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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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2
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Zhang S, Sun L, Chen B, Lin S, Gu J, Tan L, Lin M. Telocytes protect against lung tissue fibrosis through hexokinase 2-dependent pathway by secreting hepatocyte growth factor. Clin Exp Pharmacol Physiol 2023; 50:964-972. [PMID: 37715611 DOI: 10.1111/1440-1681.13823] [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: 02/19/2023] [Revised: 08/08/2023] [Accepted: 08/27/2023] [Indexed: 09/17/2023]
Abstract
Pulmonary fibrosis (PF) is one of the common manifestations of end-stage lung disease. Chronic lung failure after lung transplantation is mainly caused by bronchiolitis obliterans syndrome (BOS) and is mainly characterized by lung tissue fibrosis. Pulmonary epithelial-mesenchymal transformation (EMT) is crucial for pulmonary fibrosis. Telocytes (TCs), a new type of mesenchymal cells, play a protective role in various acute injuries. For exploring the anti-pulmonary fibrosis effect of TCs in the BOS model in vitro and the related mechanism, rat tracheal epithelial (RTE) cells were treated with transforming growth factor-β (TGF-β) to simulate lung tissue fibrosis in vitro. The RTE cells were then co-cultured with TCs primarily extracted from rat lung tissue. Western blot, Seahorse XF Analysers and enzyme-linked immunosorbent assay were used to detect the level of EMT and aerobic respiration of RTE cells. Furthermore, anti-hepatocyte growth factor (anti-HGF) antibody was exogenously added to the cultured cells to explore further mechanisms. Moreover, hexokinase 2 (HK2) in RTE cells was knocked down to assess whether it influences the blocking effect of the anti-HGF antibody. TGF-β could induce lung tissue fibrosis in RTE cells in vitro. Nevertheless, TCs co-culture decreased the level of EMT, glucose metabolic indicators (lactate and ATP) and oxygen levels. Furthermore, TCs released hepatocyte growth factor (HGF). Therefore, the exogenous addition of anti-HGF antibody in the co-culture system blocked the anti-lung tissue fibrosis effect. However, HK2 knockdown attenuated the blocking effect of the anti-HGF antibody. In conclusion, TCs can protect against lung tissue fibrosis by releasing HGF, a process dependent on HK2.
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Affiliation(s)
- Shaoyuan Zhang
- Department of Thoracic Surgery, Zhongshan Hospital (Xiamen), Fudan University, Xiamen, China
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
- Key Laboratory of Lung Inflammation and Injury, Shanghai, China
| | - Linyi Sun
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
- Key Laboratory of Lung Inflammation and Injury, Shanghai, China
| | - Borong Chen
- Department of Thoracic Surgery, Zhongshan Hospital (Xiamen), Fudan University, Xiamen, China
| | - Siyun Lin
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jianmin Gu
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
- Key Laboratory of Lung Inflammation and Injury, Shanghai, China
| | - Lijie Tan
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
- Key Laboratory of Lung Inflammation and Injury, Shanghai, China
| | - Miao Lin
- Department of Thoracic Surgery, Zhongshan Hospital (Xiamen), Fudan University, Xiamen, China
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
- Key Laboratory of Lung Inflammation and Injury, Shanghai, China
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Wu Z, Chen X, Wu S, Liu Z, Li H, Mai K, Peng Y, Zhang H, Zhang X, Zheng Z, Fu Z, Chen D. Transcriptome analysis reveals the impact of NETs activation on airway epithelial cell EMT and inflammation in bronchiolitis obliterans. Sci Rep 2023; 13:19226. [PMID: 37932341 PMCID: PMC10628238 DOI: 10.1038/s41598-023-45617-y] [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: 06/09/2023] [Accepted: 10/21/2023] [Indexed: 11/08/2023] Open
Abstract
Bronchiolitis obliterans (BO) is a chronic airway disease that was often indicated by the pathological presentation of narrowed and irreversible airways. However, the molecular mechanisms of BO pathogenesis remain unknown. Although neutrophil extracellular traps (NETs) can contribute to inflammatory disorders, their involvement in BO is unclear. This study aims to identify potential signaling pathways in BO by exploring the correlations between NETs and BO. GSE52761 and GSE137169 datasets were downloaded from gene expression omnibus (GEO) database. A series of bioinformatics analyses such as differential expression analysis, gene ontology (GO), Kyoto encyclopedia of genes and genomes (KEGG), and gene set enrichment analysis (GSEA) were performed on GSE52761 and GSE137169 datasets to identify BO potential signaling pathways. Two different types of BO mouse models were constructed to verify NETs involvements in BO. Additional experiments and bioinformatics analysis using human small airway epithelial cells (SAECs) were also performed to further elucidate differential genes enrichment with their respective signaling pathways in BO. Our study identified 115 differentially expressed genes (DEGs) that were found up-regulated in BO. Pathway enrichment analysis revealed that these genes were primarily involved in inflammatory signaling processes. Besides, we found that neutrophil extracellular traps (NETs) were formed and activated during BO. Our western blot analysis on lung tissue from BO mice further confirmed NETs activation in BO, where neutrophil elastase (NE) and myeloperoxidase (MPO) expression were found significantly elevated. Transcriptomic and bioinformatics analysis of NETs treated-SAECs also revealed that NETs-DEGs were primarily associated through inflammatory and epithelial-to-mesenchymal transition (EMT) -related pathways. Our study provides novel clues towards the understanding of BO pathogenesis, in which NETs contribute to BO pathogenesis through the activation of inflammatory and EMT associated pathways. The completion of our study will provide the basis for potential novel therapeutic targets in BO treatment.
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Affiliation(s)
- Zhongji Wu
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
| | - Xiaowen Chen
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
| | - Shangzhi Wu
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
| | - Zhenwei Liu
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
| | - Hongwei Li
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
| | - Kailin Mai
- Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
| | - Yinghui Peng
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
| | - Haidi Zhang
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
| | - Xiaodie Zhang
- Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
| | - Zhaocong Zheng
- Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
| | - Zian Fu
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
| | - Dehui Chen
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China.
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Trindade AJ. Can We See Clearly Now? Computed Tomography for Bronchiolitis Obliterans Syndrome Prognostication. Transplantation 2023; 107:e281-e282. [PMID: 37443411 PMCID: PMC10593147 DOI: 10.1097/tp.0000000000004727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 06/13/2023] [Indexed: 07/15/2023]
Affiliation(s)
- Anil J. Trindade
- Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, TN
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Diel R, Simon S, Gottlieb J. Chronic Lung Allograft Dysfunction Is Associated with Significant Disability after Lung Transplantation-A Burden of Disease Analysis in 1025 Cases. Adv Respir Med 2023; 91:432-444. [PMID: 37887076 PMCID: PMC10603923 DOI: 10.3390/arm91050033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/10/2023] [Accepted: 10/10/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Chronic lung allograft dysfunction (CLAD) is the leading cause of death after the first postoperative years of lung transplantation (LTx). OBJECTIVE To assess the number of disability-adjusted life years (DALYs) per patient with severe CLAD. METHODS The clinical and demographic data of patients who received their lung transplantation between 2010 and 2020 in the Hanover Medical School (Germany) were evaluated. RESULTS A total of 1025 lung transplant patients were followed for a median of 51 months (4.25 years); the median age at transplantation was 52.8 (interquartile range (IQR) 19) years. More than a quarter of transplant patients (271/1025 or 26.4%) developed CLAD, mostly (60%) of the bronchiolitis obliterans syndrome (BOS) phenotype. Of the CLAD patients, 99, or 36.5%, suffered from significant disability, which on average occurred after 2 years (IQR 2.55). The survival of CLAD patients with disability after transplantation was significantly lower compared to that of patients without CLAD (median 4.04 versus 5.41 years). Adjusted to the DALY estimation approach, CLAD patients lost 1.29 life years (YLL) and lived for 0.8 years with their disability (YLD), adding up to 2.09 DALYs (range 1.99-2.72) per patient. CONCLUSIONS CLAD after lung transplantation is a major public health problem and is associated with substantial disability and costs. Further work is needed to develop therapeutic interventions that reduce its development.
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Affiliation(s)
- Roland Diel
- Institute for Epidemiology, University Medical Hospital Schleswig Holstein, Campus Kiel, Niemannsweg 11, 24105 Kiel, Germany
- Lung Clinic Grosshansdorf, Airway Disease Center North (ARCN), German Center for Lung Research (DZL), 22949 Großhansdorf, Germany
| | - Susanne Simon
- Department of Respiratory Medicine, Hannover Medical School, 30625 Hannover, Germany; (S.S.); (J.G.)
| | - Jens Gottlieb
- Department of Respiratory Medicine, Hannover Medical School, 30625 Hannover, Germany; (S.S.); (J.G.)
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), 30625 Hannover, Germany
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Wu Z, Chen X, Zhang K, Liu Z, Zhang H, Zheng Z, Zhang X, Chen Y, Peng Y, Li H, Huang K, Tang S, Zhao L, Chen D. Identification of Hub Genes in the Pathogenesis of Bronchiolitis Obliterans via Bioinformatic Analysis and Experimental Verification. J Inflamm Res 2023; 16:3303-3317. [PMID: 37576152 PMCID: PMC10422971 DOI: 10.2147/jir.s419845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 07/26/2023] [Indexed: 08/15/2023] Open
Abstract
Background Bronchiolitis obliterans (BO) is a chronic disease that can arise as a complication of severe childhood pneumonia and can also impact the long-term survival of patients after lung transplantation. However, the precise molecular mechanism underlying BO remains unclear. We aimed to identify BO-associated hub genes and their molecular mechanisms. Methods BO-associated transcriptome datasets (GSE52761, GSE137169, and GSE94557) were downloaded from the Gene Expression Omnibus (GEO) database to identify differentially expressed genes (DEGs). Additional bioinformatics analyses, such as Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), and Protein-Protein Interaction (PPI) analyses, were performed to determine functional roles and DEG-associated regulatory networks. Prediction of hub genes using the 12 algorithms available in the Cytohubba plugin of Cytoscape software was also performed. Verification was performed using the BO mouse model. Results Our results revealed 57 DEGs associated with BO, of which 18 were down-regulated and 39 were up-regulated. The Cytohubba plugin data further narrowed down the 57 DEGs into 9 prominent hub genes (CCR2, CD1D, GM2A, TFEC, MPEG1, CTSS, GPNMB, BIRC2, and CTSZ). Genes such as CCR2, TFEC, MPEG1, CTSS, and CTSZ were dysregulated in 2,3-butanedione-induced BO mice, whereas TFEC, CTSS, and CTSZ were dysregulated in nitric acid-induced BO mouse models. Conclusion Our study identified and validated four novel BO biomarkers, which may allow further investigation into the development of distinct BO diagnostic markers and novel therapeutic avenues.
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Affiliation(s)
- Zhongji Wu
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People’s Republic of China
| | - Xiaowen Chen
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People’s Republic of China
| | - Kangkang Zhang
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People’s Republic of China
| | - Zhenwei Liu
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People’s Republic of China
| | - Haidi Zhang
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People’s Republic of China
| | - Zhaocong Zheng
- Guangzhou Medical University, Guangzhou, 510000, People’s Republic of China
| | - Xiaodie Zhang
- Guangzhou Medical University, Guangzhou, 510000, People’s Republic of China
| | - Yubiao Chen
- State Key Laboratory of Respiratory Diseases, Guangzhou, 510000, People’s Republic of China
| | - Yinghui Peng
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People’s Republic of China
| | - Hui Li
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People’s Republic of China
| | - Kaiyin Huang
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People’s Republic of China
| | - Sixiang Tang
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People’s Republic of China
| | - Li Zhao
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People’s Republic of China
| | - Dehui Chen
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People’s Republic of China
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Dalton JE, Lehr CJ, Gunsalus PR, Mourany L, Valapour M. Refining the Lung Allocation Score Models Fails to Improve Discrimination Performance. Chest 2023; 163:152-163. [PMID: 36030838 PMCID: PMC9899637 DOI: 10.1016/j.chest.2022.08.2217] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/29/2022] [Accepted: 08/12/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND As broader geographic sharing is implemented in lung transplant allocation through the Composite Allocation Score (CAS) system, models predicting waitlist and posttransplant (PT) survival will become more important in determining access to organs. RESEARCH QUESTION How well do CAS survival models perform, and can discrimination performance be improved with alternative statistical models or machine learning approaches? STUDY DESIGN AND METHODS Scientific Registry for Transplant Recipients (SRTR) data from 2015-2020 were used to build seven waitlist (WL) and data from 2010-2020 to build similar PT models. These included the (I) current lung allocation score (LAS)/CAS model; (II) re-estimated WL-LAS/CAS model; (III) model II incorporating nonlinear relationships; (IV) random survival forests model; (V) logistic model; (VI) linear discriminant analysis; and (VII) gradient-boosted tree model. Discrimination performance was evaluated at 1, 3, and 6 months on the waiting list and 1, 3, and 5 years PT. Area under the curve (AUC) values were estimated across subgroups. RESULTS WL model performance was similar across models with the greatest discrimination in the baseline cohort (AUC 0.93) and declined to 0.87-0.89 for 3-month and 0.84-0.85 for 6-month predictions and further diminished for residual cohorts. Discrimination performance for PT models ranged from AUC 0.58-0.61 and remained stable with increasing forecasting times but was slightly worse for residual cohorts. WL and PT variability in AUC was greatest for individuals with Medicaid insurance. INTERPRETATION Use of alternative modeling strategies and contemporary cohorts did not improve performance of models determining access to lung transplant.
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Affiliation(s)
- Jarrod E Dalton
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Carli J Lehr
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, OH
| | - Paul R Gunsalus
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Lyla Mourany
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Maryam Valapour
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, OH.
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Glanville AR, Benden C, Bergeron A, Cheng GS, Gottlieb J, Lease ED, Perch M, Todd JL, Williams KM, Verleden GM. Bronchiolitis obliterans syndrome after lung or haematopoietic stem cell transplantation: current management and future directions. ERJ Open Res 2022; 8:00185-2022. [PMID: 35898810 PMCID: PMC9309343 DOI: 10.1183/23120541.00185-2022] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 05/18/2022] [Indexed: 11/05/2022] Open
Abstract
Bronchiolitis obliterans syndrome (BOS) may develop after either lung or haematopoietic stem cell transplantation (HSCT), with similarities in histopathological features and clinical manifestations. However, there are differences in the contributory factors and clinical trajectories between the two conditions. BOS after HSCT occurs due to systemic graft-versus-host-disease (GVHD), whereas BOS after lung transplantation is limited to the lung allograft. BOS diagnosis after HSCT is more challenging, as the lung function decline may occur due to extrapulmonary GVHD, causing sclerosis or inflammation in the fascia or muscles of the respiratory girdle. Treatment is generally empirical with no established effective therapies. This review provides rare insights and commonalities of both conditions, that are not well elaborated elsewhere in contemporary literature, and highlights the importance of cross disciplinary learning from experts in other transplant modalities. Treatment algorithms for each condition are presented, based on the published literature and consensus clinical opinion. Immunosuppression should be optimised, and other conditions or contributory factors treated where possible. When initial treatment fails, the ultimate therapeutic option is lung transplantation (or re-transplantation in the case of BOS after lung transplantation) in carefully selected candidates. Novel therapies under investigation include aerosolised liposomal cyclosporine, Janus kinase inhibitors, antifibrotic therapies, and (in patients with BOS after lung transplantation) B-cell–directed therapies. Effective novel treatments that have a tangible impact on survival and thereby avoid the need for lung transplantation or re-transplantation are urgently required.
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Iglesias-Escudero M, Segundo DS, Merino-Fernandez D, Mora-Cuesta VM, Lamadrid P, Alonso-Peña M, Raso S, Iturbe D, Fernandez-Rozas S, Cifrian J, López-Hoyos M. Myeloid-Derived Suppressor Cells Are Increased in Lung Transplant Recipients and Regulated by Immunosuppressive Therapy. Front Immunol 2022; 12:788851. [PMID: 35185863 PMCID: PMC8848105 DOI: 10.3389/fimmu.2021.788851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 12/17/2021] [Indexed: 12/28/2022] Open
Abstract
Lung transplantation remains as a primary treatment for end-stage lung diseases. Although remarkable improvement has been achieved due to the immunosuppressive protocols, long-term survival for lung transplant recipients (LTR) is still limited. In the last few decades, an increasing interest has grown in the study of dysregulation of immune mechanisms underlying allograft failure. In this regard, myeloid-derived suppressor cells (MDSCs) could play an important role in the promotion of graft tolerance due to their immune regulatory function. Here, we describe for the first time circulating subsets MDSCs from LTR at several time points and we evaluate the relationship of MDSCs with sort-term lung transplant outcomes. Although no effect of MDSCs subsets on short-term clinical events was observed, our results determine that Mo-MDSCs frequencies are increased after acute cellular rejection (ACR), suggesting a possible role for Mo-MDSCs in the development of chronic lung allograft dysfunction (CLAD). Therefore, whether MDSCs subsets play a role as biomarkers of chronic rejection remains unknown and requires further investigations. Also, the effects of the different immunosuppressive treatments on these subpopulations remain under research and further studies are needed to establish to what extend MDSCs immune modulation could be responsible for allograft acceptance.
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Affiliation(s)
- María Iglesias-Escudero
- Transplant and Autoimmunity group, Research Institute-IDIVAL, Santander, Spain.,Immunology Department, Universitary Hospital Germans Trias i Pujol, Badalona, Spain
| | - David San Segundo
- Transplant and Autoimmunity group, Research Institute-IDIVAL, Santander, Spain.,Immunology Department, Universitary Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | | | - Victor M Mora-Cuesta
- Pneumology Department, Universitary Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Patricia Lamadrid
- Transplant and Autoimmunity group, Research Institute-IDIVAL, Santander, Spain
| | - Marta Alonso-Peña
- Transplant and Autoimmunity group, Research Institute-IDIVAL, Santander, Spain
| | - Sandra Raso
- Transplant and Autoimmunity group, Research Institute-IDIVAL, Santander, Spain
| | - David Iturbe
- Pneumology Department, Universitary Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Sonia Fernandez-Rozas
- Pneumology Department, Universitary Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Jose Cifrian
- Pneumology Department, Universitary Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Marcos López-Hoyos
- Transplant and Autoimmunity group, Research Institute-IDIVAL, Santander, Spain.,Immunology Department, Universitary Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain.,Molecular Biology Department, Universidad Cantabria, Santander, Spain
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10
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Kahnert K, Trudzinski FC, Berger C, Munker D, Milger K, Irlbeck M, Tomasi R, Schneider C, Michel S, Ghiani A, Herth FJF, Behr J, Jörres RA, Kneidinger N. Oxygenated Hemoglobin Predicts Outcome in Patients with Chronic Lung Allograft Dysfunction. Respiration 2022; 101:638-645. [PMID: 35354156 DOI: 10.1159/000522517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 02/07/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Long-term outcome of lung transplantation (LTx) recipients is limited by chronic lung allograft dysfunction (CLAD). In this setting of new onset respiratory failure, the amount of oxygenated hemoglobin (OxyHem; hemoglobin (Hb) concentration × fractional oxygen saturation) may provide valuable information. OBJECTIVE We hypothesized that OxyHem predicts survival of LTx recipients at the onset of CLAD. METHODS Data from 292 LTx recipients with CLAD were analyzed. After excluding patients with missing data or supplemental oxygen, the final population comprised 218 patients. The relationship between survival upon CLAD and OxyHem was analyzed by Cox regression analyses and ROC curves. RESULTS Among the 218 patients (102 males, 116 females), 128 (58.7%) died, median survival time after CLAD onset being 1,156 days. Survival was significantly associated with type of transplantation, time to CLAD, CLAD stage at onset, and OxyHem, which was superior to Hb or oxygen saturation. The risk for death after CLAD increased by 14% per reduction of OxyHem by 1 g/dL, and values below 11 g/dL corresponded to an 80% increase in mortality risk. CONCLUSION Thus, OxyHem was identified as an independent predictor of mortality after CLAD onset. Whether it is useful in supporting therapeutic decisions and potentially home monitoring in the surveillance of lung transplant recipients has to be studied further.
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Affiliation(s)
- Kathrin Kahnert
- Department of Internal Medicine V, Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), University of Munich (LMU), Munich, Germany
| | - Franziska C Trudzinski
- Thoraxklinik-Heidelberg gGmbH, Translational Lung Research Centre Heidelberg (TLRC), Member of the German Center for Lung Research, Heidelberg, Germany
| | - Christiane Berger
- Department of Internal Medicine V, Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), University of Munich (LMU), Munich, Germany
| | - Dieter Munker
- Department of Internal Medicine V, Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), University of Munich (LMU), Munich, Germany
| | - Katrin Milger
- Department of Internal Medicine V, Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), University of Munich (LMU), Munich, Germany
| | - Michael Irlbeck
- Department of Anaesthesiology, University of Munich (LMU), Munich, Germany
| | - Roland Tomasi
- Department of Anaesthesiology, University of Munich (LMU), Munich, Germany
| | | | - Sebastian Michel
- Clinic of Cardiac Surgery, Member of the German Center for Lung Research (DZL), University of Munich (LMU), Munich, Germany
| | - Alessandro Ghiani
- Department of Respiratory Medicine, Robert-Bosch-Krankenhaus Stuttgart, Stuttgart, Germany
| | - Felix J F Herth
- Thoraxklinik-Heidelberg gGmbH, Translational Lung Research Centre Heidelberg (TLRC), Member of the German Center for Lung Research, Heidelberg, Germany
| | - Juergen Behr
- Department of Internal Medicine V, Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), University of Munich (LMU), Munich, Germany
| | - Rudolf A Jörres
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Comprehensive Pneumology Center Munich (CPC-M), University of Munich (LMU), Munich, Germany
| | - Nikolaus Kneidinger
- Department of Internal Medicine V, Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), University of Munich (LMU), Munich, Germany
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11
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Gottlieb J, Verleden GM, Perchl M, Valtin C, Vallee A, Brugière O, Bravo C. Disease progression in patients with the restrictive and mixed phenotype of Chronic Lung Allograft dysfunction-A retrospective analysis in five European centers to assess the feasibility of a therapeutic trial. PLoS One 2021; 16:e0260881. [PMID: 34941934 PMCID: PMC8700042 DOI: 10.1371/journal.pone.0260881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 11/18/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Chronic Lung Allograft Dysfunction (CLAD) is a major obstacle for long term survival after lung transplantation (LTx). Besides Bronchiolitis Obliterans Syndrome, two other phenotypes of CLAD, restrictive allograft syndrome (RAS) and mixed phenotype, have been described. Trials to test in these conditions are desperately needed and analyzing natural outcome to plan such trials is essential. METHODS We performed a retrospective analysis of functional outcome in bilateral LTx recipients with RAS and mixed phenotype, transplanted between 2009 and 2018 in five large European centers with follow- up spirometry up to 12 months after diagnosis. Based on these data, sample size and power calculations for randomized therapeutic trial was estimated using two imputation methods for missing values. RESULTS Seventy patients were included (39 RAS and 31 mixed phenotype), median 3.1 years after LTx when CLAD was diagnosed. Eight, 13 and 25 patients died within 6, 9 and 12 months after diagnosis and a two patients underwent re-transplantation within 12 months leading to a graft survival of 89, 79 and 61% six, nine and 12 months after diagnosis, respectively. Observed FEV1 decline was 451 ml at 6 months and stabilized at 9 and 12 months, while FVC showed continuous decline. Using two methods of imputation, a progressive further decline after 6 months for FEV1 was noted. CONCLUSION The poor outcome of these two specific CLAD phenotypes suggests the urgent need for future therapeutic randomized trials. The number of missing values in a potential trial seems to be high and most frequently attributed to death. Survival may be used as an endpoint in clinical trials in these distinct phenotypes and imputation techniques are relevant if graft function is used as a surrogate of disease progression in future trials.
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Affiliation(s)
- Jens Gottlieb
- Dept. of Respir. Medicine OE 6870, Hannover Medical School, Hannover, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
- * E-mail:
| | - Geert M. Verleden
- Dept Respir. Med, Lung Transplant Unit, University Hospital Gasthuisberg, Leuven, Belgium
| | - Michael Perchl
- Department of Cardiology, Section for Lung transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christina Valtin
- Dept. of Respir. Medicine OE 6870, Hannover Medical School, Hannover, Germany
| | - Alexander Vallee
- Délégation à la Recherche Clinique et à l’Innovation, Hôpital Foch, Suresnes, France
| | - Olivier Brugière
- Service de Transplantation Pulmonaire et Centre de compétence de la Mucoviscidose, Hôpital Foch, Suresnes, France
| | - Carlos Bravo
- Servei de Pneumologia, Hospital Universitari Val d’Hebron, Barcelona, Spain
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12
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Kemp R, Pustulka I, Boerner G, Smela B, Hofstetter E, Sabeva Y, François C. Relationship between FEV 1 decline and mortality in patients with bronchiolitis obliterans syndrome-a systematic literature review. Respir Med 2021; 188:106608. [PMID: 34517199 DOI: 10.1016/j.rmed.2021.106608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 08/24/2021] [Accepted: 09/05/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Bronchiolitis obliterans syndrome (BOS) is one of the most severe complications and the leading cause of late mortality and morbidity after lung transplantation (LT) and allogeneic hematopoietic stem cell transplantation (allo-HSCT). No approved treatment for BOS is available. This review aimed to systematically identify and summarise the findings regarding the relationship between FEV1 decline and mortality in patients who developed BOS following LT or allo-HSCT. METHODS A systematic literature search was performed in the Medline, Embase and Cochrane reviews databases. Of the 501 potential studies identified 25 met inclusion criteria and were analysed. RESULTS Overall, 13 studies reported a relationship between FEV1 and mortality, and 12 studies reported both mortality and FEV1 results but did not investigate the relationship between them. There was heterogeneity in the analyses, which investigated the relationship between FEV1 decline and mortality across the studies in terms of levels of lung functioning, comparison to a control group, treatment, and statistical methodology; nevertheless, a clear and consistent increase in the risk of death associated with FEV1 decrease was seen in the analysed studies. CONCLUSIONS The systematic literature review identified studies and findings that support a relationship between FEV1 and mortality, with a decrease in FEV1 being statistically associated with increased risk of death. Knowing that lower FEV1 levels are associated with higher mortality rates may help assess the condition of a patient with BOS and monitor future treatment effectiveness. However, more evidence is needed to further investigate this relationship and to verify its clinical usefulness.
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Affiliation(s)
- Robert Kemp
- Breath Therapeutics, a Zambon Company, Menlo Park, CA, USA
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13
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Abstract
PURPOSE OF REVIEW Primary graft dysfunction (PGD) is a devastating complication in the acute postoperative lung transplant period, associated with high short-term mortality and chronic rejection. We review its definition, pathophysiology, risk factors, prevention, treatment strategies, and future research directions. RECENT FINDINGS New analyses suggest donation after circulatory death and donation after brain death donors have similar PGD rates, whereas donors >55 years are not associated with increased PGD risk. Recipient pretransplant diastolic dysfunction and overweight or obese recipients with predominant abdominal subcutaneous adipose tissue have increased PGD risk. Newly identified recipient biomarkers and donor and recipient genes increase PGD risk, but their clinical utility remains unclear. Mixed data still exists regarding cold ischemic time and PGD risk, and increased PGD risk with cardiopulmonary bypass remains confounded by transfusions. Portable ex vivo lung perfusion (EVLP) may prevent PGD, but its use is limited to a handful of centers. Although updates to current PGD treatment are lacking, future therapies are promising with targeted therapy and the use of EVLP to pharmacologically recondition donor lungs. SUMMARY There is significant progress in defining PGD and identifying its several risk factors, but effective prevention and treatment strategies are needed.
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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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Hage CA, Klesney-Tait J, Wille K, Arcasoy S, Yung G, Hertz M, Chan KM, Morrell M, Goldberg H, Vedantham S, Derfler MC, Commean P, Berman K, Spitznagel E, Atkinson J, Despotis G. Extracorporeal photopheresis to attenuate decline in lung function due to refractory obstructive allograft dysfunction. Transfus Med 2021; 31:292-302. [PMID: 33955079 PMCID: PMC8453798 DOI: 10.1111/tme.12779] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/18/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND This study was designed to prospectively evaluate the efficacy of extracorporeal photopheresis (ECP) to attenuate the rate of decline of FEV1 in lung transplant recipients with refractory bronchiolitis obliterans. Due to an observed higher than expected early mortality, a preliminary analysis was performed. STUDY DESIGN AND METHODS Subjects from 10 lung transplant centres were assigned to ECP treatment or to observation based on spirometric criteria, with potential crossover for those under observation. The primary endpoint of this study was to assess response to ECP (i.e., greater than a 50% decrease in the rate of FEV1 decline) before and 6 months after initiation of ECP. Mortality was also evaluated 6 and 12 months after enrolment as a secondary endpoint. RESULTS Of 44 enrolled subjects, 31 were assigned to ECP treatment while 13 were initially assigned to observation on a non-random basis using specific spirometric inclusion criteria (seven of the observation patients subsequently crossed over to receive ECP). Of evaluable patients, 95% of patients initially assigned to treatment responded to ECP with rates of FEV1 decline that were reduced by 93% in evaluable ECP-treated patients. Mortality rates (percentages) at 6 and 12 months after enrolment was 32% and 41%, respectively. The most common (92%) primary cause of death was respiratory or graft failure. Significantly (p = 0.002) higher rates of FEV1 decline were observed in the non-survivors (-212 ± 177 ml/month) when compared to the survivors (-95 ± 117 ml/month) 12 months after enrolment. In addition, 18 patients with bronchiolitis obliterans syndrome (BOS) diagnosis within 6 months of enrolment had lost 38% of their baseline lung function at BOS diagnosis and 50% of their lung function at enrolment. CONCLUSIONS These analyses suggest that earlier detection and treatment of BOS should be considered to appreciate improved outcomes with ECP.
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Affiliation(s)
| | - Chadi A Hage
- Department of Medicine, Division of Pulmonology, Indiana University, Bloomington, Indiana, USA
| | - Julia Klesney-Tait
- Department of Medicine, Division of Pulmonology, University of Iowa, Iowa City, Iowa, USA
| | - Keith Wille
- Department of Medicine, Division of Pulmonology, University of Alabama, Tuscaloosa, Alabama, USA
| | - Selim Arcasoy
- Department of Medicine, Division of Pulmonology, Columbia University of Alabama, Orange Beach, Alabama, USA
| | - Gordon Yung
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, California, USA
| | - Marshall Hertz
- Department of Medicine, Division of Pulmonology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kevin M Chan
- Department of Medicine, Division of Pulmonology, University of Michigan, Ann Arbor, Michigan, USA
| | - Matt Morrell
- Department of Medicine, Division of Pulmonology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hilary Goldberg
- Harvard Medical School, Department of Medicine, Division of Pulmonology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Suresh Vedantham
- Clinical Coordinating Center, Washington University School of Medicine, Mallinckrodt Institute of Radiology, St. Louis, Missouri, USA
| | - Mary Clare Derfler
- Clinical Coordinating Center, Washington University School of Medicine, Mallinckrodt Institute of Radiology, St. Louis, Missouri, USA
| | - Paul Commean
- Data Coordinating Center, Washington University School of Medicine, Mallinckrodt Institute of Radiology, St. Louis, Missouri, USA
| | - Keith Berman
- Health Research Associates, Mountlake Terrace, Washington, USA
| | - Ed Spitznagel
- Department of Mathematics, Washington University, St. Louis, Missouri, USA
| | - Jeff Atkinson
- Department of Internal Medicine, Division of Pulmonary Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - George Despotis
- Department of Pathology & Immunology, Division of Laboratory & Genomic Medicine, Department of Anesthesiology, Division of Cardiothoracic Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
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16
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Abstract
Bronchiolar abnormalities are common and can occur in conditions that affect either the large airways or the more distal parenchyma. In this review, we focus on the diagnosis and management of primary bronchiolar disorders, or conditions in which bronchiolitis is the predominant pathologic process, including constrictive bronchiolitis, follicular bronchiolitis, acute bronchiolitis, respiratory bronchiolitis, and diffuse panbronchiolitis. Due to the nature of abnormalities in the small airway, clinical and physiological changes in bronchiolitis can be subtle, making diagnosis challenging. Primary bronchiolar disorders frequently present with progressive dyspnea and cough that can be out of proportion to imaging and physiologic studies. Pulmonary function tests may be normal, impaired in an obstructive, restrictive, or mixed pattern, or have an isolated decrease in diffusion capacity. High-resolution computed tomography scan is an important diagnostic tool that may demonstrate one or more of the following three patterns: 1) solid centrilobular nodules, often with linear branching opacities (i.e., "tree-in-bud" pattern); 2) ill-defined ground glass centrilobular nodules; and 3) mosaic attenuation on inspiratory images that is accentuated on expiratory images, consistent with geographic air trapping. Bronchiolitis is often missed on standard transbronchial lung biopsies, as the areas of small airway involvement can be patchy. Fortunately, many patients can be diagnosed with a combination of clinical suspicion, inspiratory and expiratory high-resolution computed tomography scans, and pulmonary function testing. Joint consultation of clinicians with both radiologists and pathologists (in cases where histopathology is pursued) is critical to appropriately assess the clinical-radiographic-pathologic context in each individual patient.
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17
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Byrne D, Nador RG, English JC, Yee J, Levy R, Bergeron C, Swiston JR, Mets OM, Muller NL, Bilawich AM. Chronic Lung Allograft Dysfunction: Review of CT and Pathologic Findings. Radiol Cardiothorac Imaging 2021; 3:e200314. [PMID: 33778654 PMCID: PMC7978021 DOI: 10.1148/ryct.2021200314] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 11/02/2020] [Accepted: 11/06/2020] [Indexed: 04/14/2023]
Abstract
Chronic lung allograft dysfunction (CLAD) is the most common cause of mortality in lung transplant recipients after the 1st year of transplantation. CLAD has traditionally been classified into two distinct obstructive and restrictive forms: bronchiolitis obliterans syndrome and restrictive allograft syndrome. However, CLAD may manifest with a spectrum of imaging and pathologic findings and a combination of obstructive and restrictive physiologic abnormalities. Although the initial CT manifestations of CLAD may be nonspecific, the progression of findings at follow-up should signal the possibility of CLAD and may be present on imaging studies prior to the development of functional abnormalities of the lung allograft. This review encompasses the evolution of CT findings in CLAD, with emphasis on the underlying pathogenesis and pathologic condition, to enhance understanding of imaging findings. The purpose of this article is to familiarize the radiologist with the initial and follow-up CT findings of the obstructive, restrictive, and mixed forms of CLAD, for which early diagnosis and treatment may result in improved survival. Supplemental material is available for this article. © RSNA, 2021.
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18
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de Zwart AES, Riezebos‐Brilman A, Alffenaar JC, van den Heuvel ER, Gan CT, van der Bij W, Kerstjens HAM, Verschuuren EAM. Evaluation of 10 years of parainfluenza virus, human metapneumovirus, and respiratory syncytial virus infections in lung transplant recipients. Am J Transplant 2020; 20:3529-3537. [PMID: 32449200 PMCID: PMC7754441 DOI: 10.1111/ajt.16073] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/04/2020] [Accepted: 05/13/2020] [Indexed: 01/25/2023]
Abstract
Respiratory tract infection with pneumoviruses (PVs) and paramyxoviruses (PMVs) are increasingly associated with chronic lung allograft dysfunction (CLAD) in lung transplant recipients (LTRs). Ribavirin may be a treatment option but its effectiveness is unclear, especially with respect to infection severity. We retrospectively analyzed 10 years of PV/PMV infections in LTRs. The main end points were forced expiratory volume in 1 second (FEV1 ) at 3 and 6 months postinfection, expressed as a percentage of pre-infection FEV1 and incidence of new or progressed CLAD 6 months postinfection. A total of 139 infections were included: 88 severe infections (63%) (defined as >10% FEV1 loss at infection) and 51 mild infections (37%) (≤10% FEV1 loss). Overall postinfection CLAD incidence was 20%. Associations were estimated on postinfection FEV1 for ribavirin vs no ribavirin (+13.2% [95% CI: 7.79; 18.67]) and severe vs mild infection (-11.1% [95% CI: -14.76; -7.37]). Factors associated with CLAD incidence at 6 months were ribavirin treatment (odds ratio (OR [95% CI]) 0.24 [0.10; 0.59]), severe infection (OR [95% CI] 4.63 [1.66; 12.88]), and mycophenolate mofetil use (OR [95% CI] 0.38 [0.14; 0.97]). These data provide valuable information about the outcomes of lung transplant recipients with these infections and suggests possible associations of ribavirin use and infection severity with long-term outcomes. Well-designed prospective trials are needed to confirm these findings.
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Affiliation(s)
- Auke E. S. de Zwart
- Department of Pulmonary Diseases and TuberculosisUniversity Medical Centre GroningenUniversity of GroningenGroningenThe Netherlands
| | - Annelies Riezebos‐Brilman
- Department of Medical MicrobiologyUniversity Medical Centre UtrechtUniversity of UtrechtUtrechtThe Netherlands,Department of Medical MicrobiologyUniversity Medical Centre GroningenUniversity of GroningenGroningenThe Netherlands
| | - Jan‐Willem C. Alffenaar
- Department of Clinical Pharmacy and PharmacologyUniversity Medical Centre GroningenUniversity of GroningenGroningenThe Netherlands,Faculty of Medicine and HealthSchool of PharmacyUniversity of SydneySydneyNew South WalesAustralia,Westmead HospitalSydneyNew South WalesAustralia,Marie Bashir Institute for Infectious Diseases and BiosecuritySydneyNew South WalesAustralia
| | - Edwin R. van den Heuvel
- Department of Mathematics and Computer ScienceEindhoven University of TechnologyEindhovenThe Netherlands
| | - Christiaan Tji Gan
- Department of Pulmonary Diseases and TuberculosisUniversity Medical Centre GroningenUniversity of GroningenGroningenThe Netherlands
| | - Wim van der Bij
- Department of Pulmonary Diseases and TuberculosisUniversity Medical Centre GroningenUniversity of GroningenGroningenThe Netherlands
| | - Huib A. M. Kerstjens
- Department of Pulmonary Diseases and TuberculosisUniversity Medical Centre GroningenUniversity of GroningenGroningenThe Netherlands
| | - Erik A. M. Verschuuren
- Department of Pulmonary Diseases and TuberculosisUniversity Medical Centre GroningenUniversity of GroningenGroningenThe Netherlands
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19
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Kaza V, Zhu C, Terada LS, Wang L, Torres F, Bollineni S, Mohanka M, Banga A, Joerns J, Mohanakumar T, Li QZ. Self-reactive antibodies associated with bronchiolitis obliterans syndrome subtype of chronic lung allograft dysfunction. Hum Immunol 2020; 82:25-35. [PMID: 33129576 DOI: 10.1016/j.humimm.2020.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 10/13/2020] [Accepted: 10/14/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Chronic Lung Allograft Dysfunction (CLAD) remains the major limitation in long term survival after lung transplantation. Our objective is to evaluate for the presence of autoantibodies to self-antigens, which is a pathway along with complex interplay with immune as well as non-immune mechanisms that leads to a fibroproliferative process resulting in CLAD. METHODS Serum profiles of IgG autoantibodies were evaluated using customized proteomic microarray with 124 antigens. Output from microarray analyzed as antibody scores is correlated with bronchiolitis obliterans (BOS) subtype of CLAD using Mann-Whitney U test or Fisher exact test. Autoantibodies were evaluated for their predictive value for progressive BOS using a Cox proportional hazard model. BOS free survival and overall survival was analyzed using Kaplan-Meier survival analysis. RESULTS Forty- two patients included in the study are grouped into "stable BOS" and "progressive BOS" for comparisons. Pulmonary fibrosis is the major indication for lung transplantation in our cohort. Progressive BOS group had significantly worse survival (p < 0.005). Sixteen IgG autoantibodies are significantly elevated at baseline in progressive BOS group. Six among them correlated with worse BOS free survival (p < 0.05). In addition, these six IgG autoantibodies remain elevated at three months and one year after lung transplantation. CONCLUSION Pre-existing IgG autoantibodies correlate with progressive BOS and survival in a single center, small cohort of lung transplant recipients. Further validation with larger sample size, external cohort and confirmation with additional tissue, bronchoalveolar lavage samples are necessary to confirm the preliminary findings in our study.
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Affiliation(s)
- Vaidehi Kaza
- Division of Pulmonary Critical Care, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA.
| | - Chengsong Zhu
- Department of Immunology, Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Lance S Terada
- Division of Pulmonary Critical Care, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Li Wang
- Department of Immunology, Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Fernando Torres
- Division of Pulmonary Critical Care, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Srinivas Bollineni
- Division of Pulmonary Critical Care, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Manish Mohanka
- Division of Pulmonary Critical Care, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Amit Banga
- Division of Pulmonary Critical Care, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - John Joerns
- Division of Pulmonary Critical Care, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - T Mohanakumar
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Quan-Zhen Li
- Department of Immunology, Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA.
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20
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Arjuna A, Olson MT, Walia R, Bremner RM, Smith MA, Mohanakumar T. An update on current treatment strategies for managing bronchiolitis obliterans syndrome after lung transplantation. Expert Rev Respir Med 2020; 15:339-350. [PMID: 33054424 DOI: 10.1080/17476348.2021.1835475] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Bronchiolitis obliterans syndrome (BOS), a subtype of chronic lung allograft dysfunction, is quite common, with up to half of all lung recipients developing BOS within 5 years of transplantation. Preventive efforts are aimed at alleviating known risk factors of BOS development, while the primary goal of treatment is to delay the irreversible, fibrotic airway changes, and progressive loss of lung function. AREAS COVERED This narrative review will briefly discuss the updated definition, clinical presentation, pathogenesis, risk factors, and survival after BOS while paying particular attention to the salient evidence for optimal preventive strategies and treatments based on investigations in the modern era. EXPERT OPINION Future translational research focused on further characterizing the complex interplay between immune and nonimmune mechanisms mediating chronic lung rejection is the first step toward mitigating risk of allograft injury, improving early disease detection with noninvasive biomarkers, and ultimately, developing an effective, targeted therapy that can extend the life of the lung allograft.
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Affiliation(s)
- Ashwini Arjuna
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, Phoenix, AZ, USA
| | - Michael T Olson
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, Phoenix, AZ, USA.,Phoenix Campus, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Rajat Walia
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, Phoenix, AZ, USA
| | - Ross M Bremner
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, Phoenix, AZ, USA
| | - Michael A Smith
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, Phoenix, AZ, USA
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21
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Leuschner G, Lauseker M, Howanietz AS, Milger K, Veit T, Munker D, Schneider C, Weig T, Michel S, Barton J, Meiser B, Dinkel J, Neurohr C, Behr J, Kneidinger N. Longitudinal lung function measurements in single lung transplant recipients with chronic lung allograft dysfunction. J Heart Lung Transplant 2020; 39:1270-1278. [PMID: 32917480 DOI: 10.1016/j.healun.2020.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 08/19/2020] [Accepted: 08/20/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Phenotyping chronic lung allograft dysfunction (CLAD) in single lung transplant (SLTX) recipients is challenging. The aim of this study was to assess the diagnostic and prognostic value of longitudinal lung function tests in SLTX recipients with CLAD. METHODS A total of 295 SLTX recipients were analyzed and stratified according to native lung physiology. In addition to spirometry, measurements of static lung volumes and lung capacities were used to phenotype patients and to assess their prognostic value. Outcome was survival after CLAD onset. Patients with insufficient clinical information were excluded (n = 71). RESULTS Of 224 lung transplant recipients, 105 (46.9%) developed CLAD. Time to CLAD onset (hazard ratio [HR]: 0.82, 95% CI: 0.74-0.90; p < 0.001), severity of CLAD at onset (HR: 0.97, 95% CI: 0.94-0.99; p = 0.009), and progression after onset of CLAD (HR: 1.03, 95% CI: 1.00-1.05; p = 0.023) were associated with outcome. Phenotypes at onset were bronchiolitis obliterans syndrome (BOS) (59.1%), restrictive allograft syndrome (RAS) (12.4%), mixed phenotype (6.7%), and undefined phenotype (21.9%). Survival estimates differed significantly between phenotypes (p = 0.004), with RAS and mixed phenotype being associated with the worst survival, followed by BOS and undefined phenotype. Finally, a higher hazard for mortality was noticed for RAS (HR: 2.34, 95% CI: 0.99-5.52; p = 0.054) and mixed phenotype (HR: 3.30, 95% CI: 1.20-9.11; p = 0.021) while controlling for time to CLAD onset and severity of CLAD at onset. CONCLUSIONS Phenotyping CLAD in SLTX remains challenging with a high number of patients with an undefined phenotype despite comprehensive lung function testing. However, phenotyping is of prognostic value. Furthermore, early, severe, and progressive CLADs are associated with worse survival.
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Affiliation(s)
- Gabriela Leuschner
- Department of Internal Medicine V, Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL)
| | - Michael Lauseker
- Institute for Medical Information Processing, Biometry, and Epidemiology
| | - Anne-Sophie Howanietz
- Department of Internal Medicine V, Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL)
| | - Katrin Milger
- Department of Internal Medicine V, Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL)
| | - Tobias Veit
- Department of Internal Medicine V, Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL)
| | - Dieter Munker
- Department of Internal Medicine V, Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL)
| | | | | | | | - Jürgen Barton
- Department of Internal Medicine V, Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL)
| | | | - Julien Dinkel
- Institute for Clinical Radiology, University of Munich (LMU), Munich, Munich, Germany
| | - Claus Neurohr
- Department of Internal Medicine V, Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL)
| | - Jürgen Behr
- Department of Internal Medicine V, Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL)
| | - Nikolaus Kneidinger
- Department of Internal Medicine V, Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL).
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Incidence, management and outcome of respiratory syncytial virus infection in adult lung transplant recipients: a 9-year retrospective multicentre study. Clin Microbiol Infect 2020; 27:897-903. [PMID: 32827713 DOI: 10.1016/j.cmi.2020.07.050] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 06/20/2020] [Accepted: 07/30/2020] [Indexed: 01/02/2023]
Abstract
OBJECTIVES To analyse functional outcome parameters according to antimicrobial treatments after respiratory syncytial virus (RSV)-confirmed infection in adult lung transplant recipients. METHODS A 9-year retrospective multicentre cohort study (2011-19) included adult lung transplant recipients with RSV-confirmed infection. The first endpoint determined new allograft dysfunction (acute graft rejection and chronic lung allograft dysfunction (CLAD)) 3 months after infection. Then baseline and 3 months' postinfection forced expiratory volume in 1 second (FEV1) values were compared according to antimicrobial treatment. Univariate logistic regression analysis was performed. RESULTS RSV infection was confirmed in 77 of 424 lung transplant recipients (estimated incidence of 0.025 per patient per year; 95% confidence interval 0.018-0.036). At 3 months, 22 recipients (28.8%) developed allograft dysfunction: ten (13%) possible CLAD, six (7.9%) acute rejection and six (7.9%) CLAD. Recipients with the lowest preinfection FEV1 had a greater risk of developing pneumonia (median (interquartile range) 1.5 (1.1-1.9) vs. 2.2 (1.5-2.4) L/s, p 0.003) and a higher odds of receiving antibiotics (1.6 (1.3-2.3) vs. 2.3 (1.9-2.5) L/s, p 0.017; odds ratio 0.52, 95% confidence interval 0.27-0.99). Compared to tracheobronchitis/bronchiolitis, RSV-induced pneumonia led more frequently to hospitalization (91.7%, 22 vs. 58.0%, 29, p 0.003) and intensive care unit admission (33.3%, 8 vs. 0, p < 10-3). For ribavirin-treated recipients (24.7%, 19) and azithromycin prophylaxis (50.6%, 39), 3-month FEV1 values were not different from untreated recipients. The overall mortality was 2.5% at 1 month and 5.3% at 6 months, unrelated to RSV. CONCLUSIONS At 3 months after RSV-confirmed infection, 22 recipients (28.8%) had new allograft dysfunction. Ribavirin treatment and azithromycin prophylaxis did not prevent FEV1 decline.
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23
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Gohir W, Klement W, Singer LG, Palmer SM, Mazzulli T, Keshavjee S, Husain S. Identifying host microRNAs in bronchoalveolar lavage samples from lung transplant recipients infected with Aspergillus. J Heart Lung Transplant 2020; 39:1228-1237. [PMID: 32771440 DOI: 10.1016/j.healun.2020.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 07/06/2020] [Accepted: 07/17/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND MicroRNAs (miRNAs) are small non-coding RNAs of ∼22 nucleotides that play a crucial role in post-transcriptional regulation of gene expression. Dysregulation of miRNA expression has been shown during microbial infections. We sought to identify miRNAs that distinguish invasive aspergillosis (IA) from non-IA in lung transplant recipients (LTRs). METHODS We used NanoString nCounter Human miRNA, version 3, panel to measure miRNAs in bronchoalveolar lavage (BAL) samples from LTRs with Aspergillus colonization (ASP group) (n = 10), those with Aspergillus colonization and chronic lung allograft dysfunction (CLAD) (ASPCLAD group) (n = 7), those with IA without CLAD (IA group) (n = 10), those who developed IA with CLAD (IACLAD group) (n = 9), and control patients (controls) (n = 9). The miRNA profile was compared using the permutation test of 100,000 trials for each of the comparisons. We used mirDIP to obtain their gene targets and pathDIP to determine the pathway enrichment. RESULTS We performed pairwise comparisons between patient groups to identify differentially expressed miRNAs. A total of 5 miRNAs were found to be specific to IA, including 4 (miR-145-5p, miR-424-5p, miR-99b-5p, and miR-4488) that were upregulated and the pair (miR-4454 + miR-7975) that was downregulated in IA group vs controls. The expression change for these miRNAs was specific to patients with IA; they were not significantly differentiated between IACLAD and IA groups. Signaling pathways associated with an immunologic response to IA were found to be significantly enriched. CONCLUSIONS We report a set of 5 differentially expressed miRNAs in the BAL of LTRs with IA that might help in the development of diagnostic and prognostic tools for IA in LTRs. However, further investigation is needed in a larger cohort to validate the findings.
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Affiliation(s)
- Wajiha Gohir
- Transplant Infectious Diseases, Ajmera Family Transplant Centre
| | - William Klement
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Scott M Palmer
- Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Tony Mazzulli
- Department of Microbiology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shahid Husain
- Transplant Infectious Diseases, Ajmera Family Transplant Centre.
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24
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Sahakijpijarn S, Moon C, Ma X, Su Y, Koleng JJ, Dolocan A, Williams RO. Using thin film freezing to minimize excipients in inhalable tacrolimus dry powder formulations. Int J Pharm 2020; 586:119490. [PMID: 32603840 DOI: 10.1016/j.ijpharm.2020.119490] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 02/09/2023]
Abstract
We investigated the feasibility of preparing high-potency tacrolimus dry powder for inhalation using thin film freezing (TFF). We found that using ultra-rapid freezing can increase drug loading up to 95% while maintaining good aerosol performance. Drug loading affected the specific surface area and moisture sorption of TFF formulations, but it did not affect the chemical stability, physical stability, and dissolution of tacrolimus. Tacrolimus remained amorphous after storage at 40 °C/75% RH, and 25 °C/60% RH for up to 6 months. Lactose functioned as a bulking agent, and it had little to no effect as a stabilizer for amorphous tacrolimus due to a lack of interaction between the drug and excipient. Additionally, the aerosol performance of TFF tacrolimus/lactose (95/5) did not significantly change after six months of storage at 25 °C/60% RH. For processing parameters, the solids content and the processing temperature did not affect the aerosol performance of tacrolimus. Furthermore, both low- and high-resistance RS01 showed optimal and consistent aerosol performance over the 1-4 kPa pressure drop range. In conclusion, TFF is a suitable technology for producing inhalable powder that contain high drug loading and have less flow rate dependence.
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Affiliation(s)
- Sawittree Sahakijpijarn
- The University of Texas at Austin, College of Pharmacy, Division of Molecular Pharmaceutics and Drug Delivery, Austin, TX, USA
| | - Chaeho Moon
- The University of Texas at Austin, College of Pharmacy, Division of Molecular Pharmaceutics and Drug Delivery, Austin, TX, USA; TFF Pharmaceuticals, Inc., Austin, TX, USA
| | - Xiangyu Ma
- The University of Texas at Austin, College of Pharmacy, Division of Molecular Pharmaceutics and Drug Delivery, Austin, TX, USA
| | - Yongchao Su
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ, USA
| | | | - Andrei Dolocan
- The University of Texas at Austin, Texas Materials Institute, Austin, TX, USA
| | - Robert O Williams
- The University of Texas at Austin, College of Pharmacy, Division of Molecular Pharmaceutics and Drug Delivery, Austin, TX, USA.
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25
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Combs MP, Xia M, Wheeler DS, Belloli EA, Walker NM, Braeuer RR, Lyu DM, Murray S, Lama VN. Fibroproliferation in chronic lung allograft dysfunction: Association of mesenchymal cells in bronchoalveolar lavage with phenotypes and survival. J Heart Lung Transplant 2020; 39:815-823. [PMID: 32360292 DOI: 10.1016/j.healun.2020.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 04/06/2020] [Accepted: 04/13/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Chronic lung allograft dysfunction (CLAD), the primary cause of poor outcome after lung transplantation, arises from fibrotic remodeling of the allograft and presents as diverse clinical phenotypes with variable courses. Here, we investigate whether bronchoalveolar lavage (BAL) mesenchymal cell activity at CLAD onset can inform regarding disease phenotype, progression, and survival. METHODS Mesenchymal cell colony-forming units (CFUs) were measured in BAL obtained at CLAD onset (n = 77) and CLAD-free time post-transplant matched controls (n = 77). CFU counts were compared using Wilcoxon's rank-sum test. Cox proportional hazards and restricted means models were utilized to investigate post-CLAD survival. RESULTS Higher mesenchymal CFU counts were noted in BAL at the time of CLAD onset than in CLAD-free controls. Patients with restrictive allograft syndrome had higher BAL mesenchymal CFU count at CLAD onset than patients with bronchiolitis obliterans syndrome (p = 0.011). Patients with high mesenchymal CFU counts (≥10) at CLAD onset had worse outcomes than those with low (<10) CFU counts, with shorter average survival (2.64 years vs 4.25 years; p = 0.027) and shorter progression-free survival, defined as time to developing either CLAD Stage 3 or death (0.97 years vs 2.70 years; p < 0.001). High CFU count remained predictive of decreased overall survival and progression-free survival after accounting for the CLAD phenotype and other clinical factors in multivariable analysis. CONCLUSIONS Fulminant fibroproliferation with higher mesenchymal CFU counts in BAL is noted in restrictive allograft syndrome and is independently associated with poor survival after CLAD onset.
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Affiliation(s)
- Michael P Combs
- Department of Internal Medicine, Division of Pulmonary & Critical Care, University of Michigan, Ann Arbor, Michigan
| | - Meng Xia
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - David S Wheeler
- Department of Internal Medicine, Division of Pulmonary & Critical Care, University of Michigan, Ann Arbor, Michigan
| | - Elizabeth A Belloli
- Department of Internal Medicine, Division of Pulmonary & Critical Care, University of Michigan, Ann Arbor, Michigan
| | - Natalie M Walker
- Department of Internal Medicine, Division of Pulmonary & Critical Care, University of Michigan, Ann Arbor, Michigan
| | - Russell R Braeuer
- Department of Internal Medicine, Division of Pulmonary & Critical Care, University of Michigan, Ann Arbor, Michigan
| | - Dennis M Lyu
- Department of Internal Medicine, Division of Pulmonary & Critical Care, University of Michigan, Ann Arbor, Michigan
| | - Susan Murray
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Vibha N Lama
- Department of Internal Medicine, Division of Pulmonary & Critical Care, University of Michigan, Ann Arbor, Michigan.
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Abstract
PURPOSE OF REVIEW Incidence of community-acquired respiratory viruses (CARVs) after lung transplantation (LTx) is 10-68 cases per 100 patient-years. Infected patients may develop graft failure and there seems to be an association between CARV infection and development of chronic lung allograft dysfunction (CLAD). This review summarizes the impact of CARV infection after LTx and potential treatment strategies. RECENT FINDINGS Detection rate of CARV depends on diagnostic methods. CARV infections after LTx are reported more frequently probably attributed to improved diagnostic methods, especially nucleic acid testing. Paramyxoviridae and picornaviridae are most frequent. For paramyxoviridae, the association with CLAD is reported in various single-center observational studies. Neuraminidase inhibitors are approved for influenza and can be safely used in flu-infected LTx patients. There is no approved treatment for paramyxoviruses, most centers use ribavirin in the infected LTx recipient. SUMMARY Antivirals against CARV in LTx recipients have not yet demonstrated reduced morbidity in randomized clinical trials. Agents against CARV under development are inhibiting viral attachment and use silencing mechanisms of viral replication. The cohort of lung transplant recipients is a focus of intense research because of the high morbidity of CARV infection and intense surveillance of LTx recipeints.
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27
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Herrera S, Khan B, Singer LG, Binnie M, Chaparro C, Chow CW, Martinu T, Tomlinson G, Keshavjee S, Husain S, Tikkanen JM. Extending cytomegalovirus prophylaxis in high-risk (D+/R-) lung transplant recipients from 6 to 9 months reduces cytomegalovirus disease: A retrospective study. Transpl Infect Dis 2020; 22:e13277. [PMID: 32170813 DOI: 10.1111/tid.13277] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 02/25/2020] [Accepted: 03/08/2020] [Indexed: 12/31/2022]
Abstract
RATIONALE Cytomegalovirus (CMV)-seronegative recipients receiving a seropositive allograft (D+/R-) are at a high risk of developing CMV disease. Our program increased the duration of CMV prophylaxis from 6 to 9 months in May 2013. Here, we present the impact on the incidence of CMV infection, disease, side effects, rejection, and other factors. METHODS Retrospective cohort of 241 CMV (D+/R-) patients transplanted between January 1, 2008, and December 31, 2017. Blood CMV testing was done according to protocol. All patients received ganciclovir/valganciclovir as prophylaxis. We compared the incidence and timing of CMV infection and disease up to 6 months after cessation of prophylaxis between patients who received 9 months (May 2013 onwards) and a historical control group who received 6 months of prophylaxis (prior to May 2013). CMV infection was defined as detectable CMV viremia in the absence of symptoms. CMV disease was defined as CMV syndrome or tissue-invasive disease. Side effects of prophylaxis and CMV resistance were recorded. RESULTS A total of 116 patients were included in the 6-month group and 125 in the 9-month group. The extended 9-month CMV prophylaxis delayed the onset of CMV infection (median time to CMV infection after lung transplantation 295 vs 353 days, P < .01) but did not significantly reduce the incidence of CMV infection (65% vs 64%, P = .06, log-rank). The 9-month prophylaxis delayed the onset and decreased the incidence of CMV disease from 50% in the 6-month group to 42% (P = .02 log-rank). There was no difference in the rate of adverse effects (leukopenia in 32% in both groups, P = .53) or development of CMV resistance between the two groups (4 cases in both groups, P = .92). There were no significant differences in overall survival or the rate of chronic lung allograft dysfunction between the groups. CONCLUSIONS Extending duration of CMV prophylaxis from 6 to 9 months resulted in a delayed and decreased incidence of CMV disease in our lung transplant population. The absolute risk reduction achieved by extended CMV prophylaxis was 8%. The incidence of CMV infection, and ganciclovir resistance and side effects were similar between the two groups. Our results suggest that extending CMV prophylaxis in the highest risk CMV D+/R- group is effective in reducing CMV disease.
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Affiliation(s)
- Sabina Herrera
- Transplant Infectious Diseases, University Health Network/University of Toronto, Toronto, ON, Canada
| | - Basha Khan
- Toronto Lung Transplant Program, University Health Network/University of Toronto, Toronto, ON, Canada
| | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network/University of Toronto, Toronto, ON, Canada
| | - Matthew Binnie
- Toronto Lung Transplant Program, University Health Network/University of Toronto, Toronto, ON, Canada
| | - Cecilia Chaparro
- Toronto Lung Transplant Program, University Health Network/University of Toronto, Toronto, ON, Canada
| | - Chung-Wai Chow
- Toronto Lung Transplant Program, University Health Network/University of Toronto, Toronto, ON, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, University Health Network/University of Toronto, Toronto, ON, Canada
| | - George Tomlinson
- Department of Medicine, University Health Network / University of Toronto, Toronto, ON, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network/University of Toronto, Toronto, ON, Canada
| | - Shahid Husain
- Transplant Infectious Diseases, University Health Network/University of Toronto, Toronto, ON, Canada
| | - Jussi M Tikkanen
- Toronto Lung Transplant Program, University Health Network/University of Toronto, Toronto, ON, Canada
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Preservation of Microvascular Integrity in Murine Orthotopic Tracheal Allografts by Clopidogrel. Transplantation 2019; 103:899-908. [PMID: 30801550 DOI: 10.1097/tp.0000000000002571] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Survival after lung transplantation is mainly limited by the development of chronic lung allograft dysfunction (CLAD). The aim of this study was to investigate if platelet inhibition by clopidogrel has a functionally relevant influence on the microvascular integrity of orthotopic tracheal allografts as an anatomic basis for the development of CLAD. METHODS We orthotopically transplanted C57Bl/6 (H-2) tracheas into CBA.J (H-2) recipients who afterwards received clopidogrel (1 mg/kg). Morphometric analysis was performed by measuring epithelial height in proportion to thickness of the lamina propria (epithelium-lamina propria ratio). Tissue oxygenation was determined using a fluorescence quenching technique, and graft perfusion monitoring was performed by laser Doppler flowmetry and lectin-binding assay. Immunohistochemistry was used for detection of CD31 and inducible nitric oxide synthase while iron deposition was shown with Prussian blue reaction. Quantitative reverse transcription polymerase chain reaction analysis was used for gene expression analysis. RESULTS Isografts maintained good oxygenation and perfusion throughout the experiment, while both were drastically reduced in allografts. Treatment with clopidogrel attenuated graft hypoxia and reduced loss of perfusion. Additionally, clopidogrel led to increased epithelium-lamina propria ratio while iron deposition was impaired. Gene expression analysis revealed elevated levels of angiogenic vascular endothelial growth factor in the clopidogrel group. Improved endothelial function was shown by immunohistochemistry (CD31, inducible nitric oxide synthase). CONCLUSIONS Continuous administration of clopidogrel significantly improved tissue oxygenation, limited microvascular leakiness, and prevented airway ischemia. These data demonstrate that clopidogrel ameliorates microvascular injury during acute airway rejection, which is a known predisposing factor for the development of CLAD.
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Gan CTJ, Ward C, Meachery G, Lordan JL, Fisher AJ, Corris PA. Long-term effect of azithromycin in bronchiolitis obliterans syndrome. BMJ Open Respir Res 2019; 6:e000465. [PMID: 31673366 PMCID: PMC6797396 DOI: 10.1136/bmjresp-2019-000465] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 09/11/2019] [Accepted: 09/11/2019] [Indexed: 11/04/2022] Open
Abstract
Introduction Azithromycin stabilises and improves lung function forced expiratory volume in one second (FEV1) in lung transplantation patients with bronchiolitis obliterans syndrome (BOS). A post hoc analysis was performed to assess the long-term effect of azithromycin on FEV1, BOS progression and survival . Methods Eligible patients recruited for the initial randomised placebo-controlled trial received open-label azithromycin after 3 months and were followed up until 6 years after inclusion (n=45) to assess FEV1, BOS free progression and overall survival. Results FEV1 in the placebo group improved after open-label azithromycin and was comparable with the treatment group by 6 months. FEV1 decreased after 1 and 5 years and was not different between groups. Patients (n=18) with rapid progression of BOS underwent total lymphoid irradiation (TLI). Progression-free survival (log-rank test p=0.40) and overall survival (log-rank test p=0.28) were comparable. Survival of patients with early BOS was similar to late-onset BOS (log-rank test p=0.74). Discussion Long-term treatment with azithromycin slows down the progression of BOS, although the effect of TLI may affect the observed attenuation of FEV1 decline. BOS progression and long-term survival were not affected by randomisation to the placebo group, given the early cross-over to azithromycin and possibly due to TLI in case of further progression. Performing randomised placebo-controlled trials in lung transplantation patients with BOS with a blinded trial duration is feasible, effective and safe.
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Affiliation(s)
- C Tji-Joong Gan
- Pulmonary Diseases, University Medical Centre Groningen Thoraxcentre, Groningen, The Netherlands
| | - Chris Ward
- Transplantation Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Gerard Meachery
- Respiratory Medicine, Freeman Hospital, Newcastle upon Tyne, UK
| | | | - Andrew J Fisher
- Transplantation Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Paul A Corris
- Transplantation Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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30
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January SE, Fester KA, Bain KB, Kulkarni HS, Witt CA, Byers DE, Alexander-Brett J, Trulock EP, Hachem RR. Rabbit antithymocyte globulin for the treatment of chronic lung allograft dysfunction. Clin Transplant 2019; 33:e13708. [PMID: 31494969 DOI: 10.1111/ctr.13708] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 08/01/2019] [Accepted: 09/03/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chronic lung allograft dysfunction (CLAD) is the leading cause of death beyond the first year after lung transplantation. Several treatments have been used to prevent the progression or reverse the effects of CLAD. Cytolytic therapy with rabbit antithymocyte globulin (rATG) has previously shown to be a potential option. However, the effect on patients with restrictive allograft syndrome (RAS) versus bronchiolitis obliterans syndrome (BOS) and the effect of cumulative dosing are unknown. METHODS The charts of lung transplant patients treated with rATG at Barnes-Jewish Hospital from 2009 to 2016 were retrospectively reviewed. The primary outcome was response to rATG; patients were deemed responders if their FEV1 improved in the 6 months after rATG treatment. Safety endpoints included incidence of serum sickness, cytokine release syndrome, malignancy, and infectious complications. RESULTS 108 patients were included in this study; 43 (40%) patients were responders who experienced an increase in FEV1 after rATG therapy. No predictors of response to rATG therapy were identified. Serum sickness occurred in 22% of patients, 15% experienced cytokine release syndrome, and 19% developed an infection after therapy. CONCLUSION 40% of patients with CLAD have an improvement in lung function after treatment with rATG although the improvement was typically minimal.
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Affiliation(s)
- Spenser E January
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri
| | - Keith A Fester
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri
| | | | - Hrishikesh S Kulkarni
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri.,Division of Pulmonary and Critical Care, Washington University Physicians, Saint Louis, Missouri
| | - Chad A Witt
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri.,Division of Pulmonary and Critical Care, Washington University Physicians, Saint Louis, Missouri
| | - Derek E Byers
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri.,Division of Pulmonary and Critical Care, Washington University Physicians, Saint Louis, Missouri
| | - Jennifer Alexander-Brett
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri.,Division of Pulmonary and Critical Care, Washington University Physicians, Saint Louis, Missouri
| | - Elbert P Trulock
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri.,Division of Pulmonary and Critical Care, Washington University Physicians, Saint Louis, Missouri
| | - Ramsey R Hachem
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri.,Division of Pulmonary and Critical Care, Washington University Physicians, Saint Louis, Missouri
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Hachem RR. The role of the immune system in lung transplantation: towards improved long-term results. J Thorac Dis 2019; 11:S1721-S1731. [PMID: 31632749 DOI: 10.21037/jtd.2019.04.25] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Over the past 35 years, lung transplantation has evolved from an experimental treatment to the treatment of choice for patients with end-stage lung disease. Beyond the immediate period after lung transplantation, rejection and infection are the leading causes of death. The risk of rejection after lung transplantation is generally higher than after other solid organ transplants, and this necessitates more intensive immunosuppression. However, this more intensive treatment does not reduce the risk of rejection sufficiently, and rejection is one of the most common complications after transplantation. There are multiple forms of rejection including acute cellular rejection, antibody-mediated rejection, and chronic lung allograft dysfunction. These have posed a vexing problem for clinicians, patients, and the field of lung transplantation. Confounding matters is the inherent effect of more intensive immunosuppression on the risk of infections. Indeed, infections pose a direct problem resulting in morbidity and mortality and increase the risk of chronic lung allograft dysfunction in the ensuing weeks and months. There are complex interactions between microbes and the immune response that are the subject of ongoing studies. This review focuses on the role of the immune system in lung transplantation and highlights different forms of rejection and the impact of infections on outcomes.
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Affiliation(s)
- Ramsey R Hachem
- Division of Pulmonary & Critical Care, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
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32
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Hecker M, Hecker A, Askevold I, Kuhnert S, Reichert M, Guth S, Mayer E, Slanina H, Schüttler CG, Seeger W, Padberg W, Mayer K. Indefinite cytomegalovirus prophylaxis with valganciclovir after lung transplantation. Transpl Infect Dis 2019; 21:e13138. [PMID: 31278878 DOI: 10.1111/tid.13138] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 06/14/2019] [Accepted: 06/22/2019] [Indexed: 12/15/2022]
Abstract
Human cytomegalovirus (HCMV) infections and reactivations are common after lung transplantation and are associated with the development of bronchiolitis obliterans syndrome. Against this background, temporary HCMV prophylaxis is an established standard regimen after lung transplantation in most centers. However, the optimal duration of prophylaxis is unclear. We conducted a retrospective two-center study to determine the efficacy of indefinite lifelong HCMV prophylaxis with oral valganciclovir in a cohort of 133 lung transplant recipients with a mean follow-up time of approximately 5 years. During the follow-up period, HCMV DNA was detected in 22 recipients (16.5%). In one case, HCMV pneumonitis developed after prophylaxis had been terminated. We observed a beneficial safety profile and tolerability in our cohort, as the majority of patients still received valganciclovir after a 1- and 3-year observation period, respectively. Compared to the literature, these data indicate a beneficial effect of extended valganciclovir prophylaxis with an acceptable safety profile.
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Affiliation(s)
- Matthias Hecker
- University of Giessen and Marburg Lung Center (UGMLC), University Hospital Giessen, Justus Liebig University of Giessen, Giessen, Germany
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital Giessen, Justus Liebig University of Giessen, Giessen, Germany
| | - Ingolf Askevold
- Department of General and Thoracic Surgery, University Hospital Giessen, Justus Liebig University of Giessen, Giessen, Germany
| | - Stefan Kuhnert
- University of Giessen and Marburg Lung Center (UGMLC), University Hospital Giessen, Justus Liebig University of Giessen, Giessen, Germany
| | - Martin Reichert
- Department of General and Thoracic Surgery, University Hospital Giessen, Justus Liebig University of Giessen, Giessen, Germany
| | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
| | - Heiko Slanina
- Institute of Medical Virology, Justus Liebig University of Giessen, Giessen, Germany
| | - Christian G Schüttler
- Institute of Medical Virology, Justus Liebig University of Giessen, Giessen, Germany
| | - Werner Seeger
- University of Giessen and Marburg Lung Center (UGMLC), University Hospital Giessen, Justus Liebig University of Giessen, Giessen, Germany
| | - Winfried Padberg
- Department of General and Thoracic Surgery, University Hospital Giessen, Justus Liebig University of Giessen, Giessen, Germany
| | - Konstantin Mayer
- University of Giessen and Marburg Lung Center (UGMLC), University Hospital Giessen, Justus Liebig University of Giessen, Giessen, Germany
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Factors Associated With Mortality and Response to Extracorporeal Photopheresis in Lung Allograft Recipients With Bronchiolitis Obliterans Syndrome. Transplantation 2019; 103:1036-1042. [DOI: 10.1097/tp.0000000000002430] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Diagnosis, Pathophysiology and Experimental Models of Chronic Lung Allograft Rejection. Transplantation 2019; 102:1459-1466. [PMID: 29683998 DOI: 10.1097/tp.0000000000002250] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Chronic rejection is the Achilles heel of modern lung transplantation, characterized by a slow, progressive decline in allograft function. Clinically, this manifests as obstructive disease, restrictive disease, or a mixture of the 2 depending on the underlying pathology. The 2 major phenotypes of chronic rejection include bronchiolitis obliterans syndrome and restrictive allograft syndrome. The last decade of research has revealed that each of these phenotypes has a unique underlying pathophysiology which may require a distinct treatment regimen for optimal control. Insights into the intricate alloimmune pathways contributing to chronic rejection have been gained from both large and small animal models, suggesting directions for future research. In this review, we explore the pathological hallmarks of chronic rejection, recent insights gained from both clinical and basic science research, and the current state of animal models of chronic lung rejection.
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Prevalence of antibodies to lung self-antigens (Kα1 tubulin and collagen V) and donor specific antibodies to HLA in lung transplant recipients and implications for lung transplant outcomes: Single center experience. Transpl Immunol 2019; 54:65-72. [PMID: 30794945 DOI: 10.1016/j.trim.2019.02.006] [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: 01/21/2019] [Revised: 02/15/2019] [Accepted: 02/17/2019] [Indexed: 01/02/2023]
Abstract
PURPOSE For patients with end stage lung disease, lung transplantation (LT) remains the only definitive treatment option. Long term survival post LT is limited by acute and chronic allograft dysfunction. Antibodies to lung self-antigens Kα1Tubulin and collagen V (autoantibodies) have been implicated in adverse outcomes post LT. The aim of our study was to determine the prevalence of autoantibodies in pre- and post-transplant sera, evaluate the impact on post-transplant outcomes. METHODS In a prospective observational cohort analysis, 44 patients were enrolled who received LT between 09/01/2014 and 10/31/2015. Pre- and post-transplant sera were analyzed using enzyme-linked immunosorbent assay (ELISA) for the presence of antibodies to collagen I, collagen V, and K-alpha 1 tubulin. The outcome variables are presence of primary graft dysfunction (PGD), cumulative acute cellular rejection (ACR), treatment with pulse steroids for clinical rejection, association with DSA, and onset of Bronchiolitis Obliterans Syndrome (BOS). RESULTS In our cohort, 33 patients (75%) tested positive for the presence of autoantibodies. Pre-transplant autoantibodies were present in 23 patients (70%). Only a small percentage (26%) cleared these antibodies with standard immunosuppression. Some developed de novo post-transplant (n = 10). PGD was observed in 34% of our cohort, however the presence of autoantibodies did not correlate with increase in the incidence or severity of PGD. The prevalence of donor specific antibodies (DSA) in the entire cohort was 73%, with an increased prevalence of DSA noted in the autoantibody positive group (78.7% vs. 54.5%) than in the autoantibody negative group. BOS was observed in 20% of the cohort, with a median time to onset of 291 days' post-transplant. Patients with pre-transplant autoantibodies had a statistically significant decrease in BOS-free survival (p = 0.029 by log-rank test). CONCLUSIONS In our cohort, we observed a high prevalence of autoantibodies and DSA in lung transplant recipients. Pre-transplant autoantibodies were associated with de novo development of DSA along with a decrease in BOS-free survival. Limitations to our study include the small sample size and single center enrollment, along with limited time for follow-up.
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Prognostic significance of early pulmonary function changes after onset of chronic lung allograft dysfunction. J Heart Lung Transplant 2018; 38:184-193. [PMID: 30466803 DOI: 10.1016/j.healun.2018.10.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 10/18/2018] [Accepted: 10/24/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Chronic lung allograft dysfunction (CLAD), including the phenotypes of bronchiolitis obliterans syndrome (BOS) and restrictive CLAD (R-CLAD), represents the leading cause of late death after lung transplantation. Little is known, however, regarding the natural history or prognostic significance of pulmonary function changes after the onset of these conditions. We examined changes in forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) over the first 18 months after CLAD. We also sought to determine whether lung function changes occurring early after CLAD impact longer term outcomes. METHODS We performed a retrospective analysis of 216 bilateral lung recipients with CLAD, which included those with R-CLAD (n = 65) or BOS (n = 151). The course of FEV1 and FVC after CLAD was described. Cox proportional hazards models were used to evaluate the impact of a ≥10% decline in FEV1 or FVC within the first 6 months of CLAD on graft loss after that time. RESULTS Lung recipients with CLAD, whether BOS or R-CLAD, had the largest decreases in FEV1 and FVC within the first 6 months after onset. Moreover, a decline in FEV1 or FVC of ≥10% within the first 6 months after CLAD was associated with a significantly increased hazard for graft loss after that time (hazard ratio [HR] = 3.17, 95% confidence interval [CI] 1.56 to 6.42, p = 0.001, and HR = 2.80, 95% CI 1.66 to 4.70, p ≤ 0.001, respectively), an effect observed in both BOS and R-CLAD patients. CONCLUSIONS Early physiologic changes after CLAD were independently associated with graft loss. This suggests lung function changes after CLAD, specifically a ≥10% decline in FEV1 or FVC, could be a surrogate measure of graft survival.
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Hodge G, Hodge S, Yeo A, Nguyen P, Hopkins E, Liu H, Holmes-Liew CL, Holmes M. BOS is associated with decreased HDAC2 from steroid resistant lymphocytes in the small airways. Clin Exp Immunol 2018; 195:277-285. [PMID: 30303525 DOI: 10.1111/cei.13221] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2018] [Indexed: 11/30/2022] Open
Abstract
Immunosuppression therapies including corticosteroids fail to prevent bronchiolitis obliterans syndrome (BOS), primarily a disease of the small airways, following lung transplantation. We reported increases in steroid-resistant proinflammatory lymphocytes and their loss of histone deacetylase 2 (HDAC2), an important mediator of steroid action, in the blood of stable lung transplant recipients. We noted similar increases in the steroid-resistant lymphocytes in both the blood and small airways in BOS compared with the large airways. We hypothesized that these small airway cells would also exhibit a loss of HDAC2, and that these changes could be reversed by treatment with theophylline (HDAC2 activator). Blood, bronchoalveolar lavage and large and small airway brushings were collected from lung transplant patients with BOS (n = 12) or stable lung function (n = 18) and healthy aged-matched controls (n = 13). Intracellular proinflammatory cytokines [interferon (IFN-γ) and tumour necrosis factor (TNF)-α and HDAC2 were measured in CD8+ T, natural killer (NK) T-like and NK cells from cultured small airway brushings ± 5 mg/l theophylline ± 1 µM prednisolone using flow cytometry. Increased small airway CD8 T, NK T-like and NK cells were identified in BOS versus stable transplant and controls. In BOS, these cells exhibited increased IFN-γ/TNF-α and a loss of HDAC2. HDAC2 expression by small airway CD8+ T cells correlated with forced expiratory volume in 1 s (FEV1 ) (R = 0·880, P = 0·031). Theophylline and prednisolone synergistically up-regulated HDAC2 in CD8+ T cells. BOS is associated with loss of HDAC2 from steroid-resistant proinflammatory CD8+ T, NK T-like and NK cells in the small airways. Therapeutically increasing HDAC2 in these lymphocytes may reduce steroid resistance and improve graft survival.
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Affiliation(s)
- G Hodge
- Lung Research, Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - S Hodge
- Lung Research, Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - A Yeo
- Lung Research, Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - P Nguyen
- Lung Research, Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - E Hopkins
- Lung Research, Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - H Liu
- Lung Research, Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - C L Holmes-Liew
- Lung Research, Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia.,South Australian Lung Transplant Service, Adelaide, South Australia, Australia
| | - M Holmes
- Lung Research, Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia.,South Australian Lung Transplant Service, Adelaide, South Australia, Australia
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Parker WF, Bag R. Chronic Lung Allograft Dysfunction. CURRENT PULMONOLOGY REPORTS 2018. [DOI: 10.1007/s13665-018-0208-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Bronchiolitis obliterans syndrome-free survival after lung transplantation: An International Society for Heart and Lung Transplantation Thoracic Transplant Registry analysis. J Heart Lung Transplant 2018; 38:5-16. [PMID: 30391193 DOI: 10.1016/j.healun.2018.09.016] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 09/06/2018] [Accepted: 09/19/2018] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Lung transplant (LTx) recipients have low long-term survival and a high incidence of bronchiolitis obliterans syndrome (BOS). However, few long-term, multicenter, and precise estimates of BOS-free survival (a composite outcome of death or BOS) incidence exist. METHODS This retrospective cohort study of primary LTx recipients (1994-2011) reported to the International Society of Heart and Lung Transplantation Thoracic Transplant Registry assessed outcomes through 2012. For the composite primary outcome of BOS-free survival, we used Kaplan-Meier survival and Cox proportional hazards regression, censoring for loss to follow-up, end of study, and re-LTx. Although standard Thoracic Transplant Registry analyses censor at the last consecutive annual complete BOS status report, our analyses allowed for partially missing BOS data. RESULTS Due to BOS reporting standards, 99.1% of the cohort received LTx in North America. During 79,896 person-years of follow-up, single LTx (6,599 of 15,268 [43%]) and bilateral LTx (8,699 of 15,268 [57%]) recipients had a median BOS-free survival of 3.16 years (95% confidence interval [CI], 2.99-3.30 years) and 3.58 years (95% CI, 3.53-3.72 years), respectively. Almost 90% of the single and bilateral LTx recipients developed the composite outcome within 10 years of transplantation. Standard Registry analyses "overestimated" median BOS-free survival by 0.42 years and "underestimated" the median survival after BOS by about a half-year for both single and bilateral LTx (p < 0.05). CONCLUSIONS Most LTx recipients die or develop BOS within 4 years, and very few remain alive and free from BOS at 10 years post-LTx. Less inclusive Thoracic Transplant Registry analytic methods tend to overestimate BOS-free survival. The Registry would benefit from improved international reporting of BOS and other chronic lung allograft dysfunction (CLAD) events.
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Barbosa EJM, Lanclus M, Vos W, Van Holsbeke C, De Backer W, De Backer J, Lee J. Machine Learning Algorithms Utilizing Quantitative CT Features May Predict Eventual Onset of Bronchiolitis Obliterans Syndrome After Lung Transplantation. Acad Radiol 2018; 25:1201-1212. [PMID: 29472146 DOI: 10.1016/j.acra.2018.01.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 01/09/2018] [Accepted: 01/10/2018] [Indexed: 11/17/2022]
Abstract
RATIONALE AND OBJECTIVES Long-term survival after lung transplantation (LTx) is limited by bronchiolitis obliterans syndrome (BOS), defined as a sustained decline in forced expiratory volume in the first second (FEV1) not explained by other causes. We assessed whether machine learning (ML) utilizing quantitative computed tomography (qCT) metrics can predict eventual development of BOS. MATERIALS AND METHODS Paired inspiratory-expiratory CT scans of 71 patients who underwent LTx were analyzed retrospectively (BOS [n = 41] versus non-BOS [n = 30]), using at least two different time points. The BOS cohort experienced a reduction in FEV1 of >10% compared to baseline FEV1 post LTx. Multifactor analysis correlated declining FEV1 with qCT features linked to acute inflammation or BOS onset. Student t test and ML were applied on baseline qCT features to identify lung transplant patients at baseline that eventually developed BOS. RESULTS The FEV1 decline in the BOS cohort correlated with an increase in the lung volume (P = .027) and in the central airway volume at functional residual capacity (P = .018), not observed in non-BOS patients, whereas the non-BOS cohort experienced a decrease in the central airway volume at total lung capacity with declining FEV1 (P = .039). Twenty-three baseline qCT parameters could significantly distinguish between non-BOS patients and eventual BOS developers (P < .05), whereas no pulmonary function testing parameters could. Using ML methods (support vector machine), we could identify BOS developers at baseline with an accuracy of 85%, using only three qCT parameters. CONCLUSIONS ML utilizing qCT could discern distinct mechanisms driving FEV1 decline in BOS and non-BOS LTx patients and predict eventual onset of BOS. This approach may become useful to optimize management of LTx patients.
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Affiliation(s)
- Eduardo J Mortani Barbosa
- Perelman School of Medicine, University of Pennsylvania, Departments of Radiology and Medicine, 3400 Spruce Street, Philadelphia, PA 19104.
| | | | - Wim Vos
- FLUIDDA nv, Kontich, Belgium
| | | | - William De Backer
- University Hospital Antwerp, Department of Respiratory Medicine, Edegem, Belgium
| | | | - James Lee
- Perelman School of Medicine, University of Pennsylvania, Departments of Radiology and Medicine, 3400 Spruce Street, Philadelphia, PA 19104
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Wojarski J, Ochman M, Medrala W, Kulaczkowska Z, Karolak W, Maruszewski M, Urlik M, Wozniak-Grygiel E, Sioła M, Latos M, Biniszkiewicz P, Pyrc K, Zeglen S. Bacterial Infections During Hospital Stay and Their Impact on Mortality After Lung Transplantation: A Single-Center Study. Transplant Proc 2018; 50:2064-2069. [DOI: 10.1016/j.transproceed.2017.11.080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 11/21/2017] [Indexed: 02/02/2023]
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Liu J, Jackson K, Weinkauf J, Kapasi A, Hirji A, Meyer S, Mullen J, Nagendran J, Lien D, Halloran K. Baseline lung allograft dysfunction is associated with impaired survival after double-lung transplantation. J Heart Lung Transplant 2018; 37:895-902. [DOI: 10.1016/j.healun.2018.02.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 12/22/2017] [Accepted: 02/23/2018] [Indexed: 11/16/2022] Open
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Küppers L, Holz O, Schuchardt S, Gottlieb J, Fuge J, Greer M, Hohlfeld JM. Breath volatile organic compounds of lung transplant recipients with and without chronic lung allograft dysfunction. J Breath Res 2018; 12:036023. [PMID: 29771243 DOI: 10.1088/1752-7163/aac5af] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Chronic lung allograft dysfunction with its clinical correlative of bronchiolitis obliterans syndrome (BOS) remains the major limiting factor for long-term graft survival. Currently there are no established methods for the early diagnosis or prediction of BOS. To assess the feasibility of breath collection as a non-invasive tool and the potential of breath volatile organic compounds (VOC) for the early detection of BOS, we compared the breath VOC composition between transplant patients without and different stages of BOS. METHODS 75 outpatients (25 BOS stage 0, 25 BOS stage 1 + 2, 25 BOS stage 3) after bilateral lung transplantation were included. Exclusion criteria were active smoking, oxygen therapy and acute infection. Patients inhaled room air through a VOC and sterile filter and exhaled into an aluminum reservoir tube. Breath was loaded directly onto Tenax® TA adsorption tubes and was subsequently analyzed by gas-chromatography/mass-spectrometry. RESULTS The three groups were age and gender matched, but differed with respect to time since transplantation, the spectrum of underlying disease, and treatment regimes. Relative to patients without BOS, BOS stage 3 patients showed a larger number of different VOCs, and more pronounced differences in the level of VOCs as compared to BOS stage 1 + 2 patients. Logistic regression analysis found no differences between controls and BOS 1 + 2, but four VOCs (heptane, isopropyl-myristate, ethyl-acetate, ionone) with a significant contribution to the discrimination between controls and BOS stage 3. A combination of these four VOCs separated these groups with an area under the curve of 0.87. CONCLUSION Breath sample collection using our reservoir sampler in the clinical environment was feasible. Our results suggest that breath VOCs can discriminate severe BOS. However, convincing evidence for VOCs with a potential to detect early onset BOS is lacking.
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Affiliation(s)
- L Küppers
- Fraunhofer ITEM, Clinical Airway Research-Hannover, Germany
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Horie M, Salazar P, Saito T, Binnie M, Brock K, Yasufuku K, Azad S, Keshavjee S, Martinu T, Paul N. Quantitative chest CT for subtyping chronic lung allograft dysfunction and its association with survival. Clin Transplant 2018; 32:e13233. [DOI: 10.1111/ctr.13233] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2018] [Indexed: 12/21/2022]
Affiliation(s)
- Miho Horie
- Joint Department of Medical Imaging; University Health Network; University of Toronto; Toronto ON Canada
- Institute for Biomaterials and Biomedical Engineering; University of Toronto; Toronto ON Canada
| | | | - Tomohito Saito
- Latner Thoracic Surgery Research Laboratories; Toronto General Research Institute; University Health Network; University of Toronto; Toronto ON Canada
- Toronto Lung Transplant Program; University Health Network; University of Toronto; Toronto ON Canada
- Department of Thoracic Surgery; Kansai Medical University; Hirakata Japan
| | - Matthew Binnie
- Toronto Lung Transplant Program; University Health Network; University of Toronto; Toronto ON Canada
| | - Kristy Brock
- Department of Imaging Physics; The University of Texas M.D. Anderson Cancer Center; Houston TX USA
| | - Kazuhiro Yasufuku
- Latner Thoracic Surgery Research Laboratories; Toronto General Research Institute; University Health Network; University of Toronto; Toronto ON Canada
- Toronto Lung Transplant Program; University Health Network; University of Toronto; Toronto ON Canada
| | - Sassan Azad
- Latner Thoracic Surgery Research Laboratories; Toronto General Research Institute; University Health Network; University of Toronto; Toronto ON Canada
| | - Shaf Keshavjee
- Institute for Biomaterials and Biomedical Engineering; University of Toronto; Toronto ON Canada
- Toronto Lung Transplant Program; University Health Network; University of Toronto; Toronto ON Canada
- Department of Thoracic Surgery; Kansai Medical University; Hirakata Japan
| | - Tereza Martinu
- Toronto Lung Transplant Program; University Health Network; University of Toronto; Toronto ON Canada
| | - Narinder Paul
- Joint Department of Medical Imaging; University Health Network; University of Toronto; Toronto ON Canada
- Institute for Biomaterials and Biomedical Engineering; University of Toronto; Toronto ON Canada
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Montelukast for bronchiolitis obliterans syndrome after lung transplantation: A randomized controlled trial. PLoS One 2018; 13:e0193564. [PMID: 29624575 PMCID: PMC5889063 DOI: 10.1371/journal.pone.0193564] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 02/06/2018] [Indexed: 12/03/2022] Open
Abstract
Bronchiolitis obliterans syndrome (BOS) remains the major problem which precludes long-term survival after lung transplantation. Previously, an open label pilot study from our group demonstrated a possible beneficial effect of montelukast in progressive BOS patients with low airway neutrophilia (<15%), and already on azithromycin treatment, in whom the further decline in pulmonary function was attenuated. This was, however, a non-randomized and non-placebo controlled trial. The study design is a single center, prospective, interventional, randomized, double blind, placebo-controlled trial, with a two arm parallel group design and an allocation ratio of 1:1. Randomization to additional montelukast (10 mg/day, n = 15) or placebo (n = 15) was performed from 2010 to 2014 at the University Hospitals Leuven (Leuven, Belgium) in all consecutive patients with late-onset (>2years posttransplant) BOS ≥1. Primary end-point was freedom from graft loss 1 year after randomization; secondary end-points were acute rejection, lymphocytic bronchiolitis, respiratory infection rate; and change in FEV1, airway and systemic inflammation during the study period. Graft loss at 1 y and 2y was similar in both groups (respectively p = 0. 981 and p = 0.230). Montelukast had no effect on lung function decline in the overall cohort. However, in a post-hoc subanalysis of BOS stage 1 patients, montelukast attenuated further decline of FEV1 during the study period, both in absolute (L) (p = 0.008) and % predicted value (p = 0.0180). A linear mixed model confirmed this association. Acute rejection, lymphocytic bronchiolitis, respiratory infections, systemic and airway inflammation were comparable between groups over the study period. This randomized controlled trial showed no additional survival benefit with montelukast compared to placebo, although the study was underpowered. The administration of montelukast was associated with an attenuation of the rate of FEV1 decline, however, only in recipients with late-onset BOS stage 1.
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Abstract
The incidence of community-acquired respiratory viruses (CARVs) is ∼15 cases per 100 patient-years after lung transplantation (LTx). Paramyxoviruses account for almost 50% of the cases of CARV infection in LTx. Most patients will be symptomatic with a mean decline of 15 to 20% in forced expiratory volume in 1 second. The attributable death rate is low in recent years 15 to 25% CARV infected LTx patients will develop chronic lung allograft dysfunction within a year after CARV infection. This risk seems to be increased in comparison to the noninfected LTx recipient. Detection rate of CARV dependent on clinical awareness, sampling, and diagnostic method with nucleic acid testing by polymerase chain reaction in bronchoalveolar lavage is the gold standard after LTx. There is no approved treatment for paramyxoviruses, most centers use ribavirin by various routes. Toxicity of systemic ribavirin is of concern and some patients will have contraindication to this treatment modality. Treatment may reduce the risk to develop chronic lung allograft dysfunction and respiratory failure. Agents under development are inhibiting viral attachment and use silencing mechanisms of viral replication.
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Affiliation(s)
- Jens Gottlieb
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
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Lung Function Trajectory in Bronchiolitis Obliterans Syndrome after Allogeneic Hematopoietic Cell Transplant. Ann Am Thorac Soc 2017; 13:1932-1939. [PMID: 27513368 DOI: 10.1513/annalsats.201604-262oc] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
RATIONALE The natural history of lung function in patients with bronchiolitis obliterans syndrome (BOS) after allogeneic hematopoietic cell transplant is poorly characterized. Understanding the trajectory of lung function is necessary for prompt clinical recognition and treatment and also for the rational design of prospective studies. OBJECTIVES To describe the longitudinal trajectory of lung function parameters, including FEV1, in patients with BOS after hematopoietic cell transplant. METHODS Subjects with BOS defined by National Institutes of Health consensus guidelines criteria from a recent multicenter prospective trial of combination treatment with fluticasone, azithromycin and montelukast and a retrospective cohort from Fred Hutchinson Cancer Research Center were included. Longitudinal change in FEV1 for each patient was calculated on the basis of available pulmonary function tests in three periods: pre-BOS, from BOS diagnosis to 6 months, and 6-18 months after diagnosis. The effect of treatment on FEV1 trajectory was analyzed by univariate and multivariate linear regression. The Kaplan-Meier method was used to estimate survival. MEASUREMENTS AND MAIN RESULTS The FEV1 percent predicted value at diagnosis was 46% (interquartile range, 35-57%) for trial participants and 53% (interquartile range, 41-64%) for the retrospective cohort. There was a concomitant mild reduction in FVC, as well as a marked reduction in forced expiratory flow, midexpiratory phase, at diagnosis. While there was individual heterogeneity, the overall FEV1 trajectory was characterized by a marked decline within 6 months prior to BOS diagnosis, followed by stability of FEV1 early after diagnosis and a slow rate of decline beyond 6 months. The effect of the trial medications on FEV1 trajectory after BOS diagnosis was a mean rate of change of 0.92% predicted per month (95% confidence interval, -0.53 to 2.37) compared with the retrospective cohort, but this was not statistically significant. Two-year overall survival rates were 76% and 72% for the study participants and the retrospective cohort patients, respectively. Earlier time to diagnosis after hematopoietic cell transplant and severity of FVC at diagnosis were significantly associated with reduced survival. CONCLUSIONS The FEV1 trajectory in patients with BOS after hematopoietic cell transplant in a contemporary era of management follows a predominant pattern of rapid FEV1 decline in the 6 months prior to diagnosis, followed by FEV1 stabilization after diagnosis.
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Validation and Refinement of Chronic Lung Allograft Dysfunction Phenotypes in Bilateral and Single Lung Recipients. Ann Am Thorac Soc 2017; 13:627-35. [PMID: 27144793 DOI: 10.1513/annalsats.201510-719oc] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE The clinical course of chronic lung allograft dysfunction (CLAD) is heterogeneous. Forced vital capacity (FVC) loss at onset, which may suggest a restrictive phenotype, was associated with worse survival for bilateral lung transplant recipients in one previously published single-center study. OBJECTIVES We sought to replicate the significance of FVC loss in an independent, retrospectively identified cohort of bilateral lung transplant recipients and to investigate extended application of this approach to single lung recipients. METHODS FVC loss and other potential predictors of survival after the onset of CLAD were assessed using Kaplan-Meier and Cox proportional hazards models. MEASUREMENTS AND MAIN RESULTS FVC loss at the onset of CLAD was associated with higher mortality in an independent cohort of bilateral lung transplant recipients (hazard ratio [HR], 2.75; 95% confidence interval [CI], 2.02-3.73; P < 0.0001) and in a multicenter cohort of single lung recipients (HR, 1.80; 95% CI, 1.09-2.98; P = 0.02). Including all subjects, the deleterious impact of FVC loss on survival persisted after adjustment for other relevant clinical variables (HR, 2.36; 95% CI, 1.77-3.15; P < 0.0001). In patients who develop CLAD without FVC loss, chest computed tomography features suggestive of pleural or parenchymal fibrosis also predicted worse survival in both bilateral (HR, 2.01; 95% CI, 1.16-5.20; P = 0.02) and single recipients (HR, 2.47; 95% CI, 1.24-10.57; P = 0.02). CONCLUSIONS We independently validated the prognostic significance of FVC loss for bilateral lung recipients and demonstrated that this approach to CLAD classification also confers prognostic information for single lung transplant recipients. Improved understanding of these discrete phenotypes is critical to the development of effective therapies.
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Szczepanik A, Hulbert A, Lee HJ, Benedetti C, Snyder L, Byrns J. Effect of HMG CoA reductase inhibitors on the development of chronic lung allograft dysfunction. Clin Transplant 2017; 32. [PMID: 29151274 DOI: 10.1111/ctr.13156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2017] [Indexed: 11/30/2022]
Abstract
Lung transplant recipients (LRs) have a reduced median 5-year survival of approximately 55% primarily due to chronic lung allograft dysfunction (CLAD). Statins have anti-inflammatory and immunomodulatory effects that may facilitate CLAD prevention. This study sought to evaluate statin effect on CLAD development. Adult bilateral LRs from January 2004 to October 2013 were included. Statin group included recipients with early statin use and continued for minimum 6 months. Propensity score matching was performed for age, gender, and native lung disease to select matched nonstatin group. Competing risk approach was used to evaluate statin effect on CLAD development at 3 years while controlling for acute rejection and CMV pneumonitis. A total of 130 patients were included in each group. CLAD cumulative incidence at 3 years for statin and nonstatin groups was 20.6% (CI: 11.8%-33.5%) and 22.4% (CI: 12.2%-27.3%). Statin use was not associated with a decreased risk of CLAD (subdistribution hazard ratio [SHR]: 0.93, 95% CI: 0.55-1.59, P = .80) but was associated with a decreased risk of death (SHR: 0.45, CI: 0.22-0.90, P = .024). At 3 years, patient survival was 81.7% in statin group and 68.3% in nonstatin group (P = .012). Statins did not significantly delay the time to development of CLAD in LR but did demonstrate a benefit in patient survival.
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Affiliation(s)
| | - Amanda Hulbert
- Department of Pharmacy, Duke University Hospital, Durham, NC, USA
| | - Hui-Jie Lee
- Department of Biostatistics and Bioinformatics, Duke University Hospital, Durham, NC, USA
| | - Clark Benedetti
- Department of Pharmacy, Duke University Hospital, Durham, NC, USA
| | - Laurie Snyder
- Department of Pulmonary, Allergy, and Critical Care Medicine, Duke University Hospital, Durham, NC, USA
| | - Jennifer Byrns
- Department of Pharmacy, Duke University Hospital, Durham, NC, USA
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Abstract
Chronic lung allograft dysfunction (CLAD) is the major limitation to posttransplant survival. This review highlights the evolving definition of CLAD, risk factors, treatment, and expected outcomes after the development of CLAD.
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