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Levy L, Moshkelgosha S, Huszti E, Hunter S, Renaud-Picard B, Berra G, Kawashima M, Fernandez-Castillo J, Fuchs E, Dianti M, Ghany R, Keshavjee S, Singer LG, Tikkanen J, Martinu T. Pulmonary epithelial markers in phenotypes of chronic lung allograft dysfunction. J Heart Lung Transplant 2023; 42:1152-1160. [PMID: 36963446 DOI: 10.1016/j.healun.2023.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 02/21/2023] [Accepted: 03/10/2023] [Indexed: 03/26/2023] Open
Abstract
BACKGROUND Airway epithelial injury is thought to be a key event in the pathogenesis of chronic lung allograft dysfunction (CLAD). We investigated whether markers of epithelial activity and injury in bronchoalveolar lavage fluid (BAL) correlate with CLAD diagnosis and major CLAD phenotypes: bronchiolitis obliterans syndrome (BOS) vs restrictive allograft syndrome (RAS)-related phenotypes (including RAS, mixed phenotype, and all other patients with RAS-like opacities). METHODS CLAD status and phenotypes were retrospectively determined in a cohort of all consecutive adult, first, bilateral lung transplants performed 2010-2015, with available BAL samples. All patients with RAS-related phenotypes were included and 1:1 matched with BOS patients based on the time from transplant to CLAD-onset. Subjects who were CLAD-free for a minimum of 3 years post-transplant were 1:1 matched to CLAD patients and included as controls. Proteins that maintain the barrier function of the airway epithelial mucosa (club cell secretory protein, surfactant protein-D and epithelial mucins: MUC1, MUC5AC, MUC5B, MUC16), as well as epithelial cell death markers (M30&M65 representing epithelial cell apoptosis and overall death, respectively), were measured in BAL obtained within 6-months post CLAD onset using a double-sandwich ELISA or a multiplex bead assay. Protein levels were compared using Mann-Whitney-U-test. Association between protein levels and graft survival was assessed using Cox proportional hazards models, adjusted for CMV serology mismatch status and CLAD phenotype. RESULTS Fifty-four CLAD (27 BOS, 11 RAS, 7 mixed, 9 others with RAS-like opacities) patients and 23 CLAD-free controls were included. Median BAL levels were significantly higher in patients with CLAD compared to CLAD-free controls for M30 (124.5 vs 88.7 U/L), MUC1 (6.8 vs 3.2 pg/mL), and MUC16 (121.0 vs 30.1 pg/mL). When comparing CLAD phenotypes, M30 was significantly higher in patients with RAS-related phenotypes than BOS (160.9 vs 114.6 U/L). In multivariable models, higher M30 and MUC5B levels were associated with decreased allograft survival after CLAD onset independent of phenotype (p < 0.05 for all). CONCLUSIONS Airway epithelial mucins and cell death markers are enhanced in the BAL of patients with CLAD and can assist in differentiating between CLAD phenotypes and post-CLAD outcomes. Abnormal airway mucin expression and epithelial cell death may be involved in the pathogenesis of CLAD, and therefore their detection may aid in future selection of targeted therapies.
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Affiliation(s)
- Liran Levy
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Institute of Pulmonary Medicine, Sheba Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Sajad Moshkelgosha
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Sarah Hunter
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | | | - Gregory Berra
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Mitsuaki Kawashima
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | | | - Eyal Fuchs
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Milagros Dianti
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Jussi Tikkanen
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
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2
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Munker D, Arnold P, Leuschner G, Irlbeck M, Michel S, Kauke T, Meiser B, Behr J, Kneidinger N, Veit T. Impact of ILD-Specific Therapies on Perioperative Course in Patients with Progressive Interstitial Lung Disease Undergoing Lung Transplantation. J Clin Med 2023; 12:4996. [PMID: 37568398 PMCID: PMC10419359 DOI: 10.3390/jcm12154996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/21/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023] Open
Abstract
Immunosuppressants and antifibrotics are currently used to treat patients with various interstitial lung diseases, which may undergo lung transplantation (LTx). The retrospective study aimed to evaluate the potential effects of therapeutic regimen on the perioperative course in patients with idiopathic pulmonary fibrosis (IPF) or progressive pulmonary fibrosis (PPF) undergoing LTx. All patients with IPF and PPF undergoing LTx between January 2014 and December 2021 were included. We retrospectively screened for previous use of immunosuppressants and antifibrotic therapy. We analyzed perioperative courses, short-term outcomes, and safety retrospectively. In total, 286 patients with diagnosis of IPF or PPF were analyzed. According to the treatment regimen before LTx, the study cohort was divided into four groups and compared. No differences between antifibrotic monotherapy, combined antifibrotic and immunosuppressive therapy with regard to postoperative complications were observed. Length of mechanical ventilation was shorter in patients with antifibrotics prior to LTx. Pretreatment with antifibrotic monotherapy and a combination of antifibrotic drugs with immunosuppressive therapy, lower body mass index (BMI) and lower blood loss, were independently associated with primary graft dysfunction grades 0-3 72 hours after LTx (p < 0.001). Finally, patients with antifibrotic monotherapy developed significantly less de novo donor-specific antibodies (DSA) (p = 0.009). Higher intraoperative blood loss, etiology of interstitial lung disease (ILD) and older age were independently associated with shorter survival after LTx. Use of antifibrotic monotherapy and a combination of antifibrotic drugs with immunosuppressive therapy in IPF/PPF patients undergoing LTx, proved to be safe and might lead to beneficial effects after LTx.
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Affiliation(s)
- Dieter Munker
- Department of Medicine V, University Hospital LMU Munich, Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), 81377 Munich, Germany; (D.M.); (P.A.); (J.B.); (N.K.)
| | - Paola Arnold
- Department of Medicine V, University Hospital LMU Munich, Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), 81377 Munich, Germany; (D.M.); (P.A.); (J.B.); (N.K.)
| | - Gabriela Leuschner
- Department of Medicine V, University Hospital LMU Munich, Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), 81377 Munich, Germany; (D.M.); (P.A.); (J.B.); (N.K.)
| | - Michael Irlbeck
- Department of Anaesthesiology, University of Munich (LMU), 81377 Munich, Germany;
| | - Sebastian Michel
- Clinic of Cardiac Surgery, University of Munich (LMU), 81377 Munich, Germany;
| | - Teresa Kauke
- Department of Thoracic Surgery, University of Munich (LMU), 81377 Munich, Germany;
| | - Bruno Meiser
- Transplant Center, University of Munich, 81377 Munich, Germany
| | - Jürgen Behr
- Department of Medicine V, University Hospital LMU Munich, Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), 81377 Munich, Germany; (D.M.); (P.A.); (J.B.); (N.K.)
| | - Nikolaus Kneidinger
- Department of Medicine V, University Hospital LMU Munich, Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), 81377 Munich, Germany; (D.M.); (P.A.); (J.B.); (N.K.)
| | - Tobias Veit
- Department of Medicine V, University Hospital LMU Munich, Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), 81377 Munich, Germany; (D.M.); (P.A.); (J.B.); (N.K.)
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Leong SW, Bos S, Lordan JL, Nair A, Fisher AJ, Meachery G. Lung transplantation for interstitial lung disease: evolution over three decades. BMJ Open Respir Res 2023; 10:10/1/e001387. [PMID: 36854571 PMCID: PMC9980330 DOI: 10.1136/bmjresp-2022-001387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 12/14/2022] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Interstitial lung disease (ILD) has emerged as the most common indication for lung transplantation globally. However, post-transplant survival varies depending on the underlying disease phenotype and comorbidities. This study aimed to describe the demographics, disease classification, outcomes and factors associated with post-transplant survival in a large single-centre cohort. METHODS Data were retrospectively assessed for 284 recipients who underwent lung transplantation for ILD in our centre between 1987 and 2020. Patient characteristics and outcomes were stratified by three eras: 1987-2000, 2001-2010 and 2011-2020. RESULTS Median patients' age at time of transplantation was significantly higher in the most recent decade (56 (51-61) years, p<0.0001). Recipients aged over 50 years had worse overall survival compared with younger patients (adjusted HR, aHR 2.36, 95% CI 1.55 to 3.72, p=0.0001). Better survival was seen with bilateral versus single lung transplantation in patients younger than 50 years (log-rank p=0.0195). However, this survival benefit was no longer present in patients aged over 50 years. Reduced survival was observed in fibrotic non-specific interstitial pneumonia compared with idiopathic pulmonary fibrosis, which remained the most common indication throughout (aHR 2.61, 95% CI 1.40 to 4.60, p=0.0015). CONCLUSION In patients transplanted for end-stage ILD, older age and fibrotic non-specific interstitial pneumonia were associated with poorer post-transplant survival. The benefit of bilateral over single lung transplantation diminished with increasing age, suggesting that single lung transplantation might still be a feasible option in older candidates.
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Affiliation(s)
- Swee W Leong
- Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Department of Pulmonology, Serdang Hospital, Kajang, Malaysia
| | - Saskia Bos
- Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Translational and Clinical Research Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - James L Lordan
- Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Arun Nair
- Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Andrew J Fisher
- Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Translational and Clinical Research Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Gerard Meachery
- Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Wijbenga N, Hoek RAS, Mathot BJ, Seghers L, Moor CC, Aerts JGJV, Bos D, Manintveld OC, Hellemons ME. Diagnostic performance of electronic nose technology in chronic lung allograft dysfunction. J Heart Lung Transplant 2023; 42:236-245. [PMID: 36283951 DOI: 10.1016/j.healun.2022.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 08/22/2022] [Accepted: 09/12/2022] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND There is a need for reliable biomarkers for the diagnosis of chronic lung allograft dysfunction (CLAD). In this light, we investigated the diagnostic value of exhaled breath analysis using an electronic nose (eNose) for CLAD, CLAD phenotype, and CLAD stage in lung transplant recipients (LTR). METHODS We performed eNose measurements in LTR with and without CLAD, visiting the outpatient clinic. Through supervised machine learning, the diagnostic value of eNose for CLAD was assessed in a random training and validation set. Next, we investigated the diagnostic value of the eNose measurements combined with known risk factors for CLAD. Model performance was evaluated using ROC-analysis. RESULTS We included 152 LTR (median age 60 years, 49% females), of whom 38 with CLAD. eNose-based classification of patients with and without CLAD provided an AUC of 0.86 in the training set, and 0.82 in the validation set. After adding established risk factors for CLAD (age, gender, type of transplantation, time after transplantation and prior occurrence of acute cellular rejection) to a model with the eNose data, the discriminative ability of the model improved to an AUC of 0.94 (p = 0.02) in the training set and 0.94 (p = 0.04) in the validation set. Discrimination between BOS and RAS was good (AUC 0.95). Discriminative ability for other phenotypes (AUCs ranging 0.50-0.92) or CLAD stages (AUC 0.56) was limited. CONCLUSION Exhaled breath analysis using eNose is a promising novel biomarker for enabling diagnosis and phenotyping CLAD. eNose technology could be a valuable addition to the diagnostic armamentarium for suspected graft failure in LTR.
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Affiliation(s)
- Nynke Wijbenga
- Department of Respiratory Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands; Erasmus MC Transplant Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Rogier A S Hoek
- Department of Respiratory Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands; Erasmus MC Transplant Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bas J Mathot
- Department of Respiratory Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands; Erasmus MC Transplant Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Leonard Seghers
- Department of Respiratory Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands; Erasmus MC Transplant Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Catharina C Moor
- Department of Respiratory Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Joachim G J V Aerts
- Department of Respiratory Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Daniel Bos
- Department of Radiology & Nuclear Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Epidemiology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Olivier C Manintveld
- Department of Cardiology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands; Erasmus MC Transplant Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Merel E Hellemons
- Department of Respiratory Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands; Erasmus MC Transplant Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands.
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Mora Cuesta VM, Iturbe Fernández D, Aguado Ibáñez S, Anguera de Francisco G, Margallo Iribarnegaray J, Carrillo Hernández-Rubio J, Reig Mezquida JP, Pérez Luz V, Laporta Hernández R, de Pablo Gafas A, Solé Jover A, Cifrián Martínez JM. Antifibrotics and lung transplantation: A Spanish multicentre case-controlled study. Respirology 2022; 27:1054-1063. [PMID: 36053911 DOI: 10.1111/resp.14352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 08/08/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVE Antifibrotic drugs are the standard treatments for patients with idiopathic pulmonary fibrosis (IPF). This study aims to assess the safety of antifibrotic treatment in IPF patients undergoing lung transplantation. METHODS Patients with a diagnosis of IPF who received a lung transplant between January 2015 and June 2019 at four Spanish hospitals specialized in lung transplantation were retrospectively recruited. Cases were defined as patients receiving antifibrotic treatments at time of transplant. Each case was matched with a control who did not receive antifibrotic treatment. RESULTS A total of 164 patients were included in the study cohort (103 cases and 61 controls). There were no statistically significant differences between the cases and controls in any of the items studied related to transplantation except the time until the appearance of chest wall dehiscence: although there were no differences in the incidence of wall dehiscence in either group (12.3% vs. 13.7%; p = 0.318), the patients on antifibrotic drugs experienced it earlier (21 days [IQR = 12.5-41.5] vs. 63 days [IQR = 46.75-152.25]; p = 0.012). There were no differences in overall post-transplant survival between the two groups (p = 0.698) or in conditional survival at 30 days, 90 days, 3 years or 5 years. However, 1 year survival was significantly greater among controls (80.6% vs. 93.3%; p = 0.028). CONCLUSION There was evidence that chest wall dehiscences appeared earlier post-transplant in patients using antifibrotics, even though this factor did not significantly impact survival.
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Pulmonary graft-versus-host disease and chronic lung allograft dysfunction: two sides of the same coin? THE LANCET RESPIRATORY MEDICINE 2022; 10:796-810. [DOI: 10.1016/s2213-2600(22)00001-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/17/2021] [Accepted: 01/04/2022] [Indexed: 11/23/2022]
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