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Vélez C, Neuringer I, Schwarzenberg SJ. The foregut in cystic fibrosis. Pediatr Pulmonol 2024; 59 Suppl 1:S61-S69. [PMID: 39105333 DOI: 10.1002/ppul.27123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 05/23/2024] [Accepted: 06/01/2024] [Indexed: 08/07/2024]
Abstract
The aerodigestive organs share a kindred embryologic origin that allows for a more complete explanation as to how the foregut can remain a barrier to normalcy in people with cystic fibrosis (pwCF). The structures of the aerodigestive tract include the nasopharynx, the oropharynx, the hypopharynx, the esophagus, the stomach, as well as the supraglottic, glottic, and subglottic tubular airways (including the trachea). Additional gastrointestinal (GI) luminal/alimentary organs of the foregut include the duodenum. Extraluminal foregut structures include the liver, the gall bladder, the biliary tree, and the pancreas. There are a variety of neurologic controls within these complicated anatomic compartments to separate the transit of food and liquid from air. These structures share the same origin from the primitive foregut/mesenchyme. The vagus nerve is a critical structure that unites respiratory and digestive functions. This article comments on the interconnected nature of cystic fibrosis and the GI tract. As it relates to the foregut, this has been typically treated as simple "reflux" as the cause of worsened lung function in pwCF. That terms like gastroesophageal reflux (GER), gastroesophageal reflux disease (GERD), heartburn, and regurgitation are used interchangeably to reflect pathology further complicates matters; we offer a more physiologically accurate term called "GI-related aspiration" or "GRASP." Broadly, this term reflects that aspiration of foregut contents from the duodenum through the stomach to the esophagus, into the pharynx and the respiratory tree in pwCF. As a barrier to normalcy in pwCF, GRASP is fundamentally two disease processes-GERD and gastroparesis-that likely contribute most to the deterioration of lung disease in pwCF. In the modulator era, successful GRASP management will be critical, particularly in those post-lung transplantation (LTx), only through successful management of both GERD and gastroparesis. Standardization of clinical management algorithms for GRASP in CF-related GRASP is a key clinical and research gap preventing normalcy in pwCF; what exists nearly exclusively addresses surgical evaluations or offers guidance for the management of GI symptoms alone (with unclear parameters for respiratory disease considerations). We begin first by describing the result of GRASP damage to the lung in various stages of lung disease. This is followed by a discussion of the mechanisms by which the digestive tract can injure the lungs. We summarize what we anticipate future research directions will be to reduce the impact of GRASP as a barrier to normalcy in pwCF.
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Affiliation(s)
- Christopher Vélez
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Isabel Neuringer
- Division of Pulmonology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sarah Jane Schwarzenberg
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
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2
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O'Dwyer DN, Kim JS, Noth I. Reply to Ward et al.: Integrating Aerodigestive Investigations in Progressive Pulmonary Fibrosis. Am J Respir Crit Care Med 2024; 210:530-531. [PMID: 38941619 PMCID: PMC11351800 DOI: 10.1164/rccm.202406-1123le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Accepted: 06/27/2024] [Indexed: 06/30/2024] Open
Affiliation(s)
- David N O'Dwyer
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan; and
| | - John S Kim
- Division of Pulmonary and Critical Care Medicine, University of Virginia, Charlottesville, Virginia
| | - Imre Noth
- Division of Pulmonary and Critical Care Medicine, University of Virginia, Charlottesville, Virginia
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3
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Natalini JG, Wong KK, Nelson NC, Wu BG, Rudym D, Lesko MB, Qayum S, Lewis TC, Wong A, Chang SH, Chan JCY, Geraci TC, Li Y, Wang C, Li H, Pamar P, Schnier J, Mahoney IJ, Malik T, Darawshy F, Sulaiman I, Kugler MC, Singh R, Collazo DE, Chang M, Patel S, Kyeremateng Y, McCormick C, Barnett CR, Tsay JCJ, Brosnahan SB, Singh S, Pass HI, Angel LF, Segal LN. Longitudinal Lower Airway Microbial Signatures of Acute Cellular Rejection in Lung Transplantation. Am J Respir Crit Care Med 2024; 209:1463-1476. [PMID: 38358857 PMCID: PMC11208954 DOI: 10.1164/rccm.202309-1551oc] [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: 09/10/2023] [Accepted: 02/14/2024] [Indexed: 02/17/2024] Open
Abstract
Rationale: Acute cellular rejection (ACR) after lung transplant is a leading risk factor for chronic lung allograft dysfunction. Prior studies have demonstrated dynamic microbial changes occurring within the allograft and gut that influence local adaptive and innate immune responses. However, the lung microbiome's overall impact on ACR risk remains poorly understood. Objectives: To evaluate whether temporal changes in microbial signatures were associated with the development of ACR. Methods: We performed cross-sectional and longitudinal analyses (joint modeling of longitudinal and time-to-event data and trajectory comparisons) of 16S rRNA gene sequencing results derived from lung transplant recipient lower airway samples collected at multiple time points. Measurements and Main Results: Among 103 lung transplant recipients, 25 (24.3%) developed ACR. In comparing samples acquired 1 month after transplant, subjects who never developed ACR demonstrated lower airway enrichment with several oral commensals (e.g., Prevotella and Veillonella spp.) than those with current or future (beyond 1 mo) ACR. However, a subgroup analysis of those who developed ACR beyond 1 month revealed delayed enrichment with oral commensals occurring at the time of ACR diagnosis compared with baseline, when enrichment with more traditionally pathogenic taxa was present. In longitudinal models, dynamic changes in α-diversity (characterized by an initial decrease and a subsequent increase) and in the taxonomic trajectories of numerous oral commensals were more commonly observed in subjects with ACR. Conclusions: Dynamic changes in the lower airway microbiota are associated with the development of ACR, supporting its potential role as a useful biomarker or in ACR pathogenesis.
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Affiliation(s)
- Jake G. Natalini
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
- New York University Langone Transplant Institute, New York, New York
| | - Kendrew K. Wong
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
| | - Nathaniel C. Nelson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
| | - Benjamin G. Wu
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
- Veterans Affairs New York Harbor Healthcare System, New York, New York
| | - Darya Rudym
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
- New York University Langone Transplant Institute, New York, New York
| | - Melissa B. Lesko
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
- New York University Langone Transplant Institute, New York, New York
| | - Seema Qayum
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
- New York University Langone Transplant Institute, New York, New York
| | - Tyler C. Lewis
- New York University Langone Transplant Institute, New York, New York
| | - Adrian Wong
- New York University Langone Transplant Institute, New York, New York
| | - Stephanie H. Chang
- Department of Cardiothoracic Surgery, and
- New York University Langone Transplant Institute, New York, New York
| | - Justin C. Y. Chan
- Department of Cardiothoracic Surgery, and
- New York University Langone Transplant Institute, New York, New York
| | - Travis C. Geraci
- Department of Cardiothoracic Surgery, and
- New York University Langone Transplant Institute, New York, New York
| | - Yonghua Li
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
| | - Chan Wang
- Department of Population Health, New York University Grossman School of Medicine, New York, New York
| | - Huilin Li
- Department of Population Health, New York University Grossman School of Medicine, New York, New York
| | - Prerna Pamar
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
| | - Joseph Schnier
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
| | - Ian J. Mahoney
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
| | - Tahir Malik
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
| | - Fares Darawshy
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
- The Institute of Pulmonology, Hadassah Medical Center, Jerusalem, Israel
- The Faculty of Medicine at the Hebrew University of Jerusalem, Jerusalem, Israel
| | - Imran Sulaiman
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
- Department of Respiratory Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland; and
- Department of Respiratory Medicine, Beaumont Hospital, Dublin, Ireland
| | - Matthias C. Kugler
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
| | - Rajbir Singh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
| | - Destiny E. Collazo
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
| | - Miao Chang
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
| | - Shrey Patel
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
| | - Yaa Kyeremateng
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
| | - Colin McCormick
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
| | - Clea R. Barnett
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
| | - Jun-Chieh J. Tsay
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
- Veterans Affairs New York Harbor Healthcare System, New York, New York
| | - Shari B. Brosnahan
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
| | - Shivani Singh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
| | | | - Luis F. Angel
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
- New York University Langone Transplant Institute, New York, New York
| | - Leopoldo N. Segal
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
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Snyder ME, Kitsios GD. Lung Transplant Outcomes Keep BUGging us: Acute Cellular Rejection and the Lung Microbiome. Am J Respir Crit Care Med 2024; 209:1423-1425. [PMID: 38564413 PMCID: PMC11208966 DOI: 10.1164/rccm.202403-0499ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 04/01/2024] [Indexed: 04/04/2024] Open
Affiliation(s)
- Mark E Snyder
- Department of Medicine University of Pittsburgh Pittsburgh, Pennsylvania
| | - Georgios D Kitsios
- Department of Medicine University of Pittsburgh Pittsburgh, Pennsylvania
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Bongers KS, Massett A, O'Dwyer DN. The Oral-Lung Microbiome Axis in Connective Tissue Disease-Related Interstitial Lung Disease. Semin Respir Crit Care Med 2024; 45:449-458. [PMID: 38626906 DOI: 10.1055/s-0044-1785673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024]
Abstract
Connective tissue disease-related interstitial lung disease (CTD-ILD) is a frequent and serious complication of CTD, leading to high morbidity and mortality. Unfortunately, its pathogenesis remains poorly understood; however, one intriguing contributing factor may be the microbiome of the mouth and lungs. The oral microbiome, which is a major source of the lung microbiome through recurrent microaspiration, is altered in ILD patients. Moreover, in recent years, several lines of evidence suggest that changes in the oral and lung microbiota modulate the pulmonary immune response and thus may play a role in the pathogenesis of ILDs, including CTD-ILD. Here, we review the existing data demonstrating oral and lung microbiota dysbiosis and possible contributions to the development of CTD-ILD in rheumatoid arthritis, Sjögren's syndrome, systemic sclerosis, and systemic lupus erythematosus. We identify several areas of opportunity for future investigations into the role of the oral and lung microbiota in CTD-ILD.
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Affiliation(s)
- Kale S Bongers
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Angeline Massett
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - David N O'Dwyer
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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McGinniss JE, Graham-Wooten J, Whiteside SA, Fitzgerald AS, Khatib LA, Ma KC, DiBardino DM, Haas AR, Bushman FD, Fuchs BD, Collman RG. Microbiome Profiling Demonstrates Concordance of Endotracheal Tube Aspirates With Direct Lower Airway Sampling in Intubated Patients. Chest 2024; 165:1415-1420. [PMID: 38211701 PMCID: PMC11177094 DOI: 10.1016/j.chest.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 12/21/2023] [Accepted: 01/03/2024] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Endotracheal aspirates (ETAs) are widely used for microbiologic studies of the respiratory tract in intubated patients. However, they involve sampling through an established endotracheal tube using suction catheters, both of which can acquire biofilms that may confound results. RESEARCH QUESTION Does standard clinical ETA in intubated patients accurately reflect the authentic lower airway bacterial microbiome? STUDY DESIGN AND METHODS Comprehensive quantitative bacterial profiling using 16S rRNA V1-V2 gene sequencing was applied to compare bacterial populations captured by standard clinical ETA vs contemporaneous gold standard samples acquired directly from the lower airways through a freshly placed sterile tracheostomy tube. The study included 13 patients undergoing percutaneous tracheostomy following prolonged (median, 15 days) intubation. Metrics of bacterial composition, diversity, and relative quantification were applied to samples. RESULTS Pre-tracheostomy ETAs closely resembled the gold standard immediate post-tracheostomy airway microbiomes in bacterial composition and community features of diversity and quantification. Endotracheal tube and suction catheter biofilms also resembled cognate ETA and fresh tracheostomy communities. INTERPRETATION Unbiased molecular profiling shows that standard clinical ETA sampling has good concordance with the authentic lower airway microbiome in intubated patients.
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Affiliation(s)
- John E McGinniss
- Pulmonary, Allergy and Critical Care Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jevon Graham-Wooten
- Pulmonary, Allergy and Critical Care Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Samantha A Whiteside
- Pulmonary, Allergy and Critical Care Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ayannah S Fitzgerald
- Pulmonary, Allergy and Critical Care Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Layla A Khatib
- Pulmonary, Allergy and Critical Care Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Kevin C Ma
- Pulmonary, Allergy and Critical Care Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - David M DiBardino
- Pulmonary, Allergy and Critical Care Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Andrew R Haas
- Pulmonary, Allergy and Critical Care Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Fredric D Bushman
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Barry D Fuchs
- Pulmonary, Allergy and Critical Care Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ronald G Collman
- Pulmonary, Allergy and Critical Care Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
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7
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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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McGinniss JE, Whiteside SA, Deek RA, Simon-Soro A, Graham-Wooten J, Oyster M, Brown MD, Cantu E, Diamond JM, Li H, Christie JD, Bushman FD, Collman RG. The Lung Allograft Microbiome Associates with Pepsin, Inflammation, and Primary Graft Dysfunction. Am J Respir Crit Care Med 2022; 206:1508-1521. [PMID: 36103583 PMCID: PMC9757091 DOI: 10.1164/rccm.202112-2786oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 09/14/2022] [Indexed: 12/24/2022] Open
Abstract
Rationale: Primary graft dysfunction (PGD) is the principal cause of early morbidity and mortality after lung transplantation. The lung microbiome has been implicated in later transplantation outcomes but has not been investigated in PGD. Objectives: To define the peritransplant bacterial lung microbiome and relationship to host response and PGD. Methods: This was a single-center prospective cohort study. Airway lavage samples from donor lungs before organ procurement and recipient allografts immediately after implantation underwent bacterial 16S ribosomal ribonucleic acid gene sequencing. Recipient allograft samples were analyzed for cytokines by multiplex array and pepsin by ELISA. Measurements and Main Results: We enrolled 139 transplant subjects and obtained donor lung (n = 109) and recipient allograft (n = 136) samples. Severe PGD (persistent grade 3) developed in 15 subjects over the first 72 hours, and 40 remained without PGD (persistent grade 0). The microbiome of donor lungs differed from healthy lungs, and recipient allograft microbiomes differed from donor lungs. Development of severe PGD was associated with enrichment in the immediate postimplantation lung of oropharyngeal anaerobic taxa, particularly Prevotella. Elevated pepsin, a gastric biomarker, and a hyperinflammatory cytokine profile were present in recipient allografts in severe PGD and strongly correlated with microbiome composition. Together, immediate postimplantation allograft Prevotella/Streptococcus ratio, pepsin, and indicator cytokines were associated with development of severe PGD during the 72-hour post-transplantation period (area under the curve = 0.81). Conclusions: Lung allografts that develop PGD have a microbiome enriched in anaerobic oropharyngeal taxa, elevated gastric pepsin, and hyperinflammatory phenotype. These findings suggest a possible role for peritransplant aspiration in PGD, a potentially actionable mechanism that warrants further investigation.
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Affiliation(s)
- John E. McGinniss
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | | | | | - Aurea Simon-Soro
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | | | - Michelle Oyster
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | - Melanie D. Brown
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | | | - Joshua M. Diamond
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | - Hongzhe Li
- Department of Epidemiology, Biostatistics, and Informatics
| | - Jason D. Christie
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | - Frederic D. Bushman
- Department of Microbiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ronald G. Collman
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
- Department of Microbiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Affiliation(s)
- Alexa A. Pragman
- Infectious Disease SectionMinneapolis Veterans Affairs Health Care SystemMinneapolis, Minnesota,Division of Infectious Diseases and International MedicineUniversity of MinnesotaMinneapolis, Minnesota
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