1
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Keller MB, Newman D, Alnababteh M, Ponor L, Shah P, Mathew J, Kong H, Andargie T, Park W, Charya A, Luikart H, Aryal S, Nathan SD, Orens JB, Khush KK, Jang M, Agbor-Enoh S. Extreme elevations of donor-derived cell-free DNA increases the risk of chronic lung allograft dysfunction and death, even without clinical manifestations of disease. J Heart Lung Transplant 2024; 43:1374-1382. [PMID: 38705500 DOI: 10.1016/j.healun.2024.04.064] [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: 01/02/2024] [Revised: 03/11/2024] [Accepted: 04/25/2024] [Indexed: 05/07/2024] Open
Abstract
BACKGROUND Lung transplant recipients are traditionally monitored with pulmonary function testing (PFT) and lung biopsy to detect post-transplant complications and guide treatment. Plasma donor-derived cell free DNA (dd-cfDNA) is a novel molecular approach of assessing allograft injury, including subclinical allograft dysfunction. The aim of this study was to determine if episodes of extreme molecular injury (EMI) in lung transplant recipients increases the risk of chronic lung allograft dysfunction (CLAD) or death. METHODS This multicenter prospective cohort study included 238 lung transplant recipients. Serial plasma samples were collected for dd-cfDNA measurement by shotgun sequencing. EMI was defined as a dd-cfDNA above the third quartile of levels observed for acute rejection (dd-cfDNA level of ≥5% occurring after 45 days post-transplant). EMI was categorized as Secondary if associated with co-existing acute rejection, infection or PFT decline; or Primary if not associated with these conditions. RESULTS EMI developed in 16% of patients at a median 343.5 (IQR: 177.3-535.5) days post-transplant. Over 50% of EMI episodes were classified as Primary. EMI was associated with an increased risk of severe CLAD or death (HR: 2.78, 95% CI: 1.26-6.22, p = 0.012). The risk remained consistent for the Primary EMI subgroup (HR: 2.34, 95% CI 1.18-4.85, p = 0.015). Time to first EMI episode was a significant predictor of the likelihood of developing CLAD or death (AUC=0.856, 95% CI=0.805-0.908, p < 0.001). CONCLUSIONS Episodes of EMI in lung transplant recipients are often isolated and may not be detectable with traditional clinical monitoring approaches. EMI is associated with an increased risk of severe CLAD or death, independent of concomitant transplant complications.
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Affiliation(s)
- Michael B Keller
- Laborarory of Applied Precision Omics (APO) National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Maryland; Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland; Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - David Newman
- College of Nursing, Florida Atlantic University, Boca Raton, Florida
| | - Muhtadi Alnababteh
- Laborarory of Applied Precision Omics (APO) National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Maryland; Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Lucia Ponor
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Pali Shah
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Joby Mathew
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Hyesik Kong
- Laborarory of Applied Precision Omics (APO) National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Maryland; Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland
| | - Temesgen Andargie
- Laborarory of Applied Precision Omics (APO) National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Maryland; Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland
| | - Woojin Park
- Laborarory of Applied Precision Omics (APO) National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Maryland; Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland
| | - Ananth Charya
- Division of Pulmonary and Critical Care Medicine, University of Maryland Medical Center, Baltimore, Maryland
| | - Helen Luikart
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California; Department of Pathology, Stanford University School of Medicine, Palo Alto, California
| | - Shambhu Aryal
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Advanced Lung Disease and Lung Transplant Program, Inova Fairfax Hospital, Falls Church, Virginia
| | - Steven D Nathan
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Advanced Lung Disease and Lung Transplant Program, Inova Fairfax Hospital, Falls Church, Virginia
| | - Jonathan B Orens
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Moon Jang
- Laborarory of Applied Precision Omics (APO) National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Maryland; Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland
| | - Sean Agbor-Enoh
- Laborarory of Applied Precision Omics (APO) National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Maryland; Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland.
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Mineura K, Tanaka S, Goda Y, Terada Y, Yoshizawa A, Umemura K, Sato A, Yamada Y, Yutaka Y, Ohsumi A, Nakajima D, Hamaji M, Mennju T, Kreisel D, Date H. Fibrotic progression from acute cellular rejection is dependent on secondary lymphoid organs in a mouse model of chronic lung allograft dysfunction. Am J Transplant 2024; 24:944-953. [PMID: 38403187 PMCID: PMC11144565 DOI: 10.1016/j.ajt.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 02/16/2024] [Accepted: 02/16/2024] [Indexed: 02/27/2024]
Abstract
Chronic lung allograft dysfunction (CLAD) remains one of the major limitations to long-term survival after lung transplantation. We modified a murine model of CLAD and transplanted left lungs from BALB/c donors into B6 recipients that were treated with intermittent cyclosporine and methylprednisolone postoperatively. In this model, the lung allograft developed acute cellular rejection on day 15 which, by day 30 after transplantation, progressed to severe pleural and peribronchovascular fibrosis, reminiscent of changes observed in restrictive allograft syndrome. Lung transplantation into splenectomized B6 alymphoplastic (aly/aly) or splenectomized B6 lymphotoxin-β receptor-deficient mice demonstrated that recipient secondary lymphoid organs, such as spleen and lymph nodes, are necessary for progression from acute cellular rejection to allograft fibrosis in this model. Our work uncovered a critical role for recipient secondary lymphoid organs in the development of CLAD after pulmonary transplantation and may provide mechanistic insights into the pathogenesis of this complication.
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Affiliation(s)
- Katsutaka Mineura
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan; Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Satona Tanaka
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Yasufumi Goda
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yuriko Terada
- Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Akihiko Yoshizawa
- Department of Diagnostic Pathology, Kyoto University Hospital, Kyoto, Japan
| | - Keisuke Umemura
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Atsuyasu Sato
- Department of Respiratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoshito Yamada
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yojiro Yutaka
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akihiro Ohsumi
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Daisuke Nakajima
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masatsugu Hamaji
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Toshi Mennju
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Daniel Kreisel
- Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA; Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Hiroshi Date
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
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3
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Keller MB, Tian X, Jang MK, Meda R, Charya A, Berry GJ, Marboe CC, Kong H, Ponor IL, Aryal S, Orens JB, Shah PD, Nathan SD, Agbor-Enoh S. Higher Molecular Injury at Diagnosis of Acute Cellular Rejection Increases the Risk of Lung Allograft Failure: A Clinical Trial. Am J Respir Crit Care Med 2024; 209:1238-1245. [PMID: 38190701 PMCID: PMC11146548 DOI: 10.1164/rccm.202305-0798oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 01/08/2024] [Indexed: 01/10/2024] Open
Abstract
Rationale: The association of acute cellular rejection (ACR) with chronic lung allograft dysfunction (CLAD) in lung transplant recipients has primarily been described before consensus recommendations incorporating restrictive phenotypes. Furthermore, the association of the degree of molecular allograft injury during ACR with CLAD or death remains undefined. Objectives: To investigate the association of ACR with the risk of CLAD or death and to further investigate if this risk depends on the degree of molecular allograft injury. Methods: This multicenter, prospective cohort study included 188 lung transplant recipients. Subjects underwent serial plasma collections for donor-derived cell-free DNA (dd-cfDNA) at prespecified time points and bronchoscopy. Multivariable Cox proportional-hazards analysis was conducted to analyze the association of ACR with subsequent CLAD or death as well as the association of dd-cfDNA during ACR with risk of CLAD or death. Additional outcomes analyses were performed with episodes of ACR categorized as "high risk" (dd-cfDNA ⩾ 1%) and "low risk" (dd-cfDNA < 1%). Measurements and Main Results: In multivariable analysis, ACR was associated with the composite outcome of CLAD or death (hazard ratio [HR], 2.07 [95% confidence interval (CI), 1.05-4.10]; P = 0.036). Elevated dd-cfDNA ⩾ 1% at ACR diagnosis was independently associated with increased risk of CLAD or death (HR, 3.32; 95% CI, 1.31-8.40; P = 0.012). Patients with high-risk ACR were at increased risk of CLAD or death (HR, 3.13; 95% CI, 1.41-6.93; P = 0.005), whereas patients with low-risk status ACR were not. Conclusions: Patients with ACR are at higher risk of CLAD or death, but this may depend on the degree of underlying allograft injury at the molecular level. Clinical trial registered with www.clinicaltrials.gov (NCT02423070).
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Affiliation(s)
- Michael B. Keller
- Genomic Research Alliance for Transplantation, Bethesda, Maryland
- Laboratory of Applied Precision Omics and
- Division of Pulmonary and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Xin Tian
- Office of Biostatistics Research, NHLBI, NIH, Bethesda, Maryland
| | - Moon Kyoo Jang
- Genomic Research Alliance for Transplantation, Bethesda, Maryland
- Laboratory of Applied Precision Omics and
| | - Rohan Meda
- Laboratory of Applied Precision Omics and
| | - Ananth Charya
- University of Maryland Medical Center, Baltimore, Maryland
| | - Gerald J. Berry
- Genomic Research Alliance for Transplantation, Bethesda, Maryland
- School of Medicine, Stanford University, Stanford, California
| | - Charles C. Marboe
- Genomic Research Alliance for Transplantation, Bethesda, Maryland
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons of Columbia University, New York, New York
| | - Hyesik Kong
- Genomic Research Alliance for Transplantation, Bethesda, Maryland
- Laboratory of Applied Precision Omics and
| | - Ileana L. Ponor
- Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland; and
| | - Shambhu Aryal
- Genomic Research Alliance for Transplantation, Bethesda, Maryland
- Advanced Lung Disease and Lung Transplant Program, Inova Fairfax Hospital, Fairfax, Virginia
| | - Jonathan B. Orens
- Genomic Research Alliance for Transplantation, Bethesda, Maryland
- Division of Pulmonary and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Pali D. Shah
- Genomic Research Alliance for Transplantation, Bethesda, Maryland
- Division of Pulmonary and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Steven D. Nathan
- Genomic Research Alliance for Transplantation, Bethesda, Maryland
- Advanced Lung Disease and Lung Transplant Program, Inova Fairfax Hospital, Fairfax, Virginia
| | - Sean Agbor-Enoh
- Genomic Research Alliance for Transplantation, Bethesda, Maryland
- Laboratory of Applied Precision Omics and
- Division of Pulmonary and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland
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4
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Calabrese DR, Shaver CM. The Emperor Has Some Clothes: Emerging Molecular Diagnostics in Post-Lung Transplant Decision-Making. Am J Respir Crit Care Med 2024; 209:1182-1184. [PMID: 38387008 PMCID: PMC11146531 DOI: 10.1164/rccm.202401-0059ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 02/22/2024] [Indexed: 02/24/2024] Open
Affiliation(s)
- Daniel R Calabrese
- Department of Medicine University of California, San Francisco San Francisco, California
- San Francisco Veterans Affairs Medical Center San Francisco, California
| | - Ciara M Shaver
- Department of Medicine Vanderbilt University Medical Center Nashville, Tennessee
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5
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Keller MB, Tian X, Jang MK, Meda R, Charya A, Ozisik D, Berry GJ, Marboe CC, Kong H, Ponor IL, Aryal S, Orens JB, Shah PD, Nathan SD, Agbor-Enoh S. Organizing pneumonia is associated with molecular allograft injury and the development of antibody-mediated rejection. J Heart Lung Transplant 2024; 43:563-570. [PMID: 37972825 DOI: 10.1016/j.healun.2023.11.008] [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: 07/24/2023] [Revised: 10/28/2023] [Accepted: 11/08/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND The association between organizing pneumonia (OP) after lung transplantation with the development of acute rejection (AR) remains undefined. In addition, molecular allograft injury, as measured by donor-derived cell-free DNA (dd-cfDNA), during episodes of OP and its relationship to episodes of AR, chronic lung allograft dysfunction (CLAD), or death is unknown. METHODS This multicenter, prospective cohort study collected serial plasma samples from 188 lung transplant recipients for dd-cfDNA at the time of bronchoscopy with biopsy. Multivariable Cox regression was used to analyze the association between OP with the development of AR (antibody-mediated rejection (AMR) and acute cellular rejection (ACR)), CLAD, and death. Multivariable models were performed to test the association of dd-cfDNA at OP with the risk of AR, CLAD, or death. RESULTS In multivariable analysis, OP was associated with increased risk of AMR (hazard ratio (HR) = 2.26, 95% confidence interval (CI) 1.04-4.92, p = 0.040) but not ACR (HR = 1.29, 95% CI: 0.66-2.5, p = 0.45) or the composite outcome of CLAD or death (HR = 0.88, 95% CI, 0.47-1.65, p = 0.69). Median levels of dd-cfDNA were higher in OP compared to stable controls (1.33% vs 0.43%, p = 0.0006). Multivariable analysis demonstrated that levels of dd-cfDNA at diagnosis of OP were associated with increased risk of both AMR (HR = 1.29, 95% CI 1.03-1.62, p = 0.030) and death (HR = 1.16, 95% CI, 1.02-1.31, p = 0.026). CONCLUSIONS OP is independently associated with an increased risk of AMR but not CLAD or death. The degree of molecular allograft injury at the diagnosis of OP may further predict the risk of AMR and death.
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Affiliation(s)
- Michael B Keller
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Laboratory of Applied Precision Omics (APO), National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland; Division of Pulmonary and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Xin Tian
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Moon Kyoo Jang
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Laboratory of Applied Precision Omics (APO), National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Rohan Meda
- Laboratory of Applied Precision Omics (APO), National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Ananth Charya
- University of Maryland Medical Center, Baltimore, Maryland
| | - Deniz Ozisik
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Gerald J Berry
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Stanford University School of Medicine, Stanford, California
| | - Charles C Marboe
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons of Columbia University, New York, New York
| | - Hyesik Kong
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Laboratory of Applied Precision Omics (APO), National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Ileana L Ponor
- Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Shambhu Aryal
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Advanced Lung Disease and Lung Transplant Program, Inova Fairfax Hospital, Fairfax, Virginia
| | - Jonathan B Orens
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Division of Pulmonary and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Pali D Shah
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Division of Pulmonary and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Steven D Nathan
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Advanced Lung Disease and Lung Transplant Program, Inova Fairfax Hospital, Fairfax, Virginia
| | - Sean Agbor-Enoh
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Laboratory of Applied Precision Omics (APO), National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland; Division of Pulmonary and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland.
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Belousova N, Huszti E, Li Q, Vasileva A, Ghany R, Gabarin R, El Sanharawi M, Picard C, Hwang D, Levy L, Keshavjee S, Chow CW, Roux A, Martinu T. Center variability in the prognostic value of a cumulative acute cellular rejection "A-score" for long-term lung transplant outcomes. Am J Transplant 2024; 24:89-103. [PMID: 37625646 DOI: 10.1016/j.ajt.2023.08.014] [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: 04/27/2023] [Revised: 08/11/2023] [Accepted: 08/20/2023] [Indexed: 08/27/2023]
Abstract
The acute rejection score (A-score) in lung transplant recipients, calculated as the average of acute cellular rejection A-grades across transbronchial biopsies, summarizes the cumulative burden of rejection over time. We assessed the association between A-score and transplant outcomes in 2 geographically distinct cohorts. The primary cohort included 772 double lung transplant recipients. The analysis was repeated in 300 patients from an independent comparison cohort. Time-dependent multivariable Cox models were constructed to evaluate the association between A-score and chronic lung allograft dysfunction or graft failure. Landmark analyses were performed with A-score calculated at 6 and 12 months posttransplant. In the primary cohort, no association was found between A-score and graft outcome. However, in the comparison cohort, time-dependent A-score was associated with chronic lung allograft dysfunction both as a time-dependent variable (hazard ratio, 1.51; P < .01) and when calculated at 6 months posttransplant (hazard ratio, 1.355; P = .031). The A-score can be a useful predictor of lung transplant outcomes in some settings but is not generalizable across all centers; its utility as a prognostication tool is therefore limited.
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Affiliation(s)
- Natalia Belousova
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Program and Division of Respirology, University Health Network, Toronto, Canada; Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Canada; Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France.
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Canada
| | - Qixuan Li
- Biostatistics Research Unit, University Health Network, Toronto, Canada
| | - Anastasiia Vasileva
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Program and Division of Respirology, University Health Network, Toronto, Canada
| | - Ramy Gabarin
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Canada
| | | | - Clement Picard
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - David Hwang
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Canada
| | - Liran Levy
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Program and Division of Respirology, University Health Network, Toronto, Canada
| | - Chung-Wai Chow
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Program and Division of Respirology, University Health Network, Toronto, Canada; Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Canada
| | - Antoine Roux
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France; Paris Transplant Group, Paris, France
| | - Tereza Martinu
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Program and Division of Respirology, University Health Network, Toronto, Canada; Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Canada
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7
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Narula T, Martin AK, Asif AA, Fritz AV, Li Z, Erasmus DB, Alvarez F, Thomas M. Outcomes of Lung Transplantation in Patients With Combined Pulmonary Fibrosis and Emphysema: A Single-Center Experience. Transplant Proc 2023; 55:449-455. [PMID: 36849338 DOI: 10.1016/j.transproceed.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 12/24/2022] [Accepted: 01/24/2023] [Indexed: 02/27/2023]
Abstract
BACKGROUND Combined pulmonary fibrosis and emphysema (CPFE) is a distinct clinical entity that can progress to end-stage lung disease. Patients with CPFE may develop pulmonary hypertension and face a predicted 1-year mortality of 60%. Lung transplantation is the only curative therapeutic option for CPFE. This report describes our experience after lung transplantation in patients with CPFE. METHODS This retrospective, single-center study describes short- and long-term outcomes for adult patients who underwent lung transplant for CPFE. RESULTS The study included 19 patients with explant pathology-proven diagnosis of CPFE. The patients were transplanted between July 2005 and December 2018. Sixteen recipients (84%) had pulmonary hypertension before transplant. Of the 19 patients, 7 (37%) had primary graft dysfunction at 72 hours post-transplant. 1-, 3-, and 5-year freedom from bronchiolitis obliterans syndrome was 100%, 91% (95% CI, 75%-100%), and 82% (95% CI, 62%-100%), respectively. One-, 3-, and 5-year survival was 94% (95% CI, 84%-100%), 82% (95% CI, 65%-100%), and 74% (95% CI, 54%-100%), respectively. CONCLUSION Our experience demonstrates the safety and feasibility of lung transplant for patients with CPFE. Significant morbidity and mortality without lung transplant coupled with favorable post-transplant outcomes merit prioritization of CPFE in the Lung Allocation Score algorithm for lung transplant candidacy.
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Affiliation(s)
- Tathagat Narula
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida.
| | - Archer K Martin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
| | - Abuzar A Asif
- Internal Medicine, University of Illinois College of Medicine, Peoria, Illinois
| | - Ashley V Fritz
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
| | - Zhuo Li
- Department of Biostatistics, Mayo Clinic, Jacksonville, Florida
| | - David B Erasmus
- Division of Allergy, Pulmonary, and Critical Care Medicine and The Vanderbilt Lung Institute
| | | | - Mathew Thomas
- Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, Florida
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Personalized risk predictor for acute cellular rejection in lung transplant using soluble CD31. Sci Rep 2022; 12:17628. [PMID: 36271122 PMCID: PMC9587244 DOI: 10.1038/s41598-022-21070-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 09/22/2022] [Indexed: 01/13/2023] Open
Abstract
We evaluated the contribution of artificial intelligence in predicting the risk of acute cellular rejection (ACR) using early plasma levels of soluble CD31 (sCD31) in combination with recipient haematosis, which was measured by the ratio of arterial oxygen partial pressure to fractional oxygen inspired (PaO2/FiO2) and respiratory SOFA (Sequential Organ Failure Assessment) within 3 days of lung transplantation (LTx). CD31 is expressed on endothelial cells, leukocytes and platelets and acts as a "peace-maker" at the blood/vessel interface. Upon nonspecific activation, CD31 can be cleaved, released, and detected in the plasma (sCD31). The study included 40 lung transplant recipients, seven (17.5%) of whom experienced ACR. We modelled the plasma levels of sCD31 as a nonlinear dependent variable of the PaO2/FiO2 and respiratory SOFA over time using multivariate and multimodal models. A deep convolutional network classified the time series models of each individual associated with the risk of ACR to each individual in the cohort.
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9
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Santos J, Calabrese DR, Greenland JR. Lymphocytic Airway Inflammation in Lung Allografts. Front Immunol 2022; 13:908693. [PMID: 35911676 PMCID: PMC9335886 DOI: 10.3389/fimmu.2022.908693] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/16/2022] [Indexed: 11/16/2022] Open
Abstract
Lung transplant remains a key therapeutic option for patients with end stage lung disease but short- and long-term survival lag other solid organ transplants. Early ischemia-reperfusion injury in the form of primary graft dysfunction (PGD) and acute cellular rejection are risk factors for chronic lung allograft dysfunction (CLAD), a syndrome of airway and parenchymal fibrosis that is the major barrier to long term survival. An increasing body of research suggests lymphocytic airway inflammation plays a significant role in these important clinical syndromes. Cytotoxic T cells are observed in airway rejection, and transcriptional analysis of airways reveal common cytotoxic gene patterns across solid organ transplant rejection. Natural killer (NK) cells have also been implicated in the early allograft damage response to PGD, acute rejection, cytomegalovirus, and CLAD. This review will examine the roles of lymphocytic airway inflammation across the lifespan of the allograft, including: 1) The contribution of innate lymphocytes to PGD and the impact of PGD on the adaptive immune response. 2) Acute cellular rejection pathologies and the limitations in identifying airway inflammation by transbronchial biopsy. 3) Potentiators of airway inflammation and heterologous immunity, such as respiratory infections, aspiration, and the airway microbiome. 4) Airway contributions to CLAD pathogenesis, including epithelial to mesenchymal transition (EMT), club cell loss, and the evolution from constrictive bronchiolitis to parenchymal fibrosis. 5) Protective mechanisms of fibrosis involving regulatory T cells. In summary, this review will examine our current understanding of the complex interplay between the transplanted airway epithelium, lymphocytic airway infiltration, and rejection pathologies.
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Affiliation(s)
- Jesse Santos
- Department of Medicine University of California, San Francisco, San Francisco, CA, United States
| | - Daniel R. Calabrese
- Department of Medicine University of California, San Francisco, San Francisco, CA, United States
- Medical Service, Veterans Affairs Health Care System, San Francisco, CA, United States
| | - John R. Greenland
- Department of Medicine University of California, San Francisco, San Francisco, CA, United States
- Medical Service, Veterans Affairs Health Care System, San Francisco, CA, United States
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10
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Lewis TC, Lesko M, Rudym D, Lonze BE, Mangiola M, Natalini JG, Chan JCY, Chang SH, Angel LF. One-year immunologic outcomes of lung transplantation utilizing hepatitis C-viremic donors. Clin Transplant 2022; 36:e14749. [PMID: 35689815 DOI: 10.1111/ctr.14749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/16/2022] [Accepted: 06/03/2022] [Indexed: 11/29/2022]
Abstract
Little is known about the effects of hepatitis C viremia on immunologic outcomes in the era of direct-acting antivirals. We conducted a prospective, single-arm trial of lung transplantation from hepatitis C-infected donors into hepatitis C-naïve recipients (n = 21). Recipients were initiated on glecaprevir-pibrentasvir immediately post-transplant and were continued on therapy for a total of 8 weeks. A control group of recipients of hepatitis C-negative lungs were matched 1:1 on baseline variables (n = 21). The primary outcome was the frequency of acute cellular rejection over 1-year post-transplant. Treatment with glecaprevir-pibrentasvir was well tolerated and resulted in viremia clearance after a median of 16 days of therapy (IQR 10-24 days). At one year, there was no difference in incidence of acute cellular rejection (71.4% vs. 85.7%, P = .17) or rejection requiring treatment (33.3% vs. 57.1%, P = .12). Mean cumulative acute rejection scores were similar between groups (.46 [SD ± .53] vs. .52 [SD ± .37], P = .67). Receipt of HCV+ organs was not associated with acute rejection on unadjusted Cox regression analysis (HR .55, 95% CI .28-1.11, P = .09), or when adjusted for risk factors known to be associated with acute rejection (HR .57, 95% CI .27-1.21, P = .14). Utilization of hepatitis C infected lungs with immediate treatment leads to equivalent immunologic outcomes at 1 year.
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Affiliation(s)
- Tyler C Lewis
- Transplant Institute, NYU Langone Health, New York, New York, USA
| | - Melissa Lesko
- Transplant Institute, NYU Langone Health, New York, New York, USA
| | - Darya Rudym
- Transplant Institute, NYU Langone Health, New York, New York, USA
| | - Bonnie E Lonze
- Transplant Institute, NYU Langone Health, New York, New York, USA
| | - Massimo Mangiola
- Transplant Institute, NYU Langone Health, New York, New York, USA
| | - Jake G Natalini
- Transplant Institute, NYU Langone Health, New York, New York, USA
| | - Justin C Y Chan
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York, USA
| | - Stephanie H Chang
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York, USA
| | - Luis F Angel
- Transplant Institute, NYU Langone Health, New York, New York, USA
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11
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Cell-free DNA in lung transplantation: research tool or clinical workhorse? Curr Opin Organ Transplant 2022; 27:177-183. [PMID: 35649108 DOI: 10.1097/mot.0000000000000979] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Recent evidence indicates that plasma donor-derived cell-free DNA (dd-cfDNA) is a sensitive biomarker for the detection of underlying allograft injury, including rejection and infection. In this review, we will cover the latest evidence revolving around dd-cfDNA in lung transplantation and its role in both advancing mechanistic insight into disease states in lung transplant recipients as well as its potential clinical utility. RECENT FINDINGS Plasma dd-cfDNA increases in the setting of allograft injury, including in primary graft dysfunction, acute cellular rejection, antibody-mediated rejection and infection. Dd-cfDNA has demonstrated good performance characteristics for the detection of various allograft injury states, most notably with a high negative-predictive value for detection of acute rejection. Elevated levels of dd-cfDNA in the early posttransplant period, reflecting molecular evidence of lung allograft injury, are associated with increased risk of chronic lung allograft dysfunction and death. SUMMARY As a quantitative, molecular biomarker of lung allograft injury, dd-cfDNA holds great promise in clinical and research settings for advancing methods of posttransplant surveillance monitoring, diagnosis of allograft injury states, monitoring adequacy of immunosuppression, risk stratification and unlocking pathophysiological mechanisms of various disease.
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12
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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.
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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
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13
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Miyamoto E, Takahagi A, Ohsumi A, Martinu T, Hwang D, Boonstra KM, Joe B, Umana JM, Bei KF, Vosoughi D, Liu M, Cypel M, Keshavjee S, Juvet SC. Ex vivo delivery of regulatory T cells for control of alloimmune priming in the donor lung. Eur Respir J 2021; 59:13993003.00798-2021. [PMID: 34475226 DOI: 10.1183/13993003.00798-2021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 08/17/2021] [Indexed: 11/05/2022]
Abstract
Survival after lung transplantation (LTx) is hampered by uncontrolled inflammation and alloimmunity. Regulatory T cells (Tregs) are being studied as a cellular therapy in solid organ transplantation. Whether these systemically administered Tregs can function at the appropriate location and time is an important concern. We hypothesized that in vitro expanded, recipient-derived Tregs can be delivered to donor lungs prior to LTx via ex vivo lung perfusion (EVLP), maintaining their immunomodulatory ability.In a rat model, Wistar Kyoto (WKy) CD4+CD25high Tregs were expanded in vitro prior to EVLP. Expanded Tregs were administered to Fisher 344 (F344) donor lungs during EVLP; left lungs were transplanted into WKy recipients. Treg localisation and function post-transplant were assessed. In a proof-of-concept experiment, cryopreserved expanded human CD4+CD25+CD127low Tregs were thawed and injected into discarded human lungs during EVLP.Rat Tregs entered the lung parenchyma and retained suppressive function. Expanded Tregs had no adverse effect on donor lung physiology during EVLP; lung water as measured by wet-to-dry weight ratio was reduced by Treg therapy. The administered cells remained in the graft at 3 days post-transplant where they reduced activation of intragraft effector CD4+ T cells; these effects were diminished by day 7. Human Tregs entered the lung parenchyma during EVLP where they expressed key immunoregulatory molecules (CTLA4+, 4-1BB+, CD39+, and CD15s+).Pre-transplant Treg administration can inhibit alloimmunity within the lung allograft at early time points post- transplant. Our organ-directed approach has potential for clinical translation.
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Affiliation(s)
- Ei Miyamoto
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Akihiro Takahagi
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Akihiro Ohsumi
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Tereza Martinu
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - David Hwang
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kristen M Boonstra
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Betty Joe
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Juan Mauricio Umana
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Ke F Bei
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Vosoughi
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Mingyao Liu
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Stephen C Juvet
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
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14
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Amubieya O, Ramsey A, DerHovanessian A, Fishbein GA, Lynch JP, Belperio JA, Weigt SS. Chronic Lung Allograft Dysfunction: Evolving Concepts and Therapies. Semin Respir Crit Care Med 2021; 42:392-410. [PMID: 34030202 DOI: 10.1055/s-0041-1729175] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The primary factor that limits long-term survival after lung transplantation is chronic lung allograft dysfunction (CLAD). CLAD also impairs quality of life and increases the costs of medical care. Our understanding of CLAD continues to evolve. Consensus definitions of CLAD and the major CLAD phenotypes were recently updated and clarified, but it remains to be seen whether the current definitions will lead to advances in management or impact care. Understanding the potential differences in pathogenesis for each CLAD phenotype may lead to novel therapeutic strategies, including precision medicine. Recognition of CLAD risk factors may lead to earlier interventions to mitigate risk, or to avoid risk factors all together, to prevent the development of CLAD. Unfortunately, currently available therapies for CLAD are usually not effective. However, novel therapeutics aimed at both prevention and treatment are currently under investigation. We provide an overview of the updates to CLAD-related terminology, clinical phenotypes and their diagnosis, natural history, pathogenesis, and potential strategies to treat and prevent CLAD.
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Affiliation(s)
- Olawale Amubieya
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Allison Ramsey
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ariss DerHovanessian
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Gregory A Fishbein
- Department of Pathology, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Joseph P Lynch
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - John A Belperio
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - S Samuel Weigt
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
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15
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Morse JM, Kent-Marvick J, Barry LA, Harvey J, Okang EN, Rudd EA, Wang CY, Williams MR. Developing the Resilience Framework for Nursing and Healthcare. Glob Qual Nurs Res 2021; 8:23333936211005475. [PMID: 33869667 PMCID: PMC8020405 DOI: 10.1177/23333936211005475] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 03/08/2021] [Accepted: 03/08/2021] [Indexed: 12/11/2022] Open
Abstract
Despite four decades of resilience research, resilience remains a poor fit for practice as a scientific construct. Using the literature, we explored the concepts attributed to the development of resilience, identifying those that mitigate symptoms of distress caused by adversity and facilitate coping in seven classes of illness: transplants, cancer, mental illness, episodic illness, chronic and painful illness, unexpected events, and illness within a dyadic relationship. We identified protective, compensatory, and challenge-related coping-concept strategies that healthcare workers and patients use during the adversity experience. Healthcare-worker assessment and selection of appropriate coping concepts enable the individual to control their distress, resulting in attainment of equanimity and the state of resilience, permitting the resilient individual to work toward recovery, recalibration, and readjustment. We inductively developed and linked these conceptual components into a dynamic framework, The Resilience Framework for Nursing and Healthcare, making it widely applicable for healthcare across a variety of patients.
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Affiliation(s)
- Janice M. Morse
- University of Utah, Salt Lake City, USA
- University of Alberta
| | | | - Lisa A. Barry
- University of Utah, Salt Lake City, USA
- Intermountain Healthcare, Primary Children’s Hospital, Salt Lake City, UT, USA
| | - Jennifer Harvey
- University of Utah, Salt Lake City, USA
- Alaska Native Medical Center, Anchorage, Alaska
| | | | | | | | - Marcia R. Williams
- University of Utah, Salt Lake City, USA
- Cedarville University, Ohio
- Kettering Health Network, Cedarville, Ohio
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16
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Chu MC, Smith PJ, Reynolds JM, Palmer SM, Snyder LD, Gray AL, Blumenthal JA. Depression, Immunosuppressant Levels, and Clinical Outcomes in Postlung Transplant Recipients. Int J Psychiatry Med 2020; 55:421-436. [PMID: 32052665 DOI: 10.1177/0091217420906637] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Posttransplant depression has been linked to increased risk for adverse outcomes in lung transplant patients. Maintaining target serum immunosuppressant levels is also essential for optimal lung transplant clinical outcome and may be a crucial predictor of outcomes. Because depression could affect medication nonadherence, resulting in out-of-range immunosuppressant levels, we examined the relationship between posttransplant depression, immunosuppressant medication trough level variability, indexed by out-of-range values on clinical outcomes and coefficient of variability, and clinical outcomes. METHOD A consecutive series of 236 lung transplant recipients completed the Center for Epidemiological Studies-Depression two-month posttransplant. Immunosuppressant trough levels (i.e., tacrolimus or cyclosporine) within the range of individualized immunosuppressant targets were obtained at three-, six-, nine-month follow-up clinic visits. Clinical outcomes including hospitalizations and mortality were obtained from medical records. RESULTS Fourteen percent of patients were classified as depressed (Center for Epidemiological Studies-Depression ≥16), 144 (61%) of patients had at least 25% out-of-range immunosuppressant values, and the average coefficient of variability was 36%. Over a median of 2.6 years (interquartile range = 1.2), 32 participants died (14%) and 144 (61%) had at least one unplanned, transplant-related hospitalization. Both depression (hazard ratio = 1.45 (1.19, 1.76), p < . 01) and immunosuppressant variation (immunosuppressant out-of-range: hazard ratio = 1.41 (1.10, 1.81), p < .01) independently predicted more frequent hospitalizations and higher mortality. CONCLUSIONS Early posttransplant depression was associated with significantly worse clinical outcomes. While immunosuppressant level variability is also related to adverse outcomes, such variability does not account for increased risk observed with depression.
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Affiliation(s)
- Michael C Chu
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Patrick J Smith
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - John M Reynolds
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Scott M Palmer
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Laurie D Snyder
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Alice L Gray
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
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17
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Abstract
Airway complications (ACs) after lung transplant remain a challenge and include bronchial dehiscence, bronchial stenosis, tracheobronchomalacia, infections, and bronchial fistulas. The spectrum of complications may coexist along a continuum and can be classified as early (<1 month after transplant) or late (>1 month), and anastomotic or nonanastomotic. Bronchiolitis obliterans is the most common form of chronic lung allograft rejection. Airway compromise is seen in rare instances of lung torsion, and imaging may provide helpful diagnostic clues. Computed tomography (CT) and bronchoscopy play major roles in the diagnosis and treatment of ACs after lung transplant. Chest CT with advanced postprocessing techniques is a valuable tool in evaluating for airways complications, for initial bronchoscopic treatment planning and subsequent posttreatment assessment. Various bronchoscopic treatment options may be explored to maintain airway patency. The goal of this article is to review imaging findings of ACs after lung transplantation, with emphasis on chest CT and bronchoscopic correlation.
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18
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Sato M. Bronchiolitis obliterans syndrome and restrictive allograft syndrome after lung transplantation: why are there two distinct forms of chronic lung allograft dysfunction? ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:418. [PMID: 32355862 PMCID: PMC7186721 DOI: 10.21037/atm.2020.02.159] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Bronchiolitis obliterans syndrome (BOS) had been considered to be the representative form of chronic rejection or chronic lung allograft dysfunction (CLAD) after lung transplantation. In BOS, small airways are affected by chronic inflammation and obliterative fibrosis, whereas peripheral lung tissue remains relatively intact. However, recognition of another form of CLAD involving multiple tissue compartments in the lung, termed restrictive allograft syndrome (RAS), raised a fundamental question: why there are two phenotypes of CLAD? Increasing clinical and experimental data suggest that RAS may be a prototype of chronic rejection after lung transplantation involving both cellular and antibody-mediated alloimmune responses. Some cases of RAS are also induced by fulminant general inflammation in lung allografts. However, BOS involves alloimmune responses and the airway-centered disease process can be explained by multiple mechanisms such as external alloimmune-independent stimuli (such as infection, aspiration and air pollution), exposure of airway-specific autoantigens and airway ischemia. Localization of immune responses in different anatomical compartments in different phenotypes of CLAD might be associated with lymphoid neogenesis or the de novo formation of lymphoid tissue in lung allografts. Better understanding of distinct mechanisms of BOS and RAS will facilitate the development of effective preventive and therapeutic strategies of CLAD.
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Affiliation(s)
- Masaaki Sato
- Department of Thoracic Surgery, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
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19
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Bin Saeedan M, Mukhopadhyay S, Lane CR, Renapurkar RD. Imaging indications and findings in evaluation of lung transplant graft dysfunction and rejection. Insights Imaging 2020; 11:2. [PMID: 31900671 PMCID: PMC6942098 DOI: 10.1186/s13244-019-0822-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 11/29/2019] [Indexed: 11/16/2022] Open
Abstract
Lung transplantation is a treatment option in end-stage lung disease. Complications can develop along a continuum in the immediate or longer post-transplant period, including surgical and technical complications, primary graft dysfunction, rejection, infections, post-transplant lymphoproliferative disorder, and recurrence of the primary disease. These complications have overlapping clinical and imaging features and often co-exist. Time of onset after transplant is helpful in narrowing the differential diagnosis. In the early post transplantation period, imaging findings are non-specific and need to be interpreted in the context of the clinical picture and other investigations. In contrast, imaging plays a key role in diagnosing and monitoring patients with chronic lung allograft dysfunction. The goal of this article is to review primary graft dysfunction, acute rejection, and chronic rejection with emphasis on the role of imaging, pathology findings, and differential diagnosis.
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Affiliation(s)
- Mnahi Bin Saeedan
- Sections of Thoracic and Cardiovascular Imaging Laboratory, Imaging Institute, Cleveland Clinic, L-10, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | | | - C Randall Lane
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland, USA
| | - Rahul D Renapurkar
- Sections of Thoracic and Cardiovascular Imaging Laboratory, Imaging Institute, Cleveland Clinic, L-10, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
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20
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Parulekar AD, Kao CC. Detection, classification, and management of rejection after lung transplantation. J Thorac Dis 2019; 11:S1732-S1739. [PMID: 31632750 DOI: 10.21037/jtd.2019.03.83] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Rejection is a major complication following lung transplantation. Acute cellular rejection, lymphocytic bronchiolitis, and antibody-mediated rejection (AMR) are all risk factors for the subsequent development of chronic lung allograft dysfunction (CLAD). Acute cellular rejection and lymphocytic bronchiolitis have well defined histopathologic diagnostic criteria and grading. Diagnosis of AMR requires a multidisciplinary approach. CLAD is the major barrier to long-term survival following lung transplantation. The most common phenotype of CLAD is bronchiolitis obliterans syndrome (BOS) which is defined by a persistent obstructive decline in lung function. Restrictive allograft dysfunction (RAS) is a second phenotype of CLAD and is associated with a worse prognosis. This article will review the diagnosis, staging, clinical presentation, and treatment of acute rejection, AMR, and CLAD following lung transplantation.
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Affiliation(s)
- Amit D Parulekar
- Section of Pulmonary, Critical Care, and Sleep, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Christina C Kao
- Section of Pulmonary, Critical Care, and Sleep, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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21
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Law N, Hamandi B, Fegbeutel C, Silveira FP, Verschuuren EA, Ussetti P, Chin-Hong PV, Sole A, Holmes-Liew CL, Billaud EM, Grossi PA, Manuel O, Levine DJ, Barbers RG, Hadjiliadis D, Younus M, Aram J, Chaparro C, Singer LG, Husain S. Lack of association of Aspergillus colonization with the development of bronchiolitis obliterans syndrome in lung transplant recipients: An international cohort study. J Heart Lung Transplant 2019; 38:963-971. [PMID: 31300191 DOI: 10.1016/j.healun.2019.06.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 04/30/2019] [Accepted: 06/14/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Bronchiolitis obliterans syndrome (BOS) is a major limitation in the long-term survival of lung transplant recipients (LTRs). However, the risk factors in the development of BOS remain undetermined. We conducted an international cohort study of LTRs to assess whether Aspergillus colonization with large or small conidia is a risk factor for the development of BOS. METHODS Consecutive LTRs from January 2005 to December 2008 were evaluated. Rates of BOS and associated risk factors were recorded at 4 years. International Society of Heart and Lung Transplantation criteria were used to define fungal and other infections. A Cox proportional-hazards-model was constructed to assess the association between Aspergillus colonization and the development of BOS controlling for confounders. RESULTS A total of 747 LTRs were included. The cumulative incidence of BOS at 4 years after transplant was 33% (250 of 747). Additionally, 22% of LTRs experienced Aspergillus colonization after transplantation. Aspergillus colonization with either large (hazard ratio [HR] = 0.6, 95% confidence interval [CI] = 0.3-1.2, p = 0.12) or small conidia (HR = 0.9, 95% CI = 0.6-1.4, p = 0.74) was not associated with the development of BOS. Factors associated with increased risk of development of BOS were the male gender (HR = 1.4, 95% CI = 1.1-1.8, p = 0.02) and episodes of acute rejection (1-2 episodes, HR = 1.5, 95% CI = 1.1-2.1, p = 0.014; 3-4 episodes, HR = 1.6, 95% CI = 1.0-2.6, p = 0.036; >4 episodes, HR = 2.2, 95% CI = 1.1-4.3, p = 0.02), whereas tacrolimus use was associated with reduced risk of BOS (HR = 0.6, 95% CI = 0.5-0.9, p = 0.007). CONCLUSIONS We conclude from this large multicenter cohort of lung transplant patients, that Aspergillus colonization with large or small conidia did not show an association with the development of BOS.
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Affiliation(s)
- Nancy Law
- Division of Infectious Diseases, Multi-Organ Transplant Program, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Bassem Hamandi
- Department of Pharmacy, University Health Network, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Christine Fegbeutel
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Fernanda P Silveira
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Erik A Verschuuren
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, Groningen, The Netherlands
| | - Piedad Ussetti
- Respiratory Department, Hospital Puerta di Hierro, Madrid, Spain
| | - Peter V Chin-Hong
- Department of Medicine, University of California, San Francisco, California, USA
| | - Amparo Sole
- Respiratory Department, University and Polytechnic Hospital La Fe, Universidad de Valencia, Valencia, Spain
| | - Chien-Li Holmes-Liew
- Lung Research, Hanson Institute and Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Eliane M Billaud
- Service de Pharmacologie, AP-HP, Hôpital Européen Georges-Pompidou, Paris, France
| | - Paolo A Grossi
- Department of Infectious Diseases, University of Insubria, Varese, Italy
| | - Oriol Manuel
- Transplantation Center and Infectious Diseases Service, University Hospital of Lausanne, Lausanne, Switzerland
| | - Deborah J Levine
- Division of Pulmonary and Critical Care Medicine, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Richard G Barbers
- Division of Pulmonary and Critical Care, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Denis Hadjiliadis
- Department of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Jay Aram
- Pfizer Incorporated, New York, New York, USA
| | - Cecilia Chaparro
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shahid Husain
- Division of Infectious Diseases, Multi-Organ Transplant Program, University of Toronto, University Health Network, Toronto, Ontario, Canada.
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22
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Tague LK, Byers DE, Hachem R, Kreisel D, Krupnick AS, Kulkarni HS, Chen C, Huang HJ, Gelman A. Impact of SLCO1B3 polymorphisms on clinical outcomes in lung allograft recipients receiving mycophenolic acid. THE PHARMACOGENOMICS JOURNAL 2019; 20:69-79. [PMID: 30992538 PMCID: PMC6800829 DOI: 10.1038/s41397-019-0086-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 01/20/2019] [Accepted: 03/27/2019] [Indexed: 12/18/2022]
Abstract
Single-nucleotide polymorphisms (SNPs) in genes involved in mycophenolic acid (MPA) metabolism have been shown to contribute to variable MPA exposure, but their clinical effects are unclear. We aimed to determine if SNPs in key genes in MPA metabolism affect outcomes after lung transplantation. We performed a retrospective cohort study of 275 lung transplant recipients, 228 receiving mycophenolic acid and a control group of 47 receiving azathioprine. Six SNPs known to regulate MPA exposure from the SLCO, UGT and MRP2 families were genotyped. Primary outcome was 1-year survival. Secondary outcomes were 3-year survival, nonminimal (≥A2 or B2) acute rejection, and chronic lung allograft dysfunction (CLAD). Statistical analyses included time-to-event Kaplan-Meier with log-rank test and Cox regression modeling. We found that SLCO1B3 SNPs rs4149117 and rs7311358 were associated with decreased 1-year survival [rs7311358 HR 7.76 (1.37-44.04), p = 0.021; rs4149117 HR 7.28 (1.27-41.78), p = 0.026], increased risk for nonminimal acute rejection [rs4149117 TT334/T334G: OR 2.01 (1.06-3.81), p = 0.031; rs7311358 GG699/G699A: OR 2.18 (1.13-4.21) p = 0.019] and lower survival through 3 years for MPA patients but not for azathioprine patients. MPA carriers of either SLCO1B3 SNP had shorter survival after CLAD diagnosis (rs4149117 p = 0.048, rs7311358 p = 0.023). For the MPA patients, Cox regression modeling demonstrated that both SNPs remained independent risk factors for death. We conclude that hypofunctional SNPs in the SLCO1B3 gene are associated with an increased risk for acute rejection and allograft failure in lung transplant recipients treated with MPA.
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Affiliation(s)
- Laneshia K Tague
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University in Saint Louis, Saint Louis, MO, USA
| | - Derek E Byers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University in Saint Louis, Saint Louis, MO, USA
| | - Ramsey Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University in Saint Louis, Saint Louis, MO, USA
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in Saint Louis, Saint Louis, MO, USA
| | - Alexander S Krupnick
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Hrishikesh S Kulkarni
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University in Saint Louis, Saint Louis, MO, USA
| | - Catherine Chen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Howard J Huang
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Andrew Gelman
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in Saint Louis, Saint Louis, MO, USA.
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23
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Smirnova NF, Conlon TM, Morrone C, Dorfmuller P, Humbert M, Stathopoulos GT, Umkehrer S, Pfeiffer F, Yildirim AÖ, Eickelberg O. Inhibition of B cell-dependent lymphoid follicle formation prevents lymphocytic bronchiolitis after lung transplantation. JCI Insight 2019; 4:123971. [PMID: 30728330 DOI: 10.1172/jci.insight.123971] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 01/03/2019] [Indexed: 12/14/2022] Open
Abstract
Lung transplantation (LTx) is the only therapeutic option for many patients with chronic lung disease. However, long-term survival after LTx is severely compromised by chronic rejection (chronic lung allograft dysfunction [CLAD]), which affects 50% of recipients after 5 years. The underlying mechanisms for CLAD are poorly understood, largely due to a lack of clinically relevant animal models, but lymphocytic bronchiolitis is an early sign of CLAD. Here, we report that lymphocytic bronchiolitis occurs early in a long-term murine orthotopic LTx model, based on a single mismatch (grafts from HLA-A2:B6-knockin donors transplanted into B6 recipients). Lymphocytic bronchiolitis is followed by formation of B cell-dependent lymphoid follicles that induce adjacent bronchial epithelial cell dysfunction in a spatiotemporal fashion. B cell deficiency using recipient μMT-/- mice prevented intrapulmonary lymphoid follicle formation and lymphocytic bronchiolitis. Importantly, selective inhibition of the follicle-organizing receptor EBI2, using genetic deletion or pharmacologic inhibition, prevented functional and histological deterioration of mismatched lung grafts. In sum, we provided what we believe to be a mouse model of chronic rejection and lymphocytic bronchiolitis after LTx and identified intrapulmonary lymphoid follicle formation as a target for pharmacological intervention of long-term allograft dysfunction after LTx.
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Affiliation(s)
- Natalia F Smirnova
- Comprehensive Pneumology Center, Member of the German Center for Lung Research, Institute of Lung Biology and Disease, Helmholtz Zentrum München, Ludwig-Maximilians University Munich, Munich Germany.,Division of Respiratory Sciences and Critical Care Medicine, University of Colorado, Aurora, Colorado, USA
| | - Thomas M Conlon
- Comprehensive Pneumology Center, Member of the German Center for Lung Research, Institute of Lung Biology and Disease, Helmholtz Zentrum München, Ludwig-Maximilians University Munich, Munich Germany
| | - Carmela Morrone
- Comprehensive Pneumology Center, Member of the German Center for Lung Research, Institute of Lung Biology and Disease, Helmholtz Zentrum München, Ludwig-Maximilians University Munich, Munich Germany
| | - Peter Dorfmuller
- Faculty of Medicine, Paris-Sud University, Kremlin-Bicêtre, France.,Department of Pathology and INSERM U999, Pulmonary Hypertension, Pathophysiology and Novel Therapies, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, France
| | - Marc Humbert
- Faculty of Medicine, Paris-Sud University, Kremlin-Bicêtre, France.,Department of Pathology and INSERM U999, Pulmonary Hypertension, Pathophysiology and Novel Therapies, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, France
| | - Georgios T Stathopoulos
- Comprehensive Pneumology Center, Member of the German Center for Lung Research, Institute of Lung Biology and Disease, Helmholtz Zentrum München, Ludwig-Maximilians University Munich, Munich Germany
| | - Stephan Umkehrer
- Lehrstuhl für Biomedizinische Physik, Physik-Department and Institut für Medizintechnik, Technische Universität München, Garching, Germany
| | - Franz Pfeiffer
- Lehrstuhl für Biomedizinische Physik, Physik-Department and Institut für Medizintechnik, Technische Universität München, Garching, Germany
| | - Ali Ö Yildirim
- Comprehensive Pneumology Center, Member of the German Center for Lung Research, Institute of Lung Biology and Disease, Helmholtz Zentrum München, Ludwig-Maximilians University Munich, Munich Germany
| | - Oliver Eickelberg
- Comprehensive Pneumology Center, Member of the German Center for Lung Research, Institute of Lung Biology and Disease, Helmholtz Zentrum München, Ludwig-Maximilians University Munich, Munich Germany.,Division of Respiratory Sciences and Critical Care Medicine, University of Colorado, Aurora, Colorado, USA
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24
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Siddiqui AS, Kumar G, Majumdar T, Graviss EA, Nguyen DT, Goodarzi A, Kaleekal T. Association of methacholine challenge test with diagnosis of chronic lung allograft dysfunction in lung transplant patients. Clin Transplant 2018; 32:e13397. [PMID: 30192029 DOI: 10.1111/ctr.13397] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 08/08/2018] [Accepted: 08/23/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chronic lung allograft dysfunction (CLAD) is a complication of lung transplantation. We sought to determine whether bronchial hyperresponsiveness detected by the methacholine challenge test (MCT) at 3 months after lung transplant (LT) predicts the development of CLAD. METHODS We performed a retrospective cohort study of 140 LT patients between 1/2008 and 6/2014 who underwent MCT at 3 months after LT. Pearson's chi-squared test and Kruskal-Wallis test were used to compare categorical and continuous variables, respectively. Cox proportional hazards modeling was used to evaluate the association between CLAD and MCT. RESULTS Methacholine challenge test+ was associated with the development of overall CLAD (adjusted hazards ratio [aHR]: 3.47; 95% confidence interval [95% CI]: 1.71, 7.03; P = 0.001) and CLAD within 3 years (aHR: 4.98; 95%CI: 1.84, 13.48; P = 0.002). Subgroup analysis showed that MCT (+) is associated with overall CLAD in single lung transplant (SLT) (aHR: 8.18; 95% CI: 2.22, 30.09; P = 0.002), double lung transplant (DLT) (aHR: 3.27; 95% CI: 1.22, 8.78; P = 0.02) and CLAD within 3 years in DLT patients (aHR: 6.76; 95% CI: 1.71, 26.74; P = 0.01). CONCLUSION Methacholine challenge test+ at 3 months after LT is associated with the development of overall CLAD. Positive MCT could predict the development of early CLAD within 3 years in DLT patients.
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Affiliation(s)
- Atif S Siddiqui
- Pulmonary and Critical Care, Houston Methodist Hospital, Houston, Texas
| | - Gagan Kumar
- Pulmonary and Critical Care, Northeast Georgia Medical Center, Gainesville, Georgia
| | | | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Ahmad Goodarzi
- Pulmonary Transplant, Houston Methodist Hospital, Houston, Texas
| | - Thomas Kaleekal
- Pulmonary Transplant, Houston Methodist Hospital, Houston, Texas
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25
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Li SS, Tumin D, Krone KA, Boyer D, Kirkby SE, Mansour HM, Hayes D. Risks associated with lung transplantation in cystic fibrosis patients. Expert Rev Respir Med 2018; 12:893-904. [PMID: 30198350 DOI: 10.1080/17476348.2018.1522254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Survival after lung transplantation lags behind outcomes of other solid organ transplants, and complications from lung transplant are the second most common cause of death in cystic fibrosis. Evolving surgical techniques, therapeutics, and perioperative management have improved short-term survival after lung transplantation, yet have not translated into significant improvement in long-term mortality. Areas covered: We review risk factors for poor long-term outcomes among patients with cystic fibrosis undergoing lung transplantation to highlight areas for improvement. This includes reasons for organ dysfunction, complications of immunosuppression, further exacerbation of extrapulmonary complications of cystic fibrosis, and quality of life. A literature search was performed using PubMed-indexed journals. Expert commentary: There are multiple medical and socioeconomic barriers that threaten long-term survival following lung transplant for patients with cystic fibrosis. An understanding of the causes of each could elucidate treatment options. There is a lack of prospective, multicenter, randomized control trials due to cost, complexity, and feasibility. Ongoing prospective studies should be reserved for the most promising interventions identified in retrospective studies in order to improve long-term outcomes.
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Affiliation(s)
- Susan S Li
- a Department of Pediatrics, Nationwide Children's Hospital , The Ohio State University College of Medicine , Columbus , OH , USA
| | - Dmitry Tumin
- a Department of Pediatrics, Nationwide Children's Hospital , The Ohio State University College of Medicine , Columbus , OH , USA
| | - Katie A Krone
- b Division of Respiratory Diseases, Boston Children's Hospital , Harvard Medical School , Boston , MA, OH , USA
| | - Debra Boyer
- b Division of Respiratory Diseases, Boston Children's Hospital , Harvard Medical School , Boston , MA, OH , USA
| | - Stephen E Kirkby
- a Department of Pediatrics, Nationwide Children's Hospital , The Ohio State University College of Medicine , Columbus , OH , USA
| | - Heidi M Mansour
- c Department of Pharmacology and Toxicology , The University of Arizona Colleges of Pharmacy and Medicine , Tucson , AZ , USA
| | - Don Hayes
- a Department of Pediatrics, Nationwide Children's Hospital , The Ohio State University College of Medicine , Columbus , OH , USA
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26
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High-Resolution CT Findings of Obstructive and Restrictive Phenotypes of Chronic Lung Allograft Dysfunction: More Than Just Bronchiolitis Obliterans Syndrome. AJR Am J Roentgenol 2018; 211:W13-W21. [PMID: 29792746 DOI: 10.2214/ajr.17.19041] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The purpose of this article is to review the high-resolution CT characteristics of individual obstructive and restrictive chronic lung allograft dysfunction (CLAD) phenotypes to aid in making accurate diagnoses and guiding treatment. CONCLUSION Long-term survival and function after lung transplant are considerably worse compared with after other organ transplants. CLAD is implicated as a major limiting factor for long-term graft viability. Historically thought to be a single entity, bronchiolitis obliterans syndrome, CLAD is actually a heterogeneous group of disorders with distinct subtypes.
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27
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Lendermon EA, Dodd-O JM, Coon TA, Wang X, Ensor CR, Cardenes N, Koodray CL, Heusey HL, Bennewitz MF, Sundd P, Bullock GC, Popescu I, Guo L, O'Donnell CP, Rojas M, McDyer JF. Azithromycin Fails to Prevent Accelerated Airway Obliteration in T-bet -/- Mouse Lung Allograft Recipients. Transplant Proc 2018; 50:1566-1574. [PMID: 29880387 DOI: 10.1016/j.transproceed.2018.02.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 02/16/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Cellular and molecular mechanisms of acute and chronic lung allograft rejection have yet to be clearly defined, and obliterative bronchiolitis (OB) remains the primary limitation to survival in lung transplant recipients (LTRs). We have previously shown that T-bet-deficient recipients of full major histocompatibility complex (MHC)-mismatched, orthotopic left lung transplants develop accelerated obliterative airway disease (OAD) in the setting of acute cellular rejection characterized by robust alloimmune CD8+ interleukin (IL)-17 and interferon (IFN)-γ responses that are attenuated with neutralization of IL-17. Azithromycin has been shown to be beneficial in some LTRs with bronchiolitis obliterans syndrome/OB. Here, we evaluated the effects of azithromycin on rejection pathology and T-cell effector responses in T-bet-/- recipients of lung transplants. METHODS Orthotopic left lung transplantation was performed in BALB/c → B6 wild type or BALB/c → B6 T-bet-/- strain combinations as previously described. Mice treated with azithromycin received 10 mg/kg or 50 mg/kg subcutaneously daily. Lung allograft histopathology was analyzed at day 10 or day 21 post-transplantation, and neutrophil staining for quantification was performed using anti-myeloperoxidase. Allograft mononuclear cells were isolated at day 10 for T-cell effector cytokine response assessment using flow cytometry. RESULTS We show that while azithromycin significantly decreases lung allograft neutrophilia and CXCL1 levels and attenuates allospecific CD8+ IL-17 responses early post-transplantation, OAD persists in T-bet-deficient mice. CONCLUSIONS Our results indicate that lung allograft neutrophilia is not essential for the development of OAD in this model and suggest allospecific T-cell responses that remain despite marked attenuation of CD8+ IL-17 are sufficient for obliterative airway inflammation and fibrosis.
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Affiliation(s)
- E A Lendermon
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
| | - J M Dodd-O
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Department of Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - T A Coon
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - X Wang
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - C R Ensor
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - N Cardenes
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - C L Koodray
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - H L Heusey
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - M F Bennewitz
- Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - P Sundd
- Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - G C Bullock
- Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - I Popescu
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - L Guo
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - C P O'Donnell
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - M Rojas
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - J F McDyer
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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28
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Van Herck A, Verleden SE, Vanaudenaerde BM, Verleden GM, Vos R. Prevention of chronic rejection after lung transplantation. J Thorac Dis 2017; 9:5472-5488. [PMID: 29312757 DOI: 10.21037/jtd.2017.11.85] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Long-term survival after lung transplantation (LTx) is limited by chronic rejection (CR). Therapeutic strategies for CR have been largely unsuccessful, making prevention of CR an important and challenging therapeutic approach. In the current review, we will discuss current clinical evidence regarding prevention of CR after LTx.
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Affiliation(s)
- Anke Van Herck
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
| | - Stijn E Verleden
- Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
| | - Bart M Vanaudenaerde
- Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
| | - Geert M Verleden
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
| | - Robin Vos
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
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29
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Correa AMB, Guimarães JDS, Dos Santos E Alhadas E, Kushmerick C. Control of neuronal excitability by Group I metabotropic glutamate receptors. Biophys Rev 2017; 9:835-845. [PMID: 28836161 PMCID: PMC5662043 DOI: 10.1007/s12551-017-0301-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 07/27/2017] [Indexed: 12/12/2022] Open
Abstract
Metabotropic glutamate (mGlu) receptors couple through G proteins to regulate a large number of cell functions. Eight mGlu receptor isoforms have been cloned and classified into three Groups based on sequence, signal transduction mechanisms and pharmacology. This review will focus on Group I mGlu receptors, comprising the isoforms mGlu1 and mGlu5. Activation of these receptors initiates both G protein-dependent and -independent signal transduction pathways. The G-protein-dependent pathway involves mainly Gαq, which can activate PLCβ, leading initially to the formation of IP3 and diacylglycerol. IP3 can release Ca2+ from cellular stores resulting in activation of Ca2+-dependent ion channels. Intracellular Ca2+, together with diacylglycerol, activates PKC, which has many protein targets, including ion channels. Thus, activation of the G-protein-dependent pathway affects cellular excitability though several different effectors. In parallel, G protein-independent pathways lead to activation of non-selective cationic currents and metabotropic synaptic currents and potentials. Here, we provide a survey of the membrane transport proteins responsible for these electrical effects of Group I metabotropic glutamate receptors.
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Affiliation(s)
- Ana Maria Bernal Correa
- Graduate Program in Physiology and Pharmacology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | | | - Christopher Kushmerick
- Graduate Program in Physiology and Pharmacology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.
- Departamento de Fisiologia e Biofísica - ICB, UFMG, Av. Pres. Antônio Carlos, 6627 - Pampulha, Belo Horizonte, MG, 31270-901, Brazil.
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30
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Abstract
Despite advances in immunosuppression over the past 25 years, acute cellular rejection remains a common complication early after lung transplantation. Although acute cellular rejection has often not resulted in clinical signs or symptoms of allograft dysfunction, it has been widely recognized as a strong independent risk factor for the development of chronic rejection, emphasizing its clinical significance. In recent years, the role of humoral immunity in lung rejection has been increasingly appreciated, and antibody-mediated rejection is now recognized as a form of rejection that may result in allograft failure.
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Affiliation(s)
- Ramsey R Hachem
- Division of Pulmonary and Critical Care, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8052, St Louis, MO 63110, USA.
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31
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Shino MY, Weigt SS, Li N, Palchevskiy V, Derhovanessian A, Saggar R, Sayah DM, Huynh RH, Gregson AL, Fishbein MC, Ardehali A, Ross DJ, Lynch JP, Elashoff RM, Belperio JA. The prognostic importance of CXCR3 chemokine during organizing pneumonia on the risk of chronic lung allograft dysfunction after lung transplantation. PLoS One 2017; 12:e0180281. [PMID: 28686641 PMCID: PMC5501470 DOI: 10.1371/journal.pone.0180281] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 06/13/2017] [Indexed: 12/11/2022] Open
Abstract
RATIONALE Since the pathogenesis of chronic lung allograft dysfunction (CLAD) remains poorly defined with no known effective therapies, the identification and study of key events which increase CLAD risk is a critical step towards improving outcomes. We hypothesized that bronchoalveolar lavage fluid (BALF) CXCR3 ligand concentrations would be augmented during organizing pneumonia (OP) and that episodes of OP with marked chemokine elevations would be associated with significantly higher CLAD risk. METHODS All transbronchial biopsies (TBBX) from patients who received lung transplantation between 2000 to 2010 were reviewed. BALF concentrations of the CXCR3 ligands (CXCL9, CXCL10 and CXCL11) were compared between episodes of OP and "healthy" biopsies using linear mixed-effects models. The association between CXCR3 ligand concentrations during OP and CLAD risk was evaluated using proportional hazards models with time-dependent covariates. RESULTS There were 1894 bronchoscopies with TBBX evaluated from 441 lung transplant recipients with 169 (9%) episodes of OP and 907 (49%) non-OP histopathologic injuries. 62 (37%) episodes of OP were observed during routine surveillance bronchoscopy. Eight hundred thirty-eight (44%) TBBXs had no histopathology and were classified as "healthy" biopsies. There were marked elevations in BALF CXCR3 ligand concentrations during OP compared with "healthy" biopsies. In multivariable models adjusted for other injury patterns, OP did not significantly increase the risk of CLAD when BAL CXCR3 chemokine concentrations were not taken into account. However, OP with elevated CXCR3 ligands markedly increased CLAD risk in a dose-response manner. An episode of OP with CXCR3 concentrations greater than the 25th, 50th and 75th percentiles had HRs for CLAD of 1.5 (95% CI 1.0-2.3), 1.9 (95% CI 1.2-2.8) and 2.2 (95% CI 1.4-3.4), respectively. CONCLUSIONS This study identifies OP, a relatively uncommon histopathologic finding after lung transplantation, as a major risk factor for CLAD development when considered in the context of increased allograft expression of interferon-γ inducible ELR- CXC chemokines. We further demonstrate for the first time, the prognostic importance of BALF CXCR3 ligand concentrations during OP on subsequent CLAD risk.
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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, United States of America
- * E-mail:
| | - S. Samuel Weigt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Ning Li
- Department of Biomathematics, University of California at Los Angeles, Los Angeles, California, United States of America
| | - Vyacheslav Palchevskiy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Ariss Derhovanessian
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Rajan Saggar
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - David M. Sayah
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Richard H. Huynh
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Aric L. Gregson
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Michael C. Fishbein
- Department of Pathology, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Abbas Ardehali
- Division of Cardiothoracic Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - David J. Ross
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Joseph P. Lynch
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Robert M. Elashoff
- Department of Biomathematics, University of California at Los Angeles, Los Angeles, California, United States of America
| | - John A. Belperio
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
- Department of Biomathematics, University of California at Los Angeles, Los Angeles, California, United States of America
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32
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Shino MY, Weigt SS, Li N, Derhovanessian A, Sayah DM, Huynh RH, Saggar R, Gregson AL, Ardehali A, Ross DJ, Lynch JP, Elashoff RM, Belperio JA. Impact of Allograft Injury Time of Onset on the Development of Chronic Lung Allograft Dysfunction After Lung Transplantation. Am J Transplant 2017; 17:1294-1303. [PMID: 27676455 PMCID: PMC5368037 DOI: 10.1111/ajt.14066] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 08/16/2016] [Accepted: 09/18/2016] [Indexed: 01/25/2023]
Abstract
The impact of allograft injury time of onset on the risk of chronic lung allograft dysfunction (CLAD) remains unknown. We hypothesized that episodes of late-onset (≥6 months) allograft injury would produce an augmented CXCR3/ligand immune response, leading to increased CLAD. In a retrospective single-center study, 1894 transbronchial biopsy samples from 441 lung transplant recipients were reviewed for the presence of acute rejection (AR), lymphocytic bronchiolitis (LB), diffuse alveolar damage (DAD), and organizing pneumonia (OP). The association between the time of onset of each injury pattern and CLAD was assessed by using multivariable Cox models with time-dependent covariates. Bronchoalveolar lavage (BAL) CXCR3 ligand concentrations were compared between early- and late-onset injury patterns using linear mixed-effects models. Late-onset DAD and OP were strongly associated with CLAD: adjusted hazard ratio 2.8 (95% confidence interval 1.5-5.3) and 2.0 (1.1-3.4), respectively. The early-onset form of these injury patterns did not increase CLAD risk. Late-onset LB and acute rejection (AR) predicted CLAD in univariable models but lost significance after multivariable adjustment for late DAD and OP. AR was the only early-onset injury pattern associated with CLAD development. Elevated BAL CXCR3 ligand concentrations during late-onset allograft injury parallel the increase in CLAD risk and support our hypothesis that late allograft injuries result in a more profound CXCR3/ligand immune response.
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Affiliation(s)
- MY Shino
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1690
| | - SS Weigt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1690
| | - N Li
- Department of Biomathematics, University of California at Los Angeles, Los Angeles, CA 90095-1652
| | - A Derhovanessian
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1690
| | - DM Sayah
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1690
| | - RH Huynh
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1690
| | - R Saggar
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1690
| | - AL Gregson
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1688
| | - A Ardehali
- Division of Cardiothoracic Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1741
| | - DJ Ross
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1690
| | - JP Lynch
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1690
| | - RM Elashoff
- Department of Biomathematics, University of California at Los Angeles, Los Angeles, CA 90095-1652
| | - JA Belperio
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1690
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33
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Moore CA, Pilewski JM, Venkataramanan R, Robinson KM, Morrell MR, Wisniewski SR, Zeevi A, McDyer JF, Ensor CR. Effect of aerosolized antipseudomonals onPseudomonaspositivity and bronchiolitis obliterans syndrome after lung transplantation. Transpl Infect Dis 2017; 19. [DOI: 10.1111/tid.12688] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 11/02/2016] [Accepted: 12/08/2016] [Indexed: 01/07/2023]
Affiliation(s)
- Cody A. Moore
- Department of Pharmacy and Therapeutics; University of Pittsburgh School of Pharmacy; Pittsburgh PA USA
| | - Joseph M. Pilewski
- Division of Pulmonary, Allergy, and Critical Care Medicine; University of Pittsburgh School of Medicine; Pittsburgh PA USA
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences; University of Pittsburgh School of Pharmacy; Pittsburgh PA USA
- Department of Pathology; University of Pittsburgh; Pittsburgh PA USA
| | - Keven M. Robinson
- Division of Pulmonary, Allergy, and Critical Care Medicine; University of Pittsburgh School of Medicine; Pittsburgh PA USA
| | - Matthew R. Morrell
- Division of Pulmonary, Allergy, and Critical Care Medicine; University of Pittsburgh School of Medicine; Pittsburgh PA USA
| | - Stephen R. Wisniewski
- Department of Epidemiology; University of Pittsburgh Graduate School of Public Health; Pittsburgh PA USA
| | - Adriana Zeevi
- Department of Pathology; University of Pittsburgh; Pittsburgh PA USA
| | - John F. McDyer
- Division of Pulmonary, Allergy, and Critical Care Medicine; University of Pittsburgh School of Medicine; Pittsburgh PA USA
| | - Christopher R. Ensor
- Department of Pharmacy and Therapeutics; University of Pittsburgh School of Pharmacy; Pittsburgh PA USA
- Division of Pulmonary, Allergy, and Critical Care Medicine; University of Pittsburgh School of Medicine; Pittsburgh PA USA
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34
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Gazourian L, Ash S, Meserve EEK, Diaz A, Estepar RSJ, El-Chemaly SY, Rosas IO, Divo M, Fuhlbrigge AL, Camp PC, Ho VT, Bhatt AS, Goldberg HJ, Sholl LM, Washko GR. Quantitative computed tomography assessment of bronchiolitis obliterans syndrome after lung transplantation. Clin Transplant 2017; 31. [PMID: 28244139 DOI: 10.1111/ctr.12943] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Bronchiolitis obliterans syndrome (BOS) is a clinical manifestation of chronic allograft rejection following lung transplantation. We examined the quantitative measurements of the proximal airway and vessels and pathologic correlations in subjects with BOS. METHODS Patients who received a lung transplant at the Brigham and Women's Hospital between December 1, 2002 and December 31, 2010 were included in this study. We characterized the quantitative CT measures of proximal airways and vessels and pathological changes. RESULTS Ninety-four (46.1%) of the 204 subjects were included in the study. There was a significant increase in the airway vessel ratio in subjects who developed progressive BOS compared to controls and non-progressors. There was a significant increase in airway lumen area and decrease in vessel cross-sectional area in patients with BOS compared to controls. Patients with BOS had a significant increase in proximal airway fibrosis compared to controls. CONCLUSIONS BOS is characterized by central airway dilation and vascular remodeling, the degree of which is correlated to decrements in lung function. Our data suggest that progressive BOS is a pathologic process that affects both the central and distal airways.
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Affiliation(s)
- Lee Gazourian
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Samuel Ash
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Emily E K Meserve
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Alejandro Diaz
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Souheil Y El-Chemaly
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Ivan O Rosas
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Lung Transplant Program, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Miguel Divo
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Lung Transplant Program, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Anne L Fuhlbrigge
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Lung Transplant Program, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Phillip C Camp
- Department of Medicine, Lung Transplant Program, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Lung Transplant Program, Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Vincent T Ho
- Department of Medical Oncology, Division of Hematologic Malignancies, Dana Farber Cancer Institute, Boston, MA, USA
| | - Ami S Bhatt
- School of Medicine and Departments of Medicine and Genetics, Stanford University, Stanford, CA, USA
| | - Hilary J Goldberg
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Lung Transplant Program, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Lynette M Sholl
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - George R Washko
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
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35
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Gunasekaran M, Xu Z, Nayak D, Sharma M, Hachem R, Walia R, Bremner RM, Smith MA, Mohanakumar T. Donor-Derived Exosomes With Lung Self-Antigens in Human Lung Allograft Rejection. Am J Transplant 2017; 17:474-484. [PMID: 27278097 PMCID: PMC5340154 DOI: 10.1111/ajt.13915] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 06/02/2016] [Accepted: 06/04/2016] [Indexed: 01/25/2023]
Abstract
The immunological role of exosomes in allograft rejection remains unknown. We sought to determine whether exosomes are induced during lung allograft rejection and to define the antigenic compositions of HLA, lung-associated self-antigens (SAgs) and microRNAs (miRNAs). Exosomes were isolated from sera and bronchoalveolar lavage fluid from 30 lung transplant recipients (LTxRs) who were stable or who had acute rejection (AR) or bronchiolitis obliterans syndrome (BOS). Exosomes were defined by flow cytometry for CD63 and western blotting for annexin V SAgs, collagen V (Col-V) and Kα1 tubulin were examined by electron microscopy; miRNAs were profiled by a miRNA array. Donor HLA and SAgs were detected on exosomes from LTxRs with AR and BOS but not from stable LTxRs. Exosomes expressing Col-V were isolated from sera from LTxRs 3 mo before AR and 6 mo before BOS diagnosis, suggesting that exosomes with SAgs may be a noninvasive rejection biomarker. Exosomes isolated from LTxRs with AR or BOS also contained immunoregulatory miRNAs. We concluded that exosomes expressing donor HLA, SAgs and immunoregulatory miRNAs are present in the circulation and local site after human lung transplantation and play an important role in the immune pathogenesis of acute allograft rejection and BOS.
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Affiliation(s)
- M. Gunasekaran
- Norton Thoracic Institute St. Joseph’s Hospital and Medical Center Phoenix, Arizona
| | - Z. Xu
- Norton Thoracic Institute St. Joseph’s Hospital and Medical Center Phoenix, Arizona
| | - D. Nayak
- Norton Thoracic Institute St. Joseph’s Hospital and Medical Center Phoenix, Arizona
| | - M. Sharma
- Norton Thoracic Institute St. Joseph’s Hospital and Medical Center Phoenix, Arizona
| | - R. Hachem
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - R. Walia
- Norton Thoracic Institute St. Joseph’s Hospital and Medical Center Phoenix, Arizona
| | - R. M. Bremner
- Norton Thoracic Institute St. Joseph’s Hospital and Medical Center Phoenix, Arizona
| | - M. A. Smith
- Norton Thoracic Institute St. Joseph’s Hospital and Medical Center Phoenix, Arizona
| | - T. Mohanakumar
- Norton Thoracic Institute St. Joseph’s Hospital and Medical Center Phoenix, Arizona
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36
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Microbiome in the pathogenesis of cystic fibrosis and lung transplant-related disease. Transl Res 2017; 179:84-96. [PMID: 27559681 DOI: 10.1016/j.trsl.2016.07.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 07/26/2016] [Accepted: 07/27/2016] [Indexed: 01/01/2023]
Abstract
Significant advances in culture-independent methods have expanded our knowledge about the diversity of the lung microbial environment. Complex microorganisms and microbial communities can now be identified in the distal airways in a variety of respiratory diseases, including cystic fibrosis (CF) and the posttransplantation lung. Although there are significant methodologic concerns about sampling the lung microbiome, several studies have now shown that the microbiome of the lower respiratory tract is distinct from the upper airway. CF is a disease characterized by chronic airway infections that lead to significant morbidity and mortality. Traditional culture-dependent methods have identified a select group of pathogens that cause exacerbations in CF, but studies using bacterial 16S rRNA gene-based microarrays have shown that the CF microbiome is an intricate and dynamic bacterial ecosystem, which influences both host immune health and disease pathogenesis. These microbial communities can shift with external influences, including antibiotic exposure. In addition, there have been a number of studies suggesting a link between the gut microbiome and respiratory health in CF. Compared with CF, there is significantly less knowledge about the microbiome of the transplanted lung. Risk factors for bronchiolitis obliterans syndrome, one of the leading causes of death, include microbial infections. Lung transplant patients have a unique lung microbiome that is different than the pretransplanted microbiome and changes with time. Understanding the host-pathogen interactions in these diseases may suggest targeted therapies and improve long-term survival in these patients.
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37
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Wu PQ, Li X, Jiang WH, Yin GQ, Lei AH, Xiao Q, Huang JJ, Xie ZW, Deng L. Hypoxemia is an independent predictor of bronchiolitis obliterans following respiratory adenoviral infection in children. SPRINGERPLUS 2016; 5:1622. [PMID: 27722041 PMCID: PMC5030207 DOI: 10.1186/s40064-016-3237-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 09/06/2016] [Indexed: 01/12/2023]
Abstract
Bronchiolitis obliterans (BO) is an uncommon and severe sequela of chronic obstructive lung disease in children that results from an insult to the lower respiratory tract. Few prognostic factors achieved worldwide acknowledgment. In the present study, we retrospectively collected the children with respiratory adenoviral infection and identified the predictive factors of BO. In the period between Jan 2011 and December 2014, the consecutive in-hospital acute respiratory infection children with positive result for adenovirus were enrolled into the present study. High resolution computerized tomography and clinical symptoms were utilized as the diagnostic technique for BO. Multivariate analysis using a Logistic proportional hazards model was used to test for independent predictors of BO. A total of 544 children were included with 14 (2.57 %) patients developed BO. Compared with children without BO, BO children presented higher LDH (523.5 vs. 348 IU/ml, p = 0.033), lower blood lymphocyte count (2.23 × 109/L vs. 3.24 × 109/L, p = 0.025) and higher incidence of hypoxemia (78.6 vs. 20.8 %, p = 0.000). They presented relatively persistent fever (15.5 vs. 7 days, p = 0.000) and needed longer treatment in hospital (19.5 vs. 7 days, p = 0.000). Concerning treatment, they were given more intravenous γ-globulin (85.7 vs. 36.8 %, p = 0.000), glucocorticoids (78.6 vs. 24.3 %, p = 0.000) and mechanical ventilation (35.7 vs. 5.5 %, p = 0.001). Multiple analyses determined that hypoxemia was the only independent predictor for BO. The present study identified hypoxemia as the independent predictive factor of BO in adenoviral infected children, which was a novel and sensitive predictor for BO.
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Affiliation(s)
- Pei-Qiong Wu
- Department of Respiration, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Guangzhou, 510623 People's Republic of China
| | - Xing Li
- Institute of Human Virology, Zhongshan School of Medicine, Sun Yat-Sen University, 74 Zhongshan 2nd Road, Guangzhou, 510080 People's Republic of China.,Department of Medical Oncology, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou, 510630 People's Republic of China
| | - Wen-Hui Jiang
- Department of Respiration, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Guangzhou, 510623 People's Republic of China
| | - Gen-Quan Yin
- Department of Respiration, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Guangzhou, 510623 People's Republic of China
| | - Ai-Hua Lei
- Institute of Human Virology, Zhongshan School of Medicine, Sun Yat-Sen University, 74 Zhongshan 2nd Road, Guangzhou, 510080 People's Republic of China
| | - Qiang Xiao
- Institute of Human Virology, Zhongshan School of Medicine, Sun Yat-Sen University, 74 Zhongshan 2nd Road, Guangzhou, 510080 People's Republic of China
| | - Jian-Jun Huang
- Department of Respiration, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Guangzhou, 510623 People's Republic of China
| | - Zhi-Wei Xie
- Department of Respiration, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Guangzhou, 510623 People's Republic of China
| | - Li Deng
- Department of Respiration, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Guangzhou, 510623 People's Republic of China
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38
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Castleberry AW, Bishawi M, Worni M, Erhunmwunsee L, Speicher PJ, Osho AA, Snyder LD, Hartwig MG. Medication Nonadherence After Lung Transplantation in Adult Recipients. Ann Thorac Surg 2016; 103:274-280. [PMID: 27624294 DOI: 10.1016/j.athoracsur.2016.06.067] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 05/10/2016] [Accepted: 06/20/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Our objective was to identify potential avenues for resource allocation and patient advocacy to improve outcomes by evaluating the association between recipient sociodemographic and patient characteristics and medication nonadherence after lung transplantation. METHODS States US adult, lung-only transplantations per the United Network for Organ Sharing database were analyzed from October 1996 through December 2006, based on the period during which nonadherence information was recorded. Generalized linear models were used to determine the association of demographic, disease, and transplantation center characteristics with early nonadherence (defined as within the first year after transplantation) as well as late nonadherence (years 2 to 4 after transplantation). Outcomes comparing adherent and nonadherent patients were also evaluated. RESULTS Patients (n = 7,284) were included for analysis. Early and late nonadherence rates were 3.1% and 10.6%, respectively. Factors associated with early nonadherence were Medicaid insurance compared with private insurance (adjusted odds ratio [AOR] 2.45, 95% confidence interval [CI]: 1.16 to 5.15), and black race (AOR 2.38, 95% CI: 1.08 to 5.25). Medicaid insurance and black race were also associated with late nonadherence (AOR 2.38, 95% CI: 1.51 to 3.73 and OR 1.73, 95% CI: 1.04 to 2.89, respectively), as were age 18 to 20 years (AOR 3.41, 95% CI: 1.29 to 8.99) and grade school or lower education (AOR 1.88, 95% CI: 1.05 to 3.35). Early and late nonadherence were both associated with significantly shorter unadjusted survival (p < 0.001). CONCLUSIONS Identifying patients at risk of nonadherence may enable resource allocation and patient advocacy to improve outcomes.
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Affiliation(s)
- Anthony W Castleberry
- Department of Surgery, Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Muath Bishawi
- Department of Surgery, Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Mathias Worni
- Department of Surgery, Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina; Department of Visceral Surgery and Medicine, Inselspital, University of Berne, Berne, Switzerland
| | - Loretta Erhunmwunsee
- Department of Surgery, Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Paul J Speicher
- Department of Surgery, Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Asishana A Osho
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Laurie D Snyder
- Division of Pulmonary and Critical Care, Duke University Medical Center, Durham, North Carolina
| | - Matthew G Hartwig
- Department of Surgery, Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
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39
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Liu X, Yue Z, Yu J, Daguindau E, Kushekhar K, Zhang Q, Ogata Y, Gafken PR, Inamoto Y, Gracon A, Wilkes DS, Hansen JA, Lee SJ, Chen JY, Paczesny S. Proteomic Characterization Reveals That MMP-3 Correlates With Bronchiolitis Obliterans Syndrome Following Allogeneic Hematopoietic Cell and Lung Transplantation. Am J Transplant 2016; 16:2342-51. [PMID: 26887344 PMCID: PMC4956556 DOI: 10.1111/ajt.13750] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 02/03/2016] [Accepted: 02/05/2016] [Indexed: 01/25/2023]
Abstract
Improved diagnostic methods are needed for bronchiolitis obliterans syndrome (BOS), a serious complication after allogeneic hematopoietic cell transplantation (HCT) and lung transplantation. For protein candidate discovery, we compared plasma pools from HCT transplantation recipients with BOS at onset (n = 12), pulmonary infection (n = 16), chronic graft-versus-host disease without pulmonary involvement (n = 15) and no chronic complications after HCT (n = 15). Pools were labeled with different tags (isobaric tags for relative and absolute quantification), and two software tools identified differentially expressed proteins (≥1.5-fold change). Candidate proteins were further selected using a six-step computational biology approach. The diagnostic value of the lead candidate, matrix metalloproteinase 3 (MMP3), was evaluated by enzyme-linked immunosorbent assay in plasma of a verification cohort (n = 112) with and without BOS following HCT (n = 76) or lung transplantation (n = 36). MMP3 plasma concentrations differed significantly between patients with and without BOS (area under the receiver operating characteristic curve 0.77). Consequently, MMP3 represents a potential noninvasive blood test for diagnosis of BOS.
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Affiliation(s)
- Xiaowen Liu
- Departement of BioHealth Informatics, Indiana University
School of Informatics and Computing, Indianapolis, IN
| | - Zongliang Yue
- Departement of BioHealth Informatics, Indiana University
School of Informatics and Computing, Indianapolis, IN
| | - Jeffrey Yu
- Department of Pediatrics, Indiana University School of
Medicine, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, Indiana
University School of Medicine, Indianapolis, IN, USA
- Department of Microbiology & Immunology, Indiana
University School of Medicine, Indianapolis, IN, USA
- Indiana University Simon Cancer Center, Indiana University
School of Medicine, Indianapolis, IN, USA
| | - Etienne Daguindau
- Department of Pediatrics, Indiana University School of
Medicine, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, Indiana
University School of Medicine, Indianapolis, IN, USA
- Department of Microbiology & Immunology, Indiana
University School of Medicine, Indianapolis, IN, USA
- Indiana University Simon Cancer Center, Indiana University
School of Medicine, Indianapolis, IN, USA
| | - Kushi Kushekhar
- Department of Pediatrics, Indiana University School of
Medicine, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, Indiana
University School of Medicine, Indianapolis, IN, USA
- Department of Microbiology & Immunology, Indiana
University School of Medicine, Indianapolis, IN, USA
- Indiana University Simon Cancer Center, Indiana University
School of Medicine, Indianapolis, IN, USA
| | - Qing Zhang
- Proteomics Shared Resource, Fred Hutchinson Cancer Research
Center, Seattle, WA, USA
| | - Yuko Ogata
- Proteomics Shared Resource, Fred Hutchinson Cancer Research
Center, Seattle, WA, USA
| | - Philip R. Gafken
- Proteomics Shared Resource, Fred Hutchinson Cancer Research
Center, Seattle, WA, USA
| | - Yoshihiro Inamoto
- Clinical Research Division, Fred Hutchinson Cancer Research
Center, Seattle, WA, USA
- Division of Hematopoietic Stem Cell Transplantation,
National Cancer Center Hospital, Tokyo, Japan
| | - Adam Gracon
- Pulmonary Division, Indiana University School of Medicine,
Indianapolis, IN, USA
| | - David S. Wilkes
- Pulmonary Division, Indiana University School of Medicine,
Indianapolis, IN, USA
| | - John A. Hansen
- Clinical Research Division, Fred Hutchinson Cancer Research
Center, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA,
USA
| | - Stephanie J. Lee
- Clinical Research Division, Fred Hutchinson Cancer Research
Center, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA,
USA
| | - Jake Y. Chen
- Departement of BioHealth Informatics, Indiana University
School of Informatics and Computing, Indianapolis, IN
| | - Sophie Paczesny
- Department of Pediatrics, Indiana University School of
Medicine, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, Indiana
University School of Medicine, Indianapolis, IN, USA
- Department of Microbiology & Immunology, Indiana
University School of Medicine, Indianapolis, IN, USA
- Indiana University Simon Cancer Center, Indiana University
School of Medicine, Indianapolis, IN, USA
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40
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Abstract
CONTEXT Lung transplantation has become a viable option for definitive treatment of several end-stage lung diseases for which there are no other options available. However, long-term survival continues to be limited by chronic lung allograft dysfunction, which primarily affects the airways. OBJECTIVE To highlight the complications occurring mainly in the airways of the lung transplant recipient from the early to late posttransplant periods. DATA SOURCES Review literature focusing on the airways in patients with lung transplants and clinical experience of the authors. CONCLUSIONS Postsurgical complications and infections of the airways have decreased because of better techniques and management. Acute cellular rejection of the airways can be distinguished from infection pathologically and on cultures. Separating small from large airways need not be an issue because both are risk factors for bronchiolitis obliterans. Grading of airway rejection needs to be standardized. Chronic lung allograft dysfunction consists of both bronchiolitis obliterans and restrictive allograft syndrome, neither of which can be treated very effectively at present.
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Affiliation(s)
- Aliya N Husain
- From the Departments of Pathology (Dr Husain) and Medicine (Dr Garrity), University of Chicago, Chicago, Illinois
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41
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The Critical Role of Induced CD4+ FoxP3+ Regulatory Cells in Suppression of Interleukin-17 Production and Attenuation of Mouse Orthotopic Lung Allograft Rejection. Transplantation 2016; 99:1356-64. [PMID: 25856405 DOI: 10.1097/tp.0000000000000526] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Lung transplantation is the only definitive therapy for many forms of end-stage lung disease. Studies have demonstrated the critical role of interleukin (IL)-17 in the development of lung rejection. Regulatory T cells (Tregs) are essential for the establishment and maintenance of immune tolerance. METHODS We established mouse orthotopic lung transplantation models to investigate the importance of IL-17 and IL-17-producing cell types in acute lung allograft rejection and the efficacy of the adoptive transfer of induced Tregs (iTregs) in attenuating pathologic lesions of lung allografts. RESULTS We found that the IL-17 produced by Th17 cells and γδ T cells might make the primary contributions to the progression of acute lung allograft rejection. Interleukin-17 deficiency decreased lung allograft lesions. Exogenous iTregs maintained their FoxP3 expression levels in lung allograft recipients. Induced Tregs therapy downregulated the expressions of Th17 and IL-17 γδ T cells and increased IL-10 production in the mouse orthotopic lung transplantation models. Moreover, the adoptive transfer of iTregs prolonged the survivals of the lung allografts and attenuated the progression of acute rejection. CONCLUSION These data suggested that the adoptive transfer of iTregs could suppress the Th17 cells and IL-17 γδ cells of the recipients, decrease the expression of IL-17, and attenuate the pathology of acute lung allograft rejection. Exogenous iTregs upregulated immunosuppressive factors, such as IL-10 and suppressed IL-17-producing cells, which was one of the pathways to play a role in protecting lung allografts.
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DerHovanessian A, Weigt SS, Palchevskiy V, Shino MY, Sayah DM, Gregson AL, Noble PW, Palmer SM, Fishbein MC, Kubak BM, Ardehali A, Ross DJ, Saggar R, Lynch JP, Elashoff RM, Belperio JA. The Role of TGF-β in the Association Between Primary Graft Dysfunction and Bronchiolitis Obliterans Syndrome. Am J Transplant 2016; 16:640-9. [PMID: 26461171 PMCID: PMC4946573 DOI: 10.1111/ajt.13475] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Revised: 06/09/2015] [Accepted: 07/03/2015] [Indexed: 01/25/2023]
Abstract
Primary graft dysfunction (PGD) is a possible risk factor for bronchiolitis obliterans syndrome (BOS) following lung transplantation; however, the mechanism for any such association is poorly understood. Based on the association of TGF-β with acute and chronic inflammatory disorders, we hypothesized that it might play a role in the continuum between PGD and BOS. Thus, the association between PGD and BOS was assessed in a single-center cohort of lung transplant recipients. Bronchoalveolar lavage fluid concentrations of TGF-β and procollagen collected within 24 h of transplantation were compared across the spectrum of PGD, and incorporated into Cox models of BOS. Immunohistochemistry localized expression of TGF-β and its receptor in early lung biopsies posttransplant. We found an association between PGD and BOS in both bilateral and single lung recipients with a hazard ratio of 3.07 (95% CI 1.76-5.38) for the most severe form of PGD. TGF-β and procollagen concentrations were elevated during PGD (p < 0.01), and associated with increased rates of BOS. Expression of TGF-β and its receptor localized to allograft infiltrating mononuclear and stromal cells, and the airway epithelium. These findings validate the association between PGD and the subsequent development of BOS, and suggest that this association may be mediated by receptor/TGF-β biology.
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Affiliation(s)
- Ariss DerHovanessian
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, Los Angeles, California
| | - S. Samuel Weigt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, Los Angeles, California
| | - Vyacheslav Palchevskiy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, Los Angeles, California
| | - Michael Y. Shino
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, Los Angeles, California
| | - David M. Sayah
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, Los Angeles, California
| | - Aric L. Gregson
- Division of Infectious Diseases, Department of Medicine, University of California, Los Angeles, California
| | - Paul W. Noble
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles California
| | - Scott M. Palmer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University, Durham, North Carolina
| | - Michael C. Fishbein
- Depatment of Pathology and Laboratory Medicine, University of California, Los Angeles, California
| | - Bernard M. Kubak
- Division of Infectious Diseases, Department of Medicine, University of California, Los Angeles, California
| | - Abbas Ardehali
- Division of Cardiothoracic Surgery, Department of Surgery, University of California, Los Angeles, California
| | - David J. Ross
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, Los Angeles, California
| | - Rajan Saggar
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, Los Angeles, California
| | - Joseph P. Lynch
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, Los Angeles, California
| | - Robert M. Elashoff
- Department of Biomathematics, University of California, Los Angeles, California
| | - John A. Belperio
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, Los Angeles, California
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Wong JY, Westall GP, Snell GI. Bronchoscopic procedures and lung biopsies in pediatric lung transplant recipients. Pediatr Pulmonol 2015; 50:1406-19. [PMID: 25940429 DOI: 10.1002/ppul.23203] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 01/07/2015] [Accepted: 01/13/2015] [Indexed: 12/19/2022]
Abstract
Bronchoscopy remains a pivotal diagnostic and therapeutic intervention in pediatric patients undergoing lung transplantation (LTx). Whether performed as part of a surveillance protocol or if clinically indicated, fibre-optic bronchoscopy allows direct visualization of the transplanted allograft, and in particular, an assessment of the patency of the bronchial anastomosis (or tracheal anastomosis following heart-lung transplantation). Additionally, bronchoscopy facilitates differentiation of infective processes from rejection episodes through collection and subsequent assessment of bronchoalveolar lavage (BAL) and transbronchial biopsy (TBBx) samples. Indeed, the diagnostic criteria for the grading of acute cellular rejection is dependent upon the histopathological assessment of biopsy samples collected at the time of bronchoscopy. Typically, performed in an out-patient setting, bronchoscopy is generally a safe procedure, although complications related to hemorrhage and pneumothorax are occasionally seen. Airway complications, including stenosis, malacia, and dehiscence are diagnosed at bronchoscopy, and subsequent management including balloon dilatation, laser therapy and stent insertion can also be performed bronchoscopically. Finally, bronchoscopy has been and continues to be an important research tool allowing a better understanding of the immuno-biology of the lung allograft through the collection and analysis of collected BAL and TBBx samples. Whilst new investigational tools continue to evolve, the simple visualization and collection of samples within the lung allograft by bronchoscopy remains the gold standard in the evaluation of the lung allograft. This review describes the use and experience of bronchoscopy following lung transplantation in the pediatric setting.
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Affiliation(s)
- Jackson Y Wong
- Division of Pediatric Respiratory Medicine, Department of Pediatrics, McMaster University, Ontario, Canada
| | - Glen P Westall
- Lung Transplant Service, Alfred Hospital and Monash University, Melbourne, Australia
| | - Gregory I Snell
- Lung Transplant Service, Alfred Hospital and Monash University, Melbourne, Australia
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Cigarette smoking following lung transplantation: effects on allograft function and recipient functional performance. J Cardiopulm Rehabil Prev 2015; 35:147-53. [PMID: 25412223 DOI: 10.1097/hcr.0000000000000096] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Despite mandatory tobacco abstinence following lung transplantation (LTX), some recipients resume smoking cigarettes. The effect of smoking on allograft function, exercise performance, and symptomatology is unknown. METHODS A retrospective review was conducted of LTX recipients who received allografts over an 8-year interval and who were subjected to sequential posttransplant pulmonary function testing (PFT), 6-minute walk (6MW) testing, and assessments of exertional dyspnea (Borg score). Using post-LTX PFT results, recipients were determined to have either bronchiolitis obliterans syndrome (BOS), a manifestation of chronic allograft rejection, or normal pulmonary function (non-BOS). With respect to post-LTX pulmonary function, 6MW distances, and Borg scores, comparisons were made between these recipient groups and those who resumed smoking. RESULTS Of 34 LTX recipients identified, 13 maintained normal lung function (non-BOS), while 16 demonstrated a decline in their PFT values consistent with BOS. Five recipients began smoking at median postoperative day 365 and smoked 1 pack per day for a mean of 485.6 days. Smokers developed a deterioration of their PFT values that was similar to those with BOS (P = .47) and tended to be worse than those in the non-BOS group (P = .09). All smokers experienced a decline in 6MW distances similar to those with BOS and non-BOS but reported less exertional dyspnea (lower Borg scores) than those with BOS. CONCLUSION Recipients of LTX who resume cigarette smoking demonstrate a decline in pulmonary function similar to those afflicted with chronic allograft rejection but do not experience a decrement in their functional performance or increased dyspnea.
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Incidence, Risk Factors and Outcomes of Delayed-onset Cytomegalovirus Disease in a Large Retrospective Cohort of Lung Transplant Recipients. Transplantation 2015; 99:1658-66. [PMID: 25675196 DOI: 10.1097/tp.0000000000000549] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) replication and disease commonly occur in lung transplant recipients after stopping anti-CMV prophylaxis. The epidemiology of CMV disease is not well studied, given the difficulties in assembling representative study populations with prolonged follow-up. We hypothesized that delayed-onset CMV disease (>100 days after transplantation) occurs more commonly than early-onset CMV disease in lung transplant recipients, and is associated with an increased risk of death. METHODS We assembled a large cohort of lung transplant recipients using 2004 to 2010 International Classification of Diseases, Ninth Revision, Clinical Modification billing data from 3 Agency for Healthcare Research and Quality State Inpatient Databases, and identified demographics, comorbidities, CMV disease coded during hospital readmission and inpatient death. We used Cox proportional hazard multivariate analyses to assess for an independent association between delayed-onset CMV disease and death. RESULTS In the cohort of 1528 lung transplant recipients from 12 transplant centers, delayed-onset CMV disease occurred in 13.7% (n = 210) and early-onset CMV disease occurred in 3.3% (n = 51). Delayed-onset CMV pneumonitis was associated with inpatient death longer than 100 days after transplantation (adjusted hazard ratio, 1.6; 95% confidence interval [95% CI], 1.1-2.5), after adjusting for transplant failure/rejection (aHR, 2.5; 95% CI, 1.5-4.1), bacterial pneumonia (aHR, 2.8; 95% CI, 2.0-3.9), viral pneumonia (aHR, 1.5; 95% CI, 1.1-2.1), fungal pneumonia (aHR, 1.8; 95% CI, 1.3-2.3), single lung transplant (aHR, 1.3; 95% CI, 1.0-1.7), and idiopathic pulmonary fibrosis (aHR, 1.4; 95% CI, 1.0-1.8). CONCLUSIONS Delayed-onset CMV disease occurred more commonly than early-onset CMV disease among lung transplant recipients. These results suggest that delayed-onset CMV pneumonitis was independently associated with an increased risk of death.
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Fluticasone, Azithromycin, and Montelukast Treatment for New-Onset Bronchiolitis Obliterans Syndrome after Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2015; 22:710-716. [PMID: 26475726 DOI: 10.1016/j.bbmt.2015.10.009] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 10/07/2015] [Indexed: 12/13/2022]
Abstract
Bronchiolitis obliterans syndrome (BOS) after allogeneic hematopoietic cell transplantation (HCT) is associated with high mortality. We hypothesized that inhaled fluticasone, azithromycin, and montelukast (FAM) with a brief steroid pulse could avert progression of new-onset BOS. We tested this in a phase II, single-arm, open-label, multicenter study (NCT01307462). Thirty-six patients were enrolled within 6 months of BOS diagnosis. The primary endpoint was treatment failure, defined as 10% or greater forced expiratory volume in 1 second decline at 3 months. At 3 months, 6% (2 of 36, 95% confidence interval, 1% to 19%) had treatment failure (versus 40% in historical controls, P < .001). FAM was well tolerated. Steroid dose was reduced by 50% or more at 3 months in 48% of patients who could be evaluated (n = 27). Patient-reported outcomes at 3 months were statistically significantly improved for Short-Form 36 social functioning score and mental component score, Functional Assessment of Cancer Therapies emotional well-being, and Lee symptom scores in lung, skin, mouth, and the overall summary score compared to enrollment (n = 24). At 6 months, 36% had treatment failure (95% confidence interval, 21% to 54%, n = 13 of 36, with 6 documented failures, 7 missing pulmonary function tests). Overall survival was 97% (95% confidence interval, 84% to 100%) at 6 months. These data suggest that FAM was well tolerated and that treatment with FAM and steroid pulse may halt pulmonary decline in new-onset BOS in the majority of patients and permit reductions in systemic steroid exposure, which collectively may improve quality of life. However, additional treatments are needed for progressive BOS despite FAM.
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Mimura T, Walker N, Aoki Y, Manning CM, Murdock BJ, Myers JL, Lagstein A, Osterholzer JJ, Lama VN. Local origin of mesenchymal cells in a murine orthotopic lung transplantation model of bronchiolitis obliterans. THE AMERICAN JOURNAL OF PATHOLOGY 2015; 185:1564-74. [PMID: 25848843 DOI: 10.1016/j.ajpath.2015.03.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 02/26/2015] [Accepted: 03/02/2015] [Indexed: 10/23/2022]
Abstract
Bronchiolitis obliterans is the leading cause of chronic graft failure and long-term mortality in lung transplant recipients. Here, we used a novel murine model to characterize allograft fibrogenesis within a whole-lung microenvironment. Unilateral left lung transplantation was performed in mice across varying degrees of major histocompatibility complex mismatch combinations. B6D2F1/J (a cross between C57BL/6J and DBA/2J) (Haplotype H2b/d) lungs transplanted into DBA/2J (H2d) recipients were identified to show histopathology for bronchiolitis obliterans in all allogeneic grafts. Time course analysis showed an evolution from immune cell infiltration of the bronchioles and vessels at day 14, consistent with acute rejection and lymphocytic bronchitis, to subepithelial and intraluminal fibrotic lesions of bronchiolitis obliterans by day 28. Allografts at day 28 showed a significantly higher hydroxyproline content than the isografts (33.21 ± 1.89 versus 22.36 ± 2.33 μg/mL). At day 40 the hydroxyproline content had increased further (48.91 ± 7.09 μg/mL). Flow cytometric analysis was used to investigate the origin of mesenchymal cells in fibrotic allografts. Collagen I-positive cells (89.43% ± 6.53%) in day 28 allografts were H2Db positive, showing their donor origin. This novel murine model shows consistent and reproducible allograft fibrogenesis in the context of single-lung transplantation and represents a major step forward in investigating mechanisms of chronic graft failure.
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Affiliation(s)
- Takeshi Mimura
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Natalie Walker
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Yoshiro Aoki
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Casey M Manning
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Benjamin J Murdock
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Jeffery L Myers
- Department of Pathology, University of Michigan Health System, Ann Arbor, Michigan
| | - Amir Lagstein
- Department of Pathology, University of Michigan Health System, Ann Arbor, Michigan
| | - John J Osterholzer
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Vibha N Lama
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan.
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Mollberg NM, Farjah F, Howell E, Ortiz J, Backhus L, Mulligan MS. Impact of primary caregivers on long-term outcomes after lung transplantation. J Heart Lung Transplant 2015; 34:59-64. [DOI: 10.1016/j.healun.2014.09.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 09/17/2014] [Accepted: 09/19/2014] [Indexed: 01/09/2023] Open
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De novo donor HLA-specific antibodies predict development of bronchiolitis obliterans syndrome after lung transplantation. J Heart Lung Transplant 2014; 33:1273-81. [DOI: 10.1016/j.healun.2014.07.012] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 07/15/2014] [Accepted: 07/16/2014] [Indexed: 11/22/2022] Open
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