1
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January SE, Hubbard J, Fester KA, Dubrawka CA, Vazquez Guillamet R, Kulkarni HS, Hachem RR. Impact of Angiotensin Blockade on Development of Chronic Lung Allograft Dysfunction. J Pharm Pract 2024; 37:1170-1174. [PMID: 37923307 DOI: 10.1177/08971900231213699] [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] [Indexed: 11/07/2023]
Abstract
Background: The renin-angiotensin-aldosterone system (RAAS) is responsible for a multitude of physiological functions, including immunological effects such as promotion of TGF-β and upregulation of IL-6 and IL-8 which are also implicated in the development of chronic lung allograft dysfunction (CLAD). Blockade of the RAAS pathway in pre-clinical models has demonstrated a decrease in these cytokines and pulmonary neutrophil recruitment. Objective: This study sought to evaluate whether use of RAAS inhibitor (RAASi) in lung transplant recipients impacted CLAD-free survival. Methods: In this retrospective, single-center study, 35 lung transplant recipients who received a RAASi post-transplant were compared to 70 lung transplant recipients not exposed to a RAASi and were followed for up to 5 years post-transplant. Results: The incidence of CLAD did not differ based on RAASi treatment (34.3% in RAASi vs 38.6%, P-value .668). This was confirmed with a multivariable Cox proportional hazards model with RAASi initiation as a time-varying covariate (RAASi hazard ratio of 1.01, P-value .986). Incidence of hyperkalemia and acute kidney injury were low in the RAASi group. Conclusions: This study demonstrated no association between post-transplant RAASi use and decreased risk of CLAD development. RAASi were also well tolerated in this patient population.
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Affiliation(s)
- Spenser E January
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, MO, USA
| | - Julie Hubbard
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, MO, USA
| | - Keith A Fester
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, MO, USA
| | - Casey A Dubrawka
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, MO, USA
| | - Rodrigo Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Hrishikesh S Kulkarni
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
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2
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Combs MP, Luth JE, Falkowski NR, Wheeler DS, Walker NM, Erb-Downward JR, Wakeam E, Sjoding MW, Dunlap DG, Admon AJ, Dickson RP, Lama VN. The Lung Microbiome Predicts Mortality and Response to Azithromycin in Lung Transplant Recipients with Chronic Rejection. Am J Respir Crit Care Med 2024; 209:1360-1375. [PMID: 38271553 PMCID: PMC11146567 DOI: 10.1164/rccm.202308-1326oc] [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: 08/29/2023] [Accepted: 01/24/2024] [Indexed: 01/27/2024] Open
Abstract
Rationale: Chronic lung allograft dysfunction (CLAD) is the leading cause of death after lung transplant, and azithromycin has variable efficacy in CLAD. The lung microbiome is a risk factor for developing CLAD, but the relationship between lung dysbiosis, pulmonary inflammation, and allograft dysfunction remains poorly understood. Whether lung microbiota predict outcomes or modify treatment response after CLAD is unknown. Objectives: To determine whether lung microbiota predict post-CLAD outcomes and clinical response to azithromycin. Methods: Retrospective cohort study using acellular BAL fluid prospectively collected from recipients of lung transplant within 90 days of CLAD onset. Lung microbiota were characterized using 16S rRNA gene sequencing and droplet digital PCR. In two additional cohorts, causal relationships of dysbiosis and inflammation were evaluated by comparing lung microbiota with CLAD-associated cytokines and measuring ex vivo P. aeruginosa growth in sterilized BAL fluid. Measurements and Main Results: Patients with higher bacterial burden had shorter post-CLAD survival, independent of CLAD phenotype, azithromycin treatment, and relevant covariates. Azithromycin treatment improved survival in patients with high bacterial burden but had negligible impact on patients with low or moderate burden. Lung bacterial burden was positively associated with CLAD-associated cytokines, and ex vivo growth of P. aeruginosa was augmented in BAL fluid from transplant recipients with CLAD. Conclusions: In recipients of lung transplants with chronic rejection, increased lung bacterial burden is an independent risk factor for mortality and predicts clinical response to azithromycin. Lung bacterial dysbiosis is associated with alveolar inflammation and may be promoted by underlying lung allograft dysfunction.
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Affiliation(s)
| | | | | | | | | | | | - Elliot Wakeam
- Division of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Michael W. Sjoding
- Division of Pulmonary and Critical Care and
- Weil Institute for Critical Care Research and Innovation, Ann Arbor, Michigan
| | - Daniel G. Dunlap
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Andrew J. Admon
- Division of Pulmonary and Critical Care and
- Weil Institute for Critical Care Research and Innovation, Ann Arbor, Michigan
| | - Robert P. Dickson
- Division of Pulmonary and Critical Care and
- Weil Institute for Critical Care Research and Innovation, Ann Arbor, Michigan
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan; and
| | - Vibha N. Lama
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, Georgia
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3
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Belousova N, Cheng A, Matelski J, Vasileva A, Wu JKY, Ghany R, Martinu T, Ryan CM, Chow CW. Effects of donor smoking history on early post-transplant lung function measured by oscillometry. Front Med (Lausanne) 2024; 11:1328395. [PMID: 38654829 PMCID: PMC11037252 DOI: 10.3389/fmed.2024.1328395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 03/22/2024] [Indexed: 04/26/2024] Open
Abstract
Introduction Prior studies assessing outcomes of lung transplants from cigarette-smoking donors found mixed results. Oscillometry, a non-invasive test of respiratory impedance, detects changes in lung function of smokers prior to diagnosis of COPD, and identifies spirometrically silent episodes of rejection post-transplant. We hypothesise that oscillometry could identify abnormalities in recipients of smoking donor lungs and discriminate from non-smoking donors. Methods This prospective single-center cohort study analysed 233 double-lung recipients. Oscillometry was performed alongside routine conventional pulmonary function tests (PFT) post-transplant. Multivariable regression models were constructed to compare oscillometry and conventional PFT parameters between recipients of lungs from smoking vs non-smoking donors. Results The analysis included 109 patients who received lungs from non-smokers and 124 from smokers. Multivariable analysis identified significant differences between recipients of smoking and non-smoking lungs in the oscillometric measurements R5-19, X5, AX, R5z and X5z, but no differences in %predicted FEV1, FEV1/FVC, %predicted TLC or %predicted DLCO. An analysis of the smoking group also demonstrated associations between increasing smoke exposure, quantified in pack years, and all the oscillometry parameters, but not the conventional PFT parameters. Conclusion An interaction was identified between donor-recipient sex match and the effect of smoking. The association between donor smoking and oscillometry outcomes was significant predominantly in the female donor/female recipient group.
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Affiliation(s)
- Natalia Belousova
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Program and Division of Respirology, University Health Network, Tonronto, ON, Canada
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Pneumology, Aduch Cystic Fibrosis and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - Albert Cheng
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - John Matelski
- Pneumology, Aduch Cystic Fibrosis and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - Anastasiia Vasileva
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Joyce K. Y. Wu
- Toronto General Pulmonary Function Laboratory, University Health Network, Toronto, ON, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Program and Division of Respirology, University Health Network, Tonronto, ON, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Program and Division of Respirology, University Health Network, Tonronto, ON, Canada
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Clodagh M. Ryan
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto General Pulmonary Function Laboratory, University Health Network, Toronto, ON, Canada
| | - Chung-Wai Chow
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Program and Division of Respirology, University Health Network, Tonronto, ON, Canada
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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4
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Ohizumi Y, Kurokawa R, Amemiya S, Ito T, Sato M, Abe O. Restrictive Allograft Syndrome After COVID-19 Pneumonia: A Case Report. Cureus 2024; 16:e54583. [PMID: 38384867 PMCID: PMC10879649 DOI: 10.7759/cureus.54583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2024] [Indexed: 02/23/2024] Open
Abstract
Chronic lung allograft dysfunction (CLAD) continues to be the leading cause of death in the long term after lung transplantation (LTx). CLAD has the following two main subtypes: bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS). BOS features obstructive lung dysfunction, while RAS features restrictive lung dysfunction. Overall, RAS has a worse prognosis. The pathophysiology of CLAD is not fully understood; however, pulmonary infections can trigger CLAD, including coronavirus disease 2019 (COVID-19) pneumonia. Here, we describe a case of a 55-year-old female who received LTx about seven years ago and developed RAS after COVID-19 pneumonia. RAS was ultimately diagnosed based on the clinical course and imaging findings. Steroid pulse therapy and empirical antimicrobial therapy were initiated, but respiratory failure progressed, and the patient died 139 days after COVID-19 diagnosis, and 83 days after dyspnea progression. Clinicians should be aware of unusual stair-step clinical courses and imaging features in a given setting of pulmonary infection including COVID-19 to suspect CLAD in lung transplant patients.
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Affiliation(s)
- Yuji Ohizumi
- Radiology, Graduate School of Medicine, The University of Tokyo, Tokyo, JPN
| | - Ryo Kurokawa
- Radiology, Graduate School of Medicine, The University of Tokyo, Tokyo, JPN
| | - Shiori Amemiya
- Radiology, Graduate School of Medicine, The University of Tokyo, Tokyo, JPN
| | - Tatsuya Ito
- Respiratory Medicine, Ome Municipal General Hospital, Tokyo, JPN
| | - Masaaki Sato
- Thoracic Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, JPN
| | - Osamu Abe
- Radiology, Graduate School of Medicine, The University of Tokyo, Tokyo, JPN
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5
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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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6
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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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7
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Swaminathan AC, Barfield R, Zhang M, Povysil G, Chen C, Frankel C, Kelly F, McKinney M, Todd JL, Allen A, Palmer SM. Prevalence and significance of clonal hematopoiesis of indeterminate potential in lung transplant recipients. BMC Pulm Med 2023; 23:414. [PMID: 37904125 PMCID: PMC10614406 DOI: 10.1186/s12890-023-02703-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/11/2023] [Indexed: 11/01/2023] Open
Abstract
BACKGROUND Clonal hematopoiesis of indeterminate potential (CHIP), the age-related acquisition of somatic mutations that leads to an expanded blood cell clone, has been associated with development of a pro-inflammatory state. An enhanced or dysregulated inflammatory response may contribute to rejection after lung transplantation, however the prevalence of CHIP in lung recipients and influence of CHIP on allograft outcomes is unknown. METHODS We analyzed whole-exome sequencing data in 279 lung recipients to detect CHIP, defined by pre-specified somatic mutations in 74 genes known to promote clonal expansion of hematopoietic stem cells. We compared the burden of acute rejection (AR) over the first post-transplant year in lung recipients with vs. without CHIP using multivariable ordinal regression. Multivariate Cox proportional hazards models were used to assess the association between CHIP and CLAD-free survival. An exploratory analysis evaluated the association between the number of CHIP-associated variants and chronic lung allograft dysfunction (CLAD)-free survival. RESULTS We detected 64 CHIP-associated mutations in 45 individuals (15.7%), most commonly in TET2 (10.8%), DNMT3A (9.2%), and U2AF1 (9.2%). Patients with CHIP tended to be older but did not significantly differ from patients without CHIP in terms of race or native lung disease. Patients with CHIP did not have a higher incidence of AR over the first post-transplant year (p = 0.45) or a significantly increased risk of death or CLAD (adjusted HR 1.25, 95% CI 0.88-1.78). We did observe a significant association between the number of CHIP variants and CLAD-free survival, specifically patients with 2 or more CHIP-associated variants had an increased risk for death or CLAD (adjusted HR 3.79, 95% CI 1.98-7.27). CONCLUSIONS Lung recipients have a higher prevalence of CHIP and a larger variety of genes with CHIP-associated mutations compared with previous reports for the general population. CHIP did not increase the risk of AR, CLAD, or death in lung recipients.
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Affiliation(s)
- Aparna C Swaminathan
- Duke Clinical Research Institute, Durham, NC, USA.
- Department of Medicine, Duke University Medical Center, Durham, NC, USA.
| | - Richard Barfield
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, USA
- Center for Human Systems Immunology, School of Medicine, Duke University, Durham, USA
| | - Mengqi Zhang
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, USA
| | - Gundula Povysil
- Institute for Genomic Medicine, Columbia University Medical Center, New York, NY, USA
| | - Cliburn Chen
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, USA
- Center for Human Systems Immunology, School of Medicine, Duke University, Durham, USA
| | - Courtney Frankel
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Francine Kelly
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Matthew McKinney
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Jamie L Todd
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Andrew Allen
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, USA
| | - Scott M Palmer
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
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8
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Vasileva A, Hanafi N, Huszti E, Matelski J, Belousova N, Wu JKY, Martinu T, Ghany R, Keshavjee S, Tikkanen J, Cypel M, Yeung JC, Ryan CM, Chow CW. Intra-subject variability in oscillometry correlates with acute rejection and CLAD post-lung transplant. Front Med (Lausanne) 2023; 10:1158870. [PMID: 37305133 PMCID: PMC10248398 DOI: 10.3389/fmed.2023.1158870] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 05/04/2023] [Indexed: 06/13/2023] Open
Abstract
Background Chronic lung allograft dysfunction (CLAD) is the major cause of death post-lung transplantation, with acute cellular rejection (ACR) being the biggest contributing risk factor. Although patients are routinely monitored with spirometry, FEV1 is stable or improving in most ACR episodes. In contrast, oscillometry is highly sensitive to respiratory mechanics and shown to track graft injury associated with ACR and its improvement following treatment. We hypothesize that intra-subject variability in oscillometry measurements correlates with ACR and risk of CLAD. Methods Of 289 bilateral lung recipients enrolled for oscillometry prior to laboratory-based spirometry between December 2017 and March 2020, 230 had ≥ 3 months and 175 had ≥ 6 months of follow-up. While 37 patients developed CLAD, only 29 had oscillometry at time of CLAD onset and were included for analysis. These 29 CLAD patients were time-matched with 129 CLAD-free recipients. We performed multivariable regression to investigate the associations between variance in spirometry/oscillometry and the A-score, a cumulative index of ACR, as our predictor of primary interest. Conditional logistic regression models were built to investigate associations with CLAD. Results Multivariable regression showed that the A-score was positively associated with the variance in oscillometry measurements. Conditional logistic regression models revealed that higher variance in the oscillometry metrics of ventilatory inhomogeneity, X5, AX, and R5-19, was independently associated with increased risk of CLAD (p < 0.05); no association was found for variance in %predicted FEV1. Conclusion Oscillometry tracks graft injury and recovery post-transplant. Monitoring with oscillometry could facilitate earlier identification of graft injury, prompting investigation to identify treatable causes and decrease the risk of CLAD.
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Affiliation(s)
- Anastasiia Vasileva
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Nour Hanafi
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - John Matelski
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Natalia Belousova
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
| | - Joyce K. Y. Wu
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Pulmonary Function Laboratory, University Health Network, Toronto, ON, Canada
| | - Tereza Martinu
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
- Division of Thoracic Surgery, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jussi Tikkanen
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
- Division of Thoracic Surgery, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jonathan C. Yeung
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
- Division of Thoracic Surgery, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Clodagh M. Ryan
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Pulmonary Function Laboratory, University Health Network, Toronto, ON, Canada
| | - Chung-Wai Chow
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
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9
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Ennis SL, Olsen N, Tong WWY, Goddard L, Watson N, Weston L, Iqbal A, Patel P, Malouf MA, Plit ML, Darley DR. Specific HLA-DQ risk epitope mismatches are associated with chronic lung allograft dysfunction after lung transplantation. Am J Transplant 2023:S1600-6135(23)00401-X. [PMID: 37054889 DOI: 10.1016/j.ajt.2023.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 04/01/2023] [Indexed: 04/15/2023]
Abstract
A high-risk epitope mismatch (REM) (found in DQA1*05 + DQB1*02/DQB1*03:01) is associated with de novo donor-specific antibodies (dn-DSA) after lung transplant (LTx). Chronic lung allograft dysfunction (CLAD) remains a barrier to LTx survival. The aims of this study were to measure the association between DQ REM and risk of CLAD and death after LTx. A retrospective analysis of LTx recipients at a single centre was conducted between Jan-2014 and Apr-2019. Molecular typing at HLA-DQA/DBQ identified DQ REM. Multivariable competing risk and Cox regression models were used to measure the association between DQ REM and time-to-CLAD and time-to-death. DQ REM was detected in 96/268(35.8%) and DQ REM dn-DSA detected in 34/96(35.4%). CLAD occurred in 78(29.1%) and 98(36.6%) recipients died during follow-up. When analysed as a baseline predictor, DQ REM status was associated with CLAD (SHR 2.19 95%CI 1.40-3.43; p=0.001). After adjustment for time dependent variables, dn-DQ-REM DSA (SHR 2.43 95%CI 1.10-5.38; p=0.029) and A-grade rejection score (SHR 1.22 95%CI 1.11-1.35; p=<0.001), but not DQ REM status was associated with CLAD. DQ REM was not associated with death (HR 1.18 95%CI 0.72-1.93; p=0.51). Classification of DQ REM may identify patients at risk of poor outcomes and should be incorporated into clinical decision-making.
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Affiliation(s)
- Samantha Louse Ennis
- Department of Lung Transplantation, St Vincent's Hospital Darlinghurst, Sydney, Australia
| | - Nicholas Olsen
- Stats Central, Mark Wainwright Analytical Centre, UNSW Sydney, Sydney, Australia
| | - Winnie W Y Tong
- NSW Transplantation and Immunogenetics Services, Australian Red Cross Lifeblood; UNSW Medicine, St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Louise Goddard
- NSW Transplantation and Immunogenetics Services, Australian Red Cross Lifeblood
| | - Narelle Watson
- NSW Transplantation and Immunogenetics Services, Australian Red Cross Lifeblood
| | - Lyanne Weston
- NSW Transplantation and Immunogenetics Services, Australian Red Cross Lifeblood
| | - Ayesha Iqbal
- NSW Transplantation and Immunogenetics Services, Australian Red Cross Lifeblood
| | - Purvesh Patel
- NSW Transplantation and Immunogenetics Services, Australian Red Cross Lifeblood
| | - Monique Anne Malouf
- Department of Lung Transplantation, St Vincent's Hospital Darlinghurst, Sydney, Australia; UNSW Medicine, St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Marshall L Plit
- Department of Lung Transplantation, St Vincent's Hospital Darlinghurst, Sydney, Australia; UNSW Medicine, St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - David Ross Darley
- Department of Lung Transplantation, St Vincent's Hospital Darlinghurst, Sydney, Australia; UNSW Medicine, St Vincent's Clinical School, University of New South Wales, Sydney, Australia.
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10
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Biomarkers for Chronic Lung Allograft Dysfunction: Ready for Prime Time? Transplantation 2023; 107:341-350. [PMID: 35980878 PMCID: PMC9875844 DOI: 10.1097/tp.0000000000004270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Chronic lung allograft dysfunction (CLAD) remains a major hurdle impairing lung transplant outcome. Parallel to the better clinical identification and characterization of CLAD and CLAD phenotypes, there is an increasing urge to find adequate biomarkers that could assist in the earlier detection and differential diagnosis of CLAD phenotypes, as well as disease prognostication. The current status and state-of-the-art of biomarker research in CLAD will be discussed with a particular focus on radiological biomarkers or biomarkers found in peripheral tissue, bronchoalveolar lavage' and circulating blood' in which significant progress has been made over the last years. Ultimately, although a growing number of biomarkers are currently being embedded in the follow-up of lung transplant patients, it is clear that one size does not fit all. The future of biomarker research probably lies in the rigorous combination of clinical information with findings in tissue, bronchoalveolar lavage' or blood. Only by doing so, the ultimate goal of biomarker research can be achieved, which is the earlier identification of CLAD before its clinical manifestation. This is desperately needed to improve the prognosis of patients with CLAD after lung transplantation.
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11
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Fu A, Vasileva A, Hanafi N, Belousova N, Wu J, Rajyam SS, Ryan CM, Hantos Z, Chow CW. Characterization of chronic lung allograft dysfunction phenotypes using spectral and intrabreath oscillometry. Front Physiol 2022; 13:980942. [PMID: 36277208 PMCID: PMC9582781 DOI: 10.3389/fphys.2022.980942] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Chronic lung allograft dysfunction (CLAD) is the major cause of death beyond 2 years after lung transplantation and develops in 50% of all patients by 5 years post-transplant. CLAD is diagnosed on the basis of a sustained drop of 20% for at least 3 months in the forced expiratory volume (FEV1), compared to the best baseline value achieved post-transplant. CLAD presents as two main phenotypes: bronchiolitis obliterans syndrome (BOS) is more common and has better prognosis than restrictive allograft syndrome (RAS). Respiratory oscillometry is a different modality of lung function testing that is highly sensitive to lung mechanics. The current study investigated whether spectral and intrabreath oscillometry can differentiate between CLAD-free, BOS- and RAS-CLAD at CLAD onset, i.e., at the time of the initial 20% drop in the FEV1. Methods: A retrospective, cross-sectional analysis of 263 double lung transplant recipients who underwent paired testing with oscillometry and spirometry at the Toronto General Pulmonary Function Laboratory from 2017 to 2022 was conducted. All pulmonary function testing and CLAD diagnostics were performed following international guidelines. Statistical analysis was conducted using multiple comparisons. Findings: The RAS (n = 6) spectral oscillometry pattern differs from CLAD-free (n = 225) by right-ward shift of reactance curve similar to idiopathic pulmonary fibrosis whereas BOS (n = 32) has a pattern similar to obstructive lung disease. Significant differences were found in most spectral and intrabreath parameters between BOS, RAS, and time-matched CLAD-free patients. Post-hoc analysis revealed these differences were primarily driven by BOS instead of RAS. While no differences were found between CLAD-free and RAS patients with regards to spectral oscillometry, the intrabreath metric of reactance at end-inspiration (XeI) was significantly different (p < 0.05). BOS and RAS were differentiated by spectral oscillometry measure R5, and intrabreath resistance at end expiration, ReE (p < 0.05 for both). Conclusion: Both spectral and intrabreath oscillometry can differentiate BOS-CLAD from CLAD-free states while intrabreath oscillometry, specifically XeI, can uniquely distinguish RAS-CLAD from CLAD-free. Spectral and intrabreath oscillometry offer complementary information regarding lung mechanics in CLAD patients to help distinguish the two phenotypes and could prove useful in prognostication.
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Affiliation(s)
- Anne Fu
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Anastasiia Vasileva
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Nour Hanafi
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Natalia Belousova
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
| | - Joyce Wu
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto General Pulmonary Function Laboratory, University Health Network, Toronto, ON, Canada
| | - Sarada Sriya Rajyam
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Clodagh M. Ryan
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto General Pulmonary Function Laboratory, University Health Network, Toronto, ON, Canada
| | - Zoltán Hantos
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Chung-Wai Chow
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
- Toronto General Pulmonary Function Laboratory, University Health Network, Toronto, ON, Canada
- *Correspondence: Chung-Wai Chow,
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12
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Sun H, Deng M, Chen W, Liu M, Dai H, Wang C. Graft dysfunction and rejection of lung transplant, a review on diagnosis and management. THE CLINICAL RESPIRATORY JOURNAL 2022; 16:5-12. [PMID: 35080130 PMCID: PMC9060084 DOI: 10.1111/crj.13471] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 12/22/2021] [Indexed: 01/01/2023]
Abstract
Introduction Lung transplantation has proven to be an effective treatment option for end‐stage lung disease. However, early and late complications following transplantation remain significant causes of high mortality. Objectives In this review, we focus on the time of onset in primary graft dysfunction and rejection complications, as well as emphasize the role of imaging manifestations and pathological features in early diagnosis, thus assisting clinicians in the early detection and treatment of posttransplant complications and improving patient quality of life and survival. Data source We searched electronic databases such as PubMed, Web of Science, and EMBASE. We used the following search terms: lung transplantation complications, primary graft dysfunction, acute rejection, chronic lung allograft dysfunction, radiological findings, and diagnosis and treatment. Conclusion Primary graft dysfunction, surgical complications, immune rejection, infections, and neoplasms represent major posttransplant complications. As the main posttransplant survival limitation, chronic lung allograft dysfunction has a characteristic imaging presentation; nevertheless, the clinical and imaging manifestations are often complex and overlap, so it is essential to understand the temporal evolution of these complications to narrow the differential diagnosis for early treatment to improve prognosis. Early and late complications after lung transplantation remain essential causes of high mortality. In this review, we focus on the timing of the onset of primary graft dysfunction and rejection complications and highlight the role of imaging manifestations and clinicopathologic features in early diagnosis, thus assisting clinicians in the early detection and treatment of posttransplant complications and improving patient quality of life and survival.
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Affiliation(s)
- Haishuang Sun
- Department of Respiratory Medicine, The First Hospital of Jilin University, Jilin University, Changchun, China.,Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital; National Center for Respiratory Medicine; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; National Clinical Research Center for Respiratory Diseases, Beijing, China.,Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Beijing, China
| | - Mei Deng
- Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Beijing, China.,Department of Radiology, China-Japan Friendship Hospital, Beijing, China
| | - Wenhui Chen
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital; National Center for Respiratory Medicine; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; National Clinical Research Center for Respiratory Diseases, Beijing, China.,Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Beijing, China
| | - Min Liu
- Department of Radiology, China-Japan Friendship Hospital, Beijing, China
| | - Huaping Dai
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital; National Center for Respiratory Medicine; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; National Clinical Research Center for Respiratory Diseases, Beijing, China.,Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Beijing, China
| | - Chen Wang
- Department of Respiratory Medicine, The First Hospital of Jilin University, Jilin University, Changchun, China.,Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital; National Center for Respiratory Medicine; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; National Clinical Research Center for Respiratory Diseases, Beijing, China.,Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Beijing, China
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13
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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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14
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DeFreitas MR, McAdams HP, Azfar Ali H, Iranmanesh AM, Chalian H. Complications of Lung Transplantation: Update on Imaging Manifestations and Management. Radiol Cardiothorac Imaging 2021; 3:e190252. [PMID: 34505059 DOI: 10.1148/ryct.2021190252] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 04/02/2021] [Accepted: 07/12/2021] [Indexed: 12/23/2022]
Abstract
As lung transplantation has become the most effective definitive treatment option for end-stage chronic respiratory diseases, yearly rates of this surgery have been steadily increasing. Despite improvement in surgical techniques and medical management of transplant recipients, complications from lung transplantation are a major cause of morbidity and mortality. Some of these complications can be classified on the basis of the time they typically occur after lung transplantation, while others may occur at any time. Imaging studies, in conjunction with clinical and laboratory evaluation, are key components in diagnosing and monitoring these conditions. Therefore, radiologists play a critical role in recognizing and communicating findings suggestive of lung transplantation complications. A description of imaging features of the most common lung transplantation complications, including surgical, medical, immunologic, and infectious complications, as well as an update on their management, will be reviewed here. Keywords: Pulmonary, Thorax, Surgery, Transplantation Supplemental material is available for this article. © RSNA, 2021.
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Affiliation(s)
- Mariana R DeFreitas
- Department of Radiology, Division of Cardiothoracic Imaging (M.R.D., H.P.M., A.M.I., H.C.), and Department of Medicine, Division of Pulmonary, Allergy and Critical Care (H.A.A.), Duke University Medical Center, Durham, NC
| | - Holman Page McAdams
- Department of Radiology, Division of Cardiothoracic Imaging (M.R.D., H.P.M., A.M.I., H.C.), and Department of Medicine, Division of Pulmonary, Allergy and Critical Care (H.A.A.), Duke University Medical Center, Durham, NC
| | - Hakim Azfar Ali
- Department of Radiology, Division of Cardiothoracic Imaging (M.R.D., H.P.M., A.M.I., H.C.), and Department of Medicine, Division of Pulmonary, Allergy and Critical Care (H.A.A.), Duke University Medical Center, Durham, NC
| | - Arya M Iranmanesh
- Department of Radiology, Division of Cardiothoracic Imaging (M.R.D., H.P.M., A.M.I., H.C.), and Department of Medicine, Division of Pulmonary, Allergy and Critical Care (H.A.A.), Duke University Medical Center, Durham, NC
| | - Hamid Chalian
- Department of Radiology, Division of Cardiothoracic Imaging (M.R.D., H.P.M., A.M.I., H.C.), and Department of Medicine, Division of Pulmonary, Allergy and Critical Care (H.A.A.), Duke University Medical Center, Durham, NC
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15
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Concurrent Reductions in Spirometry Predict Mortality and Bronchiolitis Obliterans in Chronic Graft-versus-Host Disease. Ann Am Thorac Soc 2021; 18:720-723. [PMID: 33147422 DOI: 10.1513/annalsats.202008-999rl] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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16
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Belloli EA, Gu T, Wang Y, Vummidi D, Lyu DM, Combs MP, Chughtai A, Murray S, Galbán CJ, Lama VN. Radiographic Graft Surveillance in Lung Transplantation: Prognostic Role of Parametric Response Mapping. Am J Respir Crit Care Med 2021; 204:967-976. [PMID: 34319850 DOI: 10.1164/rccm.202012-4528oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Chronic lung allograft dysfunction (CLAD) results in significant morbidity following lung transplantation. Potential CLAD occurs when lung function declines to 80-90% of baseline. Better non-invasive tools to prognosticate at potential CLAD are needed. OBJECTIVES To determine if parametric response mapping (PRM), a CT voxel-wise methodology, applied to high resolution CT scans can identify patients at risk of progression to CLAD or death. METHODS Radiographic features and PRM-based CT metrics quantifying functional small airways disease (PRMfSAD) and parenchymal disease (PRMPD) were studied at potential CLAD (n=61). High PRMfSAD and high PRMPD were defined as ≥ 30%. Restricted mean modeling was performed to compare CLAD-free survival among groups. MEASUREMENTS AND MAIN RESULTS PRM metrics identified 3 unique signatures: high PRMfSAD (11.5%), high PRMPD (41%) and neither (PRMNormal; 47.5%). Patients with high PRMfSAD or PRMPD had shorter CLAD-free median survival times (0.46 years and 0.50 years) compared to patients with predominantly PRMNormal (2.03 years; p=0.004 and 0.007 compared to PRMfSAD and PRMPD groups, respectively). In multivariate modeling adjusting for single versus double lung transplant, age at transplant, BMI at potential CLAD, and time from transplant to CT, PRMfSAD or PRMPD ≥ 30% continue to be statistically significant predictors of shorter CLAD-free survival. Air trapping by radiologist interpretation was common (66%), similar across PRM groups, and was not predictive of CLAD-free survival. Ground glass opacities by radiologist read occurred in 16% of cases and was associated with decreased CLAD-free survival (p<0.001). CONCLUSIONS PRM analysis offers valuable prognostic information at potential CLAD, identifying patients most at risk of developing CLAD or death.
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Affiliation(s)
- Elizabeth A Belloli
- University of Michigan, Pulmonary & Critical Care Medicine, Ann Arbor, Michigan, United States;
| | - Tian Gu
- University of Michigan, Biostatistics, Ann Arbor, Michigan, United States
| | - Yizhuo Wang
- University of Michigan School of Public Health, 51329, Biostatistics, Ann Arbor, Michigan, United States
| | - Dharshan Vummidi
- University of Michigan, Radiology, Ann Arbor, Michigan, United States
| | - Dennis M Lyu
- University of Michigan, Internal Medicine, Division Pulmonary & Critical Care, Ann Arbor, Michigan, United States
| | - Michael P Combs
- University of Michigan, Internal Medicine, Ann Arbor, Michigan, United States
| | - Aamer Chughtai
- University of Michigan, Radiology, Ann Arbor, Michigan, United States
| | - Susan Murray
- University of Michigan, School of Public Health, Biostatistics, Ann Arbor, Michigan, United States
| | - Craig J Galbán
- Center for Molecular Imaging, Michigan, Michigan, United States
| | - Vibha N Lama
- University of Michigan, 1259, Pulmonary and Critical Care Medicine, Ann Arbor, Michigan, United States
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Pezzuto F, Lunardi F, Vadori M, Zampieri D, Casiraghi F, Azzollini N, Vuljan SE, Mammana M, Vedovelli L, Schiavon M, Gregori D, Cozzi E, Rea F, Calabrese F. Chronic lung allograft pathology lesions in two rat strain combinations. J Thorac Dis 2021; 13:2833-2843. [PMID: 34164175 PMCID: PMC8182524 DOI: 10.21037/jtd-20-3415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Chronic lung allograft dysfunction remains an obstacle to long-term survival after lung transplantation. Two phenotypes have been described: obliterative bronchiolitis and restrictive allograft syndrome. Preclinical models are essential to analyze chronic lung allograft dysfunction pathophysiology. Methods Orthotopic lung transplants from 38 Lewis into Fischer 344 (Lew→F344) and 67 Brown-Norway into Lewis (BN→Lew) rats were performed in our center in the last decade. We carefully reviewed and quantified all grafts with chronic rejection (40 cases) (18 Lew→F344, 22 BN→Lew) with the aim to investigate if histological changes of chronic lung allograft dysfunction could be also detected in rat grafts. Results All animals showed human reminiscent histological lesions. Early chronic rejection lesions were detected in BN→Lew. End-stage chronic rejection with features of obliterative bronchiolitis was observed in 33% of Lew→F344; end-stage with restrictive allograft syndrome chronic rejection in 67% and 80% of Lew→F344 and BN→Lew, respectively. BN→Lew showed higher grades of endotheliitis, vascular fibrosis, and lower grades of lymphoid aggregates than Lew→F344 (P=0.007, P=0.043, P=0.004, respectively). Conclusions Chronic rejection lesions in rat lung allografts mimic those in humans. The frequent occurrence of restrictive allograft syndrome-like lesions in BN→Lew may be related to a higher degree of mismatch in this strain combination. These animal models could allow future mechanistic studies to better understand chronic lung allograft dysfunction pathogenesis.
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Affiliation(s)
- Federica Pezzuto
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
| | - Francesca Lunardi
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
| | | | - Davide Zampieri
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
| | | | - Nadia Azzollini
- Mario Negri Institute for Pharmacological Research, Bergamo, Italy
| | - Stefania Edith Vuljan
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
| | - Marco Mammana
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
| | - Luca Vedovelli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
| | - Marco Schiavon
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
| | - Dario Gregori
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
| | - Emanuele Cozzi
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
| | - Federico Rea
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
| | - Fiorella Calabrese
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
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18
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Patrucco F, Allara E, Boffini M, Rinaldi M, Costa C, Albera C, Solidoro P. Twelve-month effects of everolimus on renal and lung function in lung transplantation: differences in chronic lung allograft dysfunction phenotypes. Ther Adv Chronic Dis 2021; 12:2040622321993441. [PMID: 33717427 PMCID: PMC7925948 DOI: 10.1177/2040622321993441] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 01/15/2021] [Indexed: 12/25/2022] Open
Abstract
Background: Chronic lung allograft dysfunction (CLAD), a complication affecting the survival of lung transplanted patients, includes two clinical phenotypes: bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS). Everolimus is used in CLAD because of its antiproliferative mechanism. In lung transplant patients treated with everolimus, the clinical course of renal and lung function has not yet been assessed systematically in CLAD, BOS and RAS patients for more than 6 months. Methods: We retrospectively evaluated the 12-month follow-up of renal and lung function of lung-transplanted patients switched to everolimus and evaluated the reduction in immunosuppressant dosage (ISD) and mortality. Subgroups were based on indication for everolimus treatment: CLAD and non-CLAD patients, BOS and RAS among CLAD patients. Results: We included 26 patients, 17 with CLAD (10 BOS, seven RAS). After 1 year from the everolimus switch, we observed renal function improvement (serum creatinine −17%, estimated glomerular filtration rate +24%) and stable pulmonary function [forced expiratory volume in the first second (FEV1) −0.5%, forced vital capacity (FVC) +0.05%]. RAS patients had progressive functional loss, whereas BOS patients had FEV1 improvement and FVC stability. All-cause mortality was higher in the CLAD versus non-CLAD group (41% versus 11%), without differences between BOS and RAS patients (p > 0.05). All patients had significant and persistent ISD reduction. Conclusion: Lung transplant patients treated with everolimus had improvements in renal function and reduced ISD. We observed sustained improvements in lung function for CLAD related to BOS subgroup results, whereas RAS confirmed the 1-year worsening functional trend. Data seem to suggest one more piece of the puzzle in CLAD phenotyping.
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Affiliation(s)
- Filippo Patrucco
- Division of Respiratory Diseases, Cardiovascular and Thoracic Department, University of Turin, Città della Salute e della Scienza di Torino, C.so Bramante 88/90, 10100 Torino, Italy
| | - Elias Allara
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Massimo Boffini
- Division of Cardiac Surgery, Cardiovascular and Thoracic Department, University of Turin, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Mauro Rinaldi
- Division of Cardiac Surgery, Cardiovascular and Thoracic Department, University of Turin, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Cristina Costa
- Division of Virology, Department of Public Health and Pediatrics, University of Turin, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Carlo Albera
- Division of Respiratory Diseases, Medical Sciences Department University of Turin and Cardiovascular and Thoracic Department, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Paolo Solidoro
- Division of Respiratory Diseases, Medical Sciences Department University of Turin and Cardiovascular and Thoracic Department, AOU Città della Salute e della Scienza di Torino, Torino, Italy
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19
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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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20
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Snyder LD, Belperio J, Budev M, Frankel C, Kirchner J, Martinu T, Neely ML, Reynolds JM, Shah P, Singer LG, Todd JL, Tsuang W, Weigt S, Palmer SM. Highlights from the clinical trials in organ transplantation (CTOT)-20 and CTOT-22 Consortium studies in lung transplant. Am J Transplant 2020; 20:1489-1494. [PMID: 32342596 PMCID: PMC7323580 DOI: 10.1111/ajt.15957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/10/2020] [Accepted: 04/17/2020] [Indexed: 01/25/2023]
Abstract
Long-term survival after lung transplant lags behind that of other commonly transplanted organs, reflecting the current incomplete understanding of the mechanisms involved in the development of posttransplant lung injury, rejection, infection, and chronic allograft dysfunction. To address this unmet need, 2 ongoing National Institute of Allergy and Infectious Disease funded studies through the Clinical Trials in Organ Transplant Consortium (CTOT) CTOT-20 and CTOT-22 were dedicated to understanding the clinical factors and biological mechanisms that drive chronic lung allograft dysfunction and those that maintain cytomegalovirus polyfunctional protective immunity. The CTOT-20 and CTOT-22 studies enrolled 800 lung transplant recipients at 5 North American centers over 3 years. Given the number and complexity of subjects included, CTOT-20 and CTOT-22 utilized innovative data transfers and capitalized on patient-entered data collection to minimize site manual data entry. The data were coupled with an extensive biosample collection strategy that included DNA, RNA, plasma, serum, bronchoalveolar lavage fluid, and bronchoalveolar lavage cell pellet. This Special Article describes the CTOT-20 and CTOT-22 protocols, data and biosample strategy, initial results, and lessons learned through study execution.
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Affiliation(s)
| | | | | | | | - Jerry Kirchner
- Duke Clinical Research institute, Durham, North Carolina
| | | | | | | | - Pali Shah
- Johns Hopkins University, Baltimore, Maryland
| | | | | | | | - Samuel Weigt
- University of California, Los Angeles, California
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21
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Yoshiyasu N, Sato M. Chronic lung allograft dysfunction post-lung transplantation: The era of bronchiolitis obliterans syndrome and restrictive allograft syndrome. World J Transplant 2020; 10:104-116. [PMID: 32864356 PMCID: PMC7428788 DOI: 10.5500/wjt.v10.i5.104] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/30/2020] [Accepted: 05/12/2020] [Indexed: 02/05/2023] Open
Abstract
Chronic lung allograft dysfunction (CLAD) following lung transplantation limits long-term survival considerably. The main reason for this is a lack of knowledge regarding the pathological condition and the establishment of treatment. The consensus statement from the International Society for Heart and Lung Transplantation on CLAD in 2019 classified CLAD into two main phenotypes: Bronchiolitis obliterans syndrome and restrictive allograft syndrome. Along with this clear classification, further exploration of the mechanisms and the development of appropriate prevention and treatment strategies for each phenotype are desired. In this review, we summarize the new definition of CLAD and update and summarize the existing knowledge on the underlying mechanisms of bronchiolitis obliterans syndrome and restrictive allograft syndrome, which have been elucidated from clinicopathological observations and animal experiments worldwide.
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Affiliation(s)
- Nobuyuki Yoshiyasu
- Department of Thoracic Surgery, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Masaaki Sato
- Department of Thoracic Surgery, The University of Tokyo Hospital, Tokyo 113-8655, Japan
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22
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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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23
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Abstract
PURPOSE OF REVIEW Chronic lung allograft dysfunction (CLAD) has been recently introduced as an umbrella-term encompassing all forms of chronic pulmonary function decline posttransplant with bronchiolitis obliterans syndrome and restrictive allograft syndrome as the most important subtypes. Differential diagnosis and management, however, remains complicated. RECENT FINDINGS Herein, we provide an overview of the different diagnostic criteria (pulmonary function, body plethysmography and radiology) used to differentiate bronchiolitis obliterans syndrome and restrictive allograft syndrome, their advantages and disadvantages as well as potential problems in making an accurate differential diagnosis. Furthermore, we discuss recent insights in CLAD management and treatment and advances in the search for accurate biomarkers of CLAD. SUMMARY Careful dissection of CLAD phenotypes is of utmost importance to assess patient prognosis, but uniform diagnostic criteria are desperately needed. There is a long way ahead, but the first steps towards this goal are now taken; tailored individualized therapy will be the golden standard to treat CLAD in the future, but randomized placebo-controlled and multicentre trials are needed to identify new and powerful therapeutic agents.
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24
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Sato M. Bronchiolitis obliterans syndrome and restrictive allograft syndrome after lung transplantation: why are there two distinct forms of chronic lung allograft dysfunction? ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:418. [PMID: 32355862 PMCID: PMC7186721 DOI: 10.21037/atm.2020.02.159] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Bronchiolitis obliterans syndrome (BOS) had been considered to be the representative form of chronic rejection or chronic lung allograft dysfunction (CLAD) after lung transplantation. In BOS, small airways are affected by chronic inflammation and obliterative fibrosis, whereas peripheral lung tissue remains relatively intact. However, recognition of another form of CLAD involving multiple tissue compartments in the lung, termed restrictive allograft syndrome (RAS), raised a fundamental question: why there are two phenotypes of CLAD? Increasing clinical and experimental data suggest that RAS may be a prototype of chronic rejection after lung transplantation involving both cellular and antibody-mediated alloimmune responses. Some cases of RAS are also induced by fulminant general inflammation in lung allografts. However, BOS involves alloimmune responses and the airway-centered disease process can be explained by multiple mechanisms such as external alloimmune-independent stimuli (such as infection, aspiration and air pollution), exposure of airway-specific autoantigens and airway ischemia. Localization of immune responses in different anatomical compartments in different phenotypes of CLAD might be associated with lymphoid neogenesis or the de novo formation of lymphoid tissue in lung allografts. Better understanding of distinct mechanisms of BOS and RAS will facilitate the development of effective preventive and therapeutic strategies of CLAD.
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Affiliation(s)
- Masaaki Sato
- Department of Thoracic Surgery, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
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25
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Kotecha S, Paraskeva MA, Levin K, Snell GI. An update on chronic lung allograft dysfunction. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:417. [PMID: 32355861 PMCID: PMC7186740 DOI: 10.21037/atm.2020.01.05] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Chronic lung allograft dysfunction (CLAD) remains a significant challenge and the major determinant of morbidity and mortality post lung transplantation (LTx). The definition of CLAD has evolved significantly over the last ten years, reflecting better understanding of pathophysiology and different phenotypes. While there is an agreed consensus approach to CLAD, questions remain regarding the limitations of lung function parameters as well as the role of imaging and histopathology. Here we present a current snapshot of the definition of CLAD, its evolution and future directions.
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Affiliation(s)
- Sakhee Kotecha
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia
| | | | - Kovi Levin
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia
| | - Gregory I Snell
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia
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26
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Todd JL, Kelly FL, Nagler A, Banner K, Pavlisko EN, Belperio JA, Brass D, Weigt SS, Palmer SM. Amphiregulin contributes to airway remodeling in chronic allograft dysfunction after lung transplantation. Am J Transplant 2020; 20:825-833. [PMID: 31665560 PMCID: PMC7042065 DOI: 10.1111/ajt.15667] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 10/04/2019] [Accepted: 10/17/2019] [Indexed: 01/25/2023]
Abstract
Chronic lung allograft dysfunction (CLAD), a condition of excess matrix deposition and airways fibrosis, limits survival after lung transplantation. Amphiregulin (Areg) is an epidermal growth factor receptor (EGFR) ligand suggested to regulate airway injury and repair. We sought to determine whether Areg expression increases in CLAD, localize the cellular source of Areg induction in CLAD, and assess its effects on airway matrix deposition. Lung fluid Areg protein was quantified in patients with or without CLAD. In situ hybridization was performed to localize Areg and EGFR transcript in CLAD and normal lung tissue. Expression of hyaluronan, a matrix constituent that accumulates in CLAD, was measured in Areg-exposed bronchial epithelial cells in the presence or absence of an EGFR inhibitor. We demonstrated that lung fluid Areg protein was significantly increased in CLAD in a discovery and replication cohort. Areg and EGFR transcripts were abundantly expressed within CLAD tissue, localized to basally distributed airway epithelial cells overlying fibrotic regions. Areg-exposed bronchial epithelial cells increased hyaluronan and hyaluronan synthase expression in an EGFR-dependent manner. Collectively, these novel observations suggest that Areg contributes to airway remodeling and CLAD. Moreover these data implicate a role for EGFR signaling in CLAD pathogenesis, suggesting novel therapeutic targets.
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Affiliation(s)
- Jamie L. Todd
- Duke University Medical Center; Department of Medicine; Division of Pulmonary, Allergy and Critical Care Medicine; Durham, North Carolina,Duke Clinical Research Institute; Duke University Medical Center; Durham, North Carolina
| | - Fran L. Kelly
- Duke University Medical Center; Department of Medicine; Division of Pulmonary, Allergy and Critical Care Medicine; Durham, North Carolina
| | - Andrew Nagler
- Duke University Medical Center; Department of Medicine; Division of Pulmonary, Allergy and Critical Care Medicine; Durham, North Carolina
| | - Kane Banner
- Duke University Medical Center; Department of Medicine; Division of Pulmonary, Allergy and Critical Care Medicine; Durham, North Carolina
| | | | - John A. Belperio
- University of California Los Angeles; Department of Medicine; Division of Pulmonary Medicine; Los Angeles, California
| | - David Brass
- Duke University Medical Center; Department of Medicine; Division of Pulmonary, Allergy and Critical Care Medicine; Durham, North Carolina
| | - S. Sam Weigt
- University of California Los Angeles; Department of Medicine; Division of Pulmonary Medicine; Los Angeles, California
| | - Scott M. Palmer
- Duke University Medical Center; Department of Medicine; Division of Pulmonary, Allergy and Critical Care Medicine; Durham, North Carolina,Duke Clinical Research Institute; Duke University Medical Center; Durham, North Carolina
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27
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Singer JP, Soong A, Chen J, Shrestha P, Zhuo H, Gao Y, Greenland JR, Hays SR, Kukreja J, Golden J, Gregorich SE, Stewart AL. Development and Preliminary Validation of the Lung Transplant Quality of Life (LT-QOL) Survey. Am J Respir Crit Care Med 2020; 199:1008-1019. [PMID: 30303408 DOI: 10.1164/rccm.201806-1198oc] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
RATIONALE Although lung transplantation aims to improve health-related quality of life (HRQL), existing instruments fail to include health domains considered important in this population. OBJECTIVES We aimed to develop a comprehensive lung transplant-specific instrument to address this shortcoming. METHODS We developed a pool of 126 candidate items addressing domains previously identified as important by lung transplant recipients. Through cognitive interviews conducted in 43 transplant recipients, items deemed irrelevant or redundant were dropped. The 84 remaining items were field tested in lung transplant recipients. Exploratory and confirmatory factor analyses were used to evaluate the factor structure, and scales were evaluated for internal consistency and construct validity. MEASUREMENTS AND MAIN RESULTS The 84-item preliminary survey was administered to 201 lung transplant recipients with a mean age of 57.9 (±12.7) years; 46% were female. After factor analyses and internal consistency evaluation, we retained 60 items comprising the Lung Transplant Quality of Life (LT-QOL) Survey. The LT-QOL contains 10 scales that measure symptoms, health perceptions, functioning, and well-being. The confirmatory factor analysis model had good approximate fit (comparative fit index = 0.990; standardized root-mean-square residual = 0.062). Cronbach αs for the 10 scales ranged from 0.75 to 0.95. Interscale correlations were consistent with hypothesized relationships. Subjects with severe chronic lung allograft dysfunction (n = 13) reported significantly worse HRQL than subjects without chronic lung allograft dysfunction (n = 168) on 6 of the 10 LT-QOL scales. CONCLUSIONS The LT-QOL is a new, multidimensional instrument that characterizes and quantifies HRQL in lung transplant recipients.
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Affiliation(s)
- Jonathan P Singer
- 1 Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine
| | - Allison Soong
- 1 Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine
| | - Joan Chen
- 1 Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine
| | - Pavan Shrestha
- 1 Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine
| | - Hanjing Zhuo
- 1 Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine
| | - Ying Gao
- 1 Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine
| | - John R Greenland
- 1 Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine
| | - Steven R Hays
- 1 Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine
| | | | - Jeffrey Golden
- 1 Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine
| | | | - Anita L Stewart
- 4 Institute for Health & Aging, University of California, San Francisco, San Francisco, California
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28
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Sacreas A, Taupin JL, Emonds MP, Daniëls L, Van Raemdonck DE, Vos R, Verleden GM, Vanaudenaerde BM, Roux A, Verleden SE. Intragraft donor-specific anti-HLA antibodies in phenotypes of chronic lung allograft dysfunction. Eur Respir J 2019; 54:13993003.00847-2019. [PMID: 31439680 DOI: 10.1183/13993003.00847-2019] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 07/31/2019] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Circulating anti-human leukocyte antigen (HLA) serum donor-specific antibodies (sDSAs) increase the risk of chronic lung allograft dysfunction (CLAD) and mortality. Discrepancies between serological and pathological/clinical findings are common. Therefore, we aimed to assess the presence of tissue-bound graft DSAs (gDSAs) in CLAD explant tissue compared with sDSAs. METHODS Tissue cores, obtained from explant lungs of unused donors (n=10) and patients with bronchiolitis obliterans syndrome (BOS; n=18) and restrictive allograft syndrome (RAS; n=18), were scanned with micro-computed tomography before elution of antibodies. Total IgG levels were measured via ELISA. Anti-HLA class I and II IgG gDSAs were identified using Luminex single antigen beads and compared with DSAs found in serum samples. RESULTS Overall, mean fluorescence intensity was higher in RAS eluates compared with BOS and controls (p<0.0001). In BOS, two patients were sDSA+/gDSA+ and two patients were sDSA-/gDSA+. In RAS, four patients were sDSA+/gDSA+, one patient was sDSA+/gDSA- and five patients were sDSA-/gDSA+. Serum and graft results combined, DSAs were more prevalent in RAS compared with BOS (56% versus 22%; p=0.04). There was spatial variability in gDSA detection in one BOS patient and three RAS patients, who were all sDSA-. Total graft IgG levels were higher in RAS than BOS (p<0.0001) and in gDSA+ versus gDSA- (p=0.0008), but not in sDSA+ versus sDSA- (p=0.33). In RAS, total IgG levels correlated with fibrosis (r= -0.39; p=0.02). CONCLUSIONS This study underlines the potential of gDSA assessment as complementary information to sDSA findings. The relevance and applications of gDSAs need further investigation.
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Affiliation(s)
- Annelore Sacreas
- Leuven Lung Transplant Group, Dept of Chronic Diseases, Metabolism and Ageing (CHROMETA), KU Leuven, Leuven, Belgium
| | - Jean-Luc Taupin
- Laboratoire d'Immunologie et Histocompatibilité, Saint-Louis Hospital, Paris, France
| | - Marie-Paule Emonds
- Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium.,Dept of Immunology and Microbiology, KU Leuven, Leuven, Belgium
| | - Liesbeth Daniëls
- Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Dirk E Van Raemdonck
- Leuven Lung Transplant Group, Dept of Chronic Diseases, Metabolism and Ageing (CHROMETA), KU Leuven, Leuven, Belgium.,Dept of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Robin Vos
- Leuven Lung Transplant Group, Dept of Chronic Diseases, Metabolism and Ageing (CHROMETA), KU Leuven, Leuven, Belgium
| | - Geert M Verleden
- Leuven Lung Transplant Group, Dept of Chronic Diseases, Metabolism and Ageing (CHROMETA), KU Leuven, Leuven, Belgium
| | - Bart M Vanaudenaerde
- Leuven Lung Transplant Group, Dept of Chronic Diseases, Metabolism and Ageing (CHROMETA), KU Leuven, Leuven, Belgium
| | - Antoine Roux
- Service de Transplantation Pulmonaire, Foch Hospital, Suresnes, France
| | - Stijn E Verleden
- Leuven Lung Transplant Group, Dept of Chronic Diseases, Metabolism and Ageing (CHROMETA), KU Leuven, Leuven, Belgium
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29
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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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30
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Swaminathan AC, Neely ML, Frankel CW, Kelly FL, Petrovski S, Durheim MT, Bush E, Snyder L, Goldstein DB, Todd JL, Palmer SM. Lung Transplant Outcomes in Patients With Pulmonary Fibrosis With Telomere-Related Gene Variants. Chest 2019; 156:477-485. [DOI: 10.1016/j.chest.2019.03.030] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 01/10/2019] [Accepted: 03/01/2019] [Indexed: 01/21/2023] Open
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31
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The pleural mesothelium and transforming growth factor-β1 pathways in restrictive allograft syndrome: A pre-clinical investigation. J Heart Lung Transplant 2019; 38:570-579. [DOI: 10.1016/j.healun.2019.02.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 01/31/2019] [Accepted: 02/01/2019] [Indexed: 12/21/2022] Open
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32
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Chronic lung allograft dysfunction: Definition, diagnostic criteria, and approaches to treatment-A consensus report from the Pulmonary Council of the ISHLT. J Heart Lung Transplant 2019; 38:493-503. [PMID: 30962148 DOI: 10.1016/j.healun.2019.03.009] [Citation(s) in RCA: 505] [Impact Index Per Article: 101.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 03/18/2019] [Indexed: 02/06/2023] Open
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33
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Glanville AR, Verleden GM, Todd JL, Benden C, Calabrese F, Gottlieb J, Hachem RR, Levine D, Meloni F, Palmer SM, Roman A, Sato M, Singer LG, Tokman S, Verleden SE, von der Thüsen J, Vos R, Snell G. Chronic lung allograft dysfunction: Definition and update of restrictive allograft syndrome-A consensus report from the Pulmonary Council of the ISHLT. J Heart Lung Transplant 2019; 38:483-492. [PMID: 31027539 DOI: 10.1016/j.healun.2019.03.008] [Citation(s) in RCA: 175] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 03/18/2019] [Indexed: 02/07/2023] Open
Affiliation(s)
- Allan R Glanville
- Lung Transplant Unit, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | | | - Jamie L Todd
- Division of Pulmonary, Allergy and Critical Care Medicine, Duke University, Durham, North Carolina, USA
| | | | - Fiorella Calabrese
- Department of Cardiothoracic and Vascular Sciences, University of Padova Medical School, Padova, Italy
| | - Jens Gottlieb
- Department of Respiratory Medicine, Hannover Medical School, Member of the German Center for Lung Research, Hannover, Germany
| | - Ramsey R Hachem
- Division of Pulmonary & Critical Care, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Deborah Levine
- Pulmonary Disease and Critical Care Medicine, University of Texas Health Science Center San Antonio, San Antonio, Texas, USA
| | - Federica Meloni
- Department of Respiratory Diseases Policlinico San Matteo Foundation & University of Pavia, Pavia, Italy
| | - Scott M Palmer
- Division of Pulmonary, Allergy and Critical Care Medicine, Duke University, Durham, North Carolina, USA
| | - Antonio Roman
- Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Masaaki Sato
- Department of Thoracic Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sofya Tokman
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | | | - Jan von der Thüsen
- Department of Pathology, University Medical Center, Rotterdam, The Netherlands
| | - Robin Vos
- University Hospital Gasthuisberg, Leuven, Belgium
| | - Gregory Snell
- Lung Transplant Service, The Alfred Hospital, Melbourne, Victoria, Australia
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34
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Role of 18F-FDG PET/CT in Restrictive Allograft Syndrome After Lung Transplantation. Transplantation 2019; 103:823-831. [DOI: 10.1097/tp.0000000000002393] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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35
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Validation of a post-transplant chronic lung allograft dysfunction classification system. J Heart Lung Transplant 2019; 38:166-173. [DOI: 10.1016/j.healun.2018.09.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 09/21/2018] [Accepted: 09/25/2018] [Indexed: 01/25/2023] Open
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36
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Martinu T, Oishi H, Juvet SC, Cypel M, Liu M, Berry GJ, Hwang DM, Keshavjee S. Spectrum of chronic lung allograft pathology in a mouse minor-mismatched orthotopic lung transplant model. Am J Transplant 2019; 19:247-258. [PMID: 30378739 DOI: 10.1111/ajt.15167] [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: 05/21/2018] [Revised: 09/11/2018] [Accepted: 09/27/2018] [Indexed: 01/25/2023]
Abstract
Chronic lung allograft dysfunction (CLAD) is a fatal condition that limits survival after lung transplantation (LTx). The pathological hallmark of CLAD is obliterative bronchiolitis (OB). A subset of patients present with a more aggressive CLAD phenotype, called restrictive allograft syndrome (RAS), characterized by lung parenchymal fibrosis (PF). The mouse orthotopic single LTx model has proven relevant to the mechanistic study of allograft injury. The minor-alloantigen-mismatched strain combination using C57BL/10(B10) donors and C57BL/6(B6) recipients reportedly leads to OB. Recognizing that OB severity is a spectrum that may coexist with other pathologies, including PF, we aimed to characterize and quantify pathologic features of CLAD in this model. Left LTx was performed in the following combinations: B10→B6, B6→B10, B6→B6. Four weeks posttransplant, blinded pathologic semi-quantitative assessment showed that OB was present in 66% of B10→B6 and 30% of B6→B10 grafts. Most mice with OB also had PF with a pattern of pleuroparenchymal fibroelastosis, reminiscent of human RAS-related pathology. Grading of pathologic changes demonstrated variable severity of airway fibrosis, PF, acute rejection, vascular fibrosis, and epithelial changes, similar to those seen in human CLAD. These assessments can make the murine LTx model a more useful tool for further mechanistic studies of CLAD pathogenesis.
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Affiliation(s)
- Tereza Martinu
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Hisashi Oishi
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Stephen C Juvet
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Mingyao Liu
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Gerald J Berry
- Department of Pathology, Stanford University Medical Center, Stanford, California
| | - David M Hwang
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada.,Department of Pathology, University Health Network, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
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37
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Fisher CE, Kapnadak SG, Lease ED, Edelman JD, Limaye AP. Interrater agreement in the diagnosis of chronic lung allograft dysfunction after lung transplantation. J Heart Lung Transplant 2018; 38:327-328. [PMID: 30638835 DOI: 10.1016/j.healun.2018.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 11/30/2018] [Accepted: 12/05/2018] [Indexed: 11/24/2022] Open
Affiliation(s)
| | - Siddhartha G Kapnadak
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Erika D Lease
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Jeffrey D Edelman
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
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38
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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: 9] [Impact Index Per Article: 1.5] [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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39
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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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40
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Spirometry States the Obvious: Recognizing Bronchiolitis Obliterans Syndrome Early after Hematopoietic Cell Transplantation. Ann Am Thorac Soc 2018; 13:1883-1884. [PMID: 27831809 DOI: 10.1513/annalsats.201608-645ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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41
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Voskrebenzev A, Greer M, Gutberlet M, Schönfeld C, Renne J, Hinrichs J, Kaireit T, Welte T, Wacker F, Gottlieb J, Vogel-Claussen J. Detection of chronic lung allograft dysfunction using ventilation-weighted Fourier decomposition MRI. Am J Transplant 2018; 18:2050-2060. [PMID: 29607606 DOI: 10.1111/ajt.14759] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 03/04/2018] [Accepted: 03/25/2018] [Indexed: 01/25/2023]
Abstract
Chronic lung allograft dysfunction (CLAD) remains the leading cause of morbidity and mortality after lung transplantation. Diagnosis requires spirometric change, which becomes increasingly difficult with advancing CLAD. Fourier decomposition magnetic resonance imaging (FD-MRI) permits acquisition of ventilated-weighted images during free-breathing. This study evaluates FD-MRI in detecting CLAD in selected patients after bilateral lung transplantation (DLTx). DLTx recipients demonstrating CLAD at various stages participated. Radiologists remained blinded to clinical status until completion of image analysis. Image acquisition used a 1.5-T MR scanner using a spoiled gradient echo sequence. After FD processing and regional fractional ventilation (RFV) quantification, the volume defect percentage at 2 thresholds (VDP1,2 ), median lung RFV and quartile coefficient of dispersion (QCD) were calculated. Sixty-two patients participated. CLAD was present in 29/62 (47%) patients, of whom 17/62 (27%) had forced expiratory volume in 1 second ≤65% at image acquisition. VDP1 was higher among these participants compared to other groups (P < .001). Increased VDP1 was associated with subsequent graft loss, with values >2% showing reduced survival, independent of degree of graft dysfunction (P = .005). VDP2 discriminated between presence or absence of CLAD (area under the curve = 0.71; P = .03). QCD increased significantly with advancing disease (P < .001). In conclusion, FD-MRI-derived parameters demonstrate potential in quantitative CLAD diagnosis and assessment after DLTx.
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Affiliation(s)
- A Voskrebenzev
- Institute of Diagnostic and Interventional Radiology, Hanover Medical School, Hanover, Germany.,Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), German Center for Lung Research, Hanover, Germany
| | - M Greer
- Department of Respiratory Medicine, Hanover Medical School, Hanover, Germany.,Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), German Center for Lung Research, Hanover, Germany
| | - M Gutberlet
- Institute of Diagnostic and Interventional Radiology, Hanover Medical School, Hanover, Germany.,Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), German Center for Lung Research, Hanover, Germany
| | - C Schönfeld
- Institute of Diagnostic and Interventional Radiology, Hanover Medical School, Hanover, Germany.,Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), German Center for Lung Research, Hanover, Germany
| | - J Renne
- Institute of Diagnostic and Interventional Radiology, Hanover Medical School, Hanover, Germany.,Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), German Center for Lung Research, Hanover, Germany
| | - J Hinrichs
- Institute of Diagnostic and Interventional Radiology, Hanover Medical School, Hanover, Germany.,Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), German Center for Lung Research, Hanover, Germany
| | - T Kaireit
- Institute of Diagnostic and Interventional Radiology, Hanover Medical School, Hanover, Germany.,Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), German Center for Lung Research, Hanover, Germany
| | - T Welte
- Department of Respiratory Medicine, Hanover Medical School, Hanover, Germany.,Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), German Center for Lung Research, Hanover, Germany
| | - F Wacker
- Institute of Diagnostic and Interventional Radiology, Hanover Medical School, Hanover, Germany.,Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), German Center for Lung Research, Hanover, Germany
| | - J Gottlieb
- Department of Respiratory Medicine, Hanover Medical School, Hanover, Germany.,Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), German Center for Lung Research, Hanover, Germany
| | - J Vogel-Claussen
- Institute of Diagnostic and Interventional Radiology, Hanover Medical School, Hanover, Germany.,Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), German Center for Lung Research, Hanover, Germany
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42
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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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43
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High-Resolution CT Findings of Obstructive and Restrictive Phenotypes of Chronic Lung Allograft Dysfunction: More Than Just Bronchiolitis Obliterans Syndrome. AJR Am J Roentgenol 2018; 211:W13-W21. [PMID: 29792746 DOI: 10.2214/ajr.17.19041] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The purpose of this article is to review the high-resolution CT characteristics of individual obstructive and restrictive chronic lung allograft dysfunction (CLAD) phenotypes to aid in making accurate diagnoses and guiding treatment. CONCLUSION Long-term survival and function after lung transplant are considerably worse compared with after other organ transplants. CLAD is implicated as a major limiting factor for long-term graft viability. Historically thought to be a single entity, bronchiolitis obliterans syndrome, CLAD is actually a heterogeneous group of disorders with distinct subtypes.
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Shino MY, Weigt SS, Li N, Derhovanessian A, Sayah DM, Saggar R, Huynh RH, Gregson AL, Ardehali A, Ross DJ, Lynch JP, Elashoff RM, Belperio JA. The Prognostic Importance of Bronchoalveolar Lavage Fluid CXCL9 During Minimal Acute Rejection on the Risk of Chronic Lung Allograft Dysfunction. Am J Transplant 2018; 18:136-144. [PMID: 28637080 PMCID: PMC5739954 DOI: 10.1111/ajt.14397] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 06/11/2017] [Accepted: 06/12/2017] [Indexed: 01/25/2023]
Abstract
The clinical significance and treatment strategies for minimal acute rejection (grade A1), the most common form of acute rejection (AR), remain controversial. In this retrospective single-center cohort study of 441 lung transplant recipients, we formally evaluate the association between minimal AR and chronic lung allograft dysfunction (CLAD) and test a novel hypothesis using bronchoalveolar lavage (BAL) CXCL9 concentration during minimal AR as a biomarker of subsequent CLAD development. In univariable and multivariable models adjusted for all histopathologic injury patterns, minimal AR was not associated with CLAD development. However, minimal AR with elevated BAL CXCL9 concentrations markedly increased CLAD risk in a dose-response manner. Minimal AR with CXCL9 concentrations greater than the 25th, 50th, and 75th percentile had adjusted hazard ratios (HRs) for CLAD of 1.1 (95% confidence interval [CI] 0.8-1.6), 1.6 (95% CI 1.1-2.3), and 2.2 (95% CI 1.4-3.4), respectively. Thus we demonstrate the utility of BAL CXCL9 measurement as a prognostic biomarker that allows discrimination of recipients at increased risk of CLAD development after minimal AR. BAL CXCL9 measurement during transbronchial biopsies may provide clinically useful prognostic data and guide treatment decisions for this common form of AR, as a possible strategy to minimize CLAD development.
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Affiliation(s)
- MY Shino
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1690
| | - SS Weigt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1690
| | - N Li
- Department of Biomathematics, University of California at Los Angeles, Los Angeles, CA 90095-1652
| | - A Derhovanessian
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1690
| | - DM Sayah
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1690
| | - R Saggar
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1690
| | - Richard H. Huynh
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1690
| | - AL Gregson
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1688
| | - A Ardehali
- Division of Cardiothoracic Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1741
| | - DJ Ross
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1690
| | - JP Lynch
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1690
| | - RM Elashoff
- Department of Biomathematics, University of California at Los Angeles, Los Angeles, CA 90095-1652
| | - JA Belperio
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1690
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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: 56] [Impact Index Per Article: 8.0] [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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48
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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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49
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Dettmer S, Shin HO, Vogel-Claussen J, Westphal M, Haverich A, Warnecke G, Welte T, Wacker F, Gottlieb J, Suhling H. CT at onset of chronic lung allograft dysfunction in lung transplant patients predicts development of the restrictive phenotype and survival. Eur J Radiol 2017. [DOI: 10.1016/j.ejrad.2017.06.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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50
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Lung clearance index is sensitive to small airway disease in pediatric lung transplant recipients. J Heart Lung Transplant 2017; 36:980-984. [DOI: 10.1016/j.healun.2017.05.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 04/29/2017] [Accepted: 05/03/2017] [Indexed: 11/22/2022] Open
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