unanswerable because incidence of recurrence, time course, and impact on the graft function are presently unknown and unpredictable.

Lung transplantation in interstitial lung disease

Interstitial lung disease is a heterogeneous group of illnesses, some of which may progress to a fibrosing stage and cause respiratory failure. For selected candidates, lung transplantation is the ultimate therapeutic option. We review data on lung transplantation for various interstitial lung diseases. We address indications, procedures, and outcomes for patients undergoing transplantation. Unique issues affecting morbidity, mortality, and recurrence of disease are discussed. We review the literature of transplantation for specific interstitial lung diseases and the outcomes of transplantation for interstitial lung diseases. Candidates with idiopathic pulmonary fibrosis experience high mortality on the waiting list, but derive significant survival benefit from lung transplantation. Recurrence is reported for several interstitial lung diseases after lung transplantation. Survival with lung transplantation for interstitial lung diseases is comparable with that attained in recipients with other indications. Lung transplantation is a well-tolerated, effective therapy for respiratory failure in interstitial lung disease.

Frequency and CT findings of recurrent disease after lung transplantation

PURPOSE

To determine the frequency and computed tomographic (CT) findings of recurrence of the primary disease after lung transplantation at six North American lung transplantation centers.

MATERIALS AND METHODS

Medical records of 1,394 lung transplant recipients were reviewed to identify patients with recurrent primary disease. Their CT scans and pathologic specimens were reviewed.

RESULTS

The frequency of disease recurrence in the six transplantation centers was 1% (15 of 1,394 patients), including six previously reported cases. Sarcoidosis recurred in nine (35%) of 26 transplants and was the most common disease to recur. Three (33%) of nine patients with recurrent sarcoidosis had correlative findings at CT. When present, CT findings were usually different at recurrence compared with pretransplantation CT findings.

CONCLUSION

A relatively small percentage of patients are at risk for recurrence of primary disease following lung transplantation. Sarcoidosis is the most common disease to recur.

Clinical insights and basic science correlates in sarcoidosis

More than a century has elapsed since the initial description of sarcoidosis, but critical aspects of the disorder remain poorly understood. Information obtained from epidemiologic observations and basic laboratory research suggests that the disease may represent an immunologic response to an exogenous agent in a genetically susceptible individual. However, a definitive etiologic role for any specific exogenous agent has never been proved, and a "candidate gene" underlying a predisposition to sarcoidosis has not yet been identified. This review presents an historical framework for considering available evidence regarding a transmissible agent in sarcoidosis and host susceptibility to the disease.

Imaging of lung transplantation

Lung transplantation is an accepted treatment for a large number of end-stage pulmonary diseases. There are several complications that pertain specifically to lung transplant recipients, including airway ischemia, reperfusion edema, infections, acute rejection, obliterative bronchiolitis, and other postoperative problems relating to surgical technique and immuno-suppressive therapy. Imaging procedures play an important role in the diagnosis and management of these problems.

The clinical management of sarcoidosis. A 50-year experience at the Johns Hopkins Hospital

Sarcoidosis is an enigmatic disease with extremely variable manifestations in pattern, severity and course. Since Longcope and Freiman's descriptive monograph in 1952 (50) summarizing the clinical findings of the first half of this century, new dimensions of assessing the disease and treatment have been added. The impact of corticosteroids is central. The present review extends the studies to the second half of this century. Earlier diagnosis is facilitated and treatment often reverses many of the disease manifestations and improves the quality and extent of life for the patient. The management issues and guidelines outlined in this paper for both intrathoracic and extrathoracic disease are based on several longitudinal studies of the sarcoidosis patients summarized here, and 50 years of clinical experience by the senior author (CJJ) at Johns Hopkins Hospital, a tertiary referral center with an active Sarcoid Clinic. Case reports are presented in the appendix. It is clear that corticosteroids are the most effective therapeutic agent for sarcoidosis, usually with impressive and prompt response. This represents the dramatic difference in this disease after 1950. No more specific or effective immunosuppressive or antiinflammatory agents have been identified. Undesirable side effects are minimal if excessive doses are avoided. The effectiveness of "steroid-sparing agents" such as methotrexate is uncertain. Although irreversible tissue damage from the disease may limit the effectiveness of treatment, benefits of corticosteroids greatly exceed the negative side effects. Since spontaneous remissions without treatment do occur, a period of observation of 2 years are more is warranted if the patient is relatively asymptomatic. Gradual radiographic progression for 2 or more years, even without major symptoms or reduction in pulmonary function, indicates the need for a trial of corticosteroid treatment, especially in white patients where symptoms may lag behind the radiographic changes. Relapses as treatment is withdrawn are frequent, especially in African-American patients, who tend to have more severe and more prolonged disease than white patients. A minimum of 1 year of treatment is recommended unless no improvement is noted after 3 months. Continued low-dose prednisone at daily doses of 10-15 mg is helpful in preventing relapses and further progression of disease. Periodic attempts at tapering are justified. Repeated relapses may indicate the need for life-long treatment. When irreversible changes are present, especially in the presence of chronic fibrotic disease, changing goals of treatment to provide optimal supportive care may represent better management than having unrealistic expectations from increased corticosteroid dosage or the addition of other potentially toxic immunosuppressive agents. Many agents related to sarcoidosis require further research. The most important question facing sarcoid researchers today is etiology. It is difficult to design specific therapy when the fundamental causes and disease mechanisms are not established. Rather than being a single disease with a single cause, it is possible that a number of genetic factors and environmental or infectious agents may result in an immune response that is manifested as sarcoidosis. Understanding basic causal mechanisms may help explain the varied disease manifestations and aid in designing curative treatments. Such etiologic questions should be explored from both a basic science and an epidemiologic approach. Therapeutic trials of new drugs such as pentoxyfylline and possibly thalidomide are needed to address their potential as well as limitations of steroid therapy. Finally, for patients who have progressed to organ failure, the problems of sarcoid recurrence in transplanted tissue, increased allograft rejection, and long-term prognosis of solid organ transplants have yet to be resolved. (ABSTRACT TRUNCATED)

Lung transplantation for lymphangioleiomyomatosis: role of imaging in the assessment of complications related to the underlying disease

PURPOSE

To identify the complications and imaging findings related to lymphangioleiomyomatosis (LAM) after lung transplantation.

MATERIALS AND METHODS

The authors retrospectively reviewed the clinical histories and imaging studies of 13 patients from five major medical centers who underwent unilateral (n = 8) or bilateral (n = 5) lung transplantation for LAM between 1991 and 1997. Complications related to LAM, both before and after transplantation, were recorded.

RESULTS

The following LAM-related complications were found during and after transplantation: excessive pleural adhesions (n = 4), native lung pneumothorax (n = 3), chylous effusion (n = 1), chylous ascites (n = 3), complications from renal angiomyolipomas (n = 4), and recurrent LAM (n = 1). Diagnosis could be made or suggested with computed tomography (CT) in all cases. Four patients (31%) died; one patient died of complications of LAM.

CONCLUSIONS

Patients who have undergone lung transplantation for LAM have increased morbidity and mortality due to complications related to their underlying disease. These LAM-related complications can be diagnosed or suggested with CT.

Medium term results of lung transplantation for end stage pulmonary sarcoidosis

BACKGROUND

Lung transplantation is an accepted therapeutic option for patients with end stage pulmonary sarcoidosis. However, the medium term outcome of transplantation in this patient group is unknown.

METHODS

This study was performed to evaluate our experience with lung transplantation for end stage pulmonary sarcoidosis. Between July 1988 and July 1997 12 patients (nine men) underwent lung transplantation for sarcoidosis at our institution. Ten underwent single lung transplantation and two double lung transplantation.

RESULTS

Survival at three and five years was 70% and 56%, respectively. Three patients developed obliterative bronchiolitis at six, 18, and 45 months. One died at the time of retransplantation. Sarcoid granulomas have recurred in the donor organ in three patients. In one the development of granulomas has been associated with clinical deterioration, necessitating retransplantation. Mean (SD) forced expiratory volumes in one second at three and five years were 1.37 (0.67) 1 and 1.34 (0.13) 1, respectively.

CONCLUSIONS

Lung transplantation is a viable option for patients with end stage pulmonary sarcoidosis. The medium term results are comparable with patients undergoing lung transplantation for other indications. Despite histological recurrence of sarcoidosis, the risk of clinically important recurrence is low.

Lung transplantation for fibrotic lung diseases

The underlying disease of a candidate for lung transplantation, especially advanced pulmonary fibrosis, can cause particular and dramatic difficulties. Pulmonary fibrosis is the end-result of a variety of pathological diseases and their associated processes. This article summarizes the diagnosis and management of some of the more common causes of fibrosis, outlines their natural histories and treatment outcomes, and describes the trade-off of pulmonary fibrosis for lung transplantation. Four main categories of end-stage fibrosis are discussed: idiopathic pulmonary fibrosis, sarcoidosis, pulmonary fibrosis from systemic diseases or drugs, and occupational- or environmental-related pulmonary fibrosis. Each group will be covered systematically and the options and indications for lung transplantation will be addressed.

Role of transplantation (lung, liver, and heart) in sarcoidosis

Organ transplantation is an option for sarcoidosis patients with end-stage lung, liver or heart disease. Survival statistics vary for the organ transplanted but are not too different from survival rates for other systemic disorders. Although infection and rejection are troublesome for all organ recipients including those with sarcoidosis, there is the added problem of recurrence of sarcoidosis in the allograft. Sarcoidosis is not an absolute contraindication for organ transplantation for the majority of transplantation centers.

Pulmonary sarcoidosis

Sarcoidosis involves the bronchi or lung in more than 90 percent of patients. Intrathoracic manifestations are protean, ranging from asymptomatic bilateral hilar lymphadenopathy to chronic, progressive, (ultimately fatal), respiratory insufficiency. The clinical course is highly variable, and optimal management and treatment are controversial. We review the salient radiographic, physiologic, and histopathologic features of pulmonary sarcoidosis and discuss rare intrathoracic complications (e.g., bronchostenosis, mycetomas, nodular sarcoidosis, necrotizing sarcoid angiitis and granulomatosis, pulmonary vascular and pleural involvement). We discuss the chest radiographic staging system and the role of ancillary diagnostic modalities including high resolution thin section computed tomographic scans (HRCT), bronchoalveolar lavage, radionuclide scan, and serum angiotensin enzyme converting enzyme. Indications for therapy and an overview of therapeutic options are outlined.

Etiology of sarcoidosis

Since sarcoidosis was first recognized as a distinct clinical entity, investigators have speculated that a transmissible agent may cause sarcoidosis. Recent attempts at directly isolating infectious organisms or indirectly detecting microbial DNA or RNA from sarcoid tissue have led to inconclusive results. Studies on the immunopathogenic origins of sarcoidosis have provided evidence of persistent antigenic stimulation at sites of inflammation that are associated with dysregulated cytokine production. To date, however, the challenge of defining the cause of sarcoidosis remains unmet.

Steroid-sparing alternative treatments for sarcoidosis

Alternatives to corticosteroids for the treatment of sarcoidosis are reviewed. These include cytotoxic agents such as methotrexate, azathioprine, and cyclophosphamide. In addition, agents such as hydroxychloroquine and cyclosporine are reviewed. The efficacy, toxicity, and timing of these drugs in the management of sarcoidosis is discussed.

Lung transplantation for respiratory failure resulting from systemic disease

BACKGROUND

Lung transplantation for pulmonary failure resulting from systemic disease is controversial. We reviewed our transplant experience in patients with sarcoidosis, scleroderma, lymphangioleiomyomatosis, and graft-versus-host disease.

METHODS

This retrospective review examined the outcome of 23 patients who underwent pulmonary transplantation for these systemic diseases. Group 1 included 15 patients with pulmonary hypertension who underwent transplantation (9 for sarcoidosis, 6 for scleroderma), and group 2 included 8 patients with normal pulmonary artery pressures who underwent transplantation (5 for lymphangioleiomyomatosis, 3 for graft-versus-host disease). The incidences of infection and rejection, pulmonary function, and survival were measured and compared with those of patients who underwent transplantation for isolated pulmonary disease.

RESULTS

Although there were no differences in the rate of infection between patients who underwent transplantation for systemic versus isolated disease, patients with pulmonary hypertension who underwent transplantation for systemic disease had significantly lower rates of rejection. Four patients with sarcoidosis and 2 with lymphangioleiomyomatosis demonstrated recurrence in the allograft. Survival was similar between patients who underwent transplantation for systemic versus isolated disease.

CONCLUSIONS

Patients with respiratory failure resulting from these systemic diseases can undergo transplantation with outcomes comparable to those obtained in patients who undergo transplantation for isolated pulmonary disease.

Lung transplantation. A disease-specific approach

Lung transplantation has emerged as a viable option for the treatment of end-stage disease attributable to a wide spectrum of primary disorders. Although many aspects of patient management are indifferent to the underlying indication, important differences related to timing of transplantation, selection of candidates, choice of procedure, and post-transplant complications exist among the various primary disease groups. Optimal utilization of transplantation for these challenging patient populations with advanced lung disease mandates a thorough appreciation of those differences.

Acute pulmonary allograft rejection. Mechanisms, diagnosis, and management

Rejection is a common complication following lung transplantation, and can lead to considerable short- and long-term morbidity. As numbers and survival rates of lung transplant recipients increase, it is apparent that acute rejection can occur months or years after transplantation, and may be resistant to standard therapies. Mechanisms of acute rejection have been well studied in other solid organ transplant recipients, and are beginning to be addressed in the lung recipient. This article addresses some of the common issues of diagnosis and management of acute rejection which arise frequently during the care of lung transplant recipients.

Lung transplantation for lymphangioleiomyomatosis

BACKGROUND

Lymphangioleiomyomatosis is a rare disease of unknown origin that usually leads to progressive deterioration of lung function and eventual death from respiratory failure. It occurs in women of reproductive age and people with tuberous sclerosis. Lung transplantation is a recent therapeutic approach.

METHODS

We conducted a retrospective study by questionnaire of 34 patients, treated at 16 transplantation centers, who underwent lung transplantation for end-stage lymphangioleiomyomatosis between 1983 and 1995.

RESULTS

Of the 34 patients, 27 received single-lung transplants; 6, bilateral transplants; and 1, a heart-lung transplant. As of August 31, 1995, the actuarial survival calculated by the Kaplan-Meier method was 69 percent after one year and 58 percent after two years. Eighteen patients were alive 33 +/- 20 months (range, 3 to 74) after transplantation. Forced expiratory volume in one second increased from 24 +/- 12 percent of the predicted value before transplantation to 48 +/- 16 percent six months after transplantation. Five early deaths (within one month) were due to hemorrhage (in one patient), acute lung injury (in three), and dehiscence of the bronchial anastomosis (in one). Eleven late deaths (after one month) were due to infections (in eight patients), bronchiolitis obliterans (in two), and metastatic nephroblastoma (in one). Disease-associated problems were extensive pleural adhesions in 18 patients, leading to moderate-to-severe intraoperative hemorrhage in 4; pneumothorax in the native lung after single-lung transplantation in 6 patients; postoperative chylothorax in 3; and recurrent lymphangioleiomyomatosis in the allograft in 1 patient, who died of disseminated aspergillosis.

CONCLUSIONS

Although disease-related complications are frequent, lung transplantation can be a valuable therapy for patients with end-stage lymphangioleiomyomatosis.

Sarcoidosis recurrence following lung transplantation

Sarcoidosis is a rare indication for lung transplantation. In this article, our experiences with recurring sarcoidosis following lung transplantation are described. Literature concerning recurrence of the disease in kidney, liver, heart and lung transmission of sarcoidosis via transplanted organs are discussed.

Presence of mRNA for interferon-gamma (IFN-gamma) in blood mononuclear cells is associated with an active stage I sarcoidosis

Peripheral blood mononuclear cells (PBMC) and bronchoalveolar lavage (BAL) cells obtained from sarcoidosis patients were investigated for the presence of mRNA for IFN-gamma. RNA was extracted from freshly obtained cells. In 12 cases PBMC were studied and in seven cases BAL cells were also available for concomitant investigation. In eight patients mRNA for IFN-gamma was present in blood and was significantly associated with stage I disease (P = 0.030). By comparison, BAL cells were less frequently positive for IFN-gamma transcripts (P = 0.039). Only one patient had simultaneous expression of IFN-gamma gene in blood and BAL cells. All other patients including four positive in blood were negative in BAL. The presence of IFN-gamma transcripts in PBMC was significantly associated with the capacity of these cells to generate IFN-gamma in unstimulated cultures. PBMC from patients showing IFN-gamma mRNA in blood were frequently high IFN-gamma producers in anti-CD3 MoAb-stimulated cultures.

Recurrence of sarcoidosis following bilateral allogeneic lung transplantation

We report the first case of recurrent sarcoidosis manifested by clinical symptoms, radiographic abnormalities, and pathologic changes in a patient following sequential double allogeneic lung transplantation. A 40-year-old male patient underwent bilateral allogeneic lung transplantation for end-stage pulmonary sarcoidosis. Thirteen months posttransplantation, he developed fatigue, shortness of breath, and bilateral upper lobe pulmonary infiltrates. Transbronchial biopsy specimens revealed noncaseating granulomata. The patient's symptoms and radiographic abnormalities resolved with an increased dose of oral prednisone.